Ovarian torsion is a condition where the ovary, and sometimes the fallopian tube, twists around the ligaments that support it within the pelvis. This twisting action constricts the blood vessels that supply the organ, causing blood flow to be severely reduced or completely cut off. This process can lead to tissue death (necrosis) in the ovary, making it a time-sensitive surgical emergency requiring immediate medical attention. While stopping the twist from ever occurring is not always possible, managing underlying anatomical risk factors is the primary way to reduce the overall risk of this serious event.
Identifying Key Risk Factors
An ovarian mass is the most common predisposing factor, accounting for most ovarian torsion cases. A cyst or tumor physically enlarges the ovary, making it heavier and structurally unbalanced, which increases the likelihood of it rotating on its supporting ligaments. The risk significantly increases when an ovarian mass reaches a size of 5 centimeters or larger.
Benign tumors, such as mature cystic teratomas, are frequently associated with torsion because of their solid components and uneven weight distribution. Hormonal changes also contribute to risk, notably during pregnancy, when softening of the pelvic ligaments and enlarged corpus luteum cysts can destabilize the ovary. Patients with a history of torsion are also at an elevated risk of recurrence in the same or the opposite ovary.
Controlled ovarian hyperstimulation syndrome (OHSS), a complication of fertility treatments, significantly increases the risk. Hormonal medications used in these treatments stimulate the ovaries to produce numerous large follicles and cysts, causing massive ovarian enlargement and making the ovaries highly susceptible to twisting.
Proactive Medical Management to Reduce Risk
Managing known ovarian masses is the most direct way to decrease torsion risk, typically involving active surveillance or surgical removal. For patients with known ovarian cysts, regular monitoring with transvaginal ultrasounds tracks the size and characteristics of the mass, helping determine if the mass is stable, growing, or warrants intervention.
A physician may recommend prophylactic surgery, known as an ovarian cystectomy, when a cyst exceeds 5-6 centimeters or appears suspicious on imaging. Removing the mass rebalances the ovary, thus eliminating the primary mechanical cause of instability. For patients undergoing fertility treatments, managing the risk of OHSS involves careful adjustment of hormone protocols and close monitoring of ovarian size.
If a patient is at high risk for recurrence (e.g., multiple torsion events or a congenitally long ovarian ligament), a procedure called oophoropexy may be considered. Oophoropexy is a surgical technique that involves fixing the ovary to the pelvic sidewall or shortening the utero-ovarian ligaments to prevent rotation. This procedure is generally reserved for patients with recurrent torsion or those without an obvious anatomical cause, and it is performed with the intent to maintain long-term fertility. Open communication with a gynecologist is important for anyone with known risk factors, such as large cysts or polycystic ovary syndrome, to ensure a personalized risk reduction plan.
Recognizing the Immediate Symptoms
Recognizing the symptoms is a form of secondary prevention that protects the viability of the ovary, as torsion can happen suddenly. The hallmark presentation is the sudden onset of severe, sharp pain, usually located in the lower abdomen or pelvis on one side. This intense pain can spread to the flank, back, or thigh.
The severe pelvic pain is frequently accompanied by significant nausea and vomiting, which occurs due to the stimulation of nerves shared by the ovary and the digestive tract. In some instances, the pain may be intermittent if the ovary partially twists and then spontaneously untwists, temporarily relieving the constriction. Even if the pain subsides, immediate medical attention is necessary to confirm the diagnosis and ensure the ovary is not at risk of re-twisting. A low-grade fever may develop later if the ovarian tissue has begun to die, but the absence of fever does not rule out torsion.
Emergency Treatment Procedures
Once a patient arrives at the hospital with suspected torsion, the first diagnostic step is often an ultrasound with Doppler flow imaging. The ultrasound helps visualize the enlarged ovary and can sometimes detect reduced or absent blood flow; however, normal flow does not definitively exclude torsion. The definitive diagnosis is typically made through direct visualization during surgery.
Immediate surgical intervention is required, and a minimally invasive laparoscopy is the standard approach for both diagnosis and treatment. The primary treatment goal for patients of reproductive age is detorsion, which involves untwisting the ovary to restore blood flow. Surgeons will attempt to save the ovary even if it appears dark or discolored, as many seemingly compromised ovaries can recover function after being untwisted.
If the ovary is clearly necrotic and beyond salvage, or if the patient is postmenopausal with a high risk of malignancy, the surgeon may perform an oophorectomy (removal of the ovary). If the torsion was caused by a benign mass, a cystectomy—the removal of the cyst while preserving the ovary—is typically performed immediately after detorsion. Timely intervention is necessary, as the window for preserving ovarian function is limited, often within hours of the onset of symptoms.