Eric R. Sokol, MDAssistant Professor that Obstetrics and also Gynecology,Assistant Professor of Urology (by Courtesy),Co-Chief, Urogynecology and also Pelvic reconstructive Surgery,Stanford University school of Medicine, Stanford, California, USA
The femalereproductive organsinclude the uterus, fallopian tubes, and the ovaries (Fig. 1). Their position, size, and anatomic connections vary substantially with age and the physiologic alters of menstruation, pregnancy, and also menopause.
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Fig. 1. Schema of the woman reproductive organs.
The uterus varies substantially in size, shape and also weight relying on the condition of parturition and also estrogenic stimulation. Theuterusis a fibromuscular organ thatcan bedivided right into the upper muscular uterine corpus and also thelower fibrous cervix, i beg your pardon extends into the vagina. The upper part of the uterus over the insertion that the fallopian tube is referred to as the fundus.The narrow section situated between corpus and also cervix is recognized as the isthmus and also lies about at the level of the food of the uterine artery and also the interior os of the cervix. The endometrial cavity lies in ~ the uterine body andis surrounded by a thick, muscular wall.
The musculature the the uterus is in number of layers. There is an external longitudinal class (stratum supra-vasculare) continuing into the fallopian tubes and also round ligaments. The vascular class (stratum vasculare) is composed of plenty of interlacing spiral groups of smooth muscles and contains plenty of blood vessels. An inside layer is composed of muscle yarn arranged both longitudinally and obliquely.
The cervix, i m sorry protrudes right into the vagina, is generally 2–3 centimeter long. The intravaginal section of the cervix, well-known as the portio vaginalis, ordinarily is covered with nonkeritinizing squamous epithelium v a variety of mucus-secreting glands (Fig. 2). The outside os is the opening of the cervix within the vagina. Above the outside os lies the fusiform endocervical canal, around 2 cm long and also lined through columnar epithelium and endocervical glands. The intersection where the squamous epithelium of the exocervix and also columnar epithelium that the endocervical canal meet, the squamocolumnar junction, is geographically variable and dependent on hormonal stimulation. The is this dynamic interface, the transformation zone, that is most delicate to the advancement of squamous neoplasia. In early childhood, throughout pregnancy, or with oral contraceptive use, columnar epithelium may prolong from the endocervical canal ~ above the exocervix, a problem known together eversion or ectopy. After ~ menopause, the transformation zone typically recedes totally into the endocervical canal.
At the upper end of the endocervical canal in ~ the junction with the uterine cavity is the inner os. The endocervical canal in the nullipara is inside wall by mucosa arranged in a series of folds. A vertical fold is existing on the anterior and also posterior cervical walls; from these, oblique crease radiate. These folds have actually been called the arbor vitae uteri or plicae palmatae. The was previously thought that tubular glands descend vertically native the surface and divide into countless branches creating compound racemose glands; however, secondary changes brought about by the intense growth activity of the columnar cells result in the development of tunnels, secondary clefts, and also exophytic processes.
Fig. 2. Photomicrograph (low power) of the epithelial lining at the junction the the cervix and vagina in the human. The glands that the cervix are certainly evident. There are no glands underlying the squamous epithelium of the vagina. (After R. Shroder.)
The endometrial cavity lies above the inner cervical os. The is approximately triangular in shape and measures roughly 3.5 cm in length. Ordinarily, the anterior and also posterior wall surfaces of the uterus lie in apposition so that tiny if any actual cavity is present. At every cornu or horn the the uterus,thecavity the the uterusbecomes consistent with the lumen of a fallopian tube. Peritoneum covers many of the body of the uterus and also the posterior cervix and also is recognized as the serosa. Laterally, the vast ligament, a double layer that peritoneum extending the neurovascular it is provided to the uterus, inserts right into the cervix and corpus. Anteriorly, the bladder lies end the isthmic and also cervical region of the uterus.
The “positions” that the uterus space of considerable interest however of much much less importance in gynecologic exercise than 50 years ago. The most common position of the uterus in a nulligravid woman is in moderate anteflexion or bent slightly anteriorly, and the uterus together a totality is inclined toward the symphysis in ante version versus the bladder, adapting its position as the last organ distends or empties (Fig. 3 and also Fig. 4). In a variable variety of women, the uterus is retroverted or skinny posteriorly or retroflexed toward the sacrum. Rather a few disabilities were attributed to these “malpositions” in the past including dysmenorrhea, practical uterine bleeding, backache, dyspareunia, and also leukorrhea. Many normal uteri space in mid position, with the axis the uterus being practically parallel to the spine.
Fig. 3. Dissection reflecting the cephalic facet of the mrs genitalia and their relationships.
Fig. 4. Transverse section of the abdomen above the crests that the ilia. This ar is 1 inch over the pubis and extends through the disk between the sacrum and the critical lumbar vertebra.
The peritoneum consist of the uterus and is separated from the uterine musculature through a slim layer that periuterine fascia, i beg your pardon is a continuation and also extension that the transversalis fascia. This cell phone fascial great is areolar tissue and also is quickly separated other than for a midline seam or raphe between the uterus and also bladder anteriorly and also between uterus and also peritoneum posteriorly in ~ the level of the isthmus. Posteriorly the sweeps down over the posterior vaginal wall and the cul-de-sac.
The blood it is provided of the uterus is obtained chiefly from the uterine arteries (Fig. 5). This arise indigenous the hypogastric artery and also swing toward the uterus, i beg your pardon they with at roughly the level of the inner os (Fig. 6 and also Fig. 7). Right here the uterine arteries divide, the descending limb coursing downward along the cervix and also lateral wall of the vagina. The ascending limb passes increase alongside the uterus and also continues listed below the fallopian tube. Constant anterior and also posterior branches go to vagina, cervix, and uterus.
Fig. 5. Arterial blood it is provided of the common tube, ovary, and also uterus. (Courtesy that Dr man A. Sampson.) (From Norris: Gonorrhoea in Women. Philadelphia: Saunders.)
Fig. 6. Ventral view of a deep dissection the the urinary bladder and also the blood it is provided to the left next of the internal genitalia, showing the relationship of the uterine ship to the ureter.
Fig. 7. Blood it is provided of thereproductive organswith relationship to the ureter and trigone the the urinary bladder.
The ovarian artery, i beg your pardon ordinarily occurs from the aorta, passes along the ovary, separating into a number of branches. In ~ several locations in the broad ligament there space anastomotic connections in between the tubal branch the the uterine artery and also the ovarian artery. A branch the the uterine artery nourishes the ring ligament. The veinsgenerally companion the arteries.
Using injection and also microradiographic and histologic techniques to examine the vascular anatomy that the uterus, Farrer-Brown et al.1 verified that the uterine arteries run a tortuous course in between the two layers that the vast ligament follow me the lateral next of the uterus and also turn laterally at the junction the the uterus and fallopian tube, run toward the hilum of the ovary, and also terminate by involvement the ovarian arteries. In the wide ligament each uterine artery provides lateral branches that immediately enter the uterus and give off tortuous anterior and posterior arcuate divisions, which operation circumferentially in the myometrium approximately at the junction the its outer and middle thirds. In the midline the terminal branches of both arcuate arteries anastomose with those of the contralateral side.
Each arcuate artery throughout its course offers off countless branches running both centrifugally in the direction of the serosa and also centripetally towards the endometrium. The arteries come the serosa at firstare directed radially and then generally became more circumferential. Over there is a plexus of small arterial radicals with a radial distribution located immediately below the serosa. The inside two-thirds the the myometrium is gave by tortuous radial branches of the arcuate arteries. They provide numerous branches end in a capillary network i beg your pardon surrounds teams of muscle fibers. One abrupt adjust in the density of the arterial pattern wake up at the junction of the basal class of the endometrium v the subjacent myometrium. The endometrial vessels are relatively sparse in comparison v those the the myometrium at every stages that the term cycle.
The uterus is partially supported by 3 pairs that ligaments. The paired round ligaments extend from the anterosuperior surface ar of the uterus v the inner inguinal rings and also through the inguinal canals to finish in the labia majors. They room composed the muscle fibers, connective tissue, blood vessels, nerves, and also lymphatics. The round ligaments large with loved one ease, particularly in pregnancy. The uterosacral ligaments room condensations the endopelvic fascia the arise indigenous the posterior wall surface of the uterus at the level the the interior cervical os. They fan out in the retroperitoneal layer and attach broadly at the second, third, and fourth segments of the sacrum.They are predominately composed of smoothmuscle but likewise containconnective tissue, blood vessels, lymphatics, and also parasympathetic nerve fibers.2 The paired cardinal (Mackenrodt"s) or transverse cervical ligaments arise native the anterior and posterior marginal wall surfaces of the cervix andfan the end laterally to insert into the fascia overlying the obturator muscles and the levator ani muscles. The cardinal ligaments type the base of the large ligament.They are composed the perivascular connective tissue and also nerves the surround the uterine artery and veins. The cardinal and also uterosacral ligament complicated is jointly called the parametrium.
The broad ligament is developed by crease of peritoneum covering the fallopian tubes, the infundibulopelvic vessels, and the hilus that the ovary. It includes a number of structures: fallopian tube, round ligament, ovarian ligament, uterine and ovarian blood vessels, nerves, lymphatics, and mesonephric remnants. Listed below the infundibulopelvic structures, the anterior and posterior leaves of peritoneum lied in apposition, leave a clear room below the tube with its tubal branch the the uterine artery. This avascular area is valuable to the surgeon in isolating the adnexal structures and in staying clear of blood vessels while performing tubal ligations.
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The endometrium present the uterine cavity and also is thought about to have actually three layers: the pars basalis, the zona spongiosa, and the superficial zona compacta. The straight branches of the radial arteries the the uterus terminate in capillaries in the basal layer, if the spiral or coiled branches penetrate to the surface epithelium, wherein they provide rise to superficial capillaries. Sinus-like dilatations that the capillaries in the superficial great are referred to as “lakes.” these vascular lakes and also capillaries room drained by little veins.
The endometrium varies greatly depending upon the step of the term cycle. Proliferation that the endometrium occurs under the influence of estrogen; maturation wake up under the affect of progesterone. The uterine endometrial cycle deserve to be divided into 3 phases: the follicular or proliferative phase, the luteal or secretory phase, and also the expression phase. The follicular, or proliferative phase, spans from the end of the menstruation till ovulation. Raising levels that estrogen induce proliferation that the functionalis native stem cells of the basalis, proliferation that endometrial glands, and also proliferation that stromal connective tissue. Endometrial glands are elongated v narrow lumens and also their epithelial cells contain some glycogen. Glycogen, however, is not secreted throughout the follicular phase. Spiral arteries elongate and also span the size of the endometrium.
After development of the corpus luteum, the endometrial glands grow, end up being tortuous, and secrete. The luteal, or secretory, phase starts at ovulation and lasts until the menstrual phase of the following cycle (Fig. 8). In ~ the beginning of the luteal phase, progesterone induces the endometrial glands to secrete glycogen, mucus, and other substances. These glands come to be tortuous and also have big lumens because of increased secretory activity. The spiral arteries expand into the superficial layer of the endometrium. The spiral capillaries build a terminal network of superficial capillaries. This changes result in the development of a predeciduum all set for the arrival of the trophoblast.