Anatomy, Abdomen and Pelvis, Uterus


Article Author:
William Gossman
Sarah Fagan
Jessica Sosa-Stanley


Article Editor:
Diana Peterson


Editors In Chief:
Niamh Condon
Terry Tressler


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Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
7/11/2019 9:26:49 PM

Introduction

The uterus is a pear-shaped dynamic organ that is responsible for a variety of functions such as gestation (pregnancy), menstruation, and labor and delivery. While most humans have one uterus, sometimes the development in utero may be incomplete, this is called a Mullerian Anomaly and can lead to many variants, ranging from a uterine septum to uterine didelphys (double uterus). In the normal anatomy, the uterus is located in the female pelvis immediately posterior to the bladder and anterior to the rectum. The female uterus is divided into three main anatomic segments (from superior to inferior): the fundus, corpus (body), and cervix (which protrudes into the vagina).[1][2][3]

The uterus is supported by several ligaments including the utero ovarian ligament, round ligament, broad ligament, cardinal ligament, and uterosacral ligaments. It is further supported (inferiorly) by the pelvic diaphragm, urogenital diaphragm, and perineal body. The uterus may naturally lie in different positions such as anteverted/retroverted, anteflexed/retroflexed, or midline, and it may be rotated (especially during pregnancy). The uterus most commonly lies in an anteflexed and anteverted position in 50% of women.

When the uterus is in a retroverted/retroflexed or "tipped" position, it may cause pelvic pain, dyspareunia, minor incontinence, fertility difficulty, and difficulty inserting tampons. In pregnancy, this may lead to uterine incarceration.

The uterus is comprised of three tissue layers which include the following:

  • Endometrium: the inner lining and consists of the functional (superficial) and basal endometrium. The functional layer responds to reproductive hormones. When this layer is shed, this results in menstrual bleeding. If there is damage to the basal endometrium, this can result in the formation of adhesions and fibrosis (Asherman syndrome)
  • Myometrium: the muscle layer and is composed of smooth muscle cells.
  • Serosa/Perimetrium: the thin outer layer composed of epithelial cells

Adenomyosis is a benign condition that occurs when the endometrial layer invades into the myometrial layer, either focally or diffusely.

Structure and Function

The uterus functions by accepting the fertilized ovum which passes through the fallopian tube. The ovum then implants into the endometrium where it receives nourishment from blood vessels developed exclusively for that purpose. As the embryo grows and matures, the uterus expands to accommodate the pregnancy. During normal labor, the uterus contracts as the cervix dilates, and this results in delivery of the infant.

Embryology

The early development of the uterus is quite complex. At about eight weeks of gestation, primordia for both female and male internal genitalia [paramesonephric (Mullerian) and mesonephric (Wolffian)] ducts appear. The sexual differentiation process involves a series of steps which occur due to growth factors, hormonal signals, and inherited genetic influences.

In the female embryo, because of the absence of a Y chromosome and lack of testosterone from any testicular tissue, the normal sequence of developmental events result in canalization and fusion of the paramesonephric (Mullerian) ducts in the middle of the pelvis which gives rise to the female pelvic organs. At this time, the mesonephric (Wolffian) ducts regress. Any abnormality that occurs during this phase of development may result in a variety of paramesonephric anomalies.

Blood Supply and Lymphatics

The uterus receives blood from the uterine and ovarian arteries, which arise from the anterior branch of the internal iliac artery. As the blood supply enters the myometrium, it branches into the arcuate arteries, which branch into the radial arteries. As they enter the level of the endometrium, they branch into the basal and spiral arteries.

Nerves

Nerves from T11 and T12 innervate the uterus. The sympathetic supply is from the hypogastric plexus, and the parasympathetic supply is from S2 to S4.

Muscles

The uterus is located between the urinary bladder anteriorly and the rectum posteriorly. The average dimensions of the uterus in an adult female are 8 cm long, 5 cm across, and 4 cm thick. The uterine cavity has an average volume of 80 mL to 200 mL. The uterus is divided into three segments namely: the body, the cervix, and the fundus.

Physiologic Variants

The anatomical position within the pelvis may vary. The normal position is an anteverted uterus, which is tipped forward, whereas a retroverted uterus is angled slightly posterior. The uterine position is also sometimes described in relation to the location of the fundus; that is, an anteflexed uterus, which is normal and where the fundus tilts forward. On the other hand, a retroflexed uterus is tilted posteriorly.

The uterus may also vary in size and shape depending on the reproductive phase of the female and response to the female sex hormones. For example, before puberty, the uterus is small, but during the reproductive years, the uterus may be quite large.

Also, a nulliparous uterus is usually smaller than a multiparous uterus. Furthermore, as the female reaches menopause, the uterus starts to atrophy chiefly due to lack of hormonal stimulation and loss of menstruation.[4][5]

Surgical Considerations

Uterine anomalies of clinical significance include:

  • Segmental hypoplasia (cervical, vaginal, fundal or combined)
  • Unicornuate uterus (with rudimentary horn and a communicating or non communicating endometrial cavity
  • Uterine didelphys
  • Bicornuate uterus 
  • Septate uterus
  • Women exposed to Diethylstilbestrol may develop a T-shaped uterus

Clinical Significance

The uterus is affected by a variety of gynecologic disorders including cancer, organ prolapse, fibroids, polyps, infections, malformations, and adhesions. Removal of the uterus is called a hysterectomy. This is the second most common surgical procedure performed on women in the United States ( a cesarean section is the most common).Uterine cancer is the most common gynecologic cancer in developed countries and is associated with excess estrogen. Exogenous sources of estrogen include tamoxifen use or unopposed estrogen replacement therapy. Tamoxifen increases the risk of endometrial cancer due to its ability to stimulate the estrogen receptors found on the endometrium. Endogenous sources of estrogen include polycystic ovary syndrome,  obesity, and estrogen-secreting tumors such as granulosa cell tumors. The majority of women with endometrial cancer will present with abnormal vaginal bleeding or postmenopausal vaginal bleeding. Less commonly, they may present with abdominal pain, change in bowel habits, weight loss, and bloat.

Other Issues

Besides uterine abnormalities, the uterus may also be associated with several types of pathological disorders such as uterine fibroids, adenomyosis, endometrial hyperplasia, endometrial cancer, Asherman syndrome, uterine prolapse, and incontinence.


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Anatomy, Abdomen and Pelvis, Uterus - References

References

Chaudhry SR,Chaudhry K, Anatomy, Abdomen and Pelvis, Uterus Round Ligament null. 2018 Jan     [PubMed]
Craig ME,Billow M, Anatomy, Abdomen and Pelvis, Broad Ligaments null. 2018 Jan     [PubMed]
Chaudhry R,Chaudhry K, Anatomy, Abdomen and Pelvis, Uterine Arteries null. 2018 Jan     [PubMed]
Alimi Y,Iwanaga J,Loukas M,Tubbs RS, The Clinical Anatomy of Endometriosis: A Review. Cureus. 2018 Sep 25     [PubMed]
Al-Qattan MM,Al-Qattan AM, Fibromodulin: Structure, Physiological Functions, and an Emphasis on its Potential Clinical Applications in Various Diseases. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 2018 Oct     [PubMed]

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