Treatment for ovarian cancer

Being told you have cancer requiring treatment will mean you may experience many different emotions such as shock, fear, anger, a sense of helplessness and a loss of control. You may not believe this is happening if you don’t feel ill.

You may be frightened about the future and what this may hold for you. These are all normal reactions which may affect you, your family and friends at this time.

We understand that this is a very difficult time for you. We aim to keep you and your family informed about your treatments. These will be discussed with you at every stage.

It can be very difficult to take everything in when you are first told about your cancer diagnosis. This booklet is designed to supplement the information given to you by other members of the healthcare team involved in your care.

If you have any concerns or questions about your diagnosis or treatment please contact us. We will try to resolve any issues you may have.

The body is made up of groups of specialised cells such as skin, liver, bone, breast cells. Worn-out cells are replaced by new ones. The growth and repair of these occurs in an organised and controlled manner. The right numbers of new cells are produced to replace the old ones.

This process can go wrong. One cell may develop its own pattern of growth and division, producing more and more abnormal cells. These abnormal cells may eventually develop into an abnormal mass of tissue or form a lump, called a tumour. Tumours can be benign or malignant. The pathologist can tell by examining cells whether they are benign or malignant.

Benign tumours are generally harmless. Unless they are causing problems, for example pain, they are generally left alone.

Malignant tumours consist of cancer cells. Some cancer cells have the ability to break away from the original (or primary tumour) and spread to other parts of the body. When these cells reach other parts of the body they can continue to grow and divide to form a new tumour. This is referred to as a secondary deposit or metastasis. Treatment can be offered for both primary and secondary disease.

It is important to remember that cancer is not one disease. There are many different types, which are all treated in different ways. For this reason you may find that other patients are undergoing different treatment to you.

This is a nurse who specialises in the care of women with gynaecological cancers and their families. He or she is your key worker and can provide information, advice and support for you and your family, from diagnosis onwards.

This may include:

• surgery
• chemotherapy/ radiotherapy
• psychosexual issues
• support agencies
• HRT and menopause information
• fertility and infertility advice or information
• lymphoedema services
• finance
• pain and symptom control
• local and national services
• hospice care

You may meet your nurse specialist at the outpatient clinic or on the ward.

Your CNS can be contacted Monday to Friday, 08.00 (8am) to 16.00 (4pm), on 01223 586892. We have a voicemail, so if no one answers your call please leave a message and we will call you back as soon as possible.

If you have any urgent problems over the weekend please contact your out–of-hours GP.

We are always available for advice. Please do not hesitate to contact us.

If you have had surgery recently, advice is available from Daphne Ward ( 01223 257206) and Clinic 24 - Gynaecology Assessment Unit (01223 217636), both of which are located in the Rosie Unit.

In the UK, ovarian cancer is the fifth most common cancer in women. The majority of cases occur in women who have gone through the menopause and are usually aged over 50, but younger women can also be affected.

The ovaries are two small oval shaped organs in the pelvis that are part of the female reproductive system. The ovaries also produce the female hormones oestrogen and progesterone.

Most ovarian cancers start in the cells that cover the surface of the ovary (the epithelium) and are called epithelial ovarian cancers.

The cause is unknown; however, there are factors which may increase a woman’s chance of getting ovarian cancer, such as:

• The risk increases with age.
• Being overweight or obese increases the risk of developing ovarian cancer.
• A family history of ovarian or breast cancer can increase your risk but does not mean you will get cancer. If you have concerns, speak with your GP or nurse specialist who can refer to genetic counsellors.
• If the number of eggs a woman releases (ovulation) during her lifetime is reduced, the risk of developing ovarian cancer is lower. Factors that reduce the number of times a woman ovulates include taking the oral contraceptive pill, being pregnant and breastfeeding.
• The risk increases slightly for those that have not had children and who have a late menopause.

The symptoms for ovarian cancer can be non-specific and can often be mistaken for other conditions. You may have experienced symptoms such as bloating, abdominal discomfort or fullness, change in bowel or indigestion patterns.

In some cases you might be able to feel a mass. An ultrasound scan is usually required to assess the features of the mass and where it is originating from.

Other tests may also be carried out such as a blood test known as Ca 125. This is a tumour marker used in conjunction with other tests to assess the risk of ovarian cancer. If there is a suspected cancer or suspicion of cancer a CT scan may also be performed to help with evaluation of the pelvic mass.

Possible outcomes of investigations

• Malignancy
• Ovarian cysts
• Borderline tumours

Even though these investigations are clinically significant and aid diagnosis, we may not be able to confirm diagnosis until we have a tissue sample from the mass. This can be obtained at biopsy or surgery; it then needs to be examined under a microscope to give a definitive diagnosis based on cell types seen. Further treatment will then be based on a confirmed diagnosis.

Benign ovarian cysts

An ovarian cyst is a fluid filled sac that develops on a woman’s ovary. In women of childbearing age, small cysts develop in the ovary every month as an egg develops. This is normal. Ovarian cysts can sometimes also be caused by an underlying condition, such as endometriosis.

The vast majority of ovarian cysts are non-cancerous (benign), although a small number are cancerous (malignant). Cancerous cysts are more common in women who have been through the menopause.

Borderline tumours

Borderline tumours are different to ovarian cancer because they don't grow into the supportive tissue of the ovary (the stroma). They tend to grow slowly and in a more controlled way than cancer cells.

They are usually diagnosed at an early stage, when the abnormal cells are still within the ovary. Occasionally some abnormal cells break away from the tumour and settle elsewhere in the body, usually the abdomen.

There are two main types of borderline ovarian tumours: serous and mucinous. Serous borderline ovarian tumours are the most common. About 65 out of 100 borderline ovarian tumours are this type.

The main treatment for borderline tumours is surgery. Most women are cured and have no further problems. There is a small risk of the tumour coming back. Very rarely, the borderline tumour cells change into cancer cells.

More information on borderline ovarian tumours is available from Ovacome and Cancer Research UK.

Surgery

The main aim of surgery is to remove as much of the cancer as possible. The surgery you are offered is dependent upon type, size and location of your cancer. A hysterectomy is often advised; this is an operation to remove your womb and sometimes other parts of female reproductive system.

• both ovaries and the fallopian tubes (called a bilateral salpingo-oophorectomy)
• the womb and cervix are removed (called a total hysterectomy)
• the layer of fatty tissue in the abdomen known as the omentum (called an omentectomy)
• biopsies and lymph nodes may also be removed to help with diagnosing your cancer

If the cancer is at an early stage and you wish to become pregnant, you may only need to have the affected ovary and tube removed. Your specialist team will discuss with you the benefits and risks of this form of surgery and they will also discuss the possibilities for fertility and make the appropriate referrals.

In late stages of the disease, surgery may not always be possible because of where the cancer is or if you are not well enough for an operation. If this is the case, your specialist team may recommend chemotherapy to shrink the tumour and relieve symptoms.

Radiotherapy is rarely used to treat ovarian cancer. It is occasionally used to treat an area of cancer that’s come back after surgery.

Chemotherapy uses anti-cancer (cytotoxic) drugs to destroy cancer cells.

Ovarian cancer usually responds well to chemotherapy and can be used in a number of different ways:

• Before surgery to shrink the tumour (called neo-adjuvant chemotherapy).
• After surgery to treat any cancer cells left post surgery.
• After surgery in early ovarian cancer to reduce the risk of cancer returning (called adjuvant chemotherapy).
• Chemotherapy maybe used as the main treatment if cancer has spread outside the abdomen or to the liver.

Your options in regard to chemotherapy and radiotherapy will be explained fully to you by your oncologist and specialist nurse if appropriate.

You might go for a check-up at the surgical outpatients after surgery. You will go to the cancer clinic if you are having or have had chemotherapy or radiotherapy. The surgeon and the oncologist might share your follow up. This means that sometimes you will see the surgeon, and the oncologist at other times.

Contact your doctor or specialist nurse if you have any concerns. You should also contact them if you notice any new symptoms between appointments; you don’t have to wait until your next visit.

This system leaves it to the patient to take the lead in arranging to see your doctor or specialist nurse. When you first finish treatment we arrange the appointment. But once your doctors are happy with your progress you can arrange them yourself.

For example, you may want to make an appointment if you have noticed any symptoms that are worrying you or if you have concerns about your health.

Important symptoms to be aware of:

• bleeding or discharge from the vagina or back passage
• pain in the pelvic area
• abdominal bloating
• any change in urinary or bowel habits

Between the time of your diagnosis and admission to hospital for surgery the gynae-oncology nurses can provide support, advice and information. Everyone has different needs at this time.

Prior to surgery you will be asked to attend for ‘pre assessment’, this may be straight after you are seen in clinic or at a pre-arranged later date.

This involves:

• a check of general state of health
• current medication
• a number of routine tests may be carried out - eg chest x-ray, electrocardiogram (ECG), blood tests

You will have been given your consent forms to read through. Please sign these and being them with you on the day of your surgery. You will have a brief opportunity to see your surgeon before your operation.

You may be examined again and the side of your operation marked. You will also go through your consent form again with your surgeon.

Planned date for surgery:………………………………………………

Please go to………………………………………………….

At………………………………

On the morning of your surgery please remember:

• Do not eat after (this includes chewing gum) …………………………………………………………………
• You may drink clear water only (non-carbonated and without flavouring) until………………………………

Please do not consume anything after these times as this may cause delay or cancellation to your surgery.

We advise you wear loose and comfortable clothing. We would also advise you to stop smoking for two days prior to surgery.

There will be some waiting involved during the day so we suggest that you bring something to do with you eg a book; and if possible for a friend or family member to be with you whilst you wait.

During a general anaesthetic (GA) medications are used to induce sleep so you are unaware of procedure/ operation and do not feel any pain or move whilst it is being undertaken.

Before having an operation you will be assessed for suitability for a general anaesthetic. This will be done at pre-assessment.

It will either be given as a:

• liquid that's injected into your veins through a cannula (a thin plastic tube that feeds into a vein, usually on the back of your hand)
• gas that you breathe in through a mask

The anaesthetic should take effect very quickly. You'll start feeling light-headed, before becoming unconscious within a minute or so. Your anaesthetist will stay with you throughout the procedure. They'll make sure you continue to receive the anaesthetic and that you stay in a controlled state of unconsciousness. They will also give you pain-relieving medicine into your veins, so that you're comfortable when you wake up.

General anaesthetics have some common side effects; nausea and vomiting, dizziness, confusion, bruising and soreness. Your anaesthetist should discuss these with you before your surgery and you will be monitored throughout your time in hospital.

Depending on your circumstances, you'll usually need to stay in hospital for a few hours to a few days after your operation.

General anaesthetics can affect your memory, concentration and reflexes for a day or two, so it's important for a responsible adult to stay with you for at least 24 hours after your operation, if you're allowed to go home. You will also be advised to avoid driving, drinking alcohol and signing any legal documents for 24 to 48 hours.

Your anaesthetist or pre-assessment team will be able to help if you have further questions.

NHS Choices – General anaesthetics - General anaesthesia

Immediately after your operation you will be transferred to the recovery area in theatre. You will be looked after there until you have woken up from your anaesthetic. You will then return to the ward.

Following your return to the ward you may remain drowsy and sleepy for a few hours.

You will go back to Daphne Ward which is located in the Rosie Unit on Level 2. This is a 19 bed female general gynaecology ward. The ward's phone number is 01223 257206

Normal visiting hours are 15.00 (3pm) to 20.00 (8pm). Please contact the ward to arrange visiting outside of these hours.

Pain

The amount of pain experienced following surgery is different for each individual and the operation you have. On the whole, most women experience less pain than expected. You will be given painkillers after your operation, including some to take home with you.

PCA (patient-controlled analgesia)

A PCA is a pump that contains a painkiller that is connected to the patient’s intravenous (IV) line, allowing you to administer regular pain relief.

You will likely wake up after surgery with a PCA. We will monitor your pain and, when it is controlled, consider converting to oral painkillers.

Epidural

An epidural is an injection in the back to help with pain post-operatively. If this is an appropriate option for you, your consultant or anaesthetist will discuss this with you before surgery.

In hospital we will encourage you to 'mobilise' (walk or move around) after your operation as this prevents post-op complications and helps speed up your recovery process.

You will also be required to wear anti-embolism stockings (TED stockings) which will help to prevent blood clots. How long you would be expected to wear these post-operatively may vary but will be explained on discharge.

During the operation a catheter will be inserted which will remain in for possibly six to 72 hours. It will usually be taken out on the ward the morning after your surgery; this will be decided by your medical team.

Before you go home we will check you are emptying your bladder properly. If there are complications you can go home with a catheter in and appropriate follow-up.

If after removal of a catheter you are initially unable to pass urine or are storing it in your bladder, we may talk to you about the option of self-catheterisation. This is usually a temporary measure.

Your wound will depend on the operation you undergo. Dissolvable stitches are used in most operations. Your medical team will inspect your wound during your stay in hospital. Please monitor your wound for redness, swelling, discharge, and the wound becoming hot to the touch. If you have concerns when you are at home please contact us.

In the first few days following your operation a vast amount of ‘internal energy’ will be required by your body to repair itself. This may leave you with only small amounts of energy for the rest of the day. You will find that your body will naturally pace itself. After a particular activity, you may find your energy levels are dipping and that you require more frequent rests.

It is important you keep mobile, moving around the house and taking regular deep breaths whilst resting to reduce risk of blood clots in the legs and also chest infections and pneumonia.

As the days and weeks pass, your energy store increases so you may be back to your normal pattern. During this time you may find that there are good days when you have lots of energy and days you feel more tired. This is normal.

Housework

In the first few weeks you may find you are only able to do light housework such as dusting and preparing light meals. As your energy levels increase you will be able to incorporate more of your daily tasks into you routine but listen to your body.

Physical exercise

If you participate in regular exercise it is advisable to refrain from this in the first few days to weeks. When your energy levels increase, gentle exercise is encourage but build this up slowly.

Driving

The main requirement for driving is that you feel safe behind the wheel. This involves being able to perform an emergency stop or to swerve very quickly. This is not usually possible in the first few weeks and often takes up to six weeks. When you feel ready we would recommend that you go for a short drive to see how well you can manage.

It is also advisable to check with your insurance company as some impose restrictions on driving for a minimum period of time after surgery.

Insurance

Just because you have a cancer diagnosis does not mean you will be unable to get insurance.

If you need information on such matters such as life insurance, travel or mortgage insurance visit the website for insurers in your area (Amii) or Macmillan information can be helpful.

Gynaecological cancers can be treated with a combination of different treatments. Each case is different and your treatment will be tailored to your individual needs.

Surgery

There are several different types of surgery. Your surgeon will discuss these with you based on your individual case.

Chemotherapy

Chemotherapy is a medicine, tablet or given as a drip that kills cancer cells. The aim of chemotherapy may be different according to the stage of disease, with some people not requiring any chemotherapy. Chemotherapy can be used to shrink disease prior to surgery, after surgery to kill any remaining cancer cells or if your cancer returns after initial treatment.

Chemotherapy is given in cycles, with a period of treatment followed by a period of rest to allow your body to recover. There are documented side effects when receiving chemotherapy; however these are dependent on the chemotherapy you receive, the dose and your individual reaction to the drug.

Side-effects may include; nausea and vomiting, tiredness/ fatigue, hair loss, sore mouth, numbness/ tingling in hands/ feet and increase risk of infection. There are medications available to help with some of these side effects.

Radiotherapy

Radiotherapy uses high-radiation beams to kill cancer cells. Although not often used as the main treatment for cancer, but it can be helpful shrinking any secondary tumours or for symptom control. Your oncologist will speak with you about this option and the associated side effects if appropriate.

Hormonal treatment

Some gynaecological malignancies, such as endometrial cancers, are sensitive to hormonal treatment and this can be used to shrink the tumour. Your oncologist will speak about this option if appropriate.

Clinical trials

A clinical trial may be discussed about with you as a potential treatment. This discussion does not commit you to taking part. You can also speak with your doctor to see if there are any clinical trials appropriate to your diagnosis.

Those who have gone through a cancer treatment describe the first few months as a 'time of change' – not so much getting back to normal, but finding out what is normal. Things may still change during your recovery and as a result of your surgery.

Eating and drinking are an important part of our lives When you have cancer, you may become more aware of what you eat and drink. You may wish to find out how diet can play a role in your recovery and future health.

A well-balanced diet is important. For a healthy diet it is important to:

• eat a variety of different foods
• eat at least five portions of fruit and vegetables in one day
• limit sugary food and drinks
• drink water
• reduce your salt intake
• drink alcohol in moderation
• most importantly, enjoy your food

You may feel tired or worn out, in fact fatigue is one of the most common complaints during the first year of recovery. Rest or sleep may not cure the type of fatigue that you have.

Here are some ideas for coping with fatigue:

• Prioritising – Decide which activities are of most value each day and cut out unnecessary tasks.
• Pacing – Balance activity and rest, and take frequent breaks. Gentle exercise can help fatigue.
• Planning – Consider whether time of day affects your fatigue and avoid unnecessary exertion. Try to space activities out throughout the week and not concentrate all activities into one day.
• Posture – Avoid bending and twisting which can be tiring. Try not to sit or stand in the same position for too long without changing your position
• Permission – Give yourself permission not to do something that you feel you should, and try to delegate to others!

You’ll probably need time to recover and adapt to body changes before you feel comfortable about having sex. How long this takes depends on what feels right for you and your partner. As with all other aspects of cancer, care information needs regarding sexuality differ for each individual.

Partners may also have concerns. Talking openly with each other can have a positive effect on your relationship and make you feel more comfortable with each other.

If you experience difficulties with your sex life and these don’t improve, talk to your doctor or specialist nurse. Try not to feel embarrassed – they’re used to giving advice on intimate problems. They can give information and advice on different ways of looking at problems or other specialist services.

Support

• Macmillan – Relationship, intimacy and sex
• Cancer Research UK – Cancer and sex

There are a lot of emotions when dealing with cancer. It’s natural to have many different thoughts and feelings after a cancer diagnosis. Some people feel upset, shocked or anxious, while others feel angry, guilty or alone. There is no right way for you to feel.

Being able to talk openly with family and friends can provide a lot of comfort.

Support groups and self-help groups give you the opportunity to share your thoughts and feelings. They can also be a good way to hear how other people affected by cancer coped with their situations. The healthcare professionals caring for you and who know your situation can also be a good source of support.

Many people also use psychological services as a source of support during and after their treatment. The Gynae-oncology Psychological Service (GPS) has been established to provide a woman-centred service for dealing with gynaecological cancer and aims to provide a space for women to discuss adapting to the impact of cancer. The GPS team includes a psychological wellbeing practitioner, clinical psychologist and consultant psychiatrist who are able to provide a variety of interventions that can offer you an integrated and holistic approach to your treatment, health and wellbeing.

Speaking with GPS can help in many areas, such as:

• helping you make sense of how you have been feeling
• adapting and coping with cancer
• managing difficult or distressing feelings
• learning ways to cope with and prepare for treatment procedures
• managing worries and living with uncertainty
• finding ways of solving problems
• making use of your own strengths and skills
• relationship difficulties
• moving forward with life after treatment has finished

If you think you may benefit from these services, please speak to your CNS who can complete a referral or explain more about GPS. You can also contact them directly on 01223 216167 (ask for Asmita or a colleague in the GPS service).

Fertility preservation is considered for patients who may undergo treatment that causes destruction of oocytes (eggs) leading to infertility. Those with greatest need to consider fertility preservation are women undergoing chemotherapy or radiation. This may also be discussed with women who are undergoing surgical removal or both ovaries (oophorectomy).

After oncology treatment women can have normal fertility, fertility followed by an early menopause, compromised fertility or ovarian failure (menopause). There is no test to predict your fertility response to treatment. For all patients desiring fertility preservation options would be individualised.

Female fertility preservation options currently available include:

• embryo cryopreservation
• oocyte cryopreservation (egg freezing)
• laparoscopic oophoropexy (ovarian transposition, key hole surgery)
• ovarian suppression (hormone treatment)
• radical trachelectomy (cervical cancer)

If you wish to discuss this further, please ask in your clinic appointment or speak with your CNS.

Some types of cancer treatment cause an early menopause. Types of cancer treatment that can cause an early menopause include:

• surgery to remove the ovaries
• radiotherapy to the pelvis
• hormone therapy
• chemotherapy

Menopause can cause:

• vaginal dryness
• hot flushes and sweating
• feeling sad or depression
• loss of confidence and self esteem
• tiredness (fatigue)
• thinning bones

Hormone replacement therapy (HRT) will reverse most of these effects for some women. It can also help with the emotional effects of menopause. Loss of sexual desire can be a problem. It is important to remember that many factors can influence the loss of sexual desire after treatment for cancer.

There are other ways to help with the symptoms of menopause if HRT is not suitable for you, such as:

• other medications to ease symptoms eg gabapentin for flushing symptoms
• complementary therapies eg homeopathy and acupuncture
• creams and lubricants for vaginal dryness

You can discuss these with your consultant and your CNS.

• Maggie Cancer Care Centre
• Patient information – Alternatives to HRT
• Royal College Obstetrics and Gynaecologists (RCOG) – Menopause and Alternatives to HRT
• Daisy Network
• Menopause – One stop guide, A practical guide to understanding and dealing with the menopause, Kathy Abernethy

Lymphoedema is the swelling caused by a buildup of lymph fluid in the surface tissue of the body. Following some gynecological cancers and therapy this buildup may occur as a result of damage to the lymphatic system due to surgery and/or radiotherapy to the lymph nodes.

Physical systems can include:

• swelling in the legs, ankles and feet
• discomfort
• infection

Lymphoedema can be a long-term condition. The symptoms usually respond well to treatment and this means in most cases it can be controlled.

If you notice any swelling, you are advised to contact the gynae-oncology clinical nurse specialists for further advice and possible assessment.

The Lymphoedema Support Network (LSN)

Macmillan - Living with lymphoedema - Information and Support

• Consultant gynecological oncologists (surgery) secretary: 01223 216251
• Gynaecological oncology clinical nurse specialists (surgery): 01223 586892
• Medical oncologists secretary: 01223 217074
• Clinical oncologists secretary: 01223 217074
• Gynaecological oncology clinical nurse specialists (chemotherapy): 01223 257049
• Specialist Radiographer - Katie Bradshaw: 01223 216580

If you call out of office hours, please leave a message on the answering machine and your call will be returned the next working day.

Adjuvant treatment - Treatment, usually chemotherapy or radiotherapy, given after surgery.

Benign - A non-cancerous growth within the body, which may interfere with the function of an organ, but does not spread.

Biopsy - The removal of a sample of tissue, which can be examined in a laboratory to find out the cause of an illness.

CA 125 – Ca 125 is a protein that is found in the blood, in most healthy women Ca 125 is usually less than 35 units per ml. However some women do have a naturally high level of Ca125 in their blood. As well as helping diagnosis ovarian cancer, Ca 125 blood tests are sometimes used to monitor the treatment of ovarian cancer or check for signs of recurrence.

Cytology - The microscopic examination of cells.

Histology - The examination of tissues to diagnose the underlying disease.

Intravenous (IV) - Given into the vein, usually by injection so that the substance can work quickly.

Laparoscopy - A minor operation which involves making a small incision in the abdomen so that a small telescope (laparoscope) can be inserted, to enable the abdomen and pelvis to be examined without performing a full laparotomy.

Laparotomy - An operation to open the abdomen.

Lymphatic system - A network of vessels that transport lymph, which is a clear fluid that comes from the blood and bathes the tissues. It contains water, protein, minerals and white blood cells. The lymph passes through a series of filters (lymph nodes) before it rejoins the blood stream.

Lymphoedema - Swelling in the arms or legs which is caused by blockage or damage to the drainage of the lymphatic system. It can happen as a result of some cancer treatments, or from the cancer itself.

Lymph Nodes - Small pearl-like glands that are connected to the lymph system and act as filters to stray bacteria or cancer cells. They also produce lymphocytes which are one of the types of white blood cells in the body. When bacteria or cancer cells reach these nodes, they can become enlarged.

Metastatic/Metastases - The spread of cancer from one part of the body to another by the lymphatic system or by the bloodstream.

Omentum - A double layer of membrane that is rich in fatty tissue and lies in front of the intestines, like an apron.

Tumour markers - Substances produced by some cancers that can be measured in the blood stream. They can be used either to assist in making a diagnosis, or to monitor how the cancer is responding to treatment.

• Gynae-oncology consultants and clinical nurse specialists team: 01223 586892
• Gynae-oncology consultants and clinical nurse specialists for chemotherapy: 01223 256 676
• Maggie Wallace Centre – Addenbrooke's Hospital: 01223 249 220
• Macmillan Cancer Support Centre, Oncology Outpatients, Addenbrooke's Hospital: 01223 274801
• Oncology Centre, Addenbrooke's: 01223 216552
• Macmillan Cancer Support, 89 Albert Embankment, London, SE1 7UQ, 0808 808 0000
• Target Ovarian Cancer: 02079235475, Email Target Ovarian Cancer
• Shine Cancer Support – Cancer support for anyone in their 20s, 30s and 40s Email Shine cancer support

• Lymphoedema Support Network (LSN)
• Macmillan - womb cancer
• Macmillan – Living with Lymphoedema
• Macmillan – Relationship, Intimacy and Sex
• NHS Choices – General Anaesthetics
• Patient information – Alternatives to HRT
• Royal College Obstetrics and Gynaecologists (RCOG) – Menopause and Alternatives to HRT
• Royal College Obstetrics and Gynaecologists (RCOG) – Recovering well