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The Cervix

The cervix is the inferior fibromuscular cylinder of the uterus that projects into the vaginal vault and contains the endocervical canal linking the uterine cavity to the vagina.

See also The Vagina for the surrounding fornices; The Ureters for the "water under the bridge" geometry; and Pelvic Neuroanatomy for the pelvic plexus.

Gross Anatomy​

The cervix is a cylinder; one cited review describes it as approximately 2 cm long. It divides anatomically into two portions:[1][2]

  • Supravaginal portion. Above the vaginal attachment, surrounded by the cardinal-ligament complex and paracervical tissues.
  • Vaginal portion (portio vaginalis). Protrudes into the vaginal vault, visible at speculum examination; demarcated from the vault by the anterior, posterior, and lateral fornices.

The canal extends from the internal os (communication with the uterine cavity) to the external os (communication with the vaginal vault). The external os is slit-like in parous women and round in nulliparas, a difference seen at pessary fitting and at colposcopy.

Three mucosal regions​

RegionEpitheliumSurface landmarks
Ectocervix (portio)Non-keratinized stratified squamous, continuous with vaginal epitheliumSmooth, pink at speculum
EndocervixSimple columnar mucus-secreting; surface thrown into plicae palmatae that increase surface areaRed, granular at speculum; lined by glands
Transformation zone (TZ)Zone of ongoing squamous metaplasia between the original and current squamocolumnar junctions (SCJ)A major site of HPV-associated cervical precancer and cancer; visibility varies by age and individual anatomy[3][4][5]

The TZ commonly becomes more visible on the ectocervix around puberty and may recede into the canal after menopause. Cervical screening follows current age- and risk-based guidance. At colposcopy after an abnormal result, the ASCCP 2023 guideline recommends endocervical curettage when the squamocolumnar junction is not fully visible and for several higher-risk findings (high-grade cytology, HPV 16/18, positive p16/Ki-67 dual stain, prior treatment for cervical precancer). It prefers endocervical curettage for patients aged 40 years and older undergoing colposcopy (BIII), with stated exceptions, and calls it unacceptable in pregnancy (EIII).[20]

Schematic of the cervical transformation zone in speculum view and in cross section

Schematic of the cervical transformation zone. Top: the cervix as seen through a speculum, showing the ectocervix, the transformation zone with Nabothian cysts, the squamocolumnar junction and the endocervix. Bottom: cross section showing columnar epithelium of the endocervix and stratified squamous epithelium of the transformation zone and ectocervix; Nabothian cysts form when endocervical mucous ducts are occluded by overgrowth of squamous epithelium from the newly formed transformation zone. Shaded cells are those derived from endocervical reserve cells. From Deng H, et al. Sci Rep. 2018;8(1):15402, Figure 1 (CC BY).[5]

Structural Supports — The Apex of Pelvic-Floor Reconstruction​

The cervix is the anchoring point of Level-I pelvic support in DeLancey's model. Two ligamentous / connective-tissue complexes suspend it:[11]

ComplexOriginInsertionContents
Cardinal ligament (Mackenrodt)Pelvic sidewall at the obturator internus fasciaLateral cervix and upper vaginaUterine artery and vein, the ureter (crossing beneath the uterine artery), pelvic plexus autonomic fibers, lymphatics
Uterosacral ligament (USL)Presacral fascia at the level of S2–S4Posterior cervix and upper vaginaSympathetic fibers from the pelvic plexus; lymphatic channels

The cardinal and uterosacral supports are mesentery-like visceral ligaments containing connective and adipose tissue, vessels, autonomic nerves and some smooth muscle; the cardinal ligament is chiefly vascular, while the deep uterosacral ligament is rich in autonomic fibers.[33] Clinically:

  • Apical prolapse (uterine / vault) represents failure of the cardinal-uterosacral (CUL) complex.
  • USLS, Manchester (Fothergill), and vaginal hysterectomy with McCall culdoplasty reinforce native apical support. Sacrocolpopexy suspends the vaginal apex to the sacral anterior longitudinal ligament with mesh.[34]
  • Cervical elongation is disproportionate cervical lengthening that may coexist with uterine descent; when the uterine body remains supported, an elongated cervix can mimic apical prolapse. Assess cervical length and apical descent separately when choosing cervical reduction, Manchester repair or apical suspension.[28][29]

Anatomical Relations — Why the Ureter Lives Under the Uterine Artery​

AspectRelationOperative note
AnteriorBladder base and trigone, separated by the vesicocervical/vesicouterine spaceThe plane of anterior dissection in hysterectomy, cervical cancer surgery, and vesicovaginal fistula repair
PosteriorRectum and the rectouterine pouch (Douglas')Approached via the posterior colpotomy; enterocele sits in this peritoneal pocket
LateralBroad ligament, cardinal ligament, uterine vessels, and ureter near the lateral cervix (distance varies)Site of potential iatrogenic ureteric injury

Water under the bridge (the ureteric injury pattern). The uterine artery crosses anterior (over) the ureter near the cervix, but the often-quoted distance of approximately 1.5–2 cm varies with anatomy and pathology. This is a recognized danger zone in hysterectomy and deep paracervical dissection. Identify the ureter and adapt the dissection to the actual anatomy.

A CT study of 499 women found the right ureter closer to the cervix than the left overall (2.0 ± 0.8 vs 2.2 ± 1.0 cm; p < .05), while among the subset with isolated cervical pathology the right ureter was farther away than the left (2.0 ± 0.6 vs 1.7 ± 0.6 cm; p < .05); age was not associated with distance. At least one ureter was within 5 mm of the cervix in 3.6% of normal scans and 10.3% of scans with cervical pathology.[27]

Vascular Supply​

The uterine artery (usually a branch of the anterior division of the internal iliac) is a principal cervical arterial supply; its horizontal parametrial segment gives one or two cervicovaginal branches near the cervix.[7][8][9][35] Additional contributions come from the vaginal artery and, in limited fashion, the middle rectal artery.

In a corrosion-cast study of 20 autopsy cervices (two near-complete casts), the endocervical mucosa showed dense, near-parallel capillaries with few interconnections; the authors suggested that this pattern may aid vascular adaptation during parturition.[7] Even superficial biopsies and LEEP excisions of the non-pregnant cervix bleed.

Venous drainage parallels the arteries to the uterine and vaginal plexuses and thence the internal iliac vein.

Lymphatic drainage of the cervix runs to parametrial, obturator, internal iliac, external iliac, and common iliac nodes, with variable posterior pathways; presacral nodes may receive cervical drainage, but a fixed posterior-lip-to-presacral pathway is not established.[43][44] These pathways guide nodal mapping and indicated lymph-node dissection in cervical-cancer surgery. Wertheim and Okabayashi are named radical-hysterectomy approaches, whereas Querleu–Morrow classes describe parametrial resection extent and consider lymph-node dissection separately.[21][45]

Innervation — Nerve-Sparing and Cervical Cancer Surgery​

The cervix has sympathetic, parasympathetic and sensory innervation and is reported to be more densely innervated than the uterine corpus and fundus.[10][11][12] This innervation is the anatomic substrate of nerve-sparing radical hysterectomy.

SourcePathwayFunction
ParasympatheticS2–S4 pelvic nerve → inferior hypogastric plexus → cardinal ligament (lateral and inferior)Smooth muscle tone and vasodilation; afferent pain fibers
SympatheticT10–L2 hypogastric nerve → inferior hypogastric plexus → uterosacral ligament (posterior)Contraction, vasoconstriction; afferent pain fibers

The inferior hypogastric plexus and its branches to the bladder, rectum and vagina are at risk during paracervical resection. In the 2017 Querleu–Morrow classification, type C1 is nerve-preserving: the hypogastric nerve, inferior hypogastric plexus and bladder branches are identified and preserved while uterine branches are divided. Type C2 does not preserve the autonomic nerves. C1 and C2 are distinct surgical extents. Functional and oncologic outcomes depend on tumor selection and operative execution.[10][11][21]

Cervical Mucus — Compressed to What's Clinically Useful​

Endocervical columnar cells produce a hydrated mucin gel that changes cyclically under estrogen and progesterone control:[13][14][15][16]

  • Periovulatory (estrogen-dominant). Thin, copious, low-viscosity, high-spinnbarkeit mucus with a "ferning" pattern when dried; permissive to sperm transit and partially protective to vaginal flora.
  • Luteal and pregnant (progesterone-dominant). Luteal mucus is relatively thick, scant and less penetrable to sperm. During pregnancy, accumulated cervical mucus forms a compact physical and immune barrier that impedes, but does not completely block, ascending microbes.[36][37]
  • Postmenopausal (hypoestrogenic). Atrophic, thin, reduced mucus, higher vaginal pH (as with vaginal atrophy; see The Vagina).

First, NICE NG123 advises considering vaginal estrogen for genitourinary symptoms and signs of menopause in a patient with prolapse.[25] Second, cervical mucus penetrability testing (the historical post-coital test) has limited modern clinical utility. Third, cervical ectopy (visible columnar epithelium on the ectocervix) is commonly physiological in younger women, oral-contraceptive users and pregnancy.

Cervical Remodeling in Pregnancy (in broad strokes)​

The non-pregnant cervix is a stiff collagen-dominant organ; pregnancy transforms it into a compliant, extensible one through four overlapping phases:[6][17][18][19][22]

  1. Softening. Collagen reorganization increases compliance early in pregnancy while the cervix remains closed and mechanically competent; marked hydration, increased hydrophilic glycosaminoglycans and tensile-strength loss characterize later ripening.[22]
  2. Ripening. Increased compliance and distensibility and reduced tissue stiffness and tensile strength, with greater hydration and collagen-matrix remodeling.[22]
  3. Dilation. Active labor opens the cervix under uterine contraction.
  4. Postpartum repair. Rapid return toward baseline structure.

Cervical insufficiency describes a clinical pattern of painless cervical dilation and pregnancy loss or very early birth in the absence of labor. Cerclage is considered for selected patients according to obstetric history, examination and current guidance, and a prior LEEP, cone or cervical trauma alone does not indicate it.

Clinical Correlations for the Reconstructive Surgeon​

  • Hysterectomy and ureteric injury. The ureter passes close to the cervix and beneath the uterine artery. Identify and protect it during dissection in this region, especially when anatomy is distorted. Cystoscopy can help evaluate suspected urinary-tract injury, but its use and interpretation depend on the operation and clinical circumstances.[24]
  • Nerve-sparing radical hysterectomy. Querleu–Morrow type C1 (but not C2) aims to preserve the hypogastric nerve, inferior hypogastric plexus and bladder branches. The extent of parametrial resection and the cancer-treatment context determine whether nerve preservation is appropriate.[21] In the SHAPE randomized trial of 700 patients with cervical tumors 2 cm or smaller and limited stromal invasion, simple hysterectomy with nodal assessment was noninferior to radical hysterectomy for pelvic recurrence at three years (2.52% versus 2.17%) and had less urinary retention beyond four weeks (0.6% versus 9.9%).[30]
  • Apical prolapse and the cervix. Uterine prolapse involves failure of the cardinal–uterosacral Level-I support complex. During USLS, sutures can compromise the nearby ureter; AUGS recommends intraoperative cystoscopy with confirmation of ureteral efflux during apical prolapse repair.[31][32] Options: vaginal hysterectomy with apical suspension (USL suspension or McCall culdoplasty), sacrospinous hysteropexy, sacrohysteropexy (mesh), and the Manchester (Fothergill) procedure (cervical shortening or amputation with uterosacral plication, often with cardinal plication; anterior colporrhaphy is added for a concomitant anterior defect) for selected uterine descent, including cervical elongation.[38] In a Dutch trial of first uterus-preserving surgery with POP-Q point D at or proximal to −1 cm, two-year composite success was 172/197 (87.3%) after Manchester versus 151/196 (77.0%) after sacrospinous hysteropexy; the composite required absence of prolapse beyond the hymen, absence of bothersome bulge symptoms and no retreatment.[39]
  • Cervical elongation. Disproportionate cervical overgrowth mimics apical prolapse; at examination the uterine body may remain within the pelvis despite a cervix below the hymen. Treatment is trachelectomy or the Manchester procedure, with or without apical suspension.
  • Conization and LEEP. Outpatient excisional procedures for CIN 2/3. Clinically relevant to obstetric outcomes (excision depth is associated with preterm delivery risk) and to the later reconstructive surgeon (cervical stenosis can cause hematometra or dysmenorrhea; cervical shortening affects fertility-preserving cerclage planning).[1]
  • Trachelectomy. Fertility-sparing cervical surgery may include conization, simple or radical trachelectomy after specialist staging and multidisciplinary selection. The ESGO/ESHRE/ESGE fertility-sparing guideline distinguishes favorable tumors around ≤2 cm from selected 2–4-cm cases and requires assessment of histology, nodal status, margins and internal-os involvement.[23]
  • Supracervical (subtotal) hysterectomy and the retained cervix. The cervical stump stays in situ, and the patient continues cervical cancer screening. Complications include persistent cyclical bleeding, stump infection, and, rarely, stump carcinoma, each of which can present to a reconstructive surgeon years later.
  • Sequelae of pelvic radiation. Radiation can cause vesicovaginal or rectovaginal fistula, cystitis, vaginal stenosis, ureteric stricture and bladder dysfunction. Repair planning depends on tissue quality, fistula location, prior treatment and patient goals. EAU reports lower repair success for irradiated than nonirradiated fistulae and weakly recommends an interposition graft when repair is undertaken. If diversion is required, it weakly recommends avoiding irradiated bowel.[24]
  • Vesicocervical space and vesicovaginal fistula. A post-hysterectomy VVF may involve the vaginal cuff and adjacent bladder dissection plane. Repair may use transvaginal or abdominal access, layered closure and, for selected complex or radiated defects, vascularized tissue interposition; an abdominal route is indicated for a high, fixed vault fistula inaccessible vaginally, but no one plane, flap or approach is required for every fistula.[24] See The Vagina.
  • Cervical cancer and the reconstructive burden. Prior radical surgery or chemoradiation can complicate fistula repair, urinary diversion, vaginal reconstruction and bladder-function care. Evaluation is tailored to the presenting problem and may include direct examination, cystoscopy and upper-tract imaging when anatomy or ureteric involvement is uncertain.[24]
  • Cerclage. McDonald (transvaginal, simpler to place) and Shirodkar (transvaginal, submucosal) are vaginal approaches. SMFM recommends offering transabdominal cerclage after a history- or ultrasound-indicated vaginal cerclage followed by spontaneous singleton delivery before 28 weeks (GRADE 1B).[40] Its checklist also lists patients with a history-based indication and too little cervix for a vaginal stitch after trachelectomy or extensive excision as potential candidates.[41] The 2023 ESGO cervical-cancer guideline separately recommends permanent cerclage during simple or radical trachelectomy (IV, B).[42] SMFM suggests both laparoscopic and open transabdominal placement (GRADE 2B) and recommends maternal-fetal medicine consultation (Best Practice).[40] Prior bladder or urethral surgery may complicate access and involve the reconstructive surgeon.
  • Postmenopausal tissue and pessary care. Vaginal estrogen may be considered when prolapse coexists with genitourinary symptoms and signs of menopause; it is not established as a way to improve pessary retention. In a 2025 placebo-controlled trial of 420 postmenopausal women in China already fitted with ring pessaries, 12-month continuation with patient-reported improvement was 181/208 (87.0%) with estrogen versus 176/203 (86.7%) with placebo (risk difference 0.3%, 95% CI −6.2 to 6.9).[26] The estrogen group had fewer reports of excessive discharge (34/208 [16.3%] versus 52/203 [25.6%]), vaginal erosion or ulcer (4/208 [1.9%] versus 14/203 [6.9%]), and vaginal bleeding (3/208 [1.4%] versus 13/203 [6.4%]).[26]

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