Sometimes, our insides literally tie themselves in knots. An uncommon but serious condition called ovarian torsion (also known as adnexal torsion) occurs when the ovary, and sometimes the fallopian tube, twist on the tissues that support them. This cuts off the blood supply to the ovary, which if not treated promptly, can cause tissue in the organ to die.   

The ovaries, which are approximately the size and shape of an almond, are located in a woman's lower abdomen, one on each side of the uterus. The ovaries have two main functions: producing hormones (including estrogen and progesterone) and releasing an egg each month for fertilization.

Ovarian torsion usually occurs on just one side and can cause sudden, intense pain and vomiting. It can also cause an infection (peritonitis) in the abdominal cavity. The majority of ovarian torsion cases affect women of reproductive age, but girls can have the condition as well.

Although ovarian torsion is not common, it is a medical emergency. Surgery will be necessary to untwist or remove the ovary. If the blood supply is cut off long enough, the ovary may no longer be able to do its normal work, which can impact fertility and cause other problems. But, the good news is that if treated promptly, women have a good chance of making a full recovery, says Linda Fan, MD, director of Gynecologic Specialties at Yale Medicine.

“At Yale, we have staff highly trained to accurately diagnose this condition, and we work closely with radiologists, who use state-of-the-art ultrasound technology,” Dr. Fan says. “And once we do make a diagnosis, we have the expertise to perform minimally invasive surgery.” 

The symptoms of a twisted ovary arise suddenly and intensely. They include severe pain in the pelvic region, as well as nausea and vomiting. The sudden pain is often preceded by occasional cramps for several days, or sometimes, for weeks (often because the ovary twists and untwists repeatedly).

“Everyone has a different pain threshold, especially if they have other pain syndromes or things that could be affecting them,” says Dr. Fan, noting that with this condition, “typically, you know something is wrong and to seek medical attention. Occasionally, this can be a difficult diagnosis to make as some conditions, such as kidney stones or diverticulitis, may also give you pelvic pain.”  

Ovarian torsion occurs most frequently in women during their reproductive years, but it does sometimes happen in prepubescent girls. Having a cyst on your ovary is the biggest risk factor for ovarian torsion, because a cyst can make the ovary unbalanced and cause it to twist on itself. 

“The ovary is attached to the uterus and to the walls of the pelvis,” explains Dr. Fan. “It’s like a ball on a string. And if you put a cyst on it, you make it lopsided by weighing it down, so it’s more likely to twist on itself.”

Here are other situations that make cysts, and in turn, torsion, more likely to occur:

• Pregnancy: When a woman ovulates, an egg is released from the follicle. It then seals itself off and forms what is called the corpus luteum, a hormone-secreting structure. If you don’t get pregnant, the corpus luteum breaks down and is reabsorbed by your body. If you do become pregnant, the corpus luteum sometimes fills with blood or fluid and turns into a cyst. This type of cyst is common and occurs most frequently in early pregnancy. It often disappears on its own, but it can cause ovarian torsion.

• Hormonal medications: Taking hormones that trigger ovulation (for infertility) can stimulate the ovaries to develop cysts, which can increase the likelihood of ovarian torsion.

Doctors typically begin to think about ovarian torsion based on hearing a patient’s symptoms and conducting a physical examination. An ultrasound (usually a transvaginal one) can confirm the diagnosis.

“If a patient has severe pelvic pain and is nauseous and I can feel the cyst during a pelvic exam, we will use transvaginal ultrasound to see if the ovary is enlarged, which could indicate torsion,” Dr. Fan explains. “Often, if we can’t immediately rule out torsion, we will go ahead with laparoscopy because we don’t want to risk losing the ovary.” 

Surgery is the only way to treat ovarian torsion. If there is a cyst, the doctor will first remove it, and then untwist the ovary and/or fallopian tube, which will restore proper blood flow. There are two procedures commonly used:

• Laparoscopy: Surgeons make a few tiny incisions in your abdomen to insert a laparoscope (a thin tube with a camera and light at the tip) and surgical instruments to remove a cyst (if necessary) and untwist the ovary and, if needed, the fallopian tube. After ensuring there is blood flow to the ovary, the surgery is complete. This can be done in the hospital under anesthesia and does not require an overnight stay.
• Laparotomy: A larger incision is made in the abdomen so that doctors can see the affected organs and untwist the ovary (and remove a cyst, if present). Your surgeon will then sew up the incision. This requires staying overnight in the hospital as the recovery from an open surgery takes longer. 

Surgeons always try to save the ovary after torsion, when possible, because a woman’s ability to have children decreases after an ovary and/or fallopian tube is removed. Overall, most women recover well from ovarian torsion and the chances of it reoccurring are slim.

“In most cases, we can save the ovary and the fallopian tube, but it depends on how long it was twisted and what caused the torsion,” Dr. Fan says. “Overall, it is a straightforward procedure that doesn’t typically take very long and most women recover fine.” 

At Yale Medicine, our surgeons are experienced at treating conditions like ovarian torsion.

“We have a caring approach to treating our patients that emphasizes individualized plans,” Dr. Fan says. “Our anesthesiologists and staff are highly skilled and trained. As a high-volume surgical center, we commonly see cases like ovarian torsion and are well-equipped to handle it.”