Medical School · Year 1 · Anatomy Pelvis Head Neck · includes a quiz and discussion video
Lecture 4: Female Reproductive System
Unit 1.5: Human Gross Anatomy III - Pelvis and Head/Neck
Learning Objectives
By the end of this lecture, students will be able to:
- Describe the anatomy of the ovaries and their suspensory structures
- Describe the anatomy of the uterine tubes, uterus, and vagina
- Identify the ligaments and peritoneal relationships of the female reproductive organs
- Describe the external genitalia (vulva)
- Explain the blood supply, innervation, and lymphatic drainage
- Correlate anatomical features with clinical conditions
Overview of the Female Reproductive System
The female reproductive system comprises the gonads (ovaries), the ductal system (uterine tubes, uterus, vagina), the external genitalia (vulva), and associated glands (greater and lesser vestibular glands). This system serves multiple functions: production of female gametes (oogenesis) and hormones (estrogen, progesterone), capture and transport of oocytes, provision of the site for fertilization (uterine tube), implantation and support of the developing embryo and fetus (uterus), and the birth canal (vagina). The cyclic hormonal changes of the menstrual cycle prepare the system for potential pregnancy each month.
<image>Panel A: Coronal section of female pelvis showing ovaries flanking uterus laterally suspended by ligaments within broad ligament. Panel B: Uterine tubes extending from superior uterus with fimbriae wrapping around ovarian surfaces. Panel C: Pear-shaped uterus occupying central pelvis with cervix projecting into upper vagina. Panel D: Vagina descending through pelvic floor to vestibule with bladder anterior and rectum posterior.</image>
The Ovaries
The ovaries are paired almond-shaped organs measuring approximately 3 by 2 by 1 centimeters, serving as both exocrine glands (releasing oocytes) and endocrine glands (producing estrogen, progesterone, and inhibin). The ovarian surface, covered by germinal epithelium (a misnomer, as germ cells derive from the yolk sac), becomes progressively more irregular after puberty due to scarring from successive ovulations and corpus luteum formation.
Each ovary occupies the ovarian fossa, a shallow depression on the lateral pelvic wall between the external and internal iliac vessels. The ovary lies posterior to the broad ligament, with its tubal (upper) pole oriented toward the uterine tube and its uterine (lower) pole toward the uterus. The medial surface faces the broad ligament, while the lateral surface contacts the parietal peritoneum overlying the obturator vessels and nerve. The posterior (free) border is related to the ureter.
Three structures suspend the ovary in position. The suspensory ligament of the ovary (infundibulopelvic ligament) extends from the pelvic brim to the tubal pole, containing the ovarian vessels and nerves—its identification and ligation are essential during oophorectomy. The ligament of the ovary (ovarian ligament) extends from the uterine pole to the uterus just below the uterine tube attachment, lying within the broad ligament; it represents the remnant of the gubernaculum. The mesovarium is the fold of broad ligament that attaches to the anterior (mesovarian) border of the ovary, through which vessels and nerves enter.
Internally, the ovary comprises a surface germinal epithelium, a thin tunica albuginea, an outer cortex containing follicles at various stages of development, and an inner medulla containing vessels, nerves, and connective tissue.
<image>Panel A: Posterior view of pelvis showing ovary in ovarian fossa with suspensory ligament extending superolaterally containing ovarian vessels. Panel B: Ligament of ovary passing medially to uterus and mesovarium connecting to broad ligament. Panel C: Inset cross-section showing germinal epithelium, tunica albuginea, and cortex with follicles at various developmental stages. Panel D: Central medulla with vessels and relationship to ureter posteriorly indicated.</image>
Ovarian Blood Supply, Innervation, and Lymphatics
The ovarian artery arises directly from the abdominal aorta at the L2 level, reflecting the ovary's embryological origin in the posterior abdominal wall. Each ovarian artery descends retroperitoneally, crosses the ureter and external iliac vessels, enters the suspensory ligament of the ovary, and runs through the mesovarium to reach the ovary. An important anastomosis exists between the ovarian artery and the ovarian branch of the uterine artery within the broad ligament, providing collateral circulation.
Venous drainage follows a similar pattern to the testis: the right ovarian vein drains directly into the inferior vena cava, while the left ovarian vein drains into the left renal vein. A pampiniform plexus exists within the broad ligament analogous to the male structure.
Lymphatic drainage from the ovary, like the testis, follows the gonadal vessels retroperitoneally to the para-aortic (lumbar) lymph nodes at the L1-L2 level. This has important implications for ovarian cancer staging and treatment—metastases spread to para-aortic nodes rather than to pelvic nodes initially.
Innervation reaches the ovary through the ovarian plexus, containing sympathetic fibers from T10-T11. This explains why ovarian pain (such as mittelschmerz, the pain of ovulation) is referred to the periumbilical region.
<image>Panel A: Ovarian artery traced from aortic origin at L2 descending retroperitoneally crossing ureter and external iliac vessels. Panel B: Ovarian artery entering suspensory ligament to reach ovary with anastomosis to uterine artery's ovarian branch in broad ligament. Panel C: Venous drainage showing left ovarian vein to left renal vein and right to IVC. Panel D: Green lymphatic vessels paralleling ovarian vessels to para-aortic nodes at L1-L2 with dermatome inset showing T10 referred pain.</image>
The Uterine (Fallopian) Tubes
The uterine tubes are paired muscular canals, each approximately 10 centimeters long, extending from the uterus to the ovary. They lie within the upper free margin of the broad ligament (mesosalpinx) and serve to capture the ovulated oocyte, provide the site for fertilization, and transport the early embryo to the uterus.
Four anatomical parts can be distinguished from lateral to medial. The infundibulum is the funnel-shaped terminal expansion that opens into the peritoneal cavity at the abdominal ostium. Finger-like projections called fimbriae extend from its margin; one fimbria, the ovarian fimbria, attaches to the tubal pole of the ovary, helping to sweep the released oocyte into the tube. The ampulla is the widest and longest segment, comprising approximately two-thirds of the tube's length; with its thin wall and complex mucosal folds, it provides the optimal environment for fertilization—most ectopic pregnancies implant here. The isthmus is the narrow, thick-walled segment approaching the uterus. The intramural (uterine or interstitial) part passes through the uterine wall, opening into the uterine cavity at the uterine ostium.
The tubal wall comprises three layers: an outer serous layer (peritoneum), a middle muscular layer (circular and longitudinal smooth muscle providing peristalsis), and an inner mucosal layer with ciliated and secretory epithelium. The cilia beat toward the uterus, while the secretions nourish gametes and early embryo.
Blood supply derives from both the tubal branches of the uterine artery (reaching the medial portions) and tubal branches of the ovarian artery (reaching the lateral portions), creating extensive anastomoses.
<image>Panel A: Uterine tube showing infundibulum with fimbriae laterally including ovarian fimbria attached to ovary. Panel B: Widest ampulla comprising two-thirds of tube length as most common site for fertilization and ectopic pregnancy. Panel C: Narrow isthmus and intramural portion entering uterine wall within mesosalpinx. Panel D: Inset cross-section through ampulla showing serosa, muscularis, and highly folded mucosa with ciliated epithelium and dual arterial supply.</image>
The Uterus
The uterus is a thick-walled muscular organ approximately 7.5 by 5 by 2.5 centimeters in the nulliparous state, shaped like an inverted pear. It serves as the site of implantation and fetal development, and its powerful muscular contractions expel the fetus at delivery.
Parts of the Uterus
The fundus is the rounded superior portion above the level of the uterine tube insertions. The body comprises the main portion of the uterus, narrowing inferiorly. The isthmus is the constricted region between the body and cervix. The cervix is the cylindrical inferior portion that projects into the vagina.
The cervix itself has two portions: the supravaginal part lies above the vaginal attachment, while the vaginal part (portio vaginalis) projects into the vagina. The external os is the opening of the cervix into the vagina (circular in nulliparous women, transverse slit in parous women), and the internal os opens into the uterine body. The cervical canal connects these openings. The vaginal fornices are the recesses around the vaginal cervix—anterior, posterior, and lateral. The posterior fornix is deepest and clinically significant as it relates to the pouch of Douglas.
Position
The uterus normally lies in an anteverted (tilted forward on the vagina, approximately 90 degrees) and anteflexed (bent forward at the isthmus, approximately 170 degrees) position. Retroversion and retroflexion are common variants, usually without clinical significance. The uterus rests upon the bladder, so the degree of anteversion varies with bladder filling.
Layers
The perimetrium is the serous covering (visceral peritoneum), continuous with the broad ligament laterally. It covers most of the body and fundus but is absent from the anterior cervix. The myometrium is the thick muscular layer comprising interlacing smooth muscle bundles; this powerful muscle enables uterine contractions. The endometrium is the mucosal lining that undergoes cyclic changes during the menstrual cycle, with a functional layer that proliferates and sheds and a basal layer that regenerates.
<image>Panel A: Sagittal section of uterus showing fundus superiorly, body centrally, isthmus as constriction, and cervix projecting into vagina. Panel B: Three uterine layers - thin serous perimetrium, thick myometrium with interlacing muscle bundles, and endometrium with functional and basal layers. Panel C: Cervical canal connecting internal and external os with vaginal fornices surrounding cervix and deep posterior fornix related to pouch of Douglas. Panel D: Inset showing normal anteverted and anteflexed position with angle measurements relative to vagina.</image>
Peritoneal Relationships and Ligaments
The peritoneum covers the fundus and body of the uterus, creating important pouches and folds. Anteriorly, the peritoneum reflects from the uterus onto the bladder, creating the vesicouterine pouch. Posteriorly, it reflects from the uterus onto the rectum, creating the rectouterine pouch (pouch of Douglas), the most dependent part of the peritoneal cavity in the supine position—fluid and pathological processes (blood, pus, malignant cells) accumulate here, and it is accessible via the posterior vaginal fornix for culdocentesis.
The Broad Ligament
The broad ligament is a double fold of peritoneum extending from the lateral margins of the uterus to the lateral pelvic wall, creating a transverse partition across the pelvis. It contains the uterine tubes, round ligament, ovarian ligament, vessels, nerves, and lymphatics within its layers. Three named portions are distinguished: the mesometrium is the largest part below the mesosalpinx and mesovarium; the mesosalpinx extends over the uterine tube in the superior free margin; and the mesovarium attaches the ovary to the posterior leaf.
Supporting Ligaments
The round ligament extends from the uterus (just below the uterine tube attachment) through the inguinal canal to the labia majora. It maintains anteversion of the uterus and is homologous to the gubernaculum in the male.
The cardinal ligament (transverse cervical ligament, Mackenrodt's ligament) extends from the cervix and upper vagina to the lateral pelvic wall at the level of the ischial spine. This is the primary support of the uterus, containing the uterine artery and veins within its condensed connective tissue.
The uterosacral ligament extends from the cervix posteriorly to the sacrum (S2-S3), passing lateral to the rectum. It helps maintain anteflexion and contains nerve fibers from the inferior hypogastric plexus. Endometriosis commonly involves these ligaments.
The pubocervical ligament extends from the cervix anteriorly to the posterior pubis, supporting the bladder neck.
<image>Panel A: Sagittal view showing vesicouterine pouch anteriorly and rectouterine pouch (pouch of Douglas) posteriorly as most dependent peritoneal point with culdocentesis route. Panel B: Coronal view of broad ligament as curtain-like structure with mesometrium, mesosalpinx, and mesovarium labeled. Panel C: Round ligament traced from uterus through inguinal canal to labium majus. Panel D: Superior view showing cardinal ligaments with uterine vessels, uterosacral ligaments to sacrum, and pubocervical ligaments anteriorly.</image>
Uterine Blood Supply
The uterine artery, a branch of the internal iliac artery, is the primary blood supply to the uterus. Its course and relationships are surgically important. The artery runs medially in the base of the broad ligament (within the cardinal ligament) and crosses the ureter approximately 2 centimeters lateral to the cervix—classically described as "water under the bridge" (the uterine artery passes over the ureter). Awareness of this relationship is essential during hysterectomy to avoid ureteral injury.
At the cervix, the uterine artery ascends along the lateral margin of the uterus between the layers of the broad ligament, becoming increasingly tortuous (accommodating uterine growth during pregnancy). It gives off vaginal branches to the upper vagina and cervix, cervical branches, branches to the uterine body, a tubal branch to the uterine tube (anastomosing with the tubal branch of the ovarian artery), and an ovarian branch (anastomosing with the ovarian artery, providing collateral circulation).
Venous drainage parallels the arterial supply, with the uterine venous plexus draining into the internal iliac veins.
Lymphatic drainage follows different routes depending on the region: the fundus drains along the ovarian vessels to para-aortic nodes; the body drains primarily to external iliac nodes; the cervix drains to external iliac, internal iliac, and sacral nodes; and a small pathway along the round ligament reaches superficial inguinal nodes.
<image>Panel A: Posterior view of uterus with uterine artery traced from internal iliac coursing medially and crossing over ureter with "water under the bridge" inset. Panel B: Ascending course along lateral uterus showing vaginal, cervical, corporeal, tubal, and ovarian branches. Panel C: Anastomosis between uterine artery ovarian branch and ovarian artery demonstrated. Panel D: Lymphatic drainage diagram showing fundus to para-aortic, body to external iliac, cervix to pelvic nodes, and round ligament to superficial inguinal.</image>
Uterine Innervation
The uterus receives autonomic innervation through the inferior hypogastric (pelvic) plexus. Sympathetic fibers originate from T12-L2 and reach the uterus via the hypogastric nerves. Parasympathetic fibers derive from pelvic splanchnic nerves (S2-S4).
Pain pathways from different parts of the uterus travel via different routes, with clinical implications for labor analgesia. Pain from the uterine body and fundus, including labor contractions, travels via sympathetic afferents through the hypogastric nerves to enter the spinal cord at T11-L2. This explains referral of uterine pain to the lower abdomen and can be blocked by epidural anesthesia at these levels. Pain from the cervix travels via parasympathetic afferents through the pelvic splanchnic nerves to enter the cord at S2-S4. Cervical dilation pain in late labor follows this pathway and requires more caudal analgesia.
The Vagina
The vagina is a fibromuscular canal approximately 8-10 centimeters long, extending from the cervix to the vestibule. The anterior wall (approximately 7.5 cm) is shorter than the posterior wall (approximately 9 cm) because the cervix enters the anterior wall at a higher level. The axis of the vagina is directed upward and backward, roughly perpendicular to the uterine axis in the normal anteverted position.
The fornices are the recesses of the vaginal lumen surrounding the cervix. The anterior, posterior, and two lateral fornices form a continuous space. The posterior fornix is the deepest and lies directly against the peritoneum of the pouch of Douglas, separated by only the vaginal wall—making it accessible for examination of the peritoneal cavity and for procedures such as culdocentesis and colpotomy.
Relations
Anteriorly, the vagina relates to the bladder base and urethra, which are embedded in the anterior vaginal wall. This relationship explains why cystocele (bladder prolapse) bulges through the anterior vaginal wall.
Posteriorly, the upper vagina is separated from the pouch of Douglas and rectum by peritoneum, while the lower vagina relates directly to the rectum (without intervening peritoneum) and the perineal body at the lowest level.
Laterally, the upper vagina is attached to the cardinal ligament and related to the ureter (which passes approximately 2 cm from the lateral fornix before entering the bladder). The lower vagina is embraced by the levator ani (puborectalis).
Structure
The vaginal wall has no glands; lubrication derives from cervical mucus and transudation through the vaginal epithelium. The mucosa is stratified squamous epithelium thrown into transverse folds called rugae. The muscularis consists of smooth muscle. The adventitia provides outer support.
Blood Supply and Innervation
The vagina receives blood from multiple sources: the vaginal artery (from internal iliac), vaginal branches of the uterine artery, middle rectal artery (posterior vagina), and internal pudendal artery (lower vagina). Venous drainage flows through the vaginal venous plexus to internal iliac veins.
Lymphatic drainage follows a pattern based on location: the upper third drains to external and internal iliac nodes, the middle third to internal iliac nodes, and the lower third to superficial inguinal nodes.
Innervation of the upper vagina derives from the uterovaginal plexus (autonomic, relatively insensitive), while the lower vagina receives somatic sensory innervation from the pudendal nerve and is quite sensitive.
<image>Panel A: Sagittal section of vagina extending from cervix to vestibule with shorter anterior wall and longer posterior wall indicated. Panel B: Fornices surrounding cervix with deep posterior fornix highlighted and pouch of Douglas shaded directly above. Panel C: Anterior relations showing bladder and urethra with posterior relations showing rectouterine pouch and rectum. Panel D: Inset of vaginal wall layers showing rugose stratified squamous mucosa, muscular layer, adventitia, and converging blood supply.</image>
The Vulva (External Genitalia)
The vulva comprises all visible external female genital structures.
The mons pubis is the fatty eminence over the pubic symphysis, covered with coarse hair after puberty.
The labia majora are the outer, hair-bearing cutaneous folds extending posteriorly from the mons pubis, homologous to the scrotum in the male. They contain subcutaneous fat, the termination of the round ligament, and the posterior labial vessels and nerves. The posterior commissure connects them posteriorly.
The labia minora are the inner, hairless folds of skin, lying within the labia majora. Anteriorly, they split to form the prepuce (hood) and frenulum of the clitoris. Posteriorly, they meet as the fourchette. They surround the vestibule and contain numerous sebaceous glands.
The clitoris is the female erectile organ, homologous to the penis. It consists of two crura attached to the ischiopubic rami (covered by ischiocavernosus muscles), which unite to form the body, terminating as the glans clitoris—the only externally visible part. The glans is richly innervated by sensory endings from the dorsal nerve of the clitoris. The prepuce partially covers the glans.
The vestibule is the space between the labia minora, containing the external urethral orifice (located approximately 2-3 cm posterior to the clitoris), the vaginal orifice (partially covered by the hymen in virginal females), and the openings of the greater and lesser vestibular glands.
The greater vestibular glands (Bartholin's glands) are pea-sized structures lying posterolateral to the vaginal orifice, deep to the bulb of the vestibule. Their ducts open into the vestibule at the junction of the middle and posterior thirds. They secrete mucus for lubrication and are homologous to the bulbourethral glands in males. Obstruction of the duct causes Bartholin's cyst.
The lesser vestibular glands are numerous small glands opening around the urethral orifice, homologous to the prostate.
The vestibular bulbs are paired masses of erectile tissue lying deep to the labia on either side of the vaginal orifice, covered by the bulbospongiosus muscles. They are homologous to the corpus spongiosum and bulb of the penis.
<image>Panel A: Perineal view of vulva showing mons pubis superiorly, labia majora as outer folds, labia minora meeting at clitoral hood anteriorly and fourchette posteriorly. Panel B: Clitoris with glans beneath prepuce and vestibule between labia minora containing urethral and vaginal orifices. Panel C: Deep dissection showing clitoral body and crura on ischiopubic rami with ischiocavernosus, and vestibular bulbs with bulbospongiosus. Panel D: Greater vestibular glands posterolateral to vaginal opening with ducts to vestibule and male homologies indicated.</image>
Blood Supply and Innervation of the External Genitalia
The arterial supply to the vulva derives primarily from the internal pudendal artery (a branch of the internal iliac), which provides the deep and dorsal arteries of the clitoris and branches to the vestibular bulbs and labia minora. The external pudendal arteries (branches of the femoral) supply the labia majora.
Venous drainage parallels the arterial supply, flowing to internal pudendal veins and external pudendal veins (to the great saphenous vein).
Lymphatic drainage from all external genital structures flows to the superficial inguinal lymph nodes—important for staging and treatment of vulvar carcinoma.
Sensory innervation is territory-dependent. The anterior portions of the labia majora and mons receive innervation from the ilioinguinal nerve (L1). The posterior labia receive posterior labial nerves from the pudendal nerve (S2-S4). The clitoris receives the dorsal nerve of the clitoris (branch of pudendal), making the glans highly sensitive.
<image>Panel A: Arterial supply from internal pudendal giving deep and dorsal clitoral arteries and branches to vestibular bulbs and labia. Panel B: External pudendal arteries to labia majora with green lymphatic vessels draining to superficial inguinal nodes. Panel C: Color-coded sensory territories showing ilioinguinal nerve (L1) to anterior labia and pudendal posterior labial nerves to posterior labia. Panel D: Dorsal nerve of clitoris from pudendal nerve traced through pudendal canal to perineal distribution.</image>
Pelvic Support Structures
The DeLancey classification describes three levels of vaginal and uterine support, conceptualizing the complex fascial and muscular structures that maintain pelvic organ position.
Level I support consists of the cardinal and uterosacral ligaments, which suspend the upper vagina and cervix from the pelvic sidewalls and sacrum. Damage at this level results in uterine prolapse and vaginal vault prolapse (after hysterectomy).
Level II support comprises the paravaginal attachments—lateral connections between the mid-vagina and the arcus tendineus fascia pelvis (a condensation of pelvic fascia along the lateral pelvic wall). Damage at this level contributes to cystocele (anterior compartment) and rectocele (posterior compartment).
Level III support involves the perineal body and urogenital diaphragm, which support the lower vagina. Damage typically results from obstetric trauma.
The pelvic floor (levator ani, particularly the puborectalis) provides a muscular platform supporting all pelvic organs. Endopelvic fascia (the condensations of visceral pelvic fascia) creates the supportive "slings" and "ligaments" attached to this muscular base.
<image>Panel A: DeLancey Level I showing cardinal and uterosacral ligaments in blue supporting cervix and upper vagina. Panel B: Level II showing green mid-vagina paravaginal attachments to arcus tendineus fascia pelvis with anterior and posterior supports. Panel C: Level III showing yellow lower vagina and perineum with perineal body and urogenital diaphragm support. Panel D: Levator ani forming muscular base for all levels with clinical annotations indicating prolapse types at each level.</image>
Clinical Correlations
Ectopic Pregnancy
Ectopic pregnancy occurs when the fertilized ovum implants outside the uterus, most commonly (approximately 95%) in the uterine tube—particularly in the ampulla. Risk factors include pelvic inflammatory disease (causing tubal damage), previous ectopic pregnancy, and tubal surgery. Tubal ectopic pregnancy may rupture, causing life-threatening intraperitoneal hemorrhage, and represents a surgical emergency.
Uterine Prolapse
Uterine prolapse results from weakening of the Level I supports (cardinal and uterosacral ligaments), allowing the uterus to descend into the vaginal canal. Severity is graded: Grade I (cervix descends into the vagina), Grade II (cervix reaches the introitus), Grade III (cervix protrudes beyond the introitus), and Grade IV (procidentia—complete uterine descent). Risk factors include vaginal childbirth, aging, obesity, and chronic increased intra-abdominal pressure. Treatment includes pessary support and surgical repair.
Ovarian Cysts and Torsion
Ovarian cysts may be functional (follicular cyst, corpus luteum cyst) or pathological (dermoid, cystadenoma, etc.). Large cysts can cause pain, and the weight of a cyst may predispose to ovarian torsion—twisting of the ovary on its vascular pedicle, causing acute pain and compromising blood supply. Torsion requires emergent surgical intervention.
Cervical Cancer
Cervical cancer develops at the transformation zone where the columnar epithelium of the endocervix meets the squamous epithelium of the ectocervix. HPV infection is the primary risk factor. The cancer spreads via lymphatics to pelvic nodes (external iliac, internal iliac, sacral) and may directly extend to involve the parametrium, bladder, rectum, and pelvic sidewall.
Endometriosis
Endometriosis is the presence of functioning endometrial tissue outside the uterus. Common sites include the ovaries (forming "chocolate cysts"), the pouch of Douglas, uterosacral ligaments, and the peritoneum of the broad ligament. Symptoms include chronic pelvic pain, dysmenorrhea, dyspareunia, and infertility.
Bartholin's Cyst and Abscess
Obstruction of the greater vestibular gland duct causes accumulation of secretions, forming a Bartholin's cyst. Infection may lead to Bartholin's abscess, presenting as a painful, tender swelling at the posterolateral vaginal introitus. Treatment includes drainage and, often, marsupialization to prevent recurrence.
<image>Panel A: Ectopic pregnancy in tubal ampulla with surrounding hemorrhage indicating rupture and uterine prolapse stages from Grade I through procidentia. Panel B: Ovarian torsion with ovary twisted on pedicle showing vascular compromise and cervical cancer spread to regional nodes. Panel C: Endometriosis sites including ovarian chocolate cyst, uterosacral ligament implants, and pouch of Douglas deposits. Panel D: Bartholin's cyst and abscess at posterolateral vaginal introitus showing duct obstruction pathology.</image>
Summary
The ovaries lie in the ovarian fossa, suspended by the suspensory ligament (containing ovarian vessels), ligament of the ovary, and mesovarium; their lymphatics drain to para-aortic nodes. The uterine tube has four parts (infundibulum with fimbriae, ampulla where fertilization occurs, isthmus, and intramural portion) and lies in the mesosalpinx. The uterus has three layers (perimetrium, myometrium, endometrium) and normally assumes an anteverted and anteflexed position. The uterine artery from the internal iliac crosses over the ureter ("water under the bridge") before ascending along the lateral uterus. The broad ligament is a peritoneal fold containing the tubes, round ligament, and vessels; the cardinal and uterosacral ligaments provide primary uterine support. The posterior vaginal fornix relates to the pouch of Douglas, the most dependent peritoneal point. The vulva includes the labia majora (homologous to scrotum), labia minora, clitoris (homologous to penis), vestibule, and Bartholin's glands (homologous to bulbourethral glands). Vulvar lymphatics drain to superficial inguinal nodes.
Key Terms
Suspensory ligament of ovary (infundibulopelvic ligament): The peritoneal fold from the pelvic brim to the tubal pole of the ovary, containing the ovarian vessels and nerves; must be ligated during oophorectomy.
Broad ligament: The double fold of peritoneum extending from the lateral uterus to the pelvic sidewall, containing the uterine tubes (mesosalpinx), round ligament, ovarian ligament, and vessels.
Cardinal ligament (transverse cervical ligament): The primary support of the uterus, extending from the cervix to the lateral pelvic wall and containing the uterine vessels.
Pouch of Douglas (rectouterine pouch): The peritoneal recess between the uterus and rectum, representing the most dependent part of the female peritoneal cavity and accessible via the posterior vaginal fornix.
Fornix: The recess of the vaginal lumen surrounding the cervix; the posterior fornix is deepest and most clinically significant.
Greater vestibular gland (Bartholin's gland): Paired glands posterolateral to the vaginal orifice that secrete lubricating mucus; homologous to the bulbourethral glands and prone to cyst and abscess formation if the duct is obstructed.
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