When is a tilted cervix normal and when is treatment required?

A tilted cervix (the narrow part or the neck of the uterus or womb) naturally occurs in many women and isn’t usually a cause for concern. However, several conditions can cause it to be tilted or fixed and may lead to further medical investigation, particularly regarding fertility and pregnancy.

Respected consultant obstetrician and gynaecologist Dr Thanga Katimada has provided a detailed insight to the condition, considering exactly what a tilted cervix is and how they are diagnosed. Furthermore, she looks at associated health issues, how a tilted cervix can affect pregnancy and birth and how problems are treated. 

What is a tilted cervix?

The term tilted cervix is often used when the womb’s neck is positioned to the front of the top of the vagina, when observed during gynaecological examination. In the vast majority of cases, this is not an abnormality, but a variation of normal. It results from the womb being tilted backwards and this is often referred to as a tilted womb.

• The uterus has three parts
  • The pear-shaped wider body
  • The womb’s neck or cervix is like a hollow cylinder and;
  • The isthmus which connects the cervix to the body of the womb

The cervix is located at the top of the vagina, such that half of it is inside the vagina and half above it. Lax tissue called ligaments hold the uterus in position and attach it to the walls of the pelvic bones.

The uterus is a very flexible organ. It can bend forward or backwards on itself at the isthmus and in relation to the vaginal attachment. Under the influence of gravity, in most women, the uterus is bent forward at the junction between the cervix and the vagina and at the isthmus. This anatomical position is known as an anteverted and anteflexed uterus. 

In an anteverted and anteflexed uterus the portion of the cervix which is visible through the vagina is displaced to the back of the vagina. Often, being able to see the cervix in this position gives the gynaecologist an impression that the uterus is most likely to be bent forwards. In this position, the cervix is easy to access and see during a speculum examination for instances such as a smear test.

Where the uterus is normally bent forward, the uterus can occasionally bend backwards towards the back passage. Because of its’ flexibility, it returns to the forward bent position after some time. A situation that some women experience when they are told that the uterus is tilted backwards on one scan and subsequently told that it is tilted forwards in the next scan. This is not unusual. 

The uterus may prefer to remain bent backwards, even normally, in some women. In these cases, the vast majority do not experience any abnormal symptoms and it is considered a variation of normal.

How do you know if you have a tilted cervix?

A tilted uterus (bent backwards) and hence a tilted neck of the womb (positioned towards the front of the top of the vagina) comes to light when a gynaecological examination or an ultrasound scan of the uterus is performed. Most women do not experience any symptoms.

Can you get pregnant if you have a tilted cervix?

It was previously thought that a tilted womb and cervix could compromise fertility. However, there is no evidence to support this.

However, conditions such as a previous pelvic infection, endometriosis or fibroids can cause the womb to be fixed in this position. In turn, these conditions can compromise fertility.

What are the health issues associated with this condition?

1. If it is difficult to see a tilted cervix during speculum examination, the gynaecologist may ask the woman to thrust the pelvis forwards by making a fist of her hands and placing it against the small of the back to bring the cervix into view. The woman’s legs may need to be supported on poles in more challenging situations to achieve the right angle in order to see the cervix. If this is the case, the GP may need to send you to the hospital for a smear test.

2. Women may experience discomfort during sexual intercourse in cases where the body of the uterus is bent acutely backwards and lies just over the back of the top of the vagina. Change in position during intercourse can overcome this.

3. If an enlarged uterus (for example, a fibroid ) is tilted backwards, this may lead to altered bowel function and habits due to pressure effects from uterus on surrounding structures .

4. Pregnant women with a womb that is tilted backwards may experience the inability to pass urine (known as urine retention). This is caused due to the growing pregnancy pushing the neck of the bladder forwards and stretching it. A catheter may be needed to drain the urine until around 12 to 16 weeks of pregnancy.  This situation usually passes; the uterus straightens out and grows out of the pelvis after 12 weeks of pregnancy.  However, urine retention may be experienced in every subsequent pregnancy.

5. Painful periods may be caused by a tilted uterus. It is difficult for menstrual blood to flow into the vagina because the passageway between the uterus and the cervix is bent. This results in the uterus working hard to expel the blood by muscle contraction and is experienced as spasms, causing pain. (Cagnacci A, Grandi G, Cannoletta M, Xholli A, Piacenti I, Volpe A. Intensity of menstrual pain and estimated angle of uterine flexion. Acta Obstet Gynecol Scand 2014; 93:58–63).

6. In some cases, a disease process causes the tilted womb to be fixed in this position and women may experience symptoms of the disease rather than the tilted womb itself. Severe pelvic infection, endometriosis and uterine fibroids are conditions that can cause the fixation to occur. In order to achieve the possibility of symptom relief, treatment of the primary condition – which often involves surgery - can correct the fixed retroversion of the uterus.

How is it treated?

This is a variation of normal and hence, in the vast majority of women, no treatment is required.

The treatment must be aimed at the primary disease in those women where the uterus is fixed in this position due to another disease process.

Those women who become pregnant with a retroverted womb which does not straighten itself after 12 weeks is known as an incarcerated uterus. If the pregnancy is allowed to grow in a womb which is incarcerated, it can cause serious consequences to the mother and baby. Not only will the woman experience difficulty opening her bowel and not be able to pass urine, but more dangerously, the wall of the womb may give way in the advanced stages of pregnancy. Several non-surgical techniques can be used to straighten the womb and in very rare cases where there is a risk of womb giving way, a surgical procedure may be necessary to release the womb from the incarcerated position.

If you need specialist advice about your tilted uterus, book a consultation with Dr Katimada via her Top Doctors profile here.