Bicornuate Uterus: Symptoms, Types, Causes and Treatment

A bicornuate uterus is a fascinating, though often challenging, congenital anomaly of the female reproductive system. While many women with this condition may never know they have it, for others, a bicornuate uterus can present with symptoms that impact fertility, pregnancy, and overall well-being. In this article, we’ll explore the symptoms, types, causes, and treatments of bicornuate uterus, drawing on recent scientific research and real patient experiences.

Symptoms of Bicornuate Uterus

A bicornuate uterus can be asymptomatic, but for some, it causes distressing and sometimes confusing symptoms. Understanding these potential signs is vital for timely diagnosis and effective management.

Symptom	Description	Prevalence/Impact	Source(s)
Abdominal Pain	Recurrent or acute lower abdominal pain	Can be severe or mild	1, 6
Infertility	Difficulty conceiving or carrying a pregnancy	Not in all cases	2, 5, 7, 11
Miscarriage	Recurrent pregnancy loss	Up to 25%	4, 5, 11
Preterm Birth	Delivery before 37 weeks	15–25%	4, 5, 11
Malpresentation	Breech or abnormal fetal positions	Increased risk	4, 5, 11
Menstrual Issues	Irregular or painful periods	Possible but less common	1, 6
Urinary/GI Symptoms	Pressure on bladder or bowels	Rare, due to mass effect	1
Asymptomatic	No symptoms; discovered incidentally	Common	5, 8

Table 1: Key Symptoms

Recognizing the Signs

A bicornuate uterus is sometimes only discovered during evaluation for infertility or miscarriage. However, it can cause:

• Acute or chronic pelvic pain: Some women present with pain, especially if there is a complication like hematometra (blood trapped in one horn) 1.
• Reproductive difficulties: Infertility, recurrent miscarriages, and preterm birth are the most commonly reported issues, but not all women will experience these problems 2 4 5 7 11 12.
• Obstetric complications: Increased rates of malpresentation (such as breech babies), cervical incompetence, and preterm premature rupture of membranes are seen 4 5 11.
• Menstrual and urinary symptoms: Occasionally, associated conditions such as endometriosis, fibroids, or hematometra can cause heavy periods, pain, or pressure symptoms affecting urination or bowel movements 1 6.

When Are Symptoms Most Noticeable?

Most women with a bicornuate uterus are asymptomatic, and the anomaly is often discovered during imaging for unrelated reasons, such as routine pregnancy scans or investigations for other gynecological issues 5 8. However, symptoms may become more apparent in the context of:

• Unexplained infertility
• Recurrent pregnancy loss
• Difficulties in labor or abnormal fetal positions
• Associated pelvic masses or complications (e.g., fibroids, hematometra, or pelvic organ prolapse) 1 6 8

The Impact of Associated Conditions

The presence of other gynecological conditions, such as fibroids, adenomyosis, or endometriosis, can increase the likelihood of symptoms and complicate the clinical picture 1 6 7. This can make diagnosis a challenge and highlights the need for comprehensive evaluation in symptomatic women.

Types of Bicornuate Uterus

While "bicornuate uterus" is an umbrella term, there are important subtypes with distinct anatomical and clinical implications. Understanding these helps guide management and predict outcomes.

Type	Description	Key Features	Source(s)
Bicornuate Bicollis	Two uterine horns, two cervices	Double cervix, ± double vagina	4, 5, 9
Bicornuate Unicollis	Two uterine horns, single cervix	One cervix, single vagina	1, 5, 6, 11
Complete Bicornuate	Full division to level of cervix	Deep fundal cleft	3, 4, 5
Partial Bicornuate	Partial division, single lower cavity	Shallow fundal indentation	3, 5
Associated Variants	With rudimentary horn, septum, or double vagina	Complex anatomy	1, 6, 9

Table 2: Subtypes of Bicornuate Uterus

Anatomy and Classification

Bicornuate uterus results from incomplete fusion of the two Müllerian ducts during embryogenesis, leading to a uterus with two "horns" 5 11. The degree of separation forms the basis for classification:

Bicornuate Bicollis

• Two cervices (and sometimes two vaginas)
• Most pronounced degree of uterine duplication
• Each horn communicates with its own cervix 4 5 9

Bicornuate Unicollis

• Two uterine horns but only one cervix and one vagina
• More common than the bicollis variant 1 5 6 11

Complete vs. Partial Bicornuate

• Complete: Division extends down to the level of the cervix, with deep external fundal cleft 3 4 5
• Partial: Only the upper part of the uterus is divided; the lower part is unified 3 5

Associated Variants

• Rudimentary horn: One horn may be underdeveloped or non-communicating, which can trap menstrual blood (hematometra), leading to pain 1 6
• Other anomalies: Sometimes, there is associated duplication of the vagina (double vagina) or septal structures 6 9

Diagnostic Tools

Diagnosis is made via imaging—ultrasound is often the first step, but MRI or hysterosalpingography provides greater detail 5. Sometimes, laparoscopy or hysteroscopy is necessary for definitive diagnosis and to guide treatment.

Clinical Importance of Type

• Partial bicornuate uterus often has better reproductive outcomes, particularly after surgical correction (metroplasty), than complete forms 3.
• Complete bicornuate uterus may behave similarly to uterus didelphys and is less amenable to surgical unification 3.
• The type of anomaly can influence pregnancy risks and surgical management choices.

Causes of Bicornuate Uterus

Understanding why a bicornuate uterus develops helps demystify this condition and informs counseling for affected women.

Cause	Mechanism/Description	Timing	Source(s)
Müllerian Duct Fusion Failure	Incomplete fusion of embryonic ducts	10th week gestation	5, 11
Genetic/Developmental Factors	Underlying genetic or idiopathic factors	Fetal development	6, 11
Not Hereditary	Usually sporadic, not typically inherited	—	5, 11
Associated Conditions	May occur with other congenital anomalies	Variable	6

Table 3: Causes and Developmental Mechanisms

Embryological Origins

The uterus is formed during fetal development from two Müllerian (paramesonephric) ducts. These ducts normally fuse to form a single uterus. In a bicornuate uterus, this fusion is incomplete, resulting in two separate upper uterine cavities that may remain partially or completely divided 5 11.

• Critical period: Fusion typically occurs around the 10th week of gestation 11.
• Result: The upper uterus has two “horns,” while the lower part may be unified or remain duplicated.

Genetic and Developmental Factors

• Most cases are sporadic; they are not inherited in a predictable Mendelian fashion 5 11.
• The precise triggers for fusion failure are not fully understood, but genetic and environmental factors have been proposed 6.
• Bicornuate uterus may appear alongside other congenital malformations, including kidney and urinary tract anomalies, though this is less common 6.

Associated Pathological Conditions

Women with bicornuate uterus may also have other uterine pathologies, such as fibroids, adenomyosis, endometriosis, or tubercular infections 1 6 7. While these are not direct causes, their presence can complicate both diagnosis and management.

Treatment of Bicornuate Uterus

Treatment is highly individualized and depends on the patient’s symptoms, reproductive goals, and the type and severity of the anomaly.

Treatment Option	Description/Indication	Outcome/Considerations	Source(s)
Observation	Asymptomatic or successful pregnancies	No intervention needed	5, 8, 12
Fertility Treatment	IUI, IVF/ICSI if associated with infertility	Comparable outcomes to normal uterus	11, 12
Surgical Correction	Metroplasty (open, laparoscopic, transvaginal)	Improves term pregnancy rates in select cases	1, 2, 3, 10
Cerclage	Cervical stitch for cervical insufficiency	May improve fetal survival	11
Management of Complications	Address fibroids, endometriosis, etc.	Reduces symptoms, improves outcome	1, 6, 7

Table 4: Treatment Approaches and Indications

When Is Treatment Needed?

Most women with bicornuate uterus do not require any intervention, especially if they are asymptomatic and have no reproductive problems 5 8 12. However, treatment is considered when:

• There is recurrent miscarriage or preterm birth
• Infertility persists after basic evaluation
• Obstetric complications (e.g., malpresentation, cervical insufficiency) are present
• There are associated pathologies (such as fibroids, endometriosis, or hematometra) causing symptoms 1 2 3 6 7

Fertility and Pregnancy Management

• Assisted reproductive technologies: Women with bicornuate uterus can conceive with intrauterine insemination (IUI) or in vitro fertilization (IVF/ICSI), and outcomes are similar to women without the anomaly 11 12.
• Pregnancy monitoring: Close follow-up is key to managing risks, including cervical length surveillance and early identification of malpresentation or cervical incompetence 5 11.

Surgical Correction (Metroplasty)

• Indications: Usually reserved for women with repeated pregnancy losses or severe uterine anatomic distortion 2 3 10.
• Procedures: Strassmann metroplasty (open or minimally invasive) surgically unifies the uterine cavity. Laparoscopic or laparoscopic-assisted transvaginal approaches are now possible, reducing recovery time 1 10.
• Outcomes: Metroplasty can significantly improve reproductive outcomes, especially in partial bicornuate uterus; however, results are less favorable in the complete type 3.
• Risks: Surgical intervention can itself carry risks, such as uterine rupture or abnormal placental attachment in future pregnancies 13.

Preventing and Managing Complications

• Cervical cerclage: Placement of a stitch to reinforce the cervix may be considered in women with a history of cervical insufficiency, as bicornuate uterus is associated with the highest rates of this complication among uterine anomalies 11.
• Treatment of associated conditions: Addressing fibroids, endometriosis, or other pelvic pathologies can optimize reproductive outcomes 1 6 7.

Counseling and Individualized Care

• Patient-centered approach: Not all women require aggressive intervention. Shared decision-making, considering reproductive desires and risk tolerance, is essential.
• Education: Women should be informed of potential risks in pregnancy and the importance of specialized obstetric care 5 13.

Conclusion

A bicornuate uterus is a rare but significant congenital uterine anomaly that can impact women in different ways. Here are the main points to remember:

• Symptoms: Most women are asymptomatic, but others may experience pelvic pain, infertility, recurrent miscarriage, preterm birth, and abnormal fetal positions.
• Types: There are several subtypes, with bicornuate bicollis and unicollis being the most common. The extent of division affects prognosis and management.
• Causes: The condition arises from incomplete fusion of the Müllerian ducts during embryonic development, usually due to sporadic, non-hereditary factors.
• Treatment: Options range from observation to fertility treatment and surgical correction, tailored to the woman’s symptoms and reproductive goals. Many women have successful pregnancies, especially with close monitoring and timely intervention.

Key takeaways:

• Bicornuate uterus is often discovered incidentally.
• Not all cases require treatment.
• Reproductive outcomes can be good, especially with individualized care.
• Surgical and non-surgical treatments are available for those with complications.
• Patient education, careful monitoring, and addressing associated pathologies are crucial for optimal outcomes.

If you suspect you may have a bicornuate uterus or are experiencing related symptoms, consult a qualified gynecologist for proper evaluation and personalized guidance.