Q: What is ovarian torsion?

A: The ovaries (a woman has two of these reproductive organs, and they are where her eggs are produced/stored) are held in place/suspended in a woman’s pelvis by a couple of ligaments. The blood supply to the ovaries comes from the abdomen and then travels along one of these suspending ligaments. The fallopian tube, also attached to ligaments in the pelvis, is the ‘tunnel’ that allows passage of an egg from a woman’s ovary to her uterus.

Ovarian torsion occurs when a woman’s ovary (or more commonly her ovary and her fallopian tube) becomes twisted around the ligaments that help hold it in place. If the twist is minor there would likely be little or no symptoms and likely little or no consequences. However, if the twist is severe enough to ‘kink’ the blood vessels, then the blood supply to the ovary may be compromised. This may potentially cause the ovary to become ischemic (inadequate blood supply) and if it persists long enough ovarian cells can die and the ovary can become necrotic.

Although it is not really known how often ovarian torsion occurs, it is overall thought to be uncommon. One study noted that almost 3 percent of gynecological surgeries were to treat ovarian torsion.

The symptoms of ovarian torsion are somewhat non-specific, and include abdominal/pelvic pain (pain occurs in essentially all ovarian torsion patients) which on occasion may be bilateral (although pain on just the affected side is much more common), nausea and/or vomiting, occasionally fever and possibly other symptoms. There may be tenderness on physical exam, but this finding is variable.

If the ovary partially twists and then untwists, the symptoms from this can ‘come and go,’ sometimes over hours, and in some cases over days and even weeks. If this occurs, the diagnosis may be even more difficult to make since these symptoms may mimic many other conditions.

Ovarian torsion can occur at any age (from a young girl to older woman), although it is most common during a woman’s reproductive age (average age of a patient with this condition is 28). Certain things may make ovarian torsion more likely to occur. For example, risk factors for ovarian torsion include a mass in/around the ovaries may push on the ovary causing it to twist (such as an ovarian cyst, a benign or malignant tumor or other mass, with the risk being higher if the mass is more than 2 inches in diameter), having had prior pelvic surgery (whether a tubal ligation or even surgery from a prior episode of torsion), pregnancy (where the changes in the woman’s pelvis may contribute to twisting; 20 percent of cases of ovarian torsion occur during pregnancy, with torsion occurring in as many as one in every 2000 pregnancies), or other causes.

Ovarian torsion is suspected based on the history and physical exam. When it is suspected, an ultrasound is typically the first test ordered (often a doppler ultrasound which utilizes the principle of the doppler effect to look for blood flow to the ovary), which may note an ovarian cyst/mass increasing the suspicion of the diagnosis, and may also demonstrate a compromised blood supply. However, a normal ultrasound result does not rule out the possibility of torsion. Other imaging tests, such as a CT or MRI scan, may be helpful in certain cases, but the definitive diagnosis of ovarian torsion is made by direct visualization of the ovary during surgery.

The definitive treatment of ovarian torsion is to surgically ‘untwist’ the ovary, and the fallopian tube if required or if the ovary has died then removal of it along with any other compromised structures. Possible surgical techniques include ‘minimally invasive’ laparoscopic surgery (utilizing a laparoscopic device that is inserted through a small incision), or open surgery (where a larger incision is made to allow the surgeon to directly see and treat the condition).

If surgery is performed in a timely fashion the ovary can usually be saved; delayed treatment is often because of a delayed diagnosis (the diagnosis of this condition is very challenging because the symptoms are so non-specific). Once the ovary is necrotic certain complications, including bleeding, infection and others, are more likely to occur. Loss of a single ovary does not usually lead to a significant reduction in the woman’s ability to get pregnant.

Since prior surgery for ovarian torsion is a risk factor for the condition to recur, using hormonal therapy (to suppress ovarian cysts), and even oophoropexy (where the ovary is surgically ‘anchored’ to prevent it from twisting again), may be recommended.
