Stealthy ovarian cancer.

We asked Dr. Marguerite Shepard, a nationally recognized professor of obstetrics and gynecology at the Indiana University School of Medicine, to tell us what a good checkup to detect early ovarian cancer should include.

She believes that a good pelvic exam should include a rectal exam to better discover an ominous enlarged ovary that might have dipped down behind the uterus.

"I perform rectal exams as part of the annual physical on every woman that I see, regardless of her age," says Dr. Shepard. "In my practice, I treat many women with endometriosis, a condition often best detected by doing a rectal exam. You can feel the ovaries if they have dropped down behind the uterus. You can feel abnormal growths in a space between the uterus and the rectum called the pouch of Douglas. A woman with ovarian cancer may have growths in this space, and one can feel them."

If anything seems unusual, Dr. Shepard explains, the next step may be a vaginal ultrasound study.

"A vaginal ultrasound examination uses sound waves to determine the location of the uterus, the size and appearance of the ovaries, and whether there is fluid present," she says. "It is an easy and effective way to see if something unusual is in the pouch of Douglas."

In general, vaginal ultrasound studies are recommended for women who are experiencing a new onset of abdominal pain; who have a positive family history for ovarian, breast or colon cancer; and who have been treated with ovulation induction agents for the treatment of infertility.

Having had a hysterectomy does not eliminate the need for an annual pelvic and rectal examination, adds Dr. Shepard. Depending on the type of surgery, a woman's cervix, fallopian tubes, and ovaries may still remain. Even if the ovaries have been removed, it is possible to develop a tumor of the abdominal cavity lining that is of the same cell type as ovarian cancer.

"A woman cannot go cavalierly along and say, `Well everything is taken out; I don't need to see the gynecologist anymore.' Not true," Dr. Shepard advises. "It doesn't mean she should not have her annual examination, and it doesn't mean that she shouldn't pay attention to symptoms."

Angela D. Smith, M.D., FACSM, is the newly elected president of the American College of Sports Medicine. She is clinical associate professor of orthopaedics at the University of Pennsylvania.