Many women are born with a congenital anomaly of the uterus, cervix, vagina, or hymen. This means that these organs developed differently than in most women, but still may be effective in the primary functions of the uterus, cervix, vagina, or hymen: menstruation, vaginal intercourse and carrying a pregnancy. Many girls and women do not realize that they have an anomaly of their reproductive organs unless they have symptoms or have imaging (like an ultrasound) or an examination where it is discovered.
The uterus and part of the vagina develop from two ridges of tissue on the left and right side of the body while a girl is still a fetus. These structures then fuse (come together) in the middle to form one structure. Most congenital anomalies happen because the two parts do not come together fully.
Different classes of congenital anomalies have been identified and are described by how much fusion in the midline happened or did not happen. Some women have no uterus or very little vagina. This is discovered when they go through puberty, but never start their periods. There can also be different amounts of uterine development. For example, there may be a uterus only on one side (unicornuate), a double uterus in the middle (didelphys
), or a partially split uterus (bicornuate
, or arcuate). Many of these anomalies are also associated with differences in the formation of the kidneys. The most minor malformations are where there is extra tissue dividing the uterus (septate uterus
), or vagina (a vaginal septum). Some women have extra tissue at their hymen, or entrance of their vagina.
Many women with a congenital anomaly of the uterus will not require any treatment. However, if you were to experience severe pain with your periods or recurrent miscarriage, your doctor might recommend surgery. For an unopened hymen or vaginal septum, usually the septum can be removed surgically, either in the clinic or in the operating room, depending on the extent of the septum. If the vagina is not fully developed, usually the vagina can be stretched to a normal length using vaginal dilators.
Occasionally some patients desire that a vagina be made, usually from tissue taken from another part of your body and made into the shape of a vagina. Usually a uterine or a vaginal septum can be removed by minimally invasive surgery. If a woman has a history of preterm delivery, she may be a candidate for a cerclage (stitch to help keep the cervix closed) during her pregnancy.
SymptomsMost women with uterine anomalies do not have symptoms and only realize that they have a uterine or vaginal anomaly during a routine exam or with an ultrasound when they are pregnant. Some women will experience symptoms. The symptoms may be not having a period during puberty, monthly abdominal pain with or without bleeding during puberty, pain or difficulty inserting a tampon, pain with intercourse or recurrent miscarriages, infertility, preterm labor or abnormal positions of the baby during pregnancy.
Extra tissue at the hymen is usually discovered when it is difficult to place a tampon, to have sex, or to have a routine pelvic exam. This extra tissue can be removed either in clinic or in the operating room.
When a girl goes through puberty, but does not start her period, the doctor may perform an examination or order an MRI to see if she has a normal uterus and vagina.
If a patient does not see menstrual bleeding externally, she may have incomplete development of her vagina or may have an obstruction that is preventing menstrual blood from exiting her uterus. Most women with an obstruction will have pain.
If there is a septum, bicornuate, or unicornuate uterus, women are still considered fertile, but is at higher risk for miscarriage, infertility, preterm labor, or that the fetus would present breech (bottom first) during labor.
DiagnosisTo diagnose a congenital anomaly of the uterus, cervix, vagina, or hymen, your doctor will start with a physical exam to examine these areas. An MRI or ultrasound is useful to examine the structures internally and are usually able to identify a uterine septum, bicornuate uterus, absent uterus, or unicornuate uterus. Also these tests can be used to examine your kidneys to see if they have developed typically. Your doctor may recommend a hysterosalpingogram to examine the cavity of the uterus, or a laparoscopy to examine the external surface.