Uterine Suspension and the Treatment of Dysmenorrhea Related to a Retroverted Uterus

Background

Uterine retroversion has been considered an anatomic variant that is largely asymptomatic. However, some of the 20 to 30% of women with a retroverted uterus experience a constellation of chronic pelvic pain symptoms including severe dysmenorrhea. When dysmenorrhea is refractory to medical therapy, possible contributing factors should be carefully considered in the process of developing a treatment plan. These factors include endometriosis, functional disorders of the urinary and gastrointestinal systems and/or pelvic floor defects. Diagnosis should include a detailed medical history and a thorough pelvic exam. Tests including laparoscopy may also identify possible causative factors.

If uterine retroversion is the only documented pathology, uterine suspension should be considered as a conservative therapy in women experiencing chronic pelvic pain including dysmenorrhea. Newer laparoscopic uterine suspension techniques and careful patient selection make it possible to obtain good long-term relief of dysmenorrhea with minimal procedure and recovery time.

Documentation

In a prospective randomized study of 62 women with symptomatic uterine retroversion, Ostrzenski found that 87.5% of the patients in the active treatment group (laparoscopic retroperitoneal hysteropexy (n=32)) experienced relief from symptoms including dysmenorrhea after at least 24-month follow-up. ¹ None of the women in the control group (diagnostic laparoscopy only (n=30)) reported symptom relief.

The patients included in the trial had no pelvic pathology other than uterine retroversion as documented in pelvic and laparoscopic exams. They also experienced all of the following symptoms: deep dyspareunia, dysmenorrhea, pressure in the bladder and frequent urination and pressure in the rectum.

Ostrzenski concludes that uterine suspension should be considered in a select group of women with complex pelvic pain symptoms and no other pathology in addition to uterine retroversion.

Carter reports that laparoscopic uterine suspension with the UPLIFT procedure provided lasting relief of dysmenorrhea in a series of 75 women with a symptomatic retroverted uterus.² Pain with menses decreased from 8.4 to 1.7 on a ten-point scale with up to two years follow-up (0 = no pain and 10 = the worst pain the patient has ever experienced).

Similarly, Serour performed laparoscopic ventrosuspension on 150 women with symptomatic retroversion and found that of the 66 patients complaining of congestive dysmenorrhea, 68% (n=45) reported improvement with follow-up from 6 to 30 months. ³

Patterson advocates laparoscopic ventrosuspension not only for patients with dyspareunia and a retroverted uterus, but also for those with otherwise unexplained dysmenorrhea, sacral backache or infertility. ⁴ In a series of 100 women who underwent laparoscopic uterine suspensions, dysmenorrhea was the primary indication in 16 cases. After an average follow-up of 40.5 months, 82% of the women (n= 14) experienced complete or partial relief of dysmenorrhea. An anteverted uterus was found during follow-up of both dysmenorrhea patients with no symptom relief. Paterson concludes that the presenting symptoms of dyspareunia, dysmenorrhea or sacral backache were almost always improved as a result of uterine suspension.

Conclusion

Uterine suspension can relieve dysmenorrhea in a significant number of women with a retroverted uterus and no other identifiable pathologies.

References

1. Ostrzenski A.
   Laparoscopic Retroperitoneal Hysteropexy, A Randomized Trial. Journal of Reproductive Medicine 1998; 43(4):361-366.
   
   
2. Carter JE.
   Carter-Thomason Uterine Suspension and Positioning by Ligament Investment, Fixation and Truncation. Journal of Reproductive Medicine 1999; 44(5):417-422.
   
   
3. Serour GJ, Hefnawi O, Kandil O, Askalani, N et al.
   Laparoscopic Ventrosuspension: A New Technique. International Journal of Gynaecological Obstetrics 1982; 20:129-131.
   
   
4. Paterson ME , Jordan JA and Logan-Edwards R.
   A Survey of 100 Patients Who Had Laparoscopic Ventrosuspensions. British Journal of Obstetrics and Gynaecology 1978; 85:468-471.