I Have Cysts. Should I Be Worried About Ovarian Torsion?
Ovarian torsion is an uncommon but serious medical condition that occurs when the ovaries or fallopian tubes become twisted.
"Ovarian torsion is one of the quintessential medical emergencies that I'm always on the lookout for in the emergency room," said Mana Lumumba-Kasongo, M.D. "It is also known as adnexal torsion. It happens when the ovary or the fallopian tubes twist on the tissues that support the ovary."
While somewhat difficult to diagnose, as the symptoms can present similarly to other conditions, getting immediate treatment is imperative. "This twisting can cut off the blood supply, and if not treated quickly, it can cause the ovary to die and no longer function," Lumumba-Kasongo added.
Although it can affect anyone, torsion occurs most often in people of reproductive age and those with ovarian cysts. Here's what you need to know.
Risk factors for ovarian torsion
Ovarian torsion only accounts for about 3 percent of all gynecological emergencies. However, a review published in the Tzu Chi Medical Journal reported the condition affects 2 percent to 15 percent of people who have undergone surgery for adnexal masses, or masses in the fallopian tubes or ovaries.
The most common presentation of gynecological adnexal masses are ovarian cysts, which form on the ovaries post-ovulation. "A cyst can make the ovary unbalanced and lead to twisting," Lumumba-Kasongo explained.
Hemant Vakharia, MBBS, BSc, MRCOG, a consultant gynecologist and advanced laparoscopic surgeon at London Gynaecology, noted the risk of torsion correlates with the cyst's size and mobility.
"Studies have shown the risk increases in cysts greater than 5 cm," Vakharia stated. "At some point in the range of cyst sizes, the opposite may then become true as it has been suggested that extremely large cysts may be less likely to torte due to insufficient space in the pelvis."
"An additional factor is how mobile the cyst is," Vakharia continued. "Some cysts are fixed to other structures by scar tissue secondary to inflammation. These cysts are much less likely to torte compared to cysts which are not attached to other structures."
Other conditions that can cause ovarian instability can also increase the chances of torsion. This includes polycystic ovary syndrome (PCOS), characterized by enlarged ovaries and many small cysts; a long ovarian ligament (the stalk connecting the ovary to the uterus); or tubal ligation (having your "tubes tied" to prevent pregnancy).
Pregnant people and those undergoing fertility treatments that stimulate ovulation are also at higher risk.
"From a fertility perspective, some patients undergoing ovulation induction can develop very large cysts or have global ovarian enlargement, which can induce the risk of torsion," Vakharia said.
"In early pregnancy, the corpus luteum cyst can become filled with blood or fluid. Normally this cyst disappears as the pregnancy continues, but if it doesn't, it can lead to torsion," Lumumba-Kasongo added.
What are the symptoms?
"The most common symptom is a sudden onset of severe one-sided lower abdominal pain. I often see women doubled over in pain with nausea and vomiting," Lumumba-Kasongo said.
Symptoms include:
- Nausea and vomiting
- Mild fever
- Cramping
- The sensation of a mass in the abdomen
"Some patients will complain of a 'colicky' type pain that comes and goes, and some may feel like the pain radiates from the side of the abdomen to down into the groin," Vakharia added.
If you experience these symptoms, doctors advise going to the hospital immediately. "The quicker your torsion is seen to, the better chance you have of saving your ovary's ability to function," said Samantha Wild, MRCGP, DFSRH, DRCOG, Women's Health Clinical Lead for Bupa Health Clinics.
Diagnosing and treating ovarian torsion
Ovarian torsion is a medical emergency. If a patient arrives at the hospital with suspected ovarian torsion, medical providers will perform an exam, including taking their pulse and checking the belly area for pain and inflammation. Next, they'll perform an internal ultrasound.
"Ovarian torsion can be difficult to diagnose because these symptoms can mimic symptoms of kidney stones, diverticulitis, appendicitis, ruptured ovarian cyst. Since time is of the essence, getting the diagnosis quickly is key," Lumumba-Kasongo said. "An ultrasound of the pelvic region makes the diagnosis of torsion easy and can confirm what my clinical suspicion and exam indicate."
In most cases, surgical intervention is necessary. This usually entails a minimally invasive laparoscopic, or "keyhole," procedure, where the surgeon makes a small incision to access the ovaries.
"Once a surgeon can see the ovarian torsion, they will decide whether the tissue can be saved by untwisting it or if it's safer to remove it completely," Wild explained. "If the ovarian torsion can be untwisted, you'll have a follow-up ultrasound after your operation to check on your ovaries."
Is it preventable?
There's no certain way to prevent torsion. Reducing the risk can be particularly challenging, Vakharia said, as many people don't know they have ovarian cysts.
"In some, ovarian torsion may [be] the first time they learn that they have a cyst and therefore it is difficult to prevent as we do not screen all women for ovarian cysts routinely," he said. "Those women that know they have a cyst can reduce the risk of torsion by having the cyst removed if it is larger than 5 cm. In most cases, removal of the cyst can be done by keyhole surgery."
As far as recurrent torsion caused by cysts—it's possible but rare, according to Wild. "However, you may be prescribed high-dose contraceptive pills, which can help reduce the chance of torsion happening again."
In some cases, a surgeon may affix the ovary to a nearby structure to prevent torsion from recurring, Vakharia added.
Whether or not you know you're in a high-risk group, Wild advises talking to your doctor if you experience any unusual symptoms, such as a change in your menstrual cycle, over a few months.
The long-term impact of ovarian torsion
If the ovary's blood supply is cut off for too long, the tissue can die (necrosis). This can affect the organ's function and may cause fertility issues.
"Due to the close relationship between the ovary and fallopian tube, the fallopian tube often twists along with the ovary and compromises its blood supply," Vakharia said. "If both the tube and ovary appear to be no longer salvageable, then they are removed during the surgery."
Fortunately, torsion usually only affects one of the ovaries and fallopian tubes. "As there are two ovaries and tubes, as long as the other side is normal, then you can still get pregnant with very good success rates," Vakharia said. "The other ovary will continue to produce follicles and the usual hormones."
"If symptoms are spotted soon enough, there's a good chance that you can make a full recovery," Wild concluded.
