Causes of Retroflexed Uterus

It is essential to differentiate between an overturned uterus’s flexible and inflexible forms. In the case of a relaxed retroflexed uterus, it can occur as early as childhood. Physicians may also observe this phenomenon following pregnancy when the uterus ultimately fails to return to its original position. Another potential cause is the atrophic uterus, which can develop during postmenopause [1].

It is worth noting that uterine atrophy, a normal aging process, results from the changing hormonal profile in a woman’s body, rendering the uterus unnecessary for reproduction.

In contrast, an immobile retroflexed uterus is often associated with inflammatory processes, prior surgeries, or endometriosis. These factors can lead to the formation of adhesions between the uterus and the rectum [1].

Endometriosis and Retroflexed Uterus: The Connections

Endometriosis, a condition in which endometrial tissue grows outside the uterine cavity, is characterized by a range of symptoms, with abdominal pain as a primary concern. These symptoms frequently manifest during menstruation or in association with sexual intercourse, sometimes accompanied by vomiting, diarrhea, or nausea [5].

The presence of unwanted endometrial tissue can lead to adhesions, resulting in the fixation and retroflection of the uterus.

Physicians often utilize the retroflexed uterus as a potential indicator of endometriosis. Direct visualization of adhesions in the pelvis can be challenging, so gynecologists rely on “soft markers,” which are indirect signs suggesting the presence of endometriosis-related adhesions. When fixed, tilted backward, and bent, the retroflexed uterus resembles a question mark. This unique shape can indicate the presence of endometriosis lesions in the pelvis [6].

Additionally, during ultrasound examinations, if the uterus exhibits no movement relative to surrounding tissues, it may signal a “frozen pelvis,” a condition often associated with severe endometriosis.

Diagnosing a Retroflexed Uterus

Given that many women with a retroflexed uterus remain asymptomatic, its diagnosis is often an incidental finding during routine gynecological check-ups. Your gynecologist may inform you unexpectedly that your uterus is retroflexed.

Gynecologists may employ transvaginal 2-D ultrasound or palpation (vaginal or rectal) to detect and confirm the presence of a retroflexed uterus.

If endometriosis is suspected, physicians will specifically examine the position of the uterus. In cases of deep infiltrating endometriosis, the uterus frequently presents in a retroflexed state [7].

For adenomyosis, a condition where endometrial glandular tissue infiltrates the uterine muscle tissue, the question mark appearance on ultrasound is also a diagnostic clue [7].

Treating a Retroflexed Uterus

If you experience no symptoms, a retroflexed uterus typically does not require treatment. However, if you experience pain or encounter difficulty with urination, several treatment options are available.

In cases of symptomatic retroflexed uteri, physicians may attempt manual repositioning, which involves using their hands to move the uterus into the correct position. Alternatively, a specialized device called the Smith-Hodge pessary can be inserted to realign the uterus [1].

If manual therapy proves effective in alleviating symptoms, you can consult your gynecologist to determine whether surgery is viable. Surgical intervention may involve shortening a retaining ligament (such as Ligg. rotunda or Ligg. sacrouterina) [1, 8].

When endometriosis adhesions are responsible for the retroflexed uterus, surgery can also be considered to mobilize the uterus, which entails breaking adhesions and removing the endometriosis. It is important to note that endometriosis lesions may recur following surgery [9].