What is Ovarian Torsion?
Ovarian torsion happens when the ovary, which is a small, egg-producing organ in a woman’s body, twists over the strong tissues (ligaments) that hold it in place. This twisting can also involve the fallopian tube, a tube that connects the ovary to the uterus (womb), and this condition is then called adnexal torsion.
The ovary stays in place within a woman’s lower abdomen (pelvis) because of multiple supporting structures. One of these is the infundibulopelvic ligament, also known as the suspensory ligament of the ovary. This ligament links the ovary to the side wall of the pelvis and also contains the critical blood vessels that supply the ovary. The ovary is also tethered to the uterus by the utero-ovarian ligament.
The ovary gets its blood mainly from two sources: the ovarian arteries and uterine arteries. When these ligaments twist, it can cause a buildup of blood (venous congestion) and fluid (edema) in the ovary, which can then squeeze and obstruct the arteries. This obstruction may eventually result in the ovary losing its blood supply. This lack of blood can cause a group of symptoms, including severe pain. It’s a serious situation that requires immediate surgical intervention.
If left untreated, it can lead to necrosis (cell death due to lack of blood), loss of the ovary and infertility (inability to become pregnant). Therefore, it’s crucial to identify and treat ovarian torsion promptly.
What Causes Ovarian Torsion?
Having an ovarian mass, or growth, that is 5 cm or larger is the main risk factor for ovarian torsion. Ovarian torsion happens when an ovary twists around the two ligaments that hold it in place. This twisting can block blood flow, first stopping blood from leaving the ovary and eventually preventing blood from entering.
A study found that in cases of confirmed ovarian torsion, 46% were related to tumors and 48% were linked to cysts. Of these growths, 89% were not cancerous, and 80% of the patients were under the age of 50. This suggests that women of reproductive age are most at risk of experiencing ovarian torsion.
However, it’s also important to know that ovarian torsion can occur in normal ovaries, especially in children. Pregnancy and fertility treatments, which can cause enlarged follicles on the ovary, are also linked with a higher risk of ovarian torsion.
Risk Factors and Frequency for Ovarian Torsion
Ovarian torsion happens to females of all ages, but it is mostly seen in women who are able to have children. Surprisingly, in a study of emergency surgeries at a women’s hospital over ten years, ovarian torsion ranked fifth most common, accounting for about 2.7 percent of the cases.
- Only 20% of patients affected are yet to start their menstrual cycles, and in half of such cases, the ovary is normal.
- Most women of child-bearing age who suffer torsion have a benign or non-cancerous ovarian mass.
- Being pregnant is also a separate risk factor for torsion. In a study of patients diagnosed with torsion, between 8 to 15% of them were pregnant.
Signs and Symptoms of Ovarian Torsion
Ovarian torsion is a condition that can cause serious pain in the lower abdomen or pelvis. This pain can take different forms – it might be sharp or dull, consistent or off-and-on, and it might even spread to the abdomen, back, or side. Interestingly, one study found that after menopause, women are more likely to experience a dull, constant pain. In contrast, women who haven’t gone through menopause often report a sharp, stabbing pain. Sometimes, these symptoms may come and go if the ovary is twisting and untwisting.
There are other signs of ovarian torsion as well. For example, it could involve feelings of nausea and vomiting. Actually, one study discovered that in young patients with lower abdominal pain, vomiting was a strong indicator of ovarian torsion. In some cases, the patient might already know about an adnexal mass (a lump in the region of the uterus, fallopian tubes, or ovaries), as this can make ovarian torsion more likely.
- Sharp or dull, constant or intermittent pain in the lower abdomen or pelvis
- Pain may spread to the abdomen, back, or side
- Nausea and vomiting
- Known adnexal mass, which makes torsion more likely
Sometimes, when the ovary has become necrotic (dead tissue), a fever may occur. Additionally, torsion can involve a tubo-ovarian abscess, which might cause abnormal bleeding or discharge from the vagina. In infants, signs of torsion can include difficulty feeding or inconsolability.
On a physical exam, the results can vary. The patient may have a tender lower abdomen or pelvic area, diffuseness, or no abdominal tenderness at all. In fact, about one in three patients do not show any abdominal tenderness at all. An abdominal mass might be found, and if the patient shows signs of guarding, rigidity, or rebound, the ovary may already be necrotic. Also, every patient should have a pelvic exam to check for masses, discharge, and cervical motion tenderness.
Testing for Ovarian Torsion
If your doctor suspects you may have ovarian torsion, they will typically start by ordering some lab tests. They may analyze your blood to look for an increase in white blood cells (which could be a sign of infection) or anemia (which could happen if the torsion is causing bleeding). Another crucial test is the serum hCG test, which checks to see if you’re pregnant, as pregnancy increases the risk of ovarian torsion. However, it’s important to note that these changes in lab results are not specific to ovarian torsion and can occur due to a number of other conditions as well. In many cases, lab values will be normal even if ovarian torsion is present.
To help visually diagnose ovarian torsion, doctors usually use an imaging test called an ultrasound with a doppler. This is a device that uses sound waves to create images of your organs and assess blood flow. Doctors will typically use both a transvaginal ultrasound (where the ultrasound probe is inserted into your vagina) and a pelvic ultrasound (where the probe is moved over your lower abdomen). The accuracy of this test in detecting ovarian torsion can vary due to many factors, including the skill of the technician conducting the test and your body’s specific structure.
Symptoms that might lead a doctor to suspect ovarian torsion from an ultrasound include swelling in the ovary, abnormal blood flow to the ovary, the ovary being larger compared to the other one, and the presence of free fluid or the “whirlpool sign” – an image that supposedly shows the blood vessels of the ovary twisted around each other.
However, because the ovaries have a dual blood supply, you might still have symptoms of ovarian torsion even if the ultrasound shows blood is flowing normally. Also, the ovary might not be twisted during the time of the ultrasound, which is why doctors can’t rely on it alone to rule out ovarian torsion. Other imaging tests like CT and MRI aren’t typically used to diagnose ovarian torsion, but they might be used to ensure that other conditions aren’t causing your symptoms, like appendicitis.
If there’s still a high suspicion of ovarian torsion despite relatively normal lab results and ultrasound images, the final step is surgical evaluation. During this procedure, a surgeon will directly visualize your ovary to see if it’s rotated.
Treatment Options for Ovarian Torsion
Ovarian torsion, a condition where the ovary twists on itself, is typically treated with a surgical procedure called detorsion, ideally performed by a gynecologist. For women of childbearing age, doctors try to save the ovary if possible. The surgeon must check whether the ovary is still healthy during surgery. Oftentimes, this surgery is done laparoscopically, which involves using a small camera to see inside the body and untwist the ovary.
If the ovary appears dark, enlarged, and has areas of bleeding, this could mean that blood flow to the ovary has been compromised. However, the ovary is often still savable even in these cases. After the detorsion procedure, more than 90% of patients have functioning ovaries, as confirmed through ultrasound, which can show follicles developing on the ovaries. As a result, surgery to save the ovary is usually the best treatment option.
Only in rare instances, if the ovary looks damaged beyond repair, gelatinous and dead, the surgeon may decide to perform a salpingo-oophorectomy – a procedure to remove the ovary and fallopian tube. If there’s a benign cyst present, the surgeon may decide to remove it during the procedure. However, if the patient is a woman who has already gone through menopause or if the cyst looks cancerous, then salpingo-oophorectomy is the best course of action.
What else can Ovarian Torsion be?
When a woman experiences abdominal pain, there could be many different reasons for it. Among women who can have children, an ectopic pregnancy is one of the first possibilities doctors usually look into. They do this by checking levels of a hormone called beta hCG. If this hormone isn’t found, we can almost certainly rule out an ectopic pregnancy. If the hormone is present, an ultrasound can confirm if the pregnancy is within the uterus. This significantly reduces the likelihood of an ectopic pregnancy but doesn’t completely exclude the chance of a heterotopic pregnancy.
Similarly, a burst ovarian cyst can have symptoms similar to an ovarian torsion. Either case could show a build-up of fluid in the pelvic area when scanned with ultrasound. Generally, if a cyst bursts, it leads to a sudden spike of intense pain, which often happens during sexual activity.
A tubo-ovarian abscess could cause pain in the lower pelvic region. This pain usually develops gradually and might come with a fever. Appendicitis can cause pain in the right side of the pelvis, along with nausea, vomiting, and fever. Blood tests may show increased white blood cells, which is a sign of infection. CT scans can help distinguish it from ovarian conditions.
In addition, there are a few other possibilities to consider for abdominal pain in a woman:
- Pyelonephritis (a type of kidney infection)
- Diverticulitis (inflammation in the intestinal wall)
- Pelvic inflammatory disease (infection of female reproductive organs)
What to expect with Ovarian Torsion
Ovarian torsion, a condition in which the ovary twists around the ligaments that hold it in place, isn’t usually life-threatening, but it can threaten the health of the ovary. In women who are still in their reproductive years, the common treatment is surgery that aims to preserve the ovary. In the majority of these cases, women have a healthy ovary as seen by ultrasound after surgery.
Preventing the twist from happening again or treating ovarian tumors more often guide treatment for women who are past menopause. They usually undergo a salpingo-oophorectomy, a procedure that involves the removal of the affected ovary and fallopian tube.
Interestingly, the vast majority of ovarian masses or growths are benign (non-cancerous). Less than 2% of ovarian torsions involve a cancerous growth, according to some case studies. However, the likelihood of a cancerous growth being involved in ovarian torsion is higher in women past menopause.
Possible Complications When Diagnosed with Ovarian Torsion
The principal problem resulting from ovarian torsion is the possible loss of the ovary and the resultant need for a surgery called a salpingo-oophorectomy. This issue could potentially impact a woman’s fertility, especially if she’s still in her childbearing years. Additional complications of torsion can include disruptions in the pelvic anatomy such as adhesions or shriveled ovaries, which might lead to fertility challenges. Surgical complications like infection or a type of blood clot called venous thromboembolism are further risks. Notably, if there is already dead tissue present, the chance of post-surgery infection is greater.
Common Complications:
- Loss of ovary requiring salpingo-oophorectomy surgery
- Potential fertility issues
- Abnormal pelvic anatomy due to adhesions or shrunken ovaries
- Surgical complications like infection
- Increased risk of post-surgery infection if dead tissue is present
- Venous thromboembolism, a type of blood clot
Preventing Ovarian Torsion
The key message for patients is to seek medical help quickly if they feel unwell. Getting a prompt diagnosis and treatment is crucial. This is particularly true for individuals who have identified risk factors for a condition called ovarian torsion, such as having an existing cyst or being pregnant, or those undergoing fertility treatments to become pregnant.
