Когда Anne Wheaton, actress and wife of actor Wil Wheaton, woke up one spring morning with excruciating pain, she naturally thought that a trip to the emergency room would fix whatever was wrong. Instead, she entered two days of horrible pain brought about by misdiagnosis, a twisted ovary, and the 6.4cm ovarian cyst that multiple doctors failed to notice on her scans. She was sent home with some medications and encouragement to tough out the supposed kidney stone that ailed her. Soon enough, she was back in the emergency room, because kidney stones do not cause days of constant agony, and an ultrasound was finally ordered to investigate further.
Doctors found that blood supply to her ovary was cut off, and she received an emergency surgery to correct the ovarian torsion within the hour. Wheaton reports that upon sharing her story, several other women reached out to share their own stories of ovarian torsion being mistaken for appendicitis or dismissed as kidney stones. So what is ovarian torsion and why does this serious, but hard-to-catch condition deserve more awareness?
Ovary overview
The ovaries are almond-sized reproductive organs that reside on either side of the Матка (well, usually—we’ll get to that). The ovary has two main jobs that work in tandem: hormone production and ovulation.
В фолликулярная фаза, a group of follicles will start to develop and turn an oocyte (immature egg) into a mature egg. Developing follicles enlarge and produce эстроген; one follicle becomes dominant, and an egg is released. After ovulation, this empty follicle becomes the лютеиновое тело and produces progesterone.
It’s important to note that even though the ovary releases eggs into the fallopian tubes, the ovary is not attached to the fallopian tubes. The ovary is held in place next to the fallopian tubes by ligaments, and the released egg has to jump the gap.
What is ovarian torsion?
Ovarian means related to the ovary; torsion means twist. In this 2023 article by Shelby Baron and Josephin Mathai, ovarian torsion is when the ovary becomes twisted up, cutting off its own blood supply [1]. Sometimes the fallopian tube can get twisted along with the ovary, in which case it is called adnexal torsion. In some cases, the ovary twists and untwists causing intermittent pain and cramping, but when the ovary gets stuck in the twisted position, this is considered a medical emergency, as this can lead to the death of the ovary (Also, it’s typically intensely painful, which is another good reason to get prompt medical attention).
Ovarian torsion is when the ovary becomes twisted up, cutting off its own blood supply. Sometimes the fallopian tube can get twisted along with the ovary, in which case it is called adnexal torsion. In some cases, the ovary twists and untwists causing intermittent pain and cramping, but when the ovary gets stuck in the twisted position, this is considered a medical emergency, as this can lead to the death of the ovary.
Ovarian torsion ranks as one of the most common gynecological surgical emergencies. This 2022 статья on ovarian torsion states that it accounts for 2.7% of все surgical emergencies [2].
Why does ovarian torsion happen?
Ovarian torsion is most common for women of reproductive age, but sometimes can happen in younger girls. The biggest risk factor for ovarian torsion is having a large cyst (5cm/3in or larger) on the ovary. This mass, being quite a bit bigger than the ovary itself, can cause the ovary to turn in place or to get pushed up above the uterus where it is more likely to twist.
In prepubescent girls, roughly half of ovarian torsion events occur with no cyst present. In pediatric cases, an ovary can sometimes end up above the uterus simply because the uterus is small and not yet big enough to keep the ovaries penned in. Ovarian torsion is also more likely in the right ovary than in the left because the colon comes down on the left side and leaves less room for the ovary to wander [1].
And while a large cyst puts an ovary at risk of torsion, the actual twisting is often blamed on a sudden movement or jostling. For women undergoing gonadotropin stimulation, a key step in egg harvesting, large cysts are a known risk and patients are often instructed to avoid high-impact activities and exercise. This case study from 2003 found that torsion risk can persist for at least two weeks after ovary stimulation and argued that patients should receive follow-up monitoring for cysts [3].
For women undergoing gonadotropin stimulation, a key step in egg harvesting, large cysts are a known risk and patients are often instructed to avoid high-impact activities and exercise. This case study from 2003 found that torsion risk can persist for at least two weeks after ovary stimulation and argued that patients should receive follow-up monitoring for cysts.
Кисты яичников
Согласно Управление по охране здоровья женщин, a cyst is a fluid-filled sac. Cysts can be functional or non-functional
Functional cysts
Most кисты яичников are functional cysts or cysts that form as part of the menstrual cycle. This includes follicle cysts, where a mature follicle fails to release an egg and continues to grow (known as luteinized unruptured follicles or LUF), and corpus luteum cysts, where the corpus luteum forms a sac and fills with fluid (these can be common during pregnancy). These kinds of cysts are common, usually small, and go away on their own within weeks or a few months.
Non-functional cysts
Non-functional cysts include endometriomas, dermoids, and cystadenomas. Endometriomas are formed from endometriosis tissue and sometimes called “chocolate cysts” because of the dark-brown, endometrial fluid inside them [4]. Endometriomas are found in more severe cases of эндометриоз.
Dermoids (also called dermoid cysts or cystic teratomas), are less-common, benign tumors that form from an oocyte that became… well, rather confused and began to differentiate and divide abnormally. The result is an oil-containing growth with random tissue like hair and teeth in a mass that can balloon to over a foot in diameter, but more commonly measure in at around four inches in diameter [5].
Наконец-то, cystadenomas are a more common type of benign tumor filled with water or mucus that can reach up to 12 inches in diameter, but are also most commonly seen at around four inches in diameter [6]. While less common than functional cysts, the potential for very large growth with dermoids and cystadenomas correlates with a greater potential for causing ovarian torsion. Recall that a three inch growth is considered a high risk for ovarian torsion, and even a two inch growth is considered dangerous and should be removed.
What are the symptoms, diagnosis, and treatment for ovarian torsion?
In the aforementioned article by Baron and Mathai, they state “Ovarian torsion is a difficult diagnosis due to vague symptoms and nonspecific labs and imaging… direct visualization by surgical evaluation is the only way to make a definitive diagnosis” [1].
Симптомы
These vague symptoms include moderate to severe lower abdominal pain and nausea and vomiting. Fever may occur if ovarian tissue has already started to die. When a patient comes to the ER with abdominal pain and no other clues, doctors have a number of conditions to consider including kidney stones, appendicitis, diverticulitis, внематочная беременность, and pelvic inflammatory disease.
Diagnosis
Most likely, unless the patient is known to have a history of ovarian cysts, a doctor will order a number of tests to start ruling out the aforementioned options, including blood and urine tests, a CAT scan, and transvaginal and abdominal ultrasound. However, although less likely than remaining twisted, the ovary can twist and untwist intermittently, and the ovaries have dual blood supply from the ovarian arteries and uterine arteries that can disguise blood flow blocks in a scan, so an ultrasound could potentially miss signs of torsion. This is why the authors stress that only surgical evaluation can definitively prove ovarian torsion. However, a large cyst would be easy to see via ultrasound, which can help doctors understand the situation.
Лечение
Once ovarian torsion is suspected, a surgeon will need to manually untwist the ovary through a laparoscopic procedure and remove the cyst (assuming that was the cause of the torsion). And while the main complication of ovarian torsion is losing the ovary, this 2003 analysis found that the ovary recovered well after being untwisted in over 91% of cases studied [7]. The longer the ovary is without blood supply, however, the less likely the ovary is to recover. Receiving prompt treatment is key in protecting future fertility.
This 2003 analysis found that the ovary recovered well after being untwisted in over 91% of cases studied. The longer the ovary is without blood supply, however, the less likely the ovary is to recover. Receiving prompt treatment is key in protecting future fertility.
Итоги
While relatively uncommon, ovarian torsion is both very serious and can have an excellent prognosis if treated soon. And since ovarian torsion generally just has pain and nausea as symptoms, there is no way to determine if your ovary is twisted on your own. In the case of severe pain, just seek medical attention as soon as possible!
However, since most adult cases of ovarian torsion are associated with a large ovarian cyst, it’s important to keep an eye on odd symptoms that might point to such a cyst. While most cysts are harmless and show no signs, some large cysts can cause pain or aches unrelated to menstrual cramps, pressure, swelling, or bloating and can cause other pelvic symptoms like difficulty emptying the bladder or bowels, frequent urinating, and spotting. While vague symptoms can be frustrating to pin down or easy to write off, knowing your body and knowing when something is off is the first step to finding answers, and receiving the care you need.
