Teaching girls to get to know and listen to their bodies as they move through puberty and beyond is an important lesson. Knowing what feels “normal” and what doesn’t, and learning how to voice those concerns to parents and health care providers is an important step for girls in learning how to be more involved in, and responsible for, their healthcare. Paying attention to symptoms, expressing concerns, and seeking help from the health care team can make a difference in patient outcomes.
One such example is sudden onset of abdominal pain, particularly if accompanied by nausea and vomiting, because this could be a sign of ovarian torsion – a rare disorder that involves the twisting of the ovary and/or fallopian tube where they are attached to the uterus and/or pelvis. The twisting results in obstruction of normal blood flow to and from the ovary.
The inability of the blood flow to leave the ovary causes it to become large and swollen. The inability for blood to reach the ovary can cause pain, ovarian tissue to die, and if the blockage persists long enough, loss of ovarian function. Time matters in protecting the ovaries if they are torsed. Experts believe the ovaries become significantly damaged starting about 10 hours after the symptoms start.
Early suspicion, diagnosis, and treatment of torsion decreases the likelihood of damage to the ovary or tube which could lead to decreased fertility.
While generally rare, ovarian torsion is most commonly seen in reproductive-aged women. Girls from 9 to 14 years old are at greatest risk due to flexibility of the tissue in their young reproductive systems. It is an emergency that must be treated as quickly as possible to protect ovarian functioning.
There are numerous causes of ovarian torsion due to the weight of cysts or other enlargements and extra looseness or length in the tissues attaching the ovaries and tubes to the uterus and pelvis. Even normal ovaries and tubes can torse. Most torsions, however, are due to a non-cancerous ovarian cyst or mass.
Ovarian torsion needs to be considered in any girl or young women who complains of sudden onset abdominal pain, particularly when the pain comes with nausea and/or vomiting. When patients complain of these things, it can be hard to sort out what is going on, since other problems (like appendicitis or kidney stones) can cause these types of symptoms.
There may be other clues that suggest torsion. Some patients will also have an elevated temperature, heart rate, and/or white blood cell count. Often, patients will look sick and have pain during their physical exam. Don’t assume stomach pain and vomiting are always caused by a common stomach bug if your child looks sick or isn’t responding to typical interventions.
Physicians seeing patients with abdominal pain and nausea and vomiting will often order a CT first to rule out appendicitis, since that is much more common than torsion, as well as a complete blood count. The CT scan may be helpful and raise suspicion for torsion if it shows an enlarged ovary. A pelvic ultrasound is more helpful with this diagnosis, however, since it can examine the ovaries and tubes more closely and also determine whether there is blood flow to and from the ovaries.
While history, physical exam, laboratory studies, and pelvic ultrasound or CT scan may suggest the diagnosis of torsion, looking inside the abdomen, directly at the ovary with diagnostic laparoscopy is the only way to know for sure. This procedure involves sending a small camera into the abdomen through an incision under the navel. If the ovary and/or fallopian tube are torsed, the surgeon detorses them to correct the problem by restoring normal anatomy and blood flow.
If necrosis of the tissues has taken place, the entire fallopian tube and ovary may need to be removed via emergency surgery. If there is an ovarian cyst or mass involved, the surgeon may remove that mass at the time of surgery. If the swelling associated with the torsion is too great, however, the surgeon may need to do a second procedure later to remove the ovarian cyst or mass.
Sometimes there is no torsion at the time of surgery, but if there is concern about torsion, the diagnostic laparoscopy may be the only way to know for sure.
Listening to one’s body is important. Should your adolescent suddenly find herself suffering from sudden abdominal pain, ask some questions. If you’re unsure about whether she should see her doctor, it’s better to be safe than sorry.
For more information on Nationwide Children’s Section of Pediatric and Adolescent Gynecology, click here.
Geri D. Hewitt, MD, is chief of the Section of Obstetrics and Gynecology at Nationwide Children’s Hospital and an associate professor of clinical obstetrics in the Departments of Obstetrics and Gynecology and Pediatrics at The Ohio State University College of Medicine.
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