Osteopathic Medicine

The Uterus and the Ovaries

Grégoire Lason & Luc Peeters

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The Uterus and the Ovaries

Grégoire Lason & Luc Peeters All rights reserved. Osteo 2000 bvba © 2013. No part of this e-book may be reproduced or made

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ISBN: 9789074400367

The International Academy of Osteopathy – I.A.O.

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Content Content ....................................................................................................................... 3

1. Introduction ............................................................................................................ 8

2. Anatomy ................................................................................................................. 9 2.1. Position ............................................................................................................ 9

2.1.1. The Uterus .................................................................................................. 9 2.1.1.1. Normal Position .................................................................................... 9 2.1.1.2. Pathological Position of the Uterus .................................................... 10 2.1.1.3. Anteversion of the Uterus .................................................................. 12 2.1.1.4. Retroposition of the Uterus ................................................................ 12 2.1.1.5. Retroversion of the Uterus ................................................................. 13 2.1.1.6. Retroflexion of the Uterus .................................................................. 13

2.1.2. The Ovaries .............................................................................................. 14 2.2. Form and Size ................................................................................................ 15

2.2.1. The Uterus ................................................................................................ 15 2.2.2. The Ovaries .............................................................................................. 16 2.2.3. Uterine Tube ............................................................................................. 16

2.3. Anatomical Fixations .................................................................................... 17 2.3.1. Sacro-Recto-Utero-Vesico-Pubic Lamina ................................................. 17 2.3.2. Uterosacral Ligaments .............................................................................. 18 2.3.3. Round Ligaments of the Uterus ................................................................ 18 2.3.4. Proper Ovarian Ligaments ........................................................................ 19 2.3.5. Suspensory Ligament of the Ovary .......................................................... 19 2.3.6. Broad Ligament ........................................................................................ 20

2.4. Blood Supply ................................................................................................. 22 2.4.1. Arterial ...................................................................................................... 22 2.4.2. Venous ..................................................................................................... 22

2.5. Innervation ..................................................................................................... 23 2.5.1. Segmental Innervation .............................................................................. 23 2.5.2. Pain .......................................................................................................... 23

3. Function ................................................................................................................ 24 3.1. General ........................................................................................................... 24 3.2. Menstrual Cycle ............................................................................................. 24 3.3. Hormonal Action ........................................................................................... 28 3.4. Regulation of Uterus Tone ........................................................................... 30 3.5. Different Phases of Pregnancy .................................................................... 32 3.6. Function of the Ovaries ................................................................................ 33

4. Mobility ................................................................................................................. 34 4.1. The Uterus ..................................................................................................... 34 4.2. The Ovaries and the Uterine Tubes ............................................................. 34

5. Patient History and physical Exam .................................................................... 35

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5.1. Pathology ....................................................................................................... 35 5.1.1. Ectopic Pregnancy .................................................................................... 35 5.1.2. Endometriosis ........................................................................................... 35 5.1.3. Myoma ...................................................................................................... 37 5.1.4. Congenital Anomalies ............................................................................... 39 5.1.5. Endometrial Polyp .................................................................................... 39 5.1.6. Benign Cervix Polyp ................................................................................. 40 5.1.7. Ovarian Cyst ............................................................................................. 40 5.1.8. Ovarian Torsion ........................................................................................ 41 5.1.9. Inflammations ........................................................................................... 41 5.1.10. Adenomyosis .......................................................................................... 41 5.1.11. Chronic Cervicitis .................................................................................... 42 5.1.12. Cancer .................................................................................................... 42

5.1.12.1. Cervix Carcinoma ............................................................................ 42 5.1.12.2. Endometrium Adenocarcinoma ........................................................ 43

5.2. Symptoms ...................................................................................................... 43 5.2.1. Anovulation ............................................................................................... 43 5.2.2. Ovular functional Bleeding ........................................................................ 44 5.2.3. Dysfunctional Uterine Bleeding ................................................................ 44 5.2.4. Trophic Changes of the female sexual Organs ........................................ 45 5.2.5. Pregnancy ................................................................................................ 45 5.2.6. Amenorrhoea ............................................................................................ 49 5.2.7. Primary Dysmenorrhea ............................................................................. 51 5.2.8. Secondary Dysmenorrhea ........................................................................ 52 5.2.9. Polycystic Ovarian Syndrome ................................................................... 52 5.2.10. Perimenopausal Period Syndrome ......................................................... 53 5.2.11. Infertility .................................................................................................. 55 5.2.12. Pelvic Pain .............................................................................................. 56 5.2.13. Ovarian Vein Syndrome ......................................................................... 57 5.2.14. ‘Nutcracker’ Syndrome ........................................................................... 58 5.2.15. Allen Masters Syndrome ........................................................................ 58 5.2.16. Oral Contraception ................................................................................. 59

5.3. Osteopathic Lesions ..................................................................................... 60 5.3.1. Adhesion Uterus-Colon ............................................................................ 60 5.3.2. Adhesion Uterus-Rectum ......................................................................... 61 5.3.3. Non-specific Adhesions ............................................................................ 62 5.3.4. Retraction of the Round Ligament ............................................................ 64 5.3.5. Congestion of the Pelvis ........................................................................... 65

6. Clinical Diagnosis ................................................................................................ 68 6.1. General Tests ................................................................................................ 68

6.1.1. Observation in Supine and Rebound Test of the Uterus .......................... 68 6.1.2. General Tests of the visceral Pelvis ......................................................... 70

6.1.2.1. Test 1 ................................................................................................. 70

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6.1.2.2. Test 2 ................................................................................................. 70 6.1.2.3. Test 3 ................................................................................................. 70 6.1.2.4. Test 4 ................................................................................................. 70 6.1.2.5. Test Criteria ....................................................................................... 70 6.1.2.6. Possible Findings ............................................................................... 70

6.2. Specific Tests ................................................................................................ 72 6.2.1. External Palpation of the Ovaries ............................................................. 72 6.2.2. External Palpation of the Uterus ............................................................... 73 6.2.3. Palpation, Provocation and Test of the Round Ligament, Patient Supine 73 6.2.4. Palpation, Provocation and Test of the Round Ligament, Patient Sidelying ............................................................................................................................ 74 6.2.5. Test of the Broad Ligament ...................................................................... 75 6.2.6. Indirect Test of the Uterosacral Ligament ................................................. 76 6.2.7. Test for Uterus Ptosis, Patient Sitting ....................................................... 76 6.2.8. Provocation Test for Ptosis, Patient Sitting .............................................. 77 6.2.9. Provocation Test for Ptosis, Patient Supine ............................................. 77 6.2.10. Test for Adhesion with the Bladder ......................................................... 78 6.2.11. Test for Adhesion with the Rectum ......................................................... 78 6.2.12. Test for Adhesion with the Sigmoid Colon .............................................. 79 6.2.13. Test for Adhesion with the Small Intestine ............................................. 79 6.2.14. Test for Adhesion between the right Ovary and the Caecum ................. 80 6.2.15. Test of the lesser Pelvis for Congestion – Anterior ................................ 80 6.2.16. Test of the lesser Pelvis for Congestion – Posterior ............................... 81 6.2.17. External Provocation of the Douglas Pouch ........................................... 81

6.3. Internal Tests ................................................................................................. 82 6.3.1. Palpation of the Cervix ............................................................................. 82 6.3.2. Palpation of the Vaginal Walls .................................................................. 82 6.3.3. Provocation Test of the Pouch of Douglas ............................................... 83 6.3.4. Provocation Test of the Vesicouterine Pouch ........................................... 84 6.3.5. Provocation and Palpation of the Ovaries ................................................ 85 6.3.6. Test for anterior Mobility of the Uterus ..................................................... 86 6.3.7. Star Test of the Junction between Cervix/Uterus Body ............................ 87 6.3.8. Test for medial Mobility of the Uterus ....................................................... 88

7. Osteopathic Techniques ..................................................................................... 89 7.1. General Techniques ...................................................................................... 89

7.1.1. Visceral Decongestion of the lesser Pelvis ............................................... 89 7.1.2. Muscular Decongestion of the lesser Pelvis ............................................. 90

7.2. Specific External Techniques ...................................................................... 91 7.2.1. Stretch of the Round Ligament ................................................................. 91 7.2.2. Indirect Stretch of the Broad Ligament ..................................................... 91 7.2.3. Indirect Stretch of the Broad Ligament ..................................................... 92 7.2.4. Drainage of the Broad Ligament, Patient Sidelying .................................. 92 7.2.5. Frictions in the Direction of the Uterosacral Ligament, Patient Sidelying . 93

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7.2.6. Stretch of the Adhesion Uterus - Bladder ................................................. 93 7.2.7. Recoil Technique between Uterus and Rectum ....................................... 94 7.2.8. Stretch of an Adhesion Uterus/Sigmoid Colon ......................................... 94 7.2.9. Stretch of the Adhesion Uterus/Small Intestine ........................................ 95 7.2.10. Lift of the Uterus ..................................................................................... 95 7.2.11. Relaxation Technique for the Lamina ..................................................... 96 7.2.12. Relaxation Technique for the Lamina ..................................................... 96 7.2.13. Drainage and Stretch of the Perineum ................................................... 97

7.3. Specific Internal Techniques ....................................................................... 98 7.3.1. Stretch of an Adhesion in the Pouch of Douglas –Technique 1 ............... 98 7.3.2. Stretch of an Adhesion in the Pouch of Douglas – Technique 2 .............. 99 7.3.3. Stretch of an Adhesion between Bladder and Uterus ............................. 100 7.3.4. Stretch of a Retraction of the Broad Ligament ....................................... 100 7.3.5. Stretch of an Adhesion between Cervix and Vaginal Wall ..................... 101

7.4. Neurolymphatic Reflex Points ................................................................... 102 7.4.1. Salpingitis ............................................................................................... 103 7.4.2. Clitoris Irritation and Vaginismus ............................................................ 103 7.4.3. Leucorrhoea ........................................................................................... 104

7.5. Final Remarks .............................................................................................. 104

8. Bibliography ....................................................................................................... 106

9. About the Authors ............................................................................................. 110

10. Acknowledgment ............................................................................................. 111

11. Visceral Osteopathy ........................................................................................ 112 11.1. Introduction ............................................................................................... 112 11.2. Motion Physiology .................................................................................... 113

11.2.1. The Motions of the Musculoskeletal System ........................................ 113 11.2.2. The Motions of the Visceral System ..................................................... 113

11.2.2.1. The Diaphragm .............................................................................. 113 11.2.2.2. The Heart ....................................................................................... 114 11.2.2.3. Peristalsis ....................................................................................... 114

11.3. Visceral Interactions ................................................................................. 114 11.3.1. General ................................................................................................. 114 11.3.2. Relationships ........................................................................................ 115

11.3.2.1. Gliding Surfaces ............................................................................. 115 11.3.2.2. Ligamentous Suspensory System ................................................. 115 11.3.2.3. The Mesentery ............................................................................... 115 11.3.2.4. The Omenta ................................................................................... 116 11.3.2.5. The Turgor Effect and the Intracavitary Pressures ........................ 116

11.4. Mobility Loss ............................................................................................. 116 11.4.1. Diaphragm Dysfunction ........................................................................ 116 11.4.2. Adhesions ............................................................................................. 116 11.4.3. Retractions ........................................................................................... 117

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11.4.4. Trophic Tissue Changes ....................................................................... 117 11.4.5. Congestion ........................................................................................... 117 11.4.6. Postural Disorders ................................................................................ 117 11.4.7. Visceral Mobility Loss ........................................................................... 118

11.5. Visceral Hypermobility ............................................................................. 119 11.6. Osteopathic Visceral Examination .......................................................... 119 11.7. Bibliography Visceral Osteopathy ........................................................... 120

12. Abbreviations ................................................................................................... 121

13. Specific Terms ................................................................................................. 122

14. All Videos ......................................................................................................... 123

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1. Introduction The osteopath is often confronted with patients suffering from low back or pelvic pain associated with somatic dysfunction of the sacrum. The initial osteopathic findings are then connective tissue swelling at the level of the sacrum, palpation pain at the level of the coccyx tip and loss of mobility of the sacrum and the pelvis.

There is often a relationship with the visceral pelvis and the back pain is often associated with the menstrual cycle.

In this e-book the anatomy and the function of the uterus and the ovaries are discussed from an osteopathic point of view.

Furthermore, it is clearly demonstrated how and when visceral techniques are most appropriately used for these organs. Both the external tests / techniques and the internal vaginal tests and techniques are described.

For the osteopath it is not only important to understand normal anatomy and physiology of these organs but it is also essential to know the anatomical, physiological, neurological, haematological and biomechanical characteristics of a condition, syndrome or disease. Only then is the osteopath able to appropriately assess and influence the regional mechanical, vascular, neurological and hormonal factors. But most importantly this allows formulation of a correct differential diagnosis which provides indication or otherwise for osteopathic treatment. Pure functional complaints can be effectively treated with osteopathy, however, even in cases of structural disease osteopathy can play a valuable complementary role as part of the multidisciplinary approach.

For the reader who is not familiar with the osteopathic visceral approach please consult chapter 11 at the end of this e-book.

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2. Anatomy (Dalley & Agur 2004, Gray 1995 & 2000, Imholtz 2001, McMinn & Hutchings 2002, Netter 2003, Sobotta 2000, Tortora 1989)

2.1. Position

2.1.1. The Uterus

2.1.1.1. Normal Position The uterus (Figure 1) is posterior to the bladder and anterior to the rectum, central in the pelvis.

The superior side of the uterus reaches to 2 cm above the pubic symphysis in a supine woman (Figure 2).

The corpus of the uterus and the cervix form an angle of 125°.

In a newborn girl the uterus extends out of the lesser pelvis and descends gradually over the years (until puberty) to the adult position.

Figure 1 - Normal position of the uterus in the sagittal plane

2 cm 125°

Dorsal Ventral

Sacr

um

Uterus

Peritoneum

Bladder

Pubis

Rectum

Peritoneal cavity

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Figure 32 - Myomas

5.1.4. Congenital Anomalies Congenital anomalies of the uterus are rare. They occur due to lack of fusion of the canals of Müller during the foetal period. The consequence is that the uterus is of two compartments: a duplex or bipartite uterus. Usually there is no problem with fertility but during pregnancy itself complications can occur.

5.1.5. Endometrial Polyp An endometrial polyp (Figure 33) is a polyp, which grows within the endometrium. This condition is benign but can lead to bleeding.

The condition cannot be palpated. The polyp can be identified with ultrasound or hysteroscope (intra-uterine observation). Surgical removal is the treatment of choice.

Figure 33 - Endometrial polyp

Cranial Caudal

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6.1.2. General Tests of the visceral Pelvis (Video 2)

6.1.2.1. Test 1 • Pelvis central/ventral.

• Pubovesical ligaments/bladder/uterus.

6.1.2.2. Test 2 • Pelvis central/dorsal.

• Uterus/Douglas pouch/rectum.

6.1.2.3. Test 3 • Pelvis lateral right.

• Bladder - internal obturator muscle/rectum - piriformis muscle/congestion broad ligament right.

6.1.2.4. Test 4 • Pelvis lateral left.

• Bladder - internal obturator muscle/rectum - piriformis muscle/congestion broad ligament left.

Video 2 - General tests of the visceral pelvis

6.1.2.5. Test Criteria These tests are for pain and resistance.

6.1.2.6. Possible Findings * If all tests are positive for resistance, with mild pain: a general pelvic congestion is present (Hobbs 1990).

The treatment consists of decongestion of all pelvic structures.

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7. Osteopathic Techniques 7.1. General Techniques

7.1.1. Visceral Decongestion of the lesser Pelvis The patient flexes both hips.

The osteopath cups both hands as deep as possible, caudal and posterior, in the lesser pelvis. The visceral mass is lifted during exhalation.

This cranial traction is held until the patient feels the traction as a stretch. The patient is then instructed to inhale again (the lift is held).

During the following exhalation the hands are placed deeper into the lesser pelvis.

This technique is repeated until the patient feels no traction.

During the last phase the osteopath holds the visceral mass cranial and instructs the patient to slowly straighten both legs along the table.

The drainage occurs mostly due to the stretch of the underlying fascia – where many of the blood vessels are embedded.

Video 20 - Visceral decongestion of the lesser pelvis

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9. About the Authors

Grégoire Lason Luc Peeters Gent (B), 21.11.54 Terhagen (B), 18.07.55

Both authors are holders of university degrees, namely the Master of Science in Osteopathy (MSc.Ost. – University of Applied Sciences), and are very active with the promotion and academic structuring of osteopathy in Europe. In 1987 they began The International Academy of Osteopathy (IAO) and are, to this day, the joint-principals of this academy. The IAO is since several years the largest teaching institute for osteopathy in Europe. Both osteopaths are members of diverse professional organisations, including the American Academy of Osteopathy (AAO), the International Osteopathic Alliance (IOA) and the World Osteopathic Health Organisation (WOHO), as part of their mission to improve osteopathic development. This osteopathic encyclopaedia aims to demonstrate the concept that a proper osteopathic examination and treatment is based upon the integration of three systems: the musculoskeletal, visceral and craniosacral systems.

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