Ovarian Torsion (Twisted Ovary)

How ovarian torsion happens

Each ovary hangs from ligaments that carry its artery and veins. If the ovary is heavier than normal, usually because of a cyst or tumor, it can swing and twist around these ligaments. The veins are squeezed first, so the ovary swells with trapped blood. Then the artery closes, and the tissue starts to die. Twisting can be partial, or it can twist and untwist repeatedly, which causes episodes of pain that come and go.

The right ovary twists more often than the left, probably because the sigmoid colon takes up space on the left and limits movement.

Ovarian torsion symptoms

• Sudden, severe pain in the lower abdomen or pelvis on one side. It may be sharp, stabbing or cramping
• pain that spreads to the back, flank or groin
• nausea and vomiting, in about 70% of cases
• pain coming in waves if the ovary twists and untwists
• low-grade fever, more likely once tissue has started to die
• a tender mass that a doctor may feel during examination

Pain often starts during or after exercise, sex or a sudden movement. Symptoms can be less typical in children and in pregnancy, which can delay diagnosis.

Causes and risk factors

• Ovarian cysts: functional cysts, dermoid cysts (teratomas) and cystadenomas are the commonest reason. Most torsions involve an ovary enlarged by a mass of 5 cm or more. See ovarian cyst.
• Fertility treatment: stimulated ovaries become large and heavy. Risk is highest with ovarian hyperstimulation syndrome.
• Pregnancy: especially in the first trimester, when a corpus luteum cyst is common.
• Polycystic ovaries: enlarged ovaries may be more mobile.
• Previous torsion or tubal ligation.
• Children: a normal ovary can twist in girls because the supporting ligaments are relatively long.

Cancerous masses twist less often because they tend to stick to surrounding tissue.

How ovarian torsion is diagnosed

Torsion can be hard to confirm before surgery. Doctors combine symptoms, examination and tests:

1. Pregnancy test: to rule out an ectopic pregnancy.
2. Pelvic examination: to check for tenderness or a mass.
3. Transvaginal or abdominal ultrasound: may show an enlarged, swollen ovary, a cyst, fluid, follicles pushed to the edge, or a "whirlpool sign" of twisted vessels. Doppler may show reduced blood flow, but normal blood flow does not rule out torsion.
4. Blood and urine tests: to look for infection, bleeding or kidney stones.
5. CT or MRI: occasionally used when the diagnosis is unclear, or MRI in pregnancy.

If torsion is strongly suspected, surgeons operate without waiting for perfect imaging.

Conditions with similar pain

Treatment

Ovarian torsion is treated with surgery, usually laparoscopy (keyhole surgery through small cuts in the belly).

• Detorsion: the surgeon untwists the ovary. Even an ovary that looks dark blue or black often recovers, so surgeons now try to preserve it, especially in young women and girls.
• Cystectomy: removing the cyst that caused the twist, sometimes at the same operation or later once swelling settles.
• Oophoropexy: stitching the ovary in place to prevent recurrence, considered in some cases such as repeat torsion.
• Oophorectomy: removal of the ovary if it is clearly dead, if a cancer is suspected, or after menopause.

Surgery in pregnancy is usually safe for both mother and baby. Painkillers and anti-nausea medicine are given beforehand, and most people go home within a day or two.

Complications

• loss of the ovary, which is more likely the longer the delay
• infection, abscess or peritonitis if dead tissue is not removed
• recurrence, particularly in children and when no cyst was found

Losing one ovary does not usually affect fertility or hormone levels, because the other ovary takes over.

Outlook

When surgery happens early, most twisted ovaries recover and keep working. Studies show many ovaries that look non-viable at surgery go on to function after detorsion. Follow-up ultrasound checks that the ovary has recovered and that any cyst has resolved.

Frequently asked questions

What are the symptoms of ovarian torsion?

The main symptoms are sudden, severe pain on one side of the lower belly or pelvis, often with nausea and vomiting. The pain may spread to the back or groin, and it may come and go if the ovary twists and untwists. A low fever can develop later.

What does twisted ovary pain feel like?

It is usually a sudden, sharp, stabbing or cramping pain low on one side that quickly becomes severe and makes it hard to stand straight or get comfortable. Many people feel sick or vomit. Intermittent torsion causes repeated attacks of similar pain that ease in between.

How long can an ovary be twisted before it dies?

There is no exact limit. Damage begins within hours, and the chance of saving the ovary falls the longer the blood supply is blocked. Surgeons aim to operate as soon as possible after diagnosis. Even after many hours, untwisting often saves the ovary, so never delay seeking care.

Can ovarian torsion resolve on its own?

A twisted ovary can sometimes untwist spontaneously, which relieves the pain. However, it often twists again, and the cyst that caused it remains. Anyone with suspected torsion needs emergency assessment even if the pain eases.

Can you get pregnant after ovarian torsion?

Yes. When the ovary is saved, it usually continues to work normally. Even if one ovary is removed, the remaining ovary can release eggs and produce hormones, and most women go on to conceive normally.