Ovarian Torsion: The Pain You Must Not Wait Out

Most of what I write is about taking your time and weighing your options. This one is the opposite.

Ovarian torsion means the ovary has twisted on the stalk that carries its blood supply. Once twisted, the blood supply is choked off, and the tissue begins to suffer. It is the fifth most common gynaecological emergency, and it is one of the very few conditions in my field where the difference between a good outcome and a lost ovary can be measured in hours rather than weeks.

The good news, and it is genuinely good: when women get to hospital in time, the ovary is usually saved. Over 90% of ovaries that are untwisted go on working normally — even many that looked black and dead when the surgeon first saw them.

What is ovarian torsion?

Your ovary is not rigidly fixed in place. It hangs on ligaments, and running through those ligaments are the vessels that supply it with blood.

If the ovary becomes heavy or enlarged — most often because of a cyst — it can rotate on that stalk, like a bag swinging on its handle until the strap twists. When it does, the veins are squeezed first, so blood can get in but not out. The ovary swells, which tightens the twist further, and eventually the arterial supply is cut off too.

That is why time matters. The process is progressive, and it accelerates.

Who does it happen to?

The single biggest risk factor is an ovarian mass of 5 cm or more — usually a cyst, and usually a benign one. Around 89% of the masses found in torsion cases are benign, so this is rarely a cancer story.

Other situations that raise the risk:

• Pregnancy, particularly the first trimester, because of the enlarged corpus luteum and the shifting position of the uterus.
• Fertility treatment, because ovulation induction enlarges the ovaries with multiple follicles.
• A previous torsion on either side.
• A dermoid cyst, which is often heavy relative to its size.

Important exception: torsion can happen to a completely normal ovary, with no cyst at all. This is particularly true in children and adolescents, and it is one reason the diagnosis gets missed in young girls.

If you already know you have an ovarian cyst, our guide to ovarian cysts and when they need surgery covers which ones need watching and which need removing.

What does it actually feel like?

Classically: sudden, severe pain on one side of the lower abdomen, often with nausea and vomiting. Many women can name the moment it started.

But it is not always classic, and this is where it becomes dangerous:

Why is torsion missed so often?

I want to be direct about this, because knowing it may be what gets you properly assessed.

First: the examination can be normal. In one series, up to a third of women with confirmed torsion had no abdominal tenderness on examination. A soft, non-tender abdomen does not rule this out.

Second, and more important: a normal Doppler scan does not exclude torsion. Ultrasound is the right first test, but the ovary has a dual blood supply, so blood flow can still be detected on Doppler in an ovary that is genuinely twisted. Ultrasound sensitivity is around 84% — useful, not conclusive.

Third: intermittent torsion confuses everyone. A scan taken during an untwisted phase can look entirely normal.

So if you are sent home with a normal scan and the pain returns or persists, go back. Say clearly: "I was told my scan was normal, but the pain has not settled, and I am worried about torsion." That sentence is not rude. It is the sentence that saves ovaries.

What happens at the hospital?

Assessment, examination, blood tests and a pelvic ultrasound with Doppler. A pregnancy test, because pregnancy changes both the differential diagnosis and the management.

If torsion is suspected, the answer is surgery, and it is usually laparoscopic — keyhole, through a few small incisions. Laparoscopy is both the definitive diagnostic test and the treatment: the surgeon can see immediately whether the ovary is twisted, and untwist it in the same operation.

It is not usually a long operation, and most women go home within a day or two.

Will I lose my ovary?

Usually not — and if anyone tells you a black-looking ovary must come out, this is worth a second opinion before you consent.

Older surgical teaching was to remove a dusky, dark ovary on the assumption it was dead, and out of a now-disproven fear about clots. Modern practice is the opposite. A dark, swollen, unpromising-looking ovary is often entirely salvageable. The colour is congestion, not death.

The evidence is strong: over 90% of ovaries that are simply untwisted go on to function normally afterwards, judged by ultrasound appearance and by follicles developing again. Removal is reserved for tissue that is unmistakably necrotic, or for women past menopause where the ovary has less to offer.

So the question to ask, if there is time to ask it, is: "Will you untwist and preserve the ovary rather than remove it?" For a woman of reproductive age the answer should almost always be yes.

Our page on laparoscopic keyhole surgery explains what this kind of operation involves generally.

What if I am pregnant?

Pregnancy raises the risk of torsion, particularly in the first trimester, and it does not change the urgency — if anything it increases it.

Laparoscopic surgery can be performed safely in pregnancy when it is needed, and torsion is one of the situations where it is needed. Delaying necessary surgery because of the pregnancy is generally more dangerous than the operation.

If you are pregnant and have sudden severe one-sided pain, tell them you are pregnant, and go in. Do not wait for a routine antenatal appointment.

Can it happen again?

Yes. Having had one torsion raises the risk of another, on either side.

Where the risk is judged to be high — recurrent episodes, or a very mobile ovary — a surgeon may discuss oophoropexy, a procedure that fixes the ovary in position to stop it rotating again. It is not routine, and it is a conversation rather than a default.

What definitely reduces risk is dealing with the underlying cause. If a large cyst caused the torsion, removing that cyst at the same operation removes the weight that made the ovary rotate.

Will it affect my fertility?

If the ovary is saved, generally not. Salvaged ovaries usually resume normal function and normal ovulation.

Even if one ovary is lost, most women conceive normally with a single healthy ovary. It is a reason to prefer ovary-preserving surgery wherever possible, not a reason to despair if that was not possible.

The variable that most affects the outcome is not luck. It is how long the ovary was twisted before anyone operated — which is decided by how quickly you go in.

If you are reading this in pain right now

Stop reading and go to an emergency department.

Do not take a strong painkiller and go to bed hoping it settles by morning — masking the pain is precisely how the hours get lost. Do not wait for a scan appointment tomorrow. Do not talk yourself out of it because you were told last month you had "just a cyst".

Take any previous scan reports with you if they are to hand. Tell them how the pain started, how severe it is, whether it has come and gone, and whether you have vomited. Say the word "torsion" out loud — it prompts the right assessment.

Getting care in Gurugram

To be clear about what belongs where: acute severe pain is a hospital emergency, not a clinic appointment. Please go to an emergency department first. Nothing on this page is a reason to wait for a consultation.

Where we can help is everything around that. If you have an ovarian cyst and want to understand your torsion risk, if you have had a torsion and want to talk about why it happened and whether it might recur, or if you have been advised to have an ovary removed and want a second opinion first — those are all conversations worth having, and there is time for them.

Our two clinics — Sector 51 (Mayfield Garden) and Sector 56 — see patients from across Gurugram, Golf Course Road, Golf Course Extension, Sohna Road, the DLF Phases, South Delhi and nearby NCR, 7 days a week including Sundays. Where surgery is needed it is done laparoscopically at NABH-accredited hospitals in Gurugram.

The bottom line

Sudden severe one-sided pelvic pain deserves a hospital the same day. Not a painkiller, not a wait-and-see, not an appointment next week.

The two things most likely to cost a woman her ovary are waiting at home because the pain briefly eased, and being reassured by a normal scan. Now you know about both.

And if you do get there in time, the odds are firmly with you: the ovary is usually untwisted, usually saved, and usually goes back to working exactly as it did before.