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The Uterus

The uterus is a muscular organ whose function (implantation, gestation, parturition and menstrual shedding) is almost entirely reproductive.

See also The Cervix (contiguous organ sharing most of these supports); The Vagina for DeLancey's support model; and The Ureters for the "water under the bridge" anatomy at the cardinal ligament.

Gray's Anatomy Fig. 1170 — Diagram of uterine and ovarian arterial branches supplying the uterus, tube, and ovary.

Gray's Anatomy Fig. 1170 — Uterine and ovarian arterial branches supplying the uterus, tube, and ovary.

Gross Anatomy​

The uterus is a pear-shaped fibromuscular organ sitting between bladder (anterior) and rectum (posterior), suspended in the pelvis by four paired ligamentous attachments and the peritoneal broad ligament. MRI and ultrasound studies use different uterine measurements.[5][6] In Chen et al.'s ultrasound study of 189 nulliparous reproductive-age women in China, mean uterine body length was 4.45 cm and mean cervical length was 3.08 cm (approximately 7.5 cm when added); mean body transverse and anteroposterior diameters were 4.31 cm and 3.59 cm, respectively. Uterine dimensions also varied with age and parity in the study population.[7] Uterine dimensions are larger in parous women.

Three anatomic regions:

RegionLocationOperative relevance
FundusAbove the insertion of the fallopian tubesPalpable landmark at delivery and during laparoscopy; an interstitial ectopic pregnancy implants in the intramural segment of the fallopian tube, whereas an eccentric intrauterine pregnancy may lie near the uterine corner[37]
Corpus (body)Main muscular massSite of fibroids, adenomyosis, endometrial cancer; the operative field of myomectomy and hysterectomy
CervixSee The CervixLevel-I support anchor; ureteric neighbor

The junction between corpus and cervix (the isthmus) is anatomically where the uterus narrows and where cesarean hysterotomy is performed (low transverse), where cesarean scar defects (isthmocele) form, and where supracervical hysterectomy transects the uterus.

Position and relations​

  • Anteverted and anteflexed is the common position: anteversion describes the cervix–vagina angle, while anteflexion describes the body–cervix angle, both directed forward.[27]
  • Retroverted in 18% of 480 general-gynecology patients assessed by empty-bladder transvaginal ultrasound[40]; a normal variant, but relevant to pessary fit, IUD placement, and surgical orientation
  • Anterior: bladder, via the vesicouterine pouch (anterior cul-de-sac)
  • Posterior: rectum, via the rectouterine pouch of Douglas (posterior cul-de-sac), the deepest peritoneal recess in the pelvis and the site of enterocele and of posterior culdotomy access
  • Lateral: broad ligament with its contents (see below); pelvic sidewall further laterally

Wall Structure​

Three layers, with a clinically distinct junctional zone visible on MRI:[3][4][5]

LayerCompositionOperative relevance
EndometriumFunctionalis (proliferates and sheds) + basalis (regenerative)Site of cyclic bleeding, endometrial hyperplasia and cancer, menstrual dysfunction; the target of endometrial ablation; sampling via pipelle / D&C
Junctional zoneInner myometrial band with tightly packed smooth muscle; MRI-visibleThickening or irregularity can contribute to an adenomyosis assessment, but a single >12 mm cutoff is not diagnostic by itself[29]
MyometriumPredominantly smooth muscle in interlacing bundles; intrinsic pacemaker activitySite of leiomyomas (submucosal / intramural / subserosal); the dissected territory of myomectomy; the contracting organ at labor and in postpartum hemorrhage
Perimetrium (serosa)Peritoneal covering of most of the uterus; anteriorly it forms the vesicouterine reflection toward the bladderThe serosal reflection is a landmark for bladder mobilization at cesarean or hysterectomy; opening the fold exposes the lower uterine segment.[49]

Ligamentous Support — The Apical Framework​

The uterus is "suspended in air" by four paired attachments, not all of which are true ligaments. For the reconstructive surgeon only two are load-bearing; the others function as conduits or positional tethers.[18][19][20][21][22]

StructureFunctionContents
Cardinal ligament (Mackenrodt / transverse cervical)Primary load-bearing Level-I support; the distal cardinal–uterosacral confluence supports the cervix and upper vagina from the pelvic sidewallUterine vessels, pelvic-plexus autonomic fibers, and lymphatics; the ureter passes through the intermediate section, making that region hazardous during dissection or suture placement.[45]
Uterosacral ligamentPosterior Level-I support; also the site of USL suspension proceduresSympathetic fibers of the pelvic plexus, lymphatics
Round ligamentPositional tether; helps maintain anteversion and is not a primary apical supportFrom uterine cornua → inguinal canal → labia majora; Sampson's artery courses with it and most often arises from the inferior epigastric or external iliac artery, with uterine anastomoses[55]
Broad ligamentPeritoneal drape; carries vessels and tubesTwo layers of peritoneum enclosing fallopian tubes, ovarian ligaments, round ligaments, and the uterine vessels laterally

Cadaveric and MRI studies describe the cardinal ligament as a perivascular or perineural sheath rather than a discrete fibrous band: a visceral mesentery of vessels, lymphatics, autonomic nerves, and fatty connective tissue extending between the pelvic sidewall and the cervix. Piver and Querleu–Morrow classifications describe the extent of radical-hysterectomy dissection in this vascular–neural sheath.[19][44] In the Querleu–Morrow scheme, type C1 preserves the inferior hypogastric plexus and bladder branches, whereas type C2 divides them.[44]

Vascular Supply​

Arterial supply is dominated by the uterine artery, which usually arises from the anterior internal iliac system but has variable branch origins; ovarian-artery anastomoses provide another axis of supply:[12][13][14][15][53]

SourceCourseTerritory
Uterine arteryInternal iliac → crosses over the ureter near the cervix (the ureter–cervix distance varies and is not a fixed operative clearance) → ascends in the broad ligament along the lateral uterus[38]Dominant supply; gives arcuate → radial → spiral arteries into endometrium
Ovarian arteryFrom aorta → infundibulopelvic (suspensory) ligament → ovary → anastomoses with the uterine artery at the cornuaUpper uterus, fundus, tubes
Contralateral uterineAcross-midline anastomoses with opposite uterine arteryAnatomical collateral pathway.[14]

Ovarian-uterine territorial shift — functional, not fixed​

The border between uterine and ovarian arterial territories may vary with menstrual phase: a small physiologic study reported greater ovarian-artery contribution to the cornual region in the follicular phase and greater uterine-artery contribution in the luteal phase.[15] Ovarian–uterine collaterals are a technical consideration in uterine-artery embolization (UAE).

Veno-arterial countercurrent exchange​

Uterine veins drain to the internal iliac venous plexus; some join the ovarian venous outlet. Close apposition of vessels permits proposed countercurrent transfer of locally released substances between ovary, tube, and uterus.[12]

Innervation​

Autonomic, with sparse somatic contribution:[11][16][17]

  • Sympathetic. T10–L2, then the superior hypogastric plexus (at the sacral promontory), paired hypogastric nerves and the inferior hypogastric (pelvic) plexus, reaching the uterus via the cardinal and uterosacral ligaments. Adrenergic α signaling can contract myometrium and constrict vessels; β signaling can relax myometrium and dilate vessels.[54]
  • Parasympathetic. S2–S4 pelvic splanchnic nerves, then the pelvic plexus, reaching the uterus via the same ligamentous routes. Cholinergic input can promote myometrial contraction, particularly in the cervix and isthmus, and vascular dilation.[54]
  • Afferent pain. Uterine visceral afferents generally track with sympathetic pathways (T10–L2). Cervical and upper-vaginal afferents can also travel with pelvic splanchnic nerves (S2–S4). During first-stage labor, pain from cervical dilation and lower-segment distension predominantly reaches T10–L1; second-stage vaginal and perineal pain travels mainly through pudendal nerves to S2–S4. These pathways guide neuraxial labor analgesia; the superior hypogastric plexus block targets the sympathetic pathway.[27][52]

The pelvic plexus sits between the cardinal ligament ventrally and the uterosacral ligament dorsally. Preserving bladder, rectal and vaginal-sexual function during radical hysterectomy turns on sparing the posterolateral component of this plexus. See The Cervix for the nerve-sparing radical-hysterectomy details.

Physiology (kept brief)​

Menstrual cycle — the endometrial framework​

The approximately 28-day cycle under the hypothalamic–pituitary–ovarian axis produces three functional phases:[2][8][9][10]

  • Menstrual (days 1–5). Progesterone withdrawal is followed by spiral-artery vasoconstriction and ischemic shedding of the functionalis.
  • Proliferative (days 6–14, estrogen-dominant). Basalis-driven regeneration, gland formation, stromal proliferation, spiral-artery growth. Endometrial thickness rises from 2–4 mm to 8–12 mm.
  • Secretory (days 15–28, progesterone-dominant). Glandular coiling and secretion, stromal decidualization, and the window of implantation (days 20–24).

ACOG's 2026 focused update recommends both transvaginal ultrasound and endometrial tissue sampling for most patients with postmenopausal bleeding, replacing routine reliance on an initial ≤4 mm ultrasound result alone; any ultrasound-only exception requires careful individual selection.[28] Persistent or recurrent bleeding still requires evaluation regardless of thickness. An incidental >4 mm measurement without bleeding does not automatically require sampling under the prior committee opinion.[35]

Myometrial quiescence and labor​

During pregnancy the myometrium is held quiescent by progesterone-dominant signaling (PR suppression of inflammatory transcription factors, repression of contraction-associated proteins, potassium-channel-mediated hyperpolarization). At labor, functional progesterone withdrawal (decline in PR activity rather than in circulating progesterone in humans) lifts this suppression: oxytocin-receptor, connexin-43, and COX-2 expression rise, calcium-channel activity rises, and coordinated contraction becomes possible.[1][23][24][25][26]

Clinical translations for the reconstructive surgeon: oxytocin and prostaglandins are uterotonics for postpartum hemorrhage, while selected agents can be used as tocolytics in obstetric care. After vaginal birth, postpartum hemorrhage response is concurrent and cause-directed: WHO guidance calls for immediate uterine massage, an oxytocic, 1 g IV tranexamic acid over 10 minutes as soon as possible and within 3 hours of birth, IV fluids, and examination for the bleeding source, with tamponade, surgery, transfusion, or other escalation when needed.[32] A second 1 g tranexamic acid dose is given if bleeding continues after 30 minutes or restarts within 24 hours of completing the first dose.[32][36]

Pregnancy remodeling​

The uterus undergoes marked smooth-muscle hypertrophy and hyperplasia, vascular expansion, and decidualization of the stroma. It returns toward baseline over the puerperium through apoptosis and matrix remodeling. Placenta accreta spectrum is a distinct disorder of placental attachment and invasion, not simply disordered postpartum involution.

Clinical Correlations for the Reconstructive Surgeon​

  • Hysterectomy approach selection. For benign disease, ACOG favors vaginal hysterectomy when feasible and laparoscopic hysterectomy over open surgery when a vaginal route is unsuitable; route selection also depends on uterine access, concurrent procedures, surgeon expertise, resources, and informed patient preference.[33] The uterine-artery pedicle sits lateral to the cervix with the ureter inferior (see The Cervix); deliberate ureter identification is an injury-prevention step.
  • Ureteric injury. The uterine-artery crossing is a common site of iatrogenic ureteric injury. Risk is concentrated in radical hysterectomy, deep paravaginal dissection, and management of post-cesarean hematoma. See The Ureters.
  • Supracervical (subtotal) hysterectomy. Preserves the cervix and some support attachments. Continuing cervical screening and possible cyclical bleeding require counseling; randomized evidence has not shown better urinary, bowel or sexual function than total hysterectomy.[30]
  • Myomectomy and fibroid mapping. Fibroids are mapped as submucosal (FIGO type 0–2), intramural (3–4), subserosal (5–7), or other (8, e.g. cervical, parasitic). Suitable submucosal fibroids are generally approached hysteroscopically; larger or more intramural type 1–2 lesions may require staged hysteroscopic resection or another route.[39] Other fibroids may be approached laparoscopically or openly, depending on size, number, and fertility plans. After abdominal (laparoscopic or open) myomectomy, a myometrial scar can affect a later pregnancy, including uterine-rupture risk; postoperative pelvic adhesions may complicate later urogynecologic surgery.[48]
  • Uterine artery embolization (UAE). An option for selected symptomatic fibroids and certain bleeding emergencies; ovarian–uterine collateral supply is a technical consideration. For people contemplating pregnancy, effects on fertility and pregnancy remain uncertain and should be discussed alongside alternatives such as myomectomy.[31] Counsel that symptoms may recur and repeat treatment may be needed; a six-trial meta-analysis found reintervention more likely after UAE than after myomectomy, with low-certainty evidence.[50]
  • Adenomyosis. Endometrial-type tissue within the myometrium can be associated with heavy bleeding and pain.[29] Junctional-zone thickening on MRI is one finding, not a stand-alone >12 mm diagnosis.[29]
  • Cesarean section and its downstream reconstruction. Cesarean surgery can cause bladder or ureteric injury and rarely urogenital fistula; prolonged obstructed labor remains a major cause where emergency obstetric care is limited.[34] Placenta accreta spectrum can require planned multidisciplinary surgery and urologic assistance with complex bladder and ureter dissection. A cesarean scar defect (isthmocele) may cause postmenstrual spotting and can be evaluated for repair when clinically appropriate.
  • Obstetric fistula. Prolonged obstructed labor can cause pressure necrosis of pelvic tissues and vesicovaginal or rectovaginal fistula.[34][56] Iatrogenic injury during obstetric or gynecologic surgery can also cause genitourinary fistula.[56][57] For genitourinary fistula, evaluation and repair timing, route, and need for tissue interposition depend on the defect and surrounding tissue; see The Vagina.[57]
  • Apical prolapse with uterine descent. Options preserve or remove the uterus: vaginal hysterectomy with USLS or SSLF, sacrospinous hysteropexy, sacrohysteropexy, or Manchester (Fothergill) procedure (cervical amputation and CUL plication). Patient counseling turns on fertility plans, prior operations, cervical and endometrial pathology, unexplained abnormal bleeding, hereditary cancer risk, and ability to continue gynecologic surveillance. The 2026 consensus advises against uterus-sparing surgery with abnormal preoperative endometrial histology or a genetic syndrome that contraindicates preservation, and against uterine or cervical preservation when cervical malignancy is suspected.[42][43]
  • Postoperative bladder, bowel, and sexual dysfunction. Proposed mechanisms include neural injury, altered support, pain and other perioperative factors; no single cause has been established for all patients. Pelvic-plexus preservation remains an important consideration in appropriately selected radical procedures.
  • Uterine rupture. Usually at the site of a prior scar (C-section, myomectomy). Surgical emergency with fetal and maternal risk.
  • Placental anomalies and hysterectomy. Complex placenta accreta spectrum cases may involve urologic support for bladder or ureter dissection and repair; prophylactic ureteric stents are individualized, not routine for every case.
  • Endometrial cancer. Most common gynecologic malignancy in high-resource settings. For presumed uterus-confined endometrial cancer, standard surgery is total hysterectomy with bilateral salpingo-oophorectomy and sentinel lymph-node biopsy for staging; side-specific lymphadenectomy follows failed mapping in selected risk groups. Ovarian preservation with bilateral salpingectomy may be considered for selected premenopausal patients younger than 45 years with FIGO 2023 IA1 or IA2 disease, low recurrence risk by molecular classification, and no hereditary ovarian cancer risk.[41] Radiation for higher stage or recurrence produces radiation cystitis, fistula, ureteric stricture, and bladder atony, the familiar reconstructive late-morbidity profile.
  • Gender-affirming hysterectomy. An option for some gender-diverse patients based on their goals, not a required component of masculinizing care. Route, whether to remove tubes or ovaries, and any preoperative evaluation are individualized.
  • Müllerian anomalies. Septate, bicornuate, didelphys, unicornuate uterus, and MRKH (Müllerian agenesis) have implications for fertility, obstetric outcomes, and reconstructive options (hysteroscopic septal resection, neovagina creation). Cross-link to The Vagina for neovaginal options in MRKH.
  • Uterine transplantation. Investigational-to-emerging option for uterine-factor infertility (MRKH, prior hysterectomy). Uterine transplantation entails complex vascular anastomoses and living-donor pelvic dissection. A 16-case robotic living-donor hysterectomy series reported ureteric injuries in two of eight early cases and none of eight later cases; careful ureteric protection remains important.[51]
  • IUD perforation. Uncommon but clinically important. The device can migrate to bladder, bowel, or peritoneum. Retrieval depends on device location: hysteroscopy remains an option for an intrauterine device, laparoscopy or open surgery for an extrauterine device, and cystoscopy may be used for an intravesical device.[46][47]

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