Ovarian torsion happens when an ovary twists on the ligaments that hold it in place, cutting off its own blood supply. It accounts for roughly 3% of gynecologic emergencies and can lead to permanent ovarian damage or loss if not treated quickly. The condition is often described as a clinical diagnosis, meaning doctors rely heavily on suspicion and symptoms rather than any single test, and that reliance makes it both treatable and frequently missed.
What Happens When an Ovary Twists
The ovary hangs in the pelvis attached by a stalk of tissue that includes blood vessels, nerves, and the fallopian tube. When the ovary rotates along this stalk, the veins that drain blood out of the ovary get pinched first, because veins have thinner walls than arteries. Blood keeps flowing in but can’t flow out, so the ovary swells, becomes congested, and eventually starts losing its blood supply entirely. If the twist is severe or lasts long enough, the tissue dies from lack of oxygen. The twist can be partial or complete, and it can come and go, which is why some people have intermittent symptoms for days before the condition becomes an emergency.
Ovarian torsion occurs in roughly 2% to 15% of patients who undergo surgery for ovarian masses, making an existing mass the single biggest risk factor.1PubMed Central. A review of ovary torsion In children and adolescents, the incidence is about 4.9 per 100,000 females aged 1 to 20. Around a quarter of pediatric cases happen in ovaries that are completely normal, with no mass or cyst at all.
Symptoms and Why They Fool Everyone
The hallmark symptom is sudden, severe pelvic pain on one side. Most patients also experience nausea and vomiting.2PubMed Central. A review of ovary torsion The pain is often described as sharp or stabbing, though roughly a quarter of patients report pain on both sides rather than just one.3Journal of Urgent Care Medicine. An Uncommon Clinical Presentation of Ovarian Torsion That bilateral pain, plus the nausea and vomiting, is part of why torsion gets confused with other conditions like appendicitis, kidney stones, ruptured ovarian cysts, ectopic pregnancy, and even food poisoning.
The trouble intensifies when the ovary twists and untwists on its own. People with intermittent torsion tend to have pain that comes and goes over one to three days, which makes it look less urgent and often leads to delayed diagnosis.4Journal of Urgent Care Medicine. An Uncommon Clinical Presentation of Ovarian Torsion When a patient shows up at the emergency department with waxing-and-waning abdominal pain, the classic teaching points toward kidney stones or gastrointestinal problems, not an ovary in jeopardy.
One case report illustrates the diagnostic challenge well: a patient with bilateral ovarian dermoid cysts presented with the textbook symptoms of pain, nausea, and vomiting, and was still missed on initial evaluation. The authors concluded that the combination of those symptoms with a known ovarian cyst larger than 5 cm, plus a high degree of clinical suspicion, remains the most reliable path to early diagnosis.5PubMed Central. A Missed Diagnosis of Ovarian Torsion in a Patient with Bilateral Ovarian Dermoid Cysts: A Case Report
Who Is Most at Risk
The biggest risk factor is having an ovarian mass. Cysts and benign tumors give the ovary extra weight and a longer effective stalk to twist around. In pediatric patients, a mass larger than 5 cm doubled the odds of torsion compared with smaller masses.6PubMed. Factors Associated with Torsion in Pediatric Patients with Ovarian Masses One study of dermoid cysts found that most torsion cases involved cysts between 6 and 9 cm in diameter, but torsion also occurred in cysts smaller than 5.5 cm, so there is no safe minimum size.7PubMed. Dermoid cysts causing adnexal torsion: What are the risk factors?
Younger age is also a consistent predictor. In the dermoid cyst study, patients who developed torsion were on average about six years younger than those who did not.8PubMed. Dermoid cysts causing adnexal torsion: What are the risk factors? One reason is that younger people tend to have longer ovarian ligaments, which gives the ovary more room to rotate. Another is that benign ovarian tumors like dermoids are common in younger age groups.
Pregnancy, especially in the first trimester, raises risk as well. The corpus luteum cyst that forms after ovulation grows larger during early pregnancy, and the shifting anatomy of a growing uterus changes the forces on ovarian ligaments. In one surgical case series, half of all torsion cases in pregnant women occurred in the first trimester.9PubMed. Surgical intervention for maternal ovarian torsion in pregnancy
Fertility Treatment as a Specific Trigger
Ovulation induction and in vitro fertilization deserve their own mention because they create a distinct and somewhat preventable risk. These treatments work by stimulating multiple follicles to grow simultaneously, which can cause the ovaries to swell dramatically. When this goes too far, it becomes ovarian hyperstimulation syndrome, and hyperstimulated ovaries are particularly vulnerable to torsion because of their increased size and weight.10International Journal of Surgery Case Reports. Ovarian Hyperstimulation secondary to clomiphene citrate resulting in ovarian torsion: A rare report
In one large IVF center, nine torsion cases were identified across more than 10,500 treatment cycles, and three of those cases occurred among 104 patients who had developed hyperstimulation syndrome.11PubMed. Adnexal torsion after gonadotrophin ovulation induction for IVF or ICSI and its conservative treatment The combination of hyperstimulation and pregnancy stacked the risk even further. While the absolute numbers are small, the irony is painful: torsion during fertility treatment can result in losing the very ovary a patient was trying to use. A case series described one patient who lost an ovary after IVF despite timely intervention, while another who was treated after ovulation induction had her ovary successfully saved, highlighting how outcomes can diverge even with rapid surgery.12PubMed Central. Ovarian torsion in infertility management – Missing the diagnosis means losing the ovary: A high price to pay
Diagnosing Torsion and the Limits of Ultrasound
Ultrasound with Doppler is the first-line imaging tool.13PubMed Central. CT features in surgically proven cases of ovarian torsion-a pictorial review The idea is simple: if the ovary has twisted enough to cut off blood flow, Doppler should show absent or reduced flow. In practice, though, the test misses a substantial number of cases. A meta-analysis of color Doppler ultrasound in pediatric patients found pooled sensitivity of about 79% and specificity around 92%.14PubMed Central. Diagnostic accuracy of ultrasound for pediatric adnexal torsion: a systematic review and meta-analysis That means roughly one in five torsion cases showed blood flow that looked normal on Doppler, leading to a falsely reassuring result.
A large adult cohort study reinforced this concern: absent Doppler flow was seen in fewer than one in five confirmed torsion cases. The study found that a combined diagnostic model incorporating clinical findings outperformed Doppler alone.15PubMed. Is color Doppler ultrasonography reliable in diagnosing adnexal torsion? A large cohort analysis The reason normal flow doesn’t rule out torsion is that partial twisting may still allow arterial blood in while blocking venous drainage. The ovary can be in serious trouble even while its arteries appear to be working.
Other imaging clues that suggest torsion include an enlarged ovary, fluid around the ovary, and the uterus being pulled toward the affected side.16PubMed. Ovarian torsion: diagnostic features on CT and MRI with pathologic correlation A visible twisted pedicle on imaging is diagnostic when present, but it is rarely seen. CT scans are not typically the go-to for suspected torsion in young women because of radiation exposure, but with the growing use of CT in emergency departments for acute abdominal pain, torsion is increasingly being caught incidentally on CT.17PubMed Central. CT features in surgically proven cases of ovarian torsion-a pictorial review MRI can help in ambiguous cases but is rarely fast enough for an emergency setting.18PubMed. Adnexal Torsion: Review of Radiologic Appearances
Lab work is generally not definitive. An elevated white blood cell count is common but nonspecific, and one pediatric study found that a high neutrophil-to-lymphocyte ratio was significantly more common in torsion cases, though it is not specific enough to confirm or exclude the diagnosis on its own.19PubMed Central. Key clinical predictors in the diagnosis of ovarian torsion in children The practical implication is that no blood test rules torsion in or out. When clinical suspicion is high, surgery shouldn’t wait for a reassuring ultrasound or a normal lab panel.
Why Timing Matters More Than Almost Anything Else
Speed is the single biggest predictor of whether the ovary survives. One study identified a cutoff of about 35 hours from symptom onset to the operating room: patients who made it to surgery before that mark had dramatically better odds of keeping their ovary, while those beyond 35 hours had roughly seven times the odds of losing it.20PubMed. Time’s a tickin’: When should surgical intervention occur in ovarian torsion? Another study found that the duration of symptoms before the patient arrived at the hospital was the most important time interval: patients who ended up needing their ovary removed had a median symptom duration of 96 hours, compared with 24 hours in those whose ovary was saved.21PubMed. Ovarian Salvage With Prompt Surgical Intervention for Adnexal Torsion: Does Timing Matter?
A third study told the same story from a slightly different angle: women who required oophorectomy (complete removal of the ovary) had waited a median of 26 hours before presenting, compared with just 6 hours for women who had conservative surgery that preserved the ovary.22PubMed. When is it too late? Ovarian preservation and duration of symptoms in ovarian torsion The consistent message across all of these studies is that the clock starts ticking when symptoms begin, not when the patient reaches the hospital. Delays in seeking care, delays in diagnosis, and delays in getting to surgery all compound.
Surgery and the Shift Toward Saving the Ovary
For a long time, the standard surgical approach to a twisted ovary was to remove it entirely. Surgeons worried that untwisting a damaged ovary could release blood clots into the circulation, causing a pulmonary embolism. That fear turned out to be largely unfounded. A review found that the rate of pulmonary embolism after torsion was about 0.2%, and untwisting the ovary did not increase that risk compared with simply removing it without untwisting.23PubMed. Adnexal torsion and pulmonary embolism: case report and review of the literature
Once that fear was debunked, conservative surgery became the clear preference, especially in younger patients. The approach involves laparoscopically untwisting the ovary (detorsion), removing any cyst if present, and leaving the ovarian tissue in place. A national trends analysis found that conservative surgery for ovarian torsion rose from about 19% of cases in 2001 to 25% by 2015, a meaningful shift but still leaving the majority of cases treated with removal.24PubMed Central. Conservative surgery for ovarian torsion in young women: perioperative complications and national trends Conservative surgery was most common in teenagers and declined sharply after age 35, likely because fertility preservation feels less urgent to surgeons treating older patients.
In pediatric practice, the consensus is even more pointed: detorsion with ovarian conservation is considered the gold standard, even when the ovary looks dark and necrotic at the time of surgery.25PubMed. Pediatric ovarian torsion A bruised, dark-looking ovary often recovers function once blood flow is restored. A prospective study tracking 45 salvaged ovaries after detorsion found that all had normal blood flow, normal volume, and follicle development on follow-up ultrasounds at one week, one month, six months, and one year. Four patients conceived during the follow-up period.26PubMed Central. Laparoscopic Detorsion and Fertility Preservation in Twisted Ischemic Adnexa – A Single-Center Prospective Study Despite this evidence, oophorectomy remains widespread. One review described the persistence of ovary removal as “harmful and unnecessary” in many cases where conservation would have been feasible.27The Obstetrician & Gynaecologist. Ovarian torsion: a modern approach to management
Preventing Recurrence With Oophoropexy
Some patients experience torsion more than once, particularly those without an obvious underlying mass. In these cases, surgeons sometimes perform oophoropexy, which involves stitching the ovary or its ligament to the pelvic wall to limit its range of motion. The most common technique shortens the ligament that connects the ovary to the uterus.
The evidence on whether this actually works is mixed. A systematic review and meta-analysis of pediatric cases found that recurrence was about 17% after detorsion alone compared with about 5% after detorsion plus oophoropexy, but the difference did not reach statistical significance.28PubMed. Role of oophoropexy in pediatric primary ovarian torsion without adnexal lesions: A systematic review and meta-analysis A smaller case series reported an even less encouraging picture, with recurrence in 80% of patients after oophoropexy, though that study specifically looked at patients with otherwise normal ovaries who had particularly stubborn recurrent torsion.29Journal of Minimally Invasive Gynecology. Efficacy of Oophoropexy in Preventing Recurrent Torsion of Otherwise Normal Adnexa The bottom line is that oophoropexy appears promising but cannot yet be recommended routinely after a first episode. It is most commonly considered after two or more episodes of torsion.30PubMed Central. Oophoropexy for Recurrent Ovarian Torsion Its long-term effects on fertility are not well studied.
Torsion During Pregnancy
Ovarian torsion in pregnancy deserves separate attention because the stakes and the surgical considerations are different. The condition carries significant risk of both maternal complications and fetal loss if treatment is delayed.31PubMed Central. Intermittent Ovarian Torsion in Pregnancy The symptoms overlap heavily with other pregnancy-related complaints like round ligament pain, ectopic pregnancy, and even morning sickness with unusual severity, which makes misdiagnosis even more common than it already is.
In one surgical series of 20 pregnant women with confirmed torsion, pelvic pain and an adnexal mass were each present in 95% of cases, while nausea and vomiting occurred in 65%. Most first-trimester cases were managed laparoscopically, which resulted in smaller incisions and shorter hospital stays compared with open surgery. Of the 20 patients, 12 went on to deliver at term and three delivered preterm but after 31 weeks.32PubMed. Surgical intervention for maternal ovarian torsion in pregnancy None had significant surgical complications. The reassuring takeaway is that surgery for torsion during pregnancy, including laparoscopy, can be performed safely in experienced hands.
Torsion in Children and Adolescents
Pediatric torsion is its own challenge. Young children can’t always describe where the pain is or how severe it feels, and the diagnosis may not occur to an emergency physician as quickly as it would in an adult woman of reproductive age. A case series found that pelvic ultrasound revealed an ovarian cyst on the symptomatic side in most pediatric patients, and the majority underwent surgery within 48 hours of presentation.33PubMed Central. Pediatric ovarian torsion: case series and review of the literature
An important detail for children: about 16% of all ovarian torsion cases occur in girls under one year of age, often related to ovarian cysts formed under the influence of maternal hormones. The recommended follow-up after detorsion in children is an ultrasound at about three months, or sooner if there is any concern about malignancy.34PubMed. Ovarian torsion in pediatric and adolescent patients: A systematic review Longer-term surveillance typically tracks ovarian volume, blood flow, and follicle development to confirm the ovary has recovered.35PubMed. Pediatric ovarian torsion: Follow-up after preservation of ovarian tissue
Isolated Fallopian Tube Torsion
A related but much rarer condition is isolated fallopian tube torsion, where the tube twists on its own without involving the ovary. It occurs most often in women of reproductive age and shares many of the same symptoms: sudden one-sided pelvic pain with nausea and vomiting.36PubMed. Isolated fallopian tube torsion: A systematic review of case reports Risk factors include hydrosalpinx (fluid-filled tube), previous tubal ligation, pelvic inflammatory disease, and cysts near the tube.
The critical difference is that imaging is even less reliable for tube torsion. A case report described a 15-year-old whose ultrasound showed normal blood flow to the ovary, making ovarian torsion seem unlikely, but surgery revealed the fallopian tube had twisted independently.37PubMed Central. Isolated Fallopian Tube Torsion: Diagnosis and Management of a Gynecologic Emergency Preoperative diagnosis is rare; the condition is almost always confirmed only at surgery. In one case series, nearly half the patients had a history of tubal ligation, and the tube had to be removed in over 80% of cases because it was already too damaged to salvage.38PubMed Central. Isolated Fallopian Tube Torsion: A Rare Twist with a Diagnostic Challenge That May Compromise Fertility Early surgical exploration in anyone with suspicious symptoms but a normal-appearing ovary on ultrasound can make the difference between saving and losing the tube.
What to Do If You Think Something Is Wrong
If you develop sudden, severe pain on one side of your pelvis, especially with nausea or vomiting, go to the emergency department. Do not wait to see if the pain resolves on its own. If you know you have an ovarian cyst, tell the triage team immediately, because that information can fast-track the diagnosis. If you are undergoing fertility treatment and your ovaries are enlarged, be aware that torsion is a recognized complication and mention your treatment to the emergency physician.
A normal-looking ultrasound does not rule out torsion. If the pain persists or worsens and the clinical picture fits, push for further evaluation. Surgeons across multiple studies have emphasized that torsion should be treated as a clinical diagnosis supported by imaging, not one that depends on imaging to be confirmed. The difference between seeking care at 6 hours and waiting until 26 hours is, statistically, the difference between keeping and losing an ovary.