Retroverted Uterus AKA Tipped Uterus

In my practice, I see many women who suffer from a retroverted uterus.  A retroverted uterus is when the uterus is tilted back toward the rectum.  A retroflexed uterus is when the uterus is flexed backward, kind of like a backbend.  “The most common condition in women over the age of 50 is retroversion combined with retroflexion, in which both the cervix and the uterus swing backward, and the cervix lies on the rectum.  At the same time, the small intestine lies on the bladder, pushing it down” (Source 1).  Unfortunately, I didn’t know how to correct a retroverted uterus back when my mom had one. She suffered from horrible low back pain when she was pregnant with my little brother due to a retroverted uterus.  She also suffered from terrible PMS, and I’m sure it was related to her uterine position.  When the uterus is not in the optimal position, it restricts the flow of lymph and blood.  Ovarian varicosities can result and lead to a disturbance in the communication between the ovaries and the hypothalamus of the brain, resulting in less than optimal levels of estrogen and/or progesterone.  Restriction in the flow of lymph allows pathological debris to accumulate, causing acidity, pain, swelling, and inflammation.  It’s like what would happen if the garbage collector and police officers in your district went on strike: garbage builds up, and mayhem ensues.

Women tell me all the time that their Ob-Gyn said that it’s normal to have retroverted or retroflexed uterus and that it doesn’t cause any problems, yet in the Obstetrics and Gynecology textbook it states that,”The retroverted, retroflexed uterus has three particular clinical associations: (1) it is especially difficult to estimate gestational age by bimanual examination, (2) it is associated with dyspareunia and dysmenorrhea, and (3) its position behind and below the sacral promontory may lead to the obstetric complication of uterine inculcation” (p. 12). “Estimation of gestational age in the late part of the first trimester may be difficult when the uterus is the RVRF or RV positions. The risk of uterine perforation during procedures such as dilation & curettage or insertion of an intrauterine device is increased in a woman with a retroflexed or anteflexed uterus. Applying traction on the cervix to pull the uterine canal into a straight line can greatly reduce this risk” (p. 37).  There’s also a rare but serious condition called incarcerated uterus. Uterine incarceration is a complication whereby a growing retroverted uterus becomes wedged into the pelvis after the first trimester of pregnancy causing dyspareunia or urinary outflow obstruction. “Women presenting with urinary retention in the second trimester should have a pelvic examination performed to exclude uterine incarceration.” (4)  Also, see source (6) below for more information.

Another variation would be the anteverted/retroflexed (tipped forward but flexed back) uterus: a common consequence of cesarean delivery. In this study “an anteverted retroflexed uterine position was found in 27% of women after cesarean delivery.”

“Restriction or ptosis of the uterus can disturb arterial, venous and lymphatic circulation in the pelvis and lower extremities. This occurs through both direct compression and reflex vascular spasms. A retroverted, non-mobile uterus is often purplish-blue in color, edematous, and heavy. When a surgeon verticalizes it and normal circulation restored, it quickly recovers its normal pinkish color.” Jean-Pierre Barral pg 143 of Urogenital Manipulation

My mother had a hysterectomy and oophorectomy (removal of the ovaries) to treat her PMS and painful periods before she had a chance to go through menopause.  I have to wonder about how this decision to have an oophorectomy at such a young age affected her brain.  My mother was 38 years old when she had the hysterectomy.  She was diagnosed with dementia at the age of 55  (although the signs started years before), and she died about seven years later.  Doing a search on Google Scholar (a resource for published scientific studies). I found several studies making this connection between premenopausal oophorectomy and dementia.

“Premenopausal bilateral oophorectomy is associated with a higher risk, suggesting a dose effect of premature estrogen deficiency on dementia. The age-dependent effect suggests that the younger brain is probably more vulnerable to estrogen deficiency.”-Hysterectomy, Oophorectomy and Risk of Dementia: A Nationwide Historical Cohort Study (Source 1)

“Both unilateral and bilateral oophorectomy preceding the onset of menopause are associated with an increased risk of cognitive impairment or dementia. The effect is age-dependent and suggests a critical age window for neuroprotection.”- Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause (Source 2)

“Laboratory studies have shown that estrogen receptors are present on cholinergic neurons and have neurotropic, antioxidant, and anti-inflammatory effects. Estrogen deficiency in middle age has been postulated to account, at least in part, for the somewhat higher incidence of AD [Alzheimer’s Disease] in women than men and may constitute a risk factor for AD.”….the incidence of dementia or mild cognitive impairment is approximately 33% higher in the women with hysterectomy than in those women with a uterus regardless of treatment with hormone therapy or placebo”-Estrogen and Demential Insights From Women’s Health Initiative Memory Study  (Source 3)

Retroverted Uterus Retroflexed Uterus Tipped uterus

retroverted and retroflexed uterus AKA tipped uterus

Possible Causes of a Retroverted Uterus
  • Severe falls to the sacrum
  • Pelvic infection and inflammation
  • Uterine scarring from infections like Chlamydia
  • Poor pelvic alignment (chronic) from wearing high heels, and sitting on the sacrum
  • Endometriosis adhesions in the rectouterine pouch
  • Sexual abuse
Signs and symptoms of a retroverted or retroflexed uterus may be one or all of these symptoms.
  • Painful periods
  • Low back pain before and during your period
  • Thin stools or constipation right before or during your period (the uterus can double in size right before and during menses from 4 ounces to 8 to 10 ounces!  That’s a lot of extra weight on the rectum.
  • Foul smelling menses (toxins from the rectum can seep into the uterus)
  • Fertility challenges (5)
  • Ovarian cysts
  • Painful intercourse
  • Endometriosis
  • Ovulation Pain
  • Sciatica (esp. with enlarged uterus, endometriosis or fibroids) (7)

If a woman with a retroverted uterus is able to get pregnant, she may suffer from low back pain and constipation until the adhesions holding the uterus to the posterior wall break free under the increasing weight of the uterus.  This usually happens around 14 weeks into the pregnancy when the uterus gets heavier.  The woman may experience back pain at this time and feel the uterus shift forward when the adhesions tear.  This varies with different women depending on how long the uterus has been tilted back.  By the way, the uterus does naturally move forward and back slightly as the bladder and rectum fill, but when the uterus remains stuck in any one position it affects the surrounding blood vessels and organs (bladder and rectum), as well as the health of the uterus and ovaries. Retroversion/retroflexion may make it difficult for the follicle to burst through the ovarian wall resulting in ovarian cysts. It has been theorized that a retroflexion may also cause retrograde blood flow into the abdominal cavity leading to endometriosis. As for the ovulation pain, the ovaries sit very close to the psoas muscles especially when the uterus is tipped back and the psoas is already tight, this can affect the genitofemoral nerve causing pain in the front of the thigh and the knee.

I have seen a uterus adhered to the rectum in a cadaver.  The person performing the dissection was able to break the adhesions between the uterus and rectum with his fingers. In a case as severe as that one, I honestly can’t imagine the manual therapies correcting a retroversion however, it should help with symptoms.

My approach to correcting retroverted uteri

involves softening, allowing and encouraging rather than forcing. Forcing can lead to more adhesions. After softening the abdominal layers with gentle abdominal massage. I perform an Ayurvedic hip massage.  The Ayurvedic hip massage is the favorite part of the treatment for many women. From a manual therapy perspective, the hip massage helps to release muscular tension around the SI joint. The massage also brings fresh blood flow to the uterus, ovaries, and intestines.  After everything is softened, I use my fingers on the outside of the lower belly to sink in and scoop the uterus forward.  I will then apply specific sacral techniques rooted in the Maya tradition to encourage the uterus to move forward.  It usually takes one to four sessions to get the uterus to move into the optimal position depending on how long the uterus has been retroverted. There are times, as mentioned above, that the position can’t be corrected manually due to strong adhesions or scar tissue. Even if the uterus can’t be coaxed out of retroversion, the massage can still help decrease symptoms by aiding blood and lymphatic flow.

Ideally, you should see a certified Arvigo® practitioner trained in these techniques for hands-on therapy. Make sure you see an Arvigo® practitioner who has completed the certification process because that’s when they learn the advanced techniques for correcting retroverted uteri.

Seeing a restorative exercise specialist for pelvic alignment may also be a good idea. The uterus attaches to the inside of the pelvis and sacrum via uterine ligaments, so if the pelvis is out of alignment the uterine ligaments won’t be loaded correctly leading to fibrosis.  A posteriorly tilted pelvis also creates more intra-abdominal pressure on the reproductive organs.

sitting in posterior tilt

how you sit can contribute to a retroverted uterus.

Obviously, your pelvis should be able to move in many planes without causing organ dysfunction, the problem is the frequency of one position.  When you sit, sit with your ASIS and pubic bone in vertical alignment.  If you have trouble sitting with a neutral pelvis or feel like you’re forcing yourself into this position, you need to release the muscles that are keeping your pelvis in a post tilt. How you get there matters. You wouldn’t want to force a position. I often recommend the Healthy Pelvis online class as a starting point. And transition to zero drop shoes! Read more about elevated heels, pelvic position, and uterine position HERE.

I wish I could have helped my mom when she was suffering from the symptoms of a retroverted uterus.  The fact that I didn’t have the knowledge to help her way back when makes me very passionate about wanting to help other women who have displaced uteri.

Update: I have been studying Visceral Manipulation™ (VM) since 2011. Visceral Manipulation™ is low force osteopathic techniques. To date, I’ve completed VM 1-5. Practitioners who have completed VM3 have learned techniques for freeing up uterine, ovarian, fallopian tube and bladder restrictions.  In my private practice, I may combine the Arvigo® Techniques with Chi Nei Tsang (Chinese abdominal massage), Visceral Manipulation™, Ayurvedic hip massage and restorative exercise depending on the individual.

Source 1  Hysterectomy, Oophorectomy and Risk of Dementia: A Nationwide Historical Cohort Study from Dementia and Geriatric Cognitive Disorders

Source 2 Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause from the Neurology– The most widely read and highly sited peer-reviewed neurology journal

Source 3 Estrogen and Demential Insights From Women’s Health Initiative Memory Study from the Journal of the American Medical Association (JAMA)

Source 4 The incarcerated gravid uterus: complications and lessons learned  Obstetrics and  Gynecology. 2014 Feb;123(2 Pt 2 Suppl 2):423-7. doi: 10.1097/AOG.0000000000000102

Source 5 Clinical variables affecting the pregnancy rate of intracervical insemination using cryopreserved donor spermatozoa: a retrospective study in china.International Journal of Fertility & Sterility. 2012 Oct;6(3):179-84. Epub 2012 Dec 17.

Source 6 Sonographic and Magnetic Resonance Imaging Findings in Uterine Incarceration

Source 7 Sciatica in the female patient: anatomical considerations, aetiology and review of the literature

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