The retroverted and retroflexed uterus: from front to back (well, mostly, back).

This post falls into the category of I-think-you-should-be-empowered-in-the-knowledge-about-your-own-body. Like this post. And this one. And this one. OBOS-style. Don't let knowledge about the lady-bits rest in the hands of providers. Enjoy :) Did you know that your uterus is not always in the same position? And not necessarily in the same position as the uterus-owner sitting next to you at the coffee shop? And, after pregnancy, it could settle into a completely different position than before? And, your provider, as well as you and your partner, could be well-informed as to where your uterus is and what trouble it might be giving you? Well, welcome to the know.I have had a number of women coming in for infertility, for pain with intercourse (dyspareunia), for IUD insertions or removals, and with pain during menses (dysmenorrhea). For a variety of reasons I have ultimately assessed their uterus, and found its position to be a possible culprit of their discomfort.This is a long post. Why? Because the more I looked into retro (tilted) uteruses, the more information I found. And I can't help but delve fully into the folds of, um, er, the research. The italics below refer to the conversation I imagine having with you, if we had hours to chat about this specific subject.This information will focus on the retro uterus: retroverted and retroflexed, to be more specific. These terms refer to the position of the uterus in the pelvis.Wait, the uterus isn't just in the same place for everyone? More or less like the vagina? Like in all the anatomical drawings?  Heck no.The uterus is held in place by four muscle-like fibers called ligaments, specifically two round ligaments, one on each side, as well as the vesico-uterine ligament in the front and the sacro-uterine ligament in the back. According to The Fenway Medical Sentinel from 1906, the belief has been that the uterus "moves freely forward and backward," and "if the rectum and bladder are empty, the uterus forms almost a right angle with the vagina." This refers to the anteverted uterus, the most common type, though we will get into that later. For a baseline visual reference, the drawing below shows this common anteverted orientation, with the uterus at a direct right angle to the vagina, pointing toward the belly button.The uterus changes its orientation in the body with any changes in or around itself. What does that mean? Depending on number of pregnancies/babies, gynecological history, body structure, menses, or physical health, uterine position may change.Say what now?Let's start with the lingo. The most common uterine positions are a jumble of prefixes and suffixes.Ante - toward the front of the body (toward the pubic bone)Retro - toward the back of the body (toward the sacrum)Version - cervix / cervical axis of the uterus pulled/pointedFlexion - uterine fundus pulled/foldedNow here's the fun part.Anteversion - uterus and cervical axis oriented toward the pubic boneAnteflexion - uterus oriented toward the pubic bone, with the anterior portion of uterus concaveAnteversion and anteflexion - a combination of the aboveRetroversion -uterus and cervical axis oriented toward the sacrumRetroflexion - uterus oriented toward the sacrum, with the anterior portion of uterus convexRetroversion and retroflexion - a combination of the aboveThen, the outliers (in the lingo, not necessarily by commonality of position itself):Retrocessed - top and bottom of uterus are pushed toward the sacrumMidposition/Vertical - uterus points straight upward toward the diaphragmHere are some good pictures that illustrate all of this complicated language.Picture reference: BabyMed. Examples of retroverted versus retroflexed uteri:Retroverted: Retroflexed: Picture reference: MayaMassageUKWhoa. So it looks like this changes where the cervix is in the vagina, too?You betcha. With severe retroversion or retroflexion, the uterus is pulled to the back of the body to the point that the cervix is pulled onto the anterior (top) wall of the vagina. For the opposite (and less symptomatic) position of severe anteversion or anteversion, the uterus would be found more on the posterior (bottom) wall. Note: Most commonly, the cervix is found toward the end of the vagina and then a little bit on the anterior wall.So, for those with retro uteruses, if you are checking inside yourself, or your partner is checking inside of you, or a provider is checking, the cervix might be just inside the vaginal opening (introitus) on the anterior wall, or might have to really go looking for it along the anterior wall of the vagina.How does anyone ever know which way the uterus is pointing?A provider, for any number of reasons, may do an internal exam to assess health of the cervix, uterus and ovaries. This is called a bimanual exam (which I have written about here). Part of this assessment includes an evaluation of uterine position, and the provider may or may not report this to you during the visit. If you have come in with a reported symptom, hopefully the provider would discuss their assessment with you to rule diagnoses in or out. Sometimes the position of the cervix is a giveaway, as mentioned above, which the provider might discover during the speculum exam. Sometimes the bimanual exam can easily feel uterine position. Sometimes, a rectal examination will rule out a retroverted uterus versus a uterine mass. Sometimes, an ultrasound is the best tool for full diagnosis.Otherwise, uterine position may remain a secret, especially if you are not having troubles that would cause you to seek answers to the questions in your pelvis.Why would it matter which way a uterus is pointing?Much of the time it does not matter. Most owners walk around without ever knowing where their uterus is, besides in their pelvis, and don't have symptoms.In the case of IUD insertions and surgical uterine procedures, it is vital to know uterine position to know the best placement for the tenaculum, to pull the uterus in position. In the case of retroversion, placing the tenaculum on the posterior lip of the cervix can pull a retroverted uterus to a vertical position*. Since most uteruses are anterior, placing the tenaculum on the anterior lip pulls these uteri in the appropriate position. Thus, knowing which way to direct the uterine sound and IUD inserter is vital to decrease risk of uterine perforation. Typically before these procedures, the provider will do an internal exam to verify uterine position to decrease risks of the procedure. Sort of a big deal. So it matters for internal procedures.*I learned this while learning manual vacuum aspiration at Planned Parenthood. Additionally, 20% of women have retroverted or retroflexed uteruses and have symptoms, and for them it might matter a lot.What symptoms are we talking about?Pelvic pain, irregular menses, painful menses, pain with sex (particularly with deep penetration or thrusting), severe back pain in early pregnancy, recurrent urine infections or urine retention, miscarriage, feeling of pelvic congestion, problems with intrauterine contraception, size larger than dates in early pregnancy, varicose veins in the legs, chronic constipation or pain with bowel movements, and, some may say, infertility.This picture shows how much a retro uterus can impact the rectum, causing issues with constipation or pain with bowel movements:What can cause the uterus to be retroverted or retroflexed?Endometriosis, fibroids, pelvic inflammatory disease/salpingitis, multiparty, lack of abdominal muscle tone, genetics, abdominal surgeries including cesarean section which cause scarring and weigh or pull the uterus into a position.According to the Arvigo website (discussed further below), bone injury such as a fall/accident, impact exercise like running on cement, and emotional armoring can also cause uterine malposition.Again, loving The Fenway resource from 1906, other causes of the retro uterus may include "Improper methods of dressing, particularly wearing tight corsets and heavy skirts suspended from the waist," "Occupations which require hours of continuous standing, or sitting at a bench or table," "Loss of the pelvic fat, which aids, to some extent, in supporting the uterus," "Prolonged dorsal decubitus after parturition or abortion, when the uterus is heavy and the parts are relaxed." The Fenway also lists many possible causes which are repeated in modern resources, including an overlap with Arvigo: "extreme nervousness."What is the most pressing question around retro uteruses right now?Infertility. The jury is still out, way out, on whether retroversion and retroflexion cause difficulties with achieving, and maintaining, pregnancy. Anatomically and physiologically speaking, it makes sense, but is not borne out in the research. FYI: The Mayo Clinic gives a definitive "no" to the question of whether retroversion causes infertility.So what does the research say?Research largely focuses on the retroverted uterus in pregnancy. At its most severe (and most rare), a retroverted uterus that does not correct itself in early pregnancy can cause what is called an incarcerated uterus, where the growing fundus does not grow out of the pelvis. Instead, it becomes trapped under the sacral promontory and causes severe pain and difficulty with normal uterine stretching.With little research on retroversion other symptoms (pelvic pain, infertility, pain with sex), this leaves the majority of women with a retroverted uterus (without the incarcerated uterus problem) up a creek, without evidence as to how to paddle.What does my favorite Attending say about retro uteruses?He tells his patients that uterine position is like left-or right-handedness, just a variation of normal. He remembers a time when the most common use of hysterectomy was for uterine retroversion. However, most providers now believe that retroversion is due to other causes, such as endometriosis or fibroids or scarring. He says that now the belief is that when the cause of the retroversion is corrected, then the uterus, even if it stays in that position, will stop causing symptoms. Sounds easy enough, but for many uterus owners, even finding someone to think about a possible root cause of retroversion of the uterus is difficult enough, let alone paying attention to and treating the initial vague symptoms of pain or infertility.Does a retroverted or retroflexed uterus need treated?As per my fav Attending above, treating the possible causes of the retro uterus could very well treat its malposition. Thus, treating endometriosis or fibroids or improving muscle tone or encouraging weight loss could very well encourage the uterus into a more mid-line or anterior position.However, this idea hinges on the belief that only a problem would cause retroversion/flexion, and that these positions are "malpositions" rather than perhaps variations on the normal. So really his left-handed or right-handed argument contradicts itself - either it's a normal variation, or it's caused by a problem that needs fixing. Hm. I'm of the belief that if it's causing symptoms, figuring out the cause, if there is one, and ultimately correcting the retroversion, remains the most important issue.For those who are symptomatic, what treatments are we talking about?1) Knee-chest position, for ten minutes, three times per day. Here's an old school picture of that happening.A few other resources describe laying one's back and alternating pulling each leg to the chest, holding each for over ten seconds.I find these interesting ideas: stretching muscles moves around pelvic ligaments and could promote a more aligned uterine position.2) Kegel's. If you are part of the majority (I am, most days) who believe that Kegel exercises can strengthen the pelvic floor, then the theory transfers further into a strong pelvic floor supporting overall pelvic muscles and appropriate pelvic ligament alignment. Read more about Kegels here. Those not in the Kegel camp are in the squatting camp - I think both are beneficial to promote strong muscles and alignment in the pelvis.3)Abdominal massage therapy. Dr. Rosita Arvigo is a well-known practitioner of abdominal massage to correct misalignment of pelvic organs, most importantly uterine malposition. Her work utilizes the "Mayan technique of abdominal massage which is an external non-invasive manipulation which repositions internal organs that have shifted, thereby restricting the flow of blood, lymph, nerve and chi." Dr. Arvigo learned this technique from a Maya Shaman, who believed that "If a woman's uterus is out of balance, so is she." According to the website, "This external massage gently lifts and guides the uterus into its optimal position in the lower pelvis." To find out more about this therapy, visit her website and check out this Huffington Post article about Maya Massage.4) Manual manipulation. This bears out in multiple resources, where manipulation of the posterior wall of the uterus toward the abdomen can right this pelvic wrong if no other factors are predisposing the posterior position. Interesting old-school picture of this happening.Anecdotally, I have tried this with a few patients suffering pelvic pain due to uterine retroversion, with little effect.5) Pessaries. For months at a time, women used to wear pessaries similar to those worn by women with uterine or bladder prolapse, to encourage the forward movement of the anterior uterine wall. These are hardly used anymore, but remain an option in the long list of corrective therapies for symptomatic uterine position.I feel like after this research, I have little resolution but to know to diagnose a retro uterus and find possible underlying causes. I am next on the hunt to find a provider to whom I can refer women with this problem for therapy and treatment.What have I left out? Do you know of great resources for retro uteruses? Any other suggestions for therapies, prevention, or treatment? Please comment!