Ovarian Torsion: Sudden Pain That Can't Wait

What is ovarian torsion?

Ovarian torsion happens when an ovary twists on the ligaments that hold it, pinching off the blood vessels that keep it alive. Without blood flow, the ovary is starved of oxygen, which causes intense pain and, if the twist is not relieved, can permanently damage the ovary.

A torsion often has a lead point — most commonly an ovarian cyst or other mass that makes the ovary heavier and easier to rotate 1Ref 1National Cancer Institute (PDQ Adult Treatment Editorial Board) (2024).Ovarian Epithelial, Fallopian Tube, and Primary Peritoneal Cancers Treatment (PDQ®)–Patient Version.An ovarian cyst or mass can enlarge the ovary and cause pelvic pain or pressure; persistent bloating or pelvic pain also warrants evaluation for other ovarian conditions.. Torsion can also happen with a normal ovary, especially in younger people, most often between ages 15 and 45, whose ovarian ligaments are more mobile. Because the blood supply is at stake, torsion is treated as a surgical emergency, and the goal is to untwist the ovary quickly, before the tissue is lost.

What does ovarian torsion feel like?

Pain from torsion usually comes on suddenly and is sharp, severe, and centered on one side of the lower abdomen or pelvis. Nausea and vomiting are common, and some people feel the pain wax and wane as the ovary partly twists and untwists.

The picture can be confusing, because sudden one-sided pelvic pain has several causes. According to ACOG's guidance on pelvic pain, this kind of pain calls for careful, prompt evaluation to tell the causes apart 2Ref 2American College of Obstetricians and Gynecologists (2020).Chronic Pelvic Pain: ACOG Practice Bulletin, Number 218.Pelvic pain in women has many gynecologic and non-gynecologic causes, and sudden, severe pain calls for careful, prompt evaluation.. In anyone who could be pregnant, an ectopic pregnancy is another dangerous cause of sudden one-sided pain that must be ruled out quickly 3Ref 3American College of Obstetricians and Gynecologists (2018).ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy.Ectopic pregnancy is a life-threatening cause of sudden one-sided pelvic pain in people who could be pregnant and must be ruled out urgently.. What torsion, ectopic pregnancy, and a ruptured cyst share is that severe, abrupt pelvic pain is not something to wait out at home.

What to do right now

Sudden, severe pelvic pain that does not ease within minutes is a reason to seek emergency care rather than wait to see if it passes. Calling 911 or going to the nearest emergency room is the safest step, especially when the pain is one-sided and comes with nausea or vomiting.

A few things help the emergency team: - Note when the pain started, where it is, and whether it has come and gone - Mention any known ovarian cyst, fertility treatment, or chance of pregnancy - Hold off on eating or drinking in case surgery is needed soon

Time matters with torsion: the ovary is most likely to be saved when the twist is relieved within about 6 to 8 hours rather than after a long delay, so getting evaluated quickly is what protects it.

What happens at the hospital?

Emergency clinicians assess torsion with a pelvic exam, an ultrasound that checks blood flow to the ovary, and blood and pregnancy tests. The ultrasound itself takes only about 20 to 30 minutes. Its findings can support the diagnosis, but they are not perfect, so the decision to operate rests on the whole picture rather than any single test.

When torsion is likely, treatment is surgery — usually laparoscopy through small incisions — to untwist the ovary and, if possible, remove any cyst that set it up. Surgeons increasingly try to save the ovary rather than remove it, even when it looks dusky at first, because ovaries often recover once blood flow returns. Acting within about 6 hours gives the best chance of preserving the ovary and its future function.

What raises the risk of ovarian torsion?

Risk rises whenever an ovary is enlarged or made heavier by a cyst or mass, which is the most common setup for a twist 1Ref 1National Cancer Institute (PDQ Adult Treatment Editorial Board) (2024).Ovarian Epithelial, Fallopian Tube, and Primary Peritoneal Cancers Treatment (PDQ®)–Patient Version.An ovarian cyst or mass can enlarge the ovary and cause pelvic pain or pressure; persistent bloating or pelvic pain also warrants evaluation for other ovarian conditions.. Pregnancy and ovarian stimulation for fertility treatment also raise the risk, because the ovaries are larger at those times.

Torsion is seen most often during the reproductive years, but it can occur at any age — including in girls before puberty and in women after menopause — which is why sudden severe pelvic pain is taken seriously across the lifespan. ACOG's ectopic-pregnancy guideline likewise stresses ruling out that cause quickly in anyone who could be pregnant 3Ref 3American College of Obstetricians and Gynecologists (2018).ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy.Ectopic pregnancy is a life-threatening cause of sudden one-sided pelvic pain in people who could be pregnant and must be ruled out urgently.. A history of chronic pelvic pain or an ovarian cyst is useful information to share. If an ovary cannot be saved, many people are reassured to learn that pregnancy is still possible with one ovary. Other conditions such as uterine fibroids can cause overlapping pelvic symptoms that are worth sorting out once the emergency is past.