Episode 11.6 Ovarian Torsion & The Pitt

We use a plotline from The Pit to separate ovarian torsion facts from TV fiction and explain why Doppler findings can’t replace clinical judgment. Then we answer a listener question on trial of labor after myomectomy and how we counsel when the data are thin and the details matter. 

• why “competency porn” and “certainty porn” can distort real expectations of care 
• how color Doppler actually works and why red and blue do not always mean artery and vein 
• PCOS misconceptions and what really increases torsion risk 
• ovarian torsion as a clinical diagnosis and why preserved Doppler flow cannot rule it out 
• ultrasound clues that help beyond flow alone, including the whirlpool sign and peripheral follicles 
• when oophoropexy might be considered and why it remains controversial 
• why detorsion usually beats oophorectomy even with a black or blue ovary 
• limits of lab tests and the need to think in probabilities, not binaries 
• false positives and false negatives in pregnancy testing, including the hook effect and real-world mix-ups 
• counseling on vaginal delivery after myomectomy, focusing on depth, cavity entry, number and location of incisions, and shared decision-making 

Be sure to check out thinkingaboutobgyn.com for more information and be sure to follow us on Instagram 

0:01 Welcome And What We Cover

0:32 The Pit Torsion Plot Setup

3:06 Competency Porn And Public Expectations

8:39 Color Doppler Basics BART Rule

10:09 PCOS Myths And Torsion Risk

13:27 Endometriosis Guidance And Clinical Diagnosis

18:29 Torsion Diagnosis Beyond Doppler Flow

24:30 Oophoropexy When It Helps And Harms

29:22 Scoring Tools For Torsion Triage

32:48 Detorsion Versus Oophorectomy And Recovery

37:09 Certainty Porn And Limits Of Tests

41:09 Pregnancy Tests False Positives And Negatives

47:10 Listener Question TOL After Myomectomy

50:01 Counseling Factors And Limited Rupture Data

55:31 Closing And Next Guest Tease

Follow us on Instagram @thinkingaboutobgyn.

Transcript

SPEAKER_01 0:01

Welcome to Thinking About OBGYN. Today's episode features Howard Harrell and Antonia Roberts discussing ovarian torsion and the pit.

SPEAKER_02 0:15

Howard?

SPEAKER_00 0:16

Antonia.

SPEAKER_02 0:17

What are we thinking about on today's episode?

The Pit Torsion Plot Setup

SPEAKER_00 0:19

Well, we've got a great listener question about trial of labor after myamectomy, and we've driven up a few talking points, mainly about ovarian torsion inspired from a recent episode of The Pit. Have you been watching The Pit?

SPEAKER_02 0:34

I don't have an HBO Mac subscription yet, but I keep hearing about this show, and I guess I'm gonna go have to go sign up for it and binge this show at some point. I hear a lot of buzz, and most most of it's good. And I people like you keep me informed about it. And I know you and Maddie talked about an episode from last season, I think where there was a shoulder dysocia scene that was a little bit weird. So they're in a new season now. What have they done this year?

SPEAKER_00 1:04

Well, in season two, episode nine, which is titled 3 p.m., it's their name for the hours of the day. There's a subplot where a patient with PCOS presents, and she eventually is discovered to have a variant torsion. The story says that she's had years of pain, hormonal changes, irregular menses, but wasn't diagnosed with PCOS until she switched to a quota gyno who finally listened to her. The resident says, well, it can take a long time to make the diagnosis, to which the patient looks at her and says, That sounds like an excuse for lazy doctoring.

SPEAKER_02 1:38

That's a burn.

SPEAKER_00 1:40

Yeah. Well, anyway, they do an ultrasound. The ER resident does a transvaginal ultrasound. So these are tip-top ER residents. And while doing the ultrasound, she says the resident says that, quote, ectopic is unlikely since the urine pregnancy test was negative. And then she reports that there are a bunch of small cysts as expected, then one big one that's about five centimeters. The patient says her gyno has been monitoring her. I guess it has a female gender. Then she says that she's going to check for blood flow to the ovary and tells her that, tells the intern, or medical student, whatever, that red is for artery and blue is for vein. She sees flow and then she tells her everything looks good. And they plan to discharge her, but they decide to keep her really only because the patient had had so many bad experiences and had begun talking about how she'd been overlooked and not listened to and things like that by previous doctors. So they keep her for observation. And then later in the episode, she's writhing in pain. That part does look like a torsion. They give her some pain meds, and then they repeat the ultrasound. And this time the blood flow is absent. And they diagnose her with intermittent torsion. I don't know why they called it intermittent at that point. So they tell her that she'll need surgery and that she needs her ovary tacked down with a stitch.

Competency Porn And Public Expectations

SPEAKER_02 2:59

Hmm. There's definitely some talking points there. Sounds like we should talk about just ovarian torsion first for a minute. But also the comment about red means artery and flu means vein on the color flow on the ultrasound really makes me wonder do they even have a medical consultant for this show?

SPEAKER_00 3:19

Well, the show is noted, at least in the media, for its medical accuracy. But the reality is in this age of super subspecialization, it's hard for a single physician to understand all the intricacies of all the specialties and the the details of what everybody does. And so that's one of the things that's maybe the most unrealistic about the pit is that these ER doctors are just portrayed as experts on almost every field of medicine without ever consulting, they ever look anything up or consult a resource, and they just know everything about A to Z about every detail of every patient just instantly.

SPEAKER_02 3:55

Well, unless they're trying to portray an e how an ER resident might think they know how to diagnose ovarian torsion, but they don't, and that was like the point, then then I yeah, I think they're a little bit off here. But I from what you're saying just now, I think in the entertainment industry, or at least on TV shows and movies, there's this idea, I think, of competency porn. We see also these law shows, forensics shows, like CSI police shows, where they're doing these everyday jobs that are more exciting and dramatic than they probably are in real life, and they're just all experts at it. And people out there have been writing about this concept of viewers want to see competence somehow. It makes them it's just like this indulgence for them to watch it, specifically in regards to this show, To the Pit. And yeah, it's like there's this satisfaction that the viewer gets from watching the actors portray professionals who are handling very complex situations with highly specialized skills and expertise and also looking amazing while they're doing it, too.

SPEAKER_00 5:06

Well, they have to be attractive. Of course. And even in the darkest times, their makeup has to be perfect, the hair has to be perfect. So yeah, the pit has become the master of this competency porn. And they create this web of diverse and complex, high-pressure medical situations and this tense environment. And then one or two attending physicians and a few medical students and some interns and residents are able to handle just the most crazy disasters and scenarios and unusual diseases that are thrown at them in a 12-hour shift. In that same episode, they demonstrate expertise in virtually every body organ system and across a variety of medical specialties. They're just experts at every situation. But of course, if you actually understand all of those other domains, trauma surgery and ENT and ophthalmology and all the other things they portray in there, well, like us, you'll probably see a lot of mistakes and a lot of superficial understanding and things like that. And I suspect that the medical consultant for the show just doesn't have a broad enough range of knowledge to prevent some of these mistakes and oversimplifications.

SPEAKER_02 6:19

Yeah, so this pen can become a real problem for any type of professionals that are being portrayed in a show like this that's in this competency porn genre because it gives the viewers, the like the lay people, pretty unrealistic expectations. So not just physicians, but there's shows about firefighters, lawyers, crime scene investigators, and policemen, FBI people. So like almost every kind of high drama, high pressure type of job that's ever been in a popular TV show can fall prey to this. And the general public ends up believing these professions are more capable and more competent than they really are. And maybe in some ways it's great because it probably inspires little kids to be like, I want to be whatever, firefighter or doctor when I grow up. But also it can increase this mismatch of what happens in real life versus what is shown on TV. And then we start seeing patients that come expecting their care to be like what it is on TV.

SPEAKER_00 7:26

Yeah, there's some thoughts that it actually leads to an increase in things like malpractice lawsuits. And I've also read about attorneys and d prosecutors finding it harder to convict people because the juries have this CSI expectation, and that's not the way most evidence of crimes actually works, and so they've seen this stuff portrayed and it doesn't meet the standards of law and order or something, and it has real life implications. Noah Wiley, the actor that's the lead of this, actually described the pit, he his words, as competency porn in an interview. And I think he takes a positive view of that because he believes that it portrays the medical system and physicians as highly skilled, competent people in a time when there, of course, is a lot of anti-physician and anti-healthcare sentiment. But as I said, in reality, it can create more dissatisfaction with the medical establishment because of inflated expectations and a perception that brilliantly capable people with nearly endless resources are always going to solve your problems no matter how complex they might be.

Color Doppler Basics BART Rule

SPEAKER_02 8:31

I guess his heart's in the right place, at least. But sometimes it might not play out that way. So let's get back to this scene. Red does not always equal artery, and blue equals vein on color flow if you're using an ultrasound.

SPEAKER_00 8:47

Right. The colors represent the direction of flow in relationship to the ultrasound probe. So there's actually an initialism or mnemonic that can help you remember this, BART. So blue away and red towards. And you can also use variance mode and you'll have other colors too, like green or brighter yellows and orange colors that show the amount of turbulence or disturbed blood flow. So that might be helpful, for example, if you had a stenotic vessel and you see these other colors. Now you could orient the probe in many circumstances in a way to where the vessels that you're looking at, you can make the red represent an artery if you orient it in such a way that the blood flow of the artery is flowing towards the ultrasound probe, and then the blue would represent the vein if you can orient it that way. But these colors are easily inverted. You can invert them with a button on the machine, you can invert them by angling the probe, or sometimes you can't put the ultrasound probe in a way to make them represent that. And of course, all this is very operator-dependent. And so in most cases, when people are putting the ultrasound on there, red does not equal artery and blue does not equal that. So you have to make it match up at best. So in fairness, it's at least a huge oversimplification. Maybe we give her the benefit of a doubt that she oriented the probe in such a way as to make red artery, but it's an oversimplification.

PCOS Myths And Torsion Risk

SPEAKER_02 10:08

Okay, yeah. Maybe she knew exactly what she was talking about. But then moving on, it also sounds like they're saying that PCOS is a big risk factor for ovarian torsion. And I think the lay public does believe that Ricker and ovarian cysts are a symptom of PCOS, or maybe even that's why it's called PCOS. But actually the cysts in polycystic appearing ovaries are generally pretty small. They're small immature follicles that are usually only two or three millimeters in size each, and there's just a lot of them. And it's not that they tend to be each these big, huge golf ball cysts all over the ovaries. And I've seen that a handful of times too, and I'm sure you have, but someone having a bunch of big cysts on their ovaries really is more the exception than the rule, and they it probably occurs just as often outside of PCOS as in someone that does have it. So big ovarian cysts are probably not related to PCOS and are probably more coincidental. So in this show, this patient's larger five centimeter cyst is likely not directly related to her PCOS. Now it's true, some PCOS patients might be going through fertility treatments, and that can lead to hyperstimulation and give them ginormous ovaries. I've personally had had this happen in my treatments. And maybe that would have been a fun twist in this show, but I don't think they were giving this side character that extensive of a backstory here.

SPEAKER_00 11:45

No, not at all. And maybe they missed an opportunity for a nice side plot because they don't have every type of subspecially medical expert consultant on the show. We are available for consultative work for the show if they need us. But they didn't ask. So they'll probably have a couple of ER docs or something that helps them out. But PCOS in and of itself, as you said, doesn't typically enlarge the ovaries that much. They are larger, but not by big cysts. The ovarian volumes are slightly larger because of all of those resting follicles. And one of the diagnostic criteria is that ovaries are typically at least 10 mls in volume, but that's still fairly small. That's not huge. Now that being said, PCOS is listed as a risk factor for torsion, but probably because the ovary starts out a little bit bigger to begin with, and therefore it takes not as big of a single large cyst or other process to make the total ovarian volume large enough to tore. So you typically need an ovary that's about six centimeters or more. And in this case, they gave her a five centimeter cyst, but you added that on to an already chronically enlarged ovary, so that gets her in the range of where you might see torsion, so that works. But a cyst greater than one centimeter in size typically is not directly related to PCOS. And PCOS, in and of itself, without some other mass, is not going to be an independent risk factor for torsion. And those larger cysts are not why we call it polycystic ovary syndrome. They're small cysts.

Endometriosis Guidance And Clinical Diagnosis

SPEAKER_02 13:20

Yeah, I can appreciate the touch point about delayed diagnosis of PCOS being lazy doctoring. But it almost seems like they've taken the issue, the real issue of delayed diagnosis of endometriosis and applied it to PCOS instead. So if she had been presenting for years to a gynecologist with oligomonorrhea, maybe hearsitism, acne, and had m many transvaginal ultrasounds and still wasn't diagnosed with PCOS, I don't think that's a lazy doctor that's not listening. I think that's a doctor who doesn't know what they're doing and lacks basic clinical knowledge. And that's not really a compelling plot point in this show because it's just bizarre. It's not a such a real world problem to have a doctor that's ordering all the right tests and still not getting the diagnosis. And so it's just not something that people in the real world, I think, get indignant about. It's like a like another example of that would be like if someone had a positive pregnancy test and they did an ultrasound that showed a baby, but the doctor still didn't know to diagnose them as being pregnant because they weren't listening. Like that doesn't line up and that just doesn't happen. That's it's like a straightforward, really uncontroversial diagnosis. So if instead this had been something that involved a doctor ignoring her pain, then unfortunately that would have been a lot more realistic and compelling because that does still happen quite broadly.

SPEAKER_00 14:55

Right. You can see that they're touching on themes that are prominent right now, and they wanted to incorporate this idea of women of color in particular going undiagnosed or unlistened to and just didn't understand maybe the specifics for this diagnosis. So that part of the story would have worked better for, say, endometriosis than PCOS. But there's no ovarian torsion or really any surgical emergencies with endometriosis, I think. So you could have done it, but it didn't pack that urgent surgery punch that they wanted, so they they didn't do that. Now, the new ACOG clinical practice guideline that's out this month, March 2026, number 10, it addresses the diagnosis of endometriosis and it seems to be responsive to the social media trends that highlight the fact that women often go many years without a diagnosis. So they recommend that a clinical diagnosis of endometriosis can be made through a symptom-based assessment, physical exam, or both, and then that's enough to initiate empiric medical treatment, and that we should suspect endometriosis in patients who have chronic pelvic pain or dysmenorrhea or dysperunia or dysuria or dyskesia or infertility, and that we should evaluate them with ultrasound.

SPEAKER_02 16:08

Isn't that what we already do?

SPEAKER_00 16:10

Well, that's what I thought when I read this new practice guideline, too. It actually doesn't change a single thing. We already develop a clinical suspicion of endometriosis and we already start empiric therapy. We don't withhold treatment for endometriosis because we haven't done a laparoscopy or something. But I think this highlights some of the issue. A patient with PCOS should be able to receive that diagnosis at practically the first visit to her gynecologist based upon history alone. We might need to do some evaluations to rule out things that mimic PCOS, but it still remains a clinical diagnosis with non-invasive parameters that we should be able to diagnose. So a patient with oligomenorrhea or an ovulator anovulatory cycles, plus either clinical or laboratory evidence of hyperanrogenism or polycystic appearing ovaries on ultrasound, or perhaps now an elevated antimalarian hormone, they have PCOS. In the same way, we've diagnosed endometriosis, or perhaps we should say suspected endometriosis clinically in patients with those symptom sets for years and gone ahead and treated empirically.

SPEAKER_02 17:16

Right. We just don't have a non-surgical test for endometriosis. But clearly a patient with painful menses, pain during intercourse, or some of the other symptoms you mentioned, is gonna be treated for those symptoms. And the treatment for dysmenorrhea, whether primary or secondary, is essentially the same. So some sort of hormonal suppression if if they're not disagreeable to that, and then NSAIDs, and most patients are gonna have improvement with that alone. And then a subset will require surgery, and it's the same thing with PCOS.

Torsion Diagnosis Beyond Doppler Flow

SPEAKER_00 17:51

Yeah, we might be living due to social media in the age of they didn't look for the root cause or they just threw pills at me. Like you get that kind of frustration from patients, but actually that's good care because you're making this empiric diagnosis and you're treating their symptoms, but you do see people resistant to that more than five or ten years ago. So I think that's why I said that this new ACOG guideline, though, about endometriosis is really just responsive to social media trends because it doesn't honestly change anything that we've already been doing, but it maybe makes it sound like ACOG is taking a stand and tackling this problem. But PCOS is a clinical diagnosis, endometriosis is a clinical diagnosis, and ovarian torsion is a clinical diagnosis. And I think that was my biggest beef with this episode of the pit is that they made it seem like the diagnosis was almost exclusively based upon color flow on the ultrasound. She had color flow and then she didn't. So one minute she needed surgery and the other minute she didn't.

SPEAKER_02 18:53

Yeah, if only it was that black and white, but something like half of surgically confirmed cases of ovarian torsion have preserved color blood flow on a Doppler exam. And it may actually be a significantly higher percentage when they're intermittent. So it's a golden rule. We are taught this very early on in our training, actually, that the presence of Doppler flow cannot rule out ovarian torsion.

SPEAKER_00 19:23

Right. Now I talk to ER providers all the time who've been falsely perhaps reassured by color flow on ultrasound that a patient doesn't have ovarian torsion, despite having a six or seven centimeter assist and lying in the bed writhing, not able to sit still because of how pain much pain they're in. So I am worried that this episode is going to reinforce the idea to ER providers and others that the diagnosis, even to patients, frankly, is dependent upon the presence of or absence of blood flow.

SPEAKER_02 19:56

Yeah. And the ovary receives blood both from the ovarian artery through the IP ligament or the inf infundibulopelvic ligament, and also the uterine artery if the patient has a uterus. So sometimes a torsion only partially occludes one of those sources, and then often it's just the partial occlusion, so blood will still flow through the torsed part, and then also through the other source, too. And then of course, if it's intermittent torsion, unless you're j you just happen to ultrasound them right at the right second or hold it there for who knows how long, then you're not gonna see any changes in blood flow because usually it's not actively torsing at the time of the ultrasound.

SPEAKER_00 20:41

Right. It's usually the venous and lymphatic flow that's blocked first or with one revolution of torsion, because the they're the lower pressure systems, the veins and the lymphatics, are more easily compressed. And by the time your arterial flow blocked, well, you may already be dealing with a very late presentation of torsion, meaning that you might even be dealing with a dead ovary. The goal is to prevent getting to that point where you lose blood supply or lose color flow. So the point most of the time is you're operating on a patient with ovarian torsion in the earlier phase, and they usually should have colored doppler flow still established to the ovary.

SPEAKER_02 21:22

Okay, but there are things that you can see on ultrasound that might help you make the diagnosis besides the color flow status. So obviously, one is enlarged ovary or an ovarian mass. Over 90% of torsions happen in an ovary that's between six to ten centimeters. Because when they're smaller than that, they tend not to be heavy enough to stay in a torsed position. They can they might kink, but they can easily unkink. And you can still have intermittent torsion even with a smaller ovary. And then when they're bigger than 10 centimeters, It's also harder for them to get tourist in the first place because they're too big. So the sweet spot for torsion seems to be somewhere between six and ten centimeters. And there is also something called the whirlpool sign that you might see.

SPEAKER_00 22:13

Yeah, I think that's actually the point of doing the color Doppler examination. I think we that's been lost somewhere. So when you place the ultrasound probe perpendicular to the axis of the twist, you can see the coiled vessels appear as concentric, circular, or snail-like, hyper-ochoic and hypoechoic rings. And if you have the color doppler turned on, you can see the blood usually still flowing through them and see the twisting. So this is what they call the whirlpool sign, and it's highly specific for torsion and is really pathamononic for torsion. That's the imaging thing you're looking for. But seeing it's also highly dependent on the operator's skill and knowledge of how to look for the sign, and I do it when I personally do the ultrasound, that's why I do it. But I have rarely seen this, these views reported by hospital radiologists or ER ultrasound techs, because I'm not sure that they're necessarily looking for that. They just put color flow on and document whether there's color flow present or not.

SPEAKER_02 23:18

Great teaching point.

SPEAKER_00 23:19

If they need a consultant to help with the OBGYN stuff, I mean wide open. Give us an email.

SPEAKER_02 23:25

Yeah, with the Whirlpool sign, you can even tell how twisted it is. If it's 360 degrees, they'll make a little C shape. And if it's more twist than that, then there'll be layers of spiral and it'll be more tightly wound.

SPEAKER_00 23:40

Right. The other thing that you can see are these enlarged edematous peripheral follicles. So this is due to congestion of the blood flowing. So the blood's still pumping in because the artery is still going, but it's not draining well because the veins and lumbatics are compressed, and so it gets congested. And this looks like peripheral edema, little peripheral follicles. And that acute swelling of the ovary against its capsule is also one of the sources of the pain that's not just due to devascularization.

Oophoropexy When It Helps And Harms

SPEAKER_02 24:10

Okay. So so far we've covered red doesn't always mean artery, and presence or absence of color, Doppler flow is not how we diagnose ovarian torsion. It's still a clinical diagnosis, and we should still have a low threshold for operating on someone who has severe pain and has a large ovarian cyst. So let's say we we take them to the OR. What's the evidence for the next thing they said in this show about tacking down the ovary?

SPEAKER_00 24:38

Yeah, the ER resident very confidently told her that she would need it tacked down or an orpexy. So this was another sort of unsatisfying decision in the episode. So this is at best, I would say, very controversial and highly debated among gynecologists and pelvic surgeons. Our data about this comes largely from retrospective case series and really just expert consensus since there are no good clinical trials. But I do think most of us would reserve ouprapexy for cases of recurrent torsion or perhaps torsion of a normal ovary where you don't have a cyst that you've removed or drained at the time of the procedure. But whether this works well or not is highly debatable. There are some small case series that show no recurrences, but then that's typical. You wouldn't expect recurrences from most surgeries for ovarian torsion. You drain the cyst or you remove the dermoid or whatever the larger cystic process might be, and you untwist it, and then it's very unusual that somebody comes back with a recurrence. And more likely they'll come back with a recurrent cyst because you should have done a cystectomy and all you did was drain it or something like that. There are even some case series in pediatric populations that found a higher rate of recurrent torsion in patients who had an ouprapexy, maybe because you're creating another point of torsion than in the patients who didn't. So very controversial.

SPEAKER_02 25:59

Yeah, interesting. In that scene, the ER doctor tells the patient that she is going to need this, even though it's not the ER doctor that's going to be doing it. It's going to be her consultant that she's just assuming. So that's interesting because she doesn't have any expertise to know that. And really that should be a recommendation she should defer to the pelvic surgeon that she's asking to come see this patient. And that happens a lot. That is a realistic aspect of this scene here that providers do speak out of school about a topic that's not in their specialty. Maybe if they're referring a patient for something specific to a different specialist, and they may set up an expectation that's not quite correct. And then when the patient sees that specialist and they're expecting what they were told to expect, and they become disappointed when there's disagreement there. But they didn't go into that whole consequence of demonstrating that that phenomenon in this show.

Scoring Tools For Torsion Triage

SPEAKER_00 27:03

So no, we never meet the gynecologist who comes down and says, actually, I'm not going to do that. So they could have. Yeah, you might kink the ureter or even nab the ureter with it. So I will say I I have had patients come in and ask for this, probably because of the internet, but it's it's problematic. I've done it too in cases typically in adolescence with recurrent torsions or again where there's no mass that you can be removed. But there's also the theoretic idea that if you fix the ovary to a static point, you might disrupt the sweeping motion of the fallopian tube and then potentially hinder egg pickup and then increase the risk of infertility or ectopic pregnancy. Again, it's theoretic. We do have some short-term data that shows that this isn't really much of a concern. But there's no high quality data about oofrapexy one way or the other. So I think the current standard of care is detorion alone, particularly for a first episode, and particularly if you're there removing the mass or cystic structure that provided the weight of the ovary that led to the torsion, and then reserving oofrapexy for patients with recurrent torsions or perhaps patients who didn't have a specific mass that led to the torsion, which could be a PCOS patient with a very large 30 or 40 ml ovary and some ligamentous laxity, and they just have recurrent intermittent torsion.

SPEAKER_02 29:25

And there are some scoring systems out there for diagnosing ovarian torsion. And these can be useful, I think, especially for non-gynacologists who don't see this all the time. So the first one of these scoring systems is the ovarian torsion diagnostic score, and it's typically used for adults. And if the score is greater than or equal to four, you should consider diagnostic laparoscopy. So one point you get for unilateral sharp localized pain, one point for sudden onset, severe colicky pain. So these are both just clinical items, two points for absent Doppler flow on ultrasound. And then you also you can also get two points for the edematous peripheral follicles or the whirlpool sign. And then there's also another point for tenderness on bimanual exam. So that's one of the scoring systems. There's another one that's a pediatric torsion score or PTS. In this one, you get two points for nausea vomiting, and those tend to be more typical symptoms of pain in younger patients. So pain that causes nausea in anyone should really should make you think about ovarian torsion. So two points for nausea vomiting, two points if the duration of pain has been less than 72 hours, one point if the ovarian volume is more than 20 ml, and one point if there's an adnexal mass. And so on this PTS scale, zero to two points is low risk, and you should think about something else besides torsion. Three to four points is moderate risk, so you should get consultation and maybe imaging if you haven't already done imaging. And then five to six points actually has a 97% positive predictive value for torsion. So you should just go to the OR. If you have five to six points on this PTS, even if there is Doppler flow present, go to the OR. And I hadn't learned about any of these scoring systems in residency, but better late than never.

SPEAKER_00 31:32

There's a few more and there's an evolving literature on validating some of these. For ER providers in particular, these scoring systems would probably be a great idea because I think when I I think when I walk in or you walk in and see a patient with a six centimeter cyst and she's writhing in the bed, we know exactly what we're going to do within five seconds of seeing her, but we're not caught up in whether or not there's color flow on the Doppler. But but maybe for non-gynacologists, again, who don't see this a lot, these can be very valuable as a triage tool. So I wish they had talked about these scoring tools and then they could have taught them to our ER providers. But I will say in patients with PCOS, remember their baseline of variant volume might already frequently be 20 milliliters or more. So you can look at that discrepancy between the symptomatic side and the asymptomatic side is another thing that you can substitute. If the symptomatic side has twice the volume of the asymptomatic side in a patient with PCOS, let's say, then torsion becomes much more likely. So sometimes the discrepancy is more important. But again, that's why PCOS would increase your baseline risk of ovarian torsion because you already have a heavier and denser ovary to begin with, and then you add a little bit more to it, and now you've got torsion, perhaps.

SPEAKER_02 32:48

And I guess they also didn't talk about the options of oporectomy versus detortion with or without cystectomy. We we don't do oporectomy as just the first science standard for torsion, but you do still hear of people just removing ovaries because they went in with the scope and they saw that the ovary was black and blue and they're worried about necrosis, maybe causing sepsis or a dead ovary syndrome. I think this logic is less common now for younger OBGYNs because we know better what we've been taught better that black and blue doesn't mean dead in an ovary. But in past generations and with older OBGYNs, I think ovarctomy probably was more common whenever they saw that the ovary was a dark color.

SPEAKER_00 33:35

What is dead ovary syndrome? That sounds horrible.

SPEAKER_02 33:39

Well, I don't it's not actually a real thing. It's the idea that the necrosis of the ovary in itself would be become a source of pain and that you know they can't just leave the ovary, untorse it, and leave it there because they'll just keep writhing in pain. That's the idea. But studies have actually shown that even when the ovaries appear to be deeply purple or black and they look like they're infarcted, if you untorse them and you leave them there, they still have a recovery rate of almost 95%. If you go back and look a few months later, they've just fully recovered and look totally normal again. So we should probably think of those color changes more as bruising. And you wouldn't if you got a big bruise on your finger, you hit it with a hammer on accident, you wouldn't cut it off because it had a deep purple bruise on it, right?

SPEAKER_00 34:33

Oh, I wish you told me that last week.

SPEAKER_02 34:35

Well, hopefully it wasn't your labor checking finger. Anyway, the point is ovarian tissue is remarkably resilient to ischemia. The primordial follicles usually will survive this insult. And some people might also decide on ophorectomy or not based on the response to reperfusion. So they'll go in, they'll detourse the ovary, and then they'll just sit there and watch it for 10 or 15 minutes and try to see if it looks like it's pinking up, and then if it doesn't pink up, they'll remove it. But even that's not correct because it might take, it usually takes a little bit longer to resolve that bruising color. So the reasons to remove an ovary are should be the same reasons that you would remove it outside of torsion. So if you're worried that it's malignant, or let's say, okay, let's say you get in and it's falling apart, like you touch it and it just liquefies and there's nothing to even grab to detorse it. That you might consider removing in a sense. And maybe it just maybe all you do to remove it is just blast it with some water and irrigate it and it just falls apart. But that's probably a case where you've operated much too late and the ovaries been completely dead for several days.

SPEAKER_00 35:52

Yeah. Well, unfortunately, I've seen, I'm older than you, and I've seen oophorectomy done automatically for torsion. And I've seen it in 14 and 15-year-old girls who had ovaries removed by a pediatric surgeon or somebody due to that black appearance. They thought that's what they were supposed to do. And of course, that really doesn't work well for future fertility if you're removing a young girl's whole ovary.

SPEAKER_02 36:18

Yeah, definitely not in that population. But maybe if it's a postmenopausal patient, may maybe it would be reasonable to take it out. You might just you might opportunistically take it out if you're doing a hysterectomy because of just their age. But if it's not falling apart and if it doesn't look like cancer, you really should be leaving the ovary there.

SPEAKER_00 36:39

Yeah. That soft, mushy stuff, they call that liquefactive necrosis. Yeah, okay, it's dead. Take it out. But basically you're going to leave almost all of these. And the old concern about a necrotic ovary causing systemic infection or SERS or peritonitis or something like that doesn't have any robust evidence. I've never heard of that happening, and it it's certainly not something that we believe in.

SPEAKER_02 37:02

Okay. Well, we're on a roll. What else did they get wrong in the pit?

Certainty Porn And Limits Of Tests

SPEAKER_00 37:06

Aaron Powell Oh Lord, well, that could probably be its own separate podcast. And I don't mean an episode, a whole series of podcasts. But I do think that there are some cognitive lessons here. So one of the problems with television series or review books or frankly social media posts and tweets is that they tend to reduce very complicated and nuanced discussions down into one or two really simplistic bullet points. But clinical medicine is complex and the thought processes behind our decisions are very complex. Medical students and residents and attendings and people writ large, they want this simplified algorithm. Just give me the yes or no decision point. Let me follow the decision tree. They'd like to have tests that are 100% sensitive and 100% specific with no false positives and no false negatives, and they'd like to know what the exact right treatment is every time for every condition. And unfortunately, our brains fall into thinking in a pattern like that, and we start to think of the tests as positive or negative, or believe that they have the ability to rule in or rule out conditions or diseases. Like in this case, the color flow ruled out torsion and then it ruled it in. But the truth is far from that simplistic world. Many of the tests that we use on a daily basis have sensitivities and specificities in the 80s and 90s, and when they drop below that, we still have tests like that with specificities of 70s and 80 percent. These tests are often clinically useless, although we may still do them because they're the best tests we have, and we have to bundle them in with all the other information we learn about the patient and try to make the best decisions we can. And we just don't need to think of them in this simplistic way and get fooled into making incorrect assumptions.

SPEAKER_02 38:49

So maybe this is another concept maybe called certainty porn.

SPEAKER_00 38:55

Yeah, certainty porn. We want to we want certitude. Our brains flee from cognitive dissonance and not having uncertainty. We hate uncertainty, and so we want to know that there is a truth and that it's knowable, and we know it all the time. Three seconds.

SPEAKER_02 39:12

One thing you always say is that we shouldn't think of tests in a binary because they are not binary. They're not positive or negative. They don't rule in or rule out disease, they just adjust the likelihood of certain conditions.

SPEAKER_00 39:26

Right. They make something more or less li less common or more probabilistically true, yeah. But a medical student or a resident, they would just like to know if there's a if there's blood flow to the ovary, they don't have to worry about torsion. And people are even looking for blood tests for torsion, like interleukin 6, for example, has been studied, but they don't work that well and they take too long to come back, and they're not clinically useful, even if they had a good predictive value. We do this, we're looking for a blood test like that for endometriosis, and we may have one someday. We may have one someday very soon, but they but it for now it's a clinical diagnosis in the absence of doing surgery and a biopsy. And even when you do surgery, the visual diagnosis of endometriosis leaves much to be desired. And when you do a biopsy and you find biopsy-proven endometriosis, that doesn't mean that it was the cause of their pain. Half the patients don't have pain from it. So truth is just much more complicated than our brains want it to be, and you can't reduce clinical medicine down to a series of absolutes or absolute rules or algorithms. Every patient's different, and every presentation is nuanced, and our tests are imperfect at best. We talked about PCOS and endometriosis and a variant torsion, and it's all being examples of a clinical diagnosis. And I think folks understand why that's true for things like that, especially when you talk about it. But it's also true for things like pregnancy or urine tract infection. These are clinical diagnoses as well. And I think people are less comfortable with that because they want the lab, they want that to be a lab-driven thing. But even the example you gave earlier of a pregnancy being a straightforward diagnosis, well, we can think of plenty of examples where it's not so straightforward.

Pregnancy Tests False Positives And Negatives

SPEAKER_02 41:07

Yeah, I guess that's true. And on that note, the resident character in the pit said ectopic pregnancy as unlikely because her pregnancy test is negative, but you haven't made fun of her for that statement, right? If the pre if the test is negative, you're not pregnant, right?

SPEAKER_00 41:24

Yeah, I know you're being sarcastic to set me up here, but yes, I that's a great example. A positive pregnancy test could mean many things that are specifically related to pregnancy on the one hand, like an intrauterine pregnancy or an ectopic pregnancy, but it could also be positive because of a recent pregnancy or a recent miscarriage or a recent abortion. It could indicate a molar pregnancy. It could be related to trigger shots that people get during fertility treatments or HCG injections for fad weight loss plans that some of these clinics do. It could indicate a germ cell tumor or gestational trophoplastic neoplasia or choriocarcinoma. It might indicate a perineoplastic syndrome. And during perimenopause and menopause, the pituitary will secrete sometimes a really small amount of HCG, and that's what leads to these persistent low positives that we get consulted on that you see in women in that age group. And some patients even have heterophilic antibodies that interfere with the blood test at least that will create a false positive result. So the test can just be misread by the patient. We all have patients who come in and think they're pregnant because they had an evaporation line. But you know what? The hospital lab technician who does a serum qualitative or a urine qualitative, they use the same cartridge in the very same way that the patient does it at home, they can misread it and see an evaporation line in the same way. So positive test doesn't mean you're pregnant necessarily. You have to use your clinical skills and put all that information together.

SPEAKER_02 42:53

Okay. Well, you've made your point there. But in this scene, she had a negative pregnancy test. So how could she have an ectopic with that?

SPEAKER_00 43:01

Well, of course, she almost certainly does not.

SPEAKER_02 43:04

Okay.

SPEAKER_00 43:04

But in the spirit of tests aren't perfect, you could have a false negative pregnancy test. So there's something called the hook effect, where HCG levels are actually too high for the test to handle. You see this a lot in molar pregnancies and sometimes in multiples or in late first the late first trimester when HCG levels are peaking, particularly in twins or triplets or moles where the levels are very high. Pregnancy tests have a sandwich assay, and so they have there's a fixed amount of capture antibodies and indicator antibodies. And if the HCG is massively elevated, then the excess hormone saturates both sets of antibodies separately, and it prevents them from forming the sandwich that you need to create that pretty colored line on the test. So if you suspect something like that, by the way, you can dilute the urine or the serum as well and repeat the test, like a 1 to 10 or even a 1 to 100 dilution.

unknown 43:59

Now

SPEAKER_00 44:00

That's not likely to be the case for an ectopic because the HTGs for ectopics are never going to be so high as to cause a hook effect, you would hope. But you can also just, of course, test too early with pregnancy tests and have a false negative. If you did a pregnancy test in the early implantation window and the HGGs are too low for detection, if you wait a few days and repeat it, then it'll be positive. Again, that's not likely for the case of an ectopic. This is going to be far enough along if it's going to cause pain or hemorrhage, then it's going to be positive. But the same thing happens essentially with diluted urine where dilution causes the HCG to be too low to detect. And that's why we recommend a first morning urine, particularly for patients trying to detect pregnancy early on. There are also cases of gestational trophoplastic disease that have a negative HCG test because the type of HCG they produce, for example, the HCG core fragments, an example, it doesn't bind to the antibody that most tests use. So imagine an ectopic that was GTN that produced an HCG core fragment instead of the regular HCG.

SPEAKER_02 45:00

That could have happened.

SPEAKER_00 45:01

That sounds more like how we need a fictional case report series here. But then, okay, what would actually happen in this situation? Just real life problems. So some you're using an expired or damaged test. You're looking at the test too early and not waiting the three to five minutes necessary for development. Or more likely you've just mixed up the sample and you ran somebody else's urine for that patient and it just came back negative. So like that happens in real life.

SPEAKER_02 45:30

Well, yeah, and act mixing up the results could definitely happen in this episode too, because in this episode their electronic health records are down, and then there's all this confusion and chaos of using paper charts and using people as runners with labels to run the urine and the blood to the lab and run back. And this brings some very vivid real life memories for me. The few times our hospital electronic health records have crashed. We always take those systems for granted. Whether we like the systems or not, we just always assume they're just infallible. But they do crash from time to time. And then we have to use paper. So if you were ever going to mix up a blood or urine test, this is the most likely scenario that would happen in.

SPEAKER_00 46:18

Right. And that would be the most likely reason, of course, in this episode. But I've seen this happen three or four times in my career where a patient went to the ER, and in retrospect, it's clear that the blood or urine was mixed up with another patient and the wrong results were put on the wrong chart or in the wrong system. So no test is perfect. Humans are not perfect. And so I don't mind her saying that ectopic is unlikely. And that's actually the right way to think about it. It's very unlikely, in fact, but nothing is impossible. And we should say things are unlikely or less likely rather than things like they're ruled out. And we should think in probabilistic terms, as a reminder at least, that no test is perfect and none of these scoring systems are perfect, and we're not perfect. And so we're never certain.

Listener Question TOL After Myomectomy

SPEAKER_02 47:02

Okay. Well, despite that we're taking shots at the pit every time they have something OBG WAN related, it really does sound like an entertaining show. And it is still on my list to watch the full thing one day. But we have a listener question to get to, so I'm going to read that next. Hi, could you comment on vaginal delivery after myomectomy? What factors do you consider in offering a toe lamb? Number of incisions, location, size, fundal involvement, and other op note details like whether the cavity was entered, whether it was laparos laparoscopic or open, what's the interval from surgery to pregnancy? I'd appreciate to hear the details in your counseling for interested patients. For context, I have a patient with a history of a robotic myomectomy with removal of an eight centimeter anterior fibroid op note specifying no entry into the cavity. Thanks. Sincerely, scarred, not scared.

SPEAKER_00 48:04

They came up with that one on their own. We appreciate it when you guys come up with them on your own, because we're not that creative. Okay, well, I think these patients are always very challenging. The listeners already identified most of the important considerations that we think about for a V BAM or a TOE LAM, as they said. So yeah. So the first is the depth of the myometrial incision. If this is a subsurrosal fibroid that didn't involve the deep mimetrium, then the risk of rupture is negligible. And certainly if it's pedunculated, it's likely no higher than baseline. But on the other extreme of that is a fibroid that's transmural that entered through, or at least your surgery entered into the endometrial cavity. But obviously there's a spectrum here. So let's say that the uterine wall is a centimeter thick where the fibroid is removed. Well, if you've entered the outer two millimeters of it, then the risk is likely negligible. But if you've entered nine millimeters, you still haven't entered the cavity, but you basically only left the endometrium intact or one millimeter of myimetrium, that's at a higher risk than the two millimeter person. So it's a spectrum.

SPEAKER_02 49:12

Yeah, and I think ACOG recognizes this as a gray area. In their committee opinion, 831, which is about medically indicated late preterm and early term deliveries, they have a pretty broad range of recommended delivery timing for patients with, quote, prior myomectomy requiring cesarean. And they don't even strictly define what kind of myomectomy requires a cesarean to begin with. But then they also include a vague blurb about how timing within that range, I think they say something like uh I want to say 30 36 to 38 plus six or something like that. It's a broad range.

SPEAKER_00 49:50

Yeah. But how do you consider it like a classical cesarean or do you consider it like a vertical incision or two prior C sections? Yeah.

Counseling Factors And Limited Rupture Data

SPEAKER_02 49:58

They have a vague blurb about how the timing within that range should account for specific details about the myomectomy, what our listener mentioned.

SPEAKER_00 50:06

Right. But without having much specificity because we don't have a lot of data. And as you can imagine, this is going to be the sort of thing where there just aren't good studies for this because of how much variety there is. And then the next consideration is how many myomectomies were performed. So one small myomectomy with minimal myometral invasion may increase the risk of just slightly, but if you did six of them, well, all of a sudden you might find your risk of uterine rupture is multiplicatively higher than what we would normally tolerate as a risk for rupture, which is about 1% or less. Then there's some evidence that posterior myomectomies carry a greater risk than anterior myomectomies, but there's not a lot of detail there in the literature either.

SPEAKER_02 50:48

Yeah. And the listener also mentioned the method of surgery. So whether open technique, laparoscopic, robotic, and whether that makes a difference. I think the thought there is one of those approaches might use more cautery than another, and then the closure techniques might be different.

SPEAKER_00 51:06

Right. It makes sense that maybe an open technique would be more likely associated with cold dissection, less tissue devascularization than a multilayer closure. Robotic probably has more cautery, but still a multilayer closure, though they may use more barb suture if that matters. And then with straight stick laparoscopic myomectomy, there's probably cautery for sure, but less suture layers closed than by the other techniques just due to the difficulty of it. But if you can imagine all of the problems we've had over the years trying to understand whether or not a one-layer versus two-layer closure at the time of cesarean is better for future trials of labor and rupture risk. And we have pretty robust retrospective data about that, then clearly you can imagine that the data here is incredibly poor. So I would say that it's too poor to suggest a decision about a trial of labor be based upon whether or not the case was carried out laparoscopically versus laparatomically or robotically versus laparoscopically. And the ideas of multilayer closure versus single layer closure or whether or not cautery was used or not used, and the theoretic ideas about thermal damage and the effects on healing. All of that is theoretical, and we don't have really any robust real-world data to support making decisions on it.

SPEAKER_02 52:25

And then what about the time interval from myomectomy to pregnancy?

SPEAKER_00 52:29

Aaron Powell Well, information about timing is going to be extrapolated from just basic surgical principles and so recommendations about waiting six to twelve months between myomectomy and conception are just based upon how we know the healing process works and allowing for full collagen remodeling and scar maturation. And of course, there can be data extrapolated from uterine rupture risk at the time of cesarean based upon those elements, but that's a relative risk factor, and as we discussed recently, it's not even really robustly supported for cesarean about that timing. So again, heavy on theory, light on data.

SPEAKER_02 53:02

Is there any actual studies about that?

SPEAKER_00 53:04

Aaron Powell Certainly nothing high quality. There's a review we can put a link to published in 2016 that looked at 23 studies that had 1,825 patients, and they found 11 ruptures. That's an overall rupture rate of among the women who labored of only 0.4%, of 0.47%. It was 0.93% for everybody, but a lot of them had repeat sections. But just about half a percent for the women undergoing a trial of labor after myomectomy, 1.5% of women had a rupture before the onset of labor. So and some of these were very early, like 24-25 weeks, so I'm sure those are the more extensive myomectomies that probably wouldn't have been allowed to labor anyway. And they were not able to find any specific risk factors in that analysis that told us anything of use here, but presumably the patients in the group that underwent a trial of labor all had myomectomies that didn't involve entering the cavity. A lot of the studies are too small to be super meaningful. There's a 2005 paper that examined 47 pregnancies among 40 patients. And these patients said it they were all had had laparoscopic myomectomies. They attempted vaginal birth in 23 of the pregnancies and were successful in 19. None of them had a uterine rupture, and most of the women who had delivered had an intramural fibroid. So it's too small of a sample size to make any conclusions on, and really that's the story of all of these articles, just too small to know.

SPEAKER_02 54:26

Yeah, so definitely less clear information to to give very emphatic counseling on this. But it sounds like from these limited studies, we can probably say that for women who had a myomectomy that did not enter the cavity, it seems like the risk of rupture is comparable to that for a TOLAC with one prior low transverse caesarean. But then we just have to use our clinical judgment about patients with extensive, multiple deep transmural or fundal incisions. And those patients probably should be treated more like a prior classical and get an earlier like 30 36, 37 week repeat c-section, but or primary c-section. But unfortunately, not a lot of concrete or clear answers. It's shared decision making, discussing risks, benefits, and uncertainties with the patient in front of you, specifically in with her her individual situation.

Closing And Next Guest Tease

SPEAKER_00 55:23

Yeah. And it sounds like SCARD but not scared is very thoughtful about this and understands the these issues. But just like we've been discussing, if you're looking for black and white on this issue, it's not there. This is some of the subtleties and nuances that make medicine so complicated. When I do my emectomies, I try to have a conversation with the patients afterwards about whether or not I think they are candidates for a trial of labor or whether they should just plan on a cesarean. Because I feel like I'm the one that most knows at that moment how extensive my surgery really was relative to the thickness of their uterus and all of these factors we're discussing. So it's expert opinion.

SPEAKER_02 55:59

All right. Well, thanks for the question. I'm looking forward to the next episode. It sounds like you've planned to have Emily Donalin, and you're gonna discuss her article from the March Green Journal, which is a really good article. It's really ambitious, which I love. So I'm just looking forward to that conversation.

SPEAKER_00 56:17

Yeah, and it's gonna be great. And go ahead and read that article in this month's Green Journal and then look forward to the conversation. Like you, Emily listens to the show. So very exciting to have her on and look forward to our conversation. So we'll see that in two weeks.

SPEAKER_01 56:33

See you then. Thanks for listening. Be sure to check out thinking about objen.com for more information and be sure to follow us on Instagram. We'll be back in two weeks.