At the Bedside

  • First move in any reproductive-age patient: urine/serum pregnancy test.
  • Positive pregnancy test + pelvic pain/bleeding = ectopic until proven otherwise.
  • Key diagnoses to separate:
  • Ovarian torsion: sudden unilateral pelvic pain, nausea/vomiting, intermittent episodes, adnexal tenderness/mass. Can occur with normal Doppler flow.
  • Ruptured/hemorrhagic ovarian cyst: acute unilateral pain, often mid-cycle or postcoital; may have free fluid and anemia if significant bleed.
  • Tubo-ovarian abscess: pelvic pain + fever + discharge/CMT/adnexal tenderness; often PID spectrum.
  • Ovarian hyperstimulation syndrome: recent fertility therapy, enlarged ovaries, ascites, hemoconcentration, VTE risk.
  • Ovarian neoplasm complications: torsion, rupture, mass effect.
  • Exam:
  • Vitals: fever, hypotension, tachycardia, shock.
  • Abdominal exam: peritonitis suggests rupture/hemoperitoneum, TOA rupture, appendicitis.
  • Pelvic exam: discharge, cervical motion tenderness, adnexal tenderness/mass, bleeding.
  • Workup:
  • Urine/serum hCG.
  • CBC, CMP, UA.
  • Type & screen if bleeding, significant pain, pregnancy, surgical concern, or unstable.
  • GC/CT NAAT, wet prep if discharge/PID concern.
  • Transvaginal pelvic ultrasound with Doppler: first-line imaging.
  • Torsion findings: enlarged ovary, peripheral follicles, stromal edema, free fluid, twisted pedicle/“whirlpool sign.”
  • Normal Doppler does not exclude torsion due to dual ovarian blood supply.
  • CT abdomen/pelvis if diagnosis unclear or appendicitis/stone/diverticulitis suspected, but do not delay GYN consult if torsion likely.
  • Management:
  • Torsion: NPO, IV access, analgesia/antiemetics, urgent GYN consult for diagnostic laparoscopy and detorsion. Ovarian salvage often possible even if ischemic-appearing.
  • Ruptured cyst:
  • Stable, mild symptoms: analgesia, observation, outpatient GYN follow-up.
  • Unstable, falling Hgb, large hemoperitoneum, anticoagulated: resuscitate, type/cross, GYN consult, possible operative management.
  • TOA: broad-spectrum antibiotics + GYN admission. Drainage/surgery if rupture, sepsis, pregnancy, large abscess, or no improvement in 48–72 hr.
  • OHSS: IV fluids, antiemetics, electrolyte correction, monitor urine output, consider admission for severe ascites, hypoxia, AKI, hemoconcentration, VTE.
  • Disposition:
  • Admit/OR: suspected torsion, TOA, unstable hemorrhagic cyst, peritonitis, severe OHSS.
  • Discharge possible: stable simple/hemorrhagic cyst with controlled pain, reliable follow-up, no pregnancy/ectopic concern, no torsion concern.
A Classic Presentation
A 27-year-old woman presents with sudden severe right pelvic pain and vomiting. She has intermittent similar pain for 2 days. Pregnancy test is negative. Exam shows right adnexal tenderness without fever. Ultrasound shows a 6 cm enlarged right ovary with peripheral follicles and some Doppler flow. Despite flow, torsion remains likely; she is made NPO, given IV opioids/antiemetics, and GYN is called for urgent laparoscopy.

Study Directive

  • Draw a differential map for female pelvic pain by pregnancy test result.
  • Review ultrasound images of torsion: enlarged ovary, peripheral follicles, free fluid, whirlpool sign.
  • Practice a 60-second consult script for suspected torsion: age, pregnancy status, pain timing, exam, ultrasound, NPO status, vitals.
  • Memorize outpatient PID antibiotics and indications for admission/TOA management.

Recent Literature