Müllerian anomalies represent a group of congenital disorders of the reproductive tract, affecting 5–7 % of those born with a female reproductive tract and 13.3 % with a history of miscarriage.1,2 Variations in Müllerian anomalies fall into two categories: non-obstructive and obstructive. While non-obstructive Müllerian anomalies usually present without symptoms, obstructive Müllerian anomalies commonly present with pain, requiring surgical intervention to create a menstrual outflow tract, which often requires complex reconstructive surgery. These anomalies carry the additional risks of endometriosis, preterm birth, fetal malpresentation, ectopic pregnancy, and infertility which are important counseling points.2,3,4 It is important for pediatric medical and surgical providers to be familiar with the presenting signs and symptoms of Müllerian anomalies and recognize when to refer a patient to a facility for expertise in management. Here, we will focus on the clinical considerations for diagnosis and management of complex obstructive Müllerian anomalies with a brief review of non-obstructive Müllerian anomalies.