A long post of all the info I've been learning!
TL;DR A tilted uterus is normal (~1 in 4 women), pretty much always ignored medically because most don't have problems from it, but some people do and there's things you can do to make it better.
What is a tilted uterus?
Basically, all uteruses have a tilt to some degree. The uterus is mobile and can lie in all kinds of positions depending on the person. Even in the same person, the uterus will usually move around a bit depending on how you're moving, if you've used the bathroom lately or if you're turned on. If you aren't on hormonal birth control, it will also change positions throughout the month (it rises during ovulation, and drops during your period). Overtime, it can also change position as muscles and ligaments relax or weaken.
Usually when people say 'tilted' they mean a uterus and cervix that are angled towards your back or butt. There's a lot of terms for it: tipped, backwards, retroverted, retroflexed, retrocessed etc. It's also a very general term. For example, two people can have a retroverted uterus but one uterus might be almost pointing straight upwards while the other might be pressed into the rectum.
Getting more precise.
The most well-explained definitions I've heard was from a gynecologist that took the time to make a video since it's so often misunderstood. It's a long video though so to summarize, tilt/angle is based on two things: Version and Flexion. Version means the angle between the cervix and vagina, and flexion means the angle between the cervix and body of the uterus. Based on that, the postions are:
Version (which way the cervix is tilting towards)
- Anteversion: The cervix is angled towards the bladder (cervix opening points towards rectum).
- Midposition: The cervix is angled straight up.
- Retroversion: The cervix is angled towards the rectum (cervix opening points towards bladder).
Flexion (which way the uterus bends)
- Anteflexion: The body of the uterus bends towards the bladder.
- Midposition: Straight, no bend.
- Retroflexion: The body of the uterus bends towards the rectum.
Most version/flexion positions match up e.g. Antverted/Anteflexed, Retroverted/Retroflexed. But, sometimes the uterus will bend in the opposite direction of the cervix.
What's Normal?
The typical or natural position of the uterus is Anteverted/Anteflexed (facing forward with a slight bend towards the bladder). Other positions that are common are Midposition/Anteflexion, Midposition/Retroflexion, Retroversion/Midposition and Retroversion/Retroflexion.
Combos like Anteversion/Retroflexion, Retroversion/Anteflexion or Midposition/Midposition are pretty rare and associated with C-sections. Severe or 'acute' angles are also less common, and seem to cause the most issues (see study on period pain associated with severe anteflexion and retroflexion).
All variations are considered normal, unless there is pain or other symptoms.
Why is there a possibility of symptoms with something that's considered normal?
One of the biggest reasons that tilted uterus issues get ignored is that many gynecologists don't know that it can cause problems. At one point in time, a tilted uterus was thought to cause infertility and treatment to correct it was common. When this showed later on not the be the case, training and treatment options dropped off.
Often, and especially in cases of infertility and severe pain, another condition is also present alongside a tilted uterus. For example, endometriosis, infection and scar tissue can cause pain and infertility. And, they're also able to cause tilt by weighing the uterus down and sticking it to other organs.
Lastly, the majority of tilted uterus-havers seem to have either mild or no symptoms at all.
When you put those reasons together, I would guess that the probability for a tilted uterus to be causing problems is a little skewed. If most doctors are unlikely to diagnose it, how would that not skew how many people are impacted? If only people with severe issues are seeking help, how many people are dealing with milder symptoms?
If you do have symptoms without another condition present, this is called symptomatic uterine retroversion (or whatever the abnormal position is). There isn't much out there on that term, but it came from a gynecologist I saw at a pelvic pain centre.
What are the symptoms?
The most common symptoms are:
- Painful periods - Most likely because the angle makes it harder for blood to exit the uterus, so there is more cramping involved. Some people experience low back cramps instead of abdomen.
- Painful sex - Usually only with deep penetration or certain positions. Painful collision between the penis, finger or toy and the cervix or uterus is more likely to happen. Pain or discomfort is usually felt deep in the vagina or pelvic area, and can also linger afterwards.
- Minor urinary incontinence and/or UTIs - If the tilt means frequent UTIs, UTI-like symptoms, or that you accidentally pee yourself a little when you cough or sneeze, pelvic floor dysfunction is most likely involved.
- Frequent constipation - When the uterus presses into the rectum, this can cause constipation and other GI symptoms (especially during your period).
- Difficulty or pain with insertion/internal devices - For many it can feel like menstrual cups or tampons won't sit properly, leading to more leakage. Insertion is usually more difficult and may be painful or require multiple attempts. Diaphragms can also feel like they aren’t fitting properly over the cervix.
- Painful gynecological exams and procedures - Routine exams using a speculum or procedures like IUD insertion can also be more painful and difficult. This is especially likely if your health provider has difficulty finding your cervix. If the tilt is severe, there is a greater risk of perforation during procedures.
- Infertility or difficulty conceiving - If other conditions like endometriosis, PID or scar tissue are causing the tilt, this is most likely the reason for troubles getting pregnant.
- Pregnancy: symptoms and possible complications - In early pregnancy, you might experience more back pain and UTIs. For some, a tilted uterus might mean your bump won't show until later on. It can also be harder for the fetus to be detected through regular transabdominal ultrasound since the uterus is further back. In rare cases (1 out of 3000 pregnancies), the uterus can become incarcerated or unable to move out of the pelvis. If this is not corrected, miscarriage can occur or if pregnancy continues other complications can result.
Symptoms listed on more holistic/altnerative health sites include irregular menstrual cycles, dark/clotty/foul-smelling menstrual blood, hormone imbalance, depression, anxiety, early menopause, chronic low back pain, yeast infections, ovarian cycsts/polyps, miscarriage and unexplained pelvic pain.
Management & Treatment Options
- General Tips + Remedies
- For period pain: Common remedies like heating packs, over the counter pain medicine, hormonal birth control, hot baths, diet or exercise.
- For painful sex: Take your time before having penetrative sex, even if you're turned on mentally your body might need more time. Use lubricant. Avoid positions that hurt, or find angles and adjustments that work for you. Explore non-penetrative sex.
- For urinary incontience/UTIs: Practice squeezing and releasing pelvic floor muscles. Try to make sure your bladder is fully emptied when you pee. Stay hydrated and don't put off going to the bathroom.
- For constipation/GI symptoms: Practice squeezing and releasing pelvic floor muscles to help you relax and more easily pass stool. Eat more fibre, stay hydrated and don't put off going to the bathroom.
- For difficulty with insertion/internal devices: Find angles and adjustments that work best for your body. Squatting or bending a knee can help. Inserting the device lower can help prevent leakage. Make sure your menstrual cup is the right fit for your cervix height. If you're having trouble finding your cervix, you might find it pulled off to one side of your vagina.
- For difficulty with gynecological exams/procedures: Let your health care practitioner know so that they can help you be more comfortable. Try exercises or adjustments that can help make the cervix come forward (standing up and jumping, laying down and lifting knees to chest, making fists and putting them under your butt). Focus on diaphragm breathing.
- Buffer Devices. If you have painful sex, devices to control penetration depth can be placed on your partner's penis or on your sex toy, and are usually customizable to find a depth that works best for you. OhNut and Perfect Fit both offer options.
- Pessary. A lever or Hodge pessary device can be used to support the uterus and reposition it. Pessaries are rarely prescribed to treat a tilted uterus and may cause irritation, infection or painful sex.
- Exercises. You might be able to temporarily reposition the uterus through certain exercises. See Exercises for a Tipped Uterus.
- Manual repositioning. A doctor or health practitioner may be able to manually reposition the uterus during a pelvic examination, or through non-surgical alignment techniques. (See 'A Better Choice')
- Abdominal massage. Massage may help reposition pelvic and abdominal organs by loosening muscles and adhesions. There may be additional benefits if pelvic circulation is improved. (See Arvigo/Mayan Abdominal Massage, 'Retroverted Uterus, A Natural Solution' and Efficacy of the Arvigo Techniques on Dysmenorrhea Symptoms in Women)
- Pelvic Floor Physiotherapy. A pelvic floor therapist will be able to assess the pelvic floor muscles and ligaments for weakness or tightness which may be contributing to or caused by a tilted uterus. Strengthening and/or learning to relax these muscles might help bring the uterus into a forward position. Even if pelvic floor therapy cannot reposition the uterus, relaxing muscles and improving muscle strength can have other benefits and lessen pain overall (See Displaced Uterus Causing Pelvic Pain and Pelvic Floor Therapy).
- Surgery: Laparoscopic Uterine Lift / Ventrosuspension procedure. In more severe cases the uterus can be repositioned surgically (I don't reccommend it, but if you're curious you can watch this TV episode where a surgeon performs ventrosuspension *be warned it's NSFW\). You can also take a look at these before and after photos *\again NSFW****. The surgery involves placing a stich in the round ligaments of the uterus to make them shorter, and moving the uterus into a forward facing or more neutral position. It takes around 15 minutes to perform, and is done as a day surgery with no required overnight stay. Some other info to note:
- This procedure is not often performed and rarely taught in ob-gyn residencies. Gynecologists specializing in pelvic pain are most likely to be able to perform this procedure.
- Sometimes underlying causes such as adhesions or infection are found during the surgery which did not appear on previous ultrasounds or exams. The surgeon will usually be able to remove any adhesions during the same surgery.
- Complications are very low, although ligaments can re-stretch overtime. Pregnancy will usually re-stretch the ligaments.
- There is some debate over its usefulness and efficacy (See Symptomatic retrodisplaced uterus: better treated by surgery or psychology?). Long-term success rates range from 33-100%, but this gets complicated since chronic pain and other complicated conditions aren't always excluded. Those who will benefit the most have either: collision pain during deep penetration with no other known cause, pelvic adhesions causing pain and infertility, painful periods with no other known cause and uterine prolapse.
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