Cervix

The cervix or cervix uteri (Latin: neck of the uterus) is

the lower part of the uterus in the human female reproductive system. In a non-pregnant woman, the cervix is
usually between 2 and 3 cm long and roughly cylindrical
in shape. The narrow, central cervical canal runs along its
entire length, connecting the uterine cavity and the lumen
of the vagina. The opening into the uterus is called the
internal os and the opening into the vagina is called the
external os. The lower part of the cervix, known as the
vaginal portion of the cervix (or ectocervix), bulges into
the top of the vagina. The cervix has been documented
anatomically since at least the time of Hippocrates, over
2,000 years ago.

Uterine
tube

r
Ute
ine

ll
wa

Internal
orifice
Cavity of
cervix

The cervical canal is a passage through which sperm must

travel to fertilize an egg cell after sexual intercourse. Several methods of contraception, including cervical caps
and cervical diaphragms aim to block or prevent the passage of sperm through the cervical canal. Cervical mucus is used in several methods of fertility awareness, such
as the Creighton model and Billings method, due to its
changes in consistency throughout the menstrual period.
During vaginal childbirth, the cervix must atten and
dilate to allow the fetus to progress along the birth canal.
Midwives and doctors use the extent of the dilation of the
cervix to assist decision-making during childbirth.

External
orifice

Vagina
Diagram of the uterus and part of the vagina. The cervix is the
lower part of the uterus situated between the external os (external
orice) and internal os (internal orice). The endocervical canal
connects the interior of the vagina and the cavity of the body of
uterus.

The endocervical canal is lined with a single layer of

column-shaped cells, while the ectocervix is covered with
multiple layers of cells topped with at cells. The two
types of epithelia meet the squamocolumnar junction. Infection with the human papillomavirus (HPV) can cause
changes in the epithelium, which can lead to cancer of
the cervix. Cervical cytology tests can often detect cervical cancer and its precursors, and enable early successful treatment. Ways to avoid HPV include avoiding sex,
using condoms, and HPV vaccination. HPV vaccines,
developed in the early 21st century, reduce the risk of
cervical cancer by preventing infections from the main
cancer-causing strains of HPV.[1]

Cavity of
body

the vagina is called the supravaginal portion of cervix.[3]

A central canal, known as the cervical canal, runs along
its length and connects the cavity of the body of the uterus
with the lumen of the vagina.[3] The openings are known
as the internal os and external orice of the uterus (or
external os) respectively.[3] The mucosa lining the cervical canal is known as the endocervix[4] and the mucosa
covering the ectocervix is known as the exocervix.[5] The
cervix has an inner mucosal layer, a thick layer of smooth
muscle, and posteriorly the supravaginal portion has a
serosal covering consisting of connective tissue and overlying peritoneum.[3]
In front of the upper part of the cervix lies the bladder,
separated from it by cellular connective tissue known as
parametrium, which also extends over the sides of the
cervix.[3] To the rear, the supravaginal cervix is covered
by peritoneum, which runs onto the back of the vaginal
wall and then turns upwards and onto the rectum forming the recto-uterine pouch.[3] The cervix is more tightly
connected to surrounding structures than the rest of the
uterus.[6]

Structure

The cervix is part of the female reproductive system.

Around 23 centimetres (0.81.2 in) in length,[2] it is the
lower narrower part of the uterus continuous above with
the broader upper partor bodyof the uterus.[3] The
lower end of the cervix bulges through the anterior wall
of the vagina, and is referred to as the vaginal portion of The cervical canal varies greatly in length and width becervix (or ectocervix) while the rest of the cervix above tween women and over the course of a womans life,[2]
1

1 STRUCTURE
After menstruation and directly under the inuence of
estrogen, the cervix undergoes a series of changes in position and texture. During most of the menstrual cycle,
the cervix remains rm, and is positioned low and closed.
However, as ovulation approaches, the cervix becomes
softer and rises to open in response to the higher levels of
estrogen present.[11] These changes are also accompanied
by changes in cervical mucus,[12] described below.

1.1 Development

A normal cervix of an adult viewed using a bivalved vaginal

speculum. The functional squamocolumnar junction surrounds
the external os and is visible as the irregular demarcation between
the lighter and darker shades of pink mucosa

and can measure 8 mm (0.3 in) at its widest diameter in

premenopausal adults.[7] It is wider in the middle and narrower at each end. The anterior and posterior walls of the
canal each have a vertical fold, from which ridges run diagonally upwards and laterally. These are known as palmate folds due to their resemblance to a palm leaf. The
anterior and posterior ridges are arranged in such a way
that they interlock with each other and close the canal.
They are often eaced after pregnancy.[6]

As a component of the female reproductive system, the

cervix is derived from the two paramesonephric ducts
(also called Mllerian ducts), which develop around the
sixth week of embryogenesis. During development,
the outer parts of the two ducts fuse, forming a single
urogenital canal that will become the vagina, cervix and
uterus.[13] The cervix grows in size at a smaller rate than
the body of the uterus, so the relative size of the cervix
over time decreases, decreasing from being much larger
than the body of the uterus in fetal life, twice as large
during childhood, and decreasing to its adult size, smaller
than the uterus, after puberty.[9] In fetal development,
the original squamous epithelium of the cervix is derived
from the urogenital sinus and the original columnar epithelium is derived from the paramesonephric duct. The
point at which these two original epithelia meet is called
the original squamocolumnar junction.[14]:1516

The ectocervix has a convex, elliptical surface and is divided into anterior and posterior lips. The size and shape 1.2
of the external opening and the ectocervix can vary according to age, hormonal state, and whether natural or
normal childbirth has taken place. In women who have
not had a vaginal delivery, the external os is a small circular opening, and in women who have had a vaginal delivery, the external os is slit-like.[7] On average, the ectocervix is 3 cm (1.2 in) long and 2.5 cm (1 in) wide.[2]

Histology

Blood is supplied to the cervix by the descending branch

of the uterine artery[8] and drains into the uterine vein.[9]
The pelvic splanchnic nerves, emerging as S2S3, transmit the sensation of pain from the cervix to the brain.[4] The squamocolumnar junction of the cervix: The ectocervix, with
These nerves travel along the uterosacral ligaments, its stratied squamous epithelium, is visible on the left. Simple
columnar epithelium, typical of the endocervix, is visible on the
which pass from the uterus to the anterior sacrum.[8]
Three channels facilitate lymphatic drainage from the
cervix.[10] The anterior and lateral cervix drains to nodes
along the uterine arteries, travelling along the cardinal ligaments at the base of the broad ligament to the external
iliac lymph nodes and ultimately the paraaortic lymph
nodes. The posterior and lateral cervix drains along the
uterine arteries to the internal iliac lymph nodes and ultimately the paraaortic lymph nodes, and the posterior
section of the cervix drains to the obturator and presacral lymph nodes.[2][9][10] However, there are variations
as lymphatic drainage from the cervix travels to dierent
sets of pelvic nodes in some people. This has implications
in scanning nodes for involvement in cervical cancer.[10]

right. A layer of connective tissue is visible under both types of

epithelium.

The endocervical mucosa is about 3 mm thick, lined

with a single layer of columnar mucous cells, and contains numerous tubular mucous glands which empty viscous alkaline mucus into the lumen.[3] In contrast, the
extocervix is covered with nonkeratinized stratied squamous epithelium,[3] which resembles the squamous epithelium lining the vaginal.[15]:41 The junction between
these two types of epithelia is called the squamocolumnar
junction.[15]:40811 Underlying both types of epithelium is
a tough layer of collagen.[16] The mucosa of the endocervix is not shed during menstruation.[3] The cervix has

2.2

Cervical mucus

more brous tissue, including collagen and elastin, than ferning.[11]

the rest of the uterus.[3]
In prepubertal girls, the functional squamocolumnar junction is present just within the endocervical
canal.[15]:411 Upon entering puberty, due to hormonal
inuence, and during pregnancy, the columnar epithelium extends outwards over the ectocervix as the cervix
everts.[14]:106 Hence, this also causes the squamocolumnar junction to move outwards onto the vaginal portion of the cervix, where it is exposed to the acidic
vaginal environment.[14]:106[15]:411 The exposed columnar epithelium can undergo physiological metaplasia
and change to tougher metaplastic squamous epithelium in days or weeks,[15]:25 which when mature is
very similar to the original squamous epithelium.[15]:411
The new squamocolumnar junction is therefore internal to the original squamocolumnar junction, and the
zone of unstable epithelium between the two junctions is
called the transformation zone of the cervix.[15]:411 After
menopause, the uterine structures involute and the functional squamocolumnar junction moves into the endocervical canal.[15]:41

2.2 Cervical mucus

Several hundred glands in the endocervix produce 2060
ml of cervical mucus a day, increasing to 600 ml around
the time of ovulation. It is viscous as it contains large proteins known as mucins. The viscosity and water content
varies during the menstrual cycle; mucus is composed
of around 93% water, reaching 98% at midcycle. These
changes allow it to function either as a barrier or a transport medium to spermatozoa. It contains electrolytes
such as calcium, sodium, and potassium; organic components such as glucose, amino acids, and soluble proteins;
trace elements including zinc, copper, iron, manganese,
and selenium; free fatty acids; enzymes such as amylase;
and prostaglandins.[12] Its consistency is determined by
the inuence of the hormones estrogen and progesterone.
At midcycle around the time of ovulationa period of
high estrogen levels the mucus is thin and serous to allow sperm to enter the uterus, and is more alkaline and
hence more hospitable to sperm.[19] It is also higher in
electrolytes, which results in the ferning pattern that
can be observed in drying mucus under low magnication; as the mucus dries, the salts crystallize, resembling
the leaves of a fern.[11] The mucus has stretchy character described as Spinnbarkeit most prominent around the
time of ovulation.[22]

Nabothian cysts (or Nabothian follicles) form in the

transformation zone where the lining of metaplastic epithelium has replaced mucous epithelium and caused
a strangulation of the outlet of some of the mucous glands.[15]:410411 A build up of mucus in the
glands forms Nabothian cysts, usually less than about 5
mm in diameter,[3] which are considered physiological
At other times in the cycle, the mucus is thick and more
rather than pathological.[15]:411 Both gland openings and
acidic due to the eects of progesterone.[19] This inferNabothian cysts are helpful to identify the transformation
tile mucus acts as a barrier to sperm from entering the
zone.[14]:106
uterus.[23] Women taking an oral contraceptive pill also
have thick mucus from the eects of progesterone.[19]
Thick mucus also prevents pathogens from interfering
with a nascent pregnancy.[24]
2 Function

2.1

Fertility

The cervical canal is a pathway through which sperm enter the uterus after sexual intercourse,[17] and some forms
of articial insemination.[18] Some sperm remains in cervical crypts, infoldings of the endocervix, which act as a
reservoir, releasing sperm over several hours and maximising the chances of fertilisation.[19] A theory states
the cervical and uterine contractions during orgasm draw
semen into the uterus.[17] Although the upsuck theory
has been generally accepted for some years, it has been
disputed due to lack of evidence, small sample size, and
methodological errors.[20][21]
Some methods of fertility awareness, such as the
Creighton model and the Billings method involve estimating a womans periods of fertility and infertility by observing physiological changes in her body. Among these
changes are several involving the quality of her cervical
mucus: the sensation it causes at the vulva, its elasticity (Spinnbarkeit), its transparency, and the presence of

A cervical mucus plug, called the operculum, forms inside the cervical canal during pregnancy. This provides a protective seal for the uterus against the entry of
pathogens and against leakage of uterine uids. The mucus plug is also known to have antibacterial properties.
This plug is released as the cervix dilates, either during
the rst stage of childbirth or shortly before.[25] It is visible as a blood-tinged mucous discharge.[26]

2.3 Childbirth
The cervix plays a major role in childbirth. As the fetus
descends within the uterus in preparation for birth, the
presenting part, usually the head, rests on and is supported by the cervix.[27] As labour progresses, the cervix
becomes softer and shorter, begins to dilate, and rotates
to face anteriorly.[28] The support the cervix provides to
the fetal head starts to give way when the uterus begins
its contractions. During childbirth, the cervix must dilate
to a diameter of more than 10 cm (4 in) to accommodate
the head of the fetus as it descends from the uterus to

3 CLINICAL SIGNIFICANCE

the vagina. In becoming wider, the cervix also becomes 3.1

shorter, a phenomenon known as eacement.[27]
Along with other factors, midwives and doctors use the
extent of cervical dilation to assist decision making during childbirth.[29][30] Generally, the active rst stage of
labour, when the uterine contractions become strong and
regular,[29] begins when the cervical dilation is more than
35 cm (1.22.0 in).[31][32] The second phase of labor begins when the cervix has dilated to 10 cm (4 in), which
is regarded as its fullest dilation,[27] and is when active
pushing and contractions push the baby along the birth
canal leading to the birth of the baby.[30] The number of
past vaginal deliveries is a strong factor in inuencing how
rapidly the cervix is able to dilate in labour.[27] The time
taken for the cervix to dilate and eace is one factor used
in reporting systems such as the Bishop score, used to
recommend whether interventions such as a forceps delivery, induction, or Caesarean section should be used in
childbirth.[27]

Cancer

Main article: Cervical cancer

In 2008, cervical cancer was the third-most common cancer in women worldwide, with rates varying geographically from less than one to more than 50 cases per
100,000 women.[38] It is a leading cause of cancer-related
death in poor countries, where delayed diagnosis leading to poor outcomes is common.[39] The introduction
of routine screening has resulted in fewer cases of (and
deaths from) cervical cancer, however this has mainly
taken place in developed countries. Most developing
countries have limited or no screening, and 85% of the
global burden occurring there.[40]

Cervical cancer nearly always involves human papillomavirus (HPV) infection.[41][42] HPV is a virus with numerous strains, several of which predispose to precanCervical incompetence is a condition in which shortening
cerous changes in the cervical epithelium, particularly in
of the cervix due to dilation and thinning occurs, before
the transformation zone, which is the most common area
term pregnancy. Short cervical length is the strongest prefor cervical cancer to start.[43] HPV vaccines, such as
[28]
dictor of preterm birth.
Gardasil and Cervarix, reduce the incidence of cervical
cancer, by inoculating against the viral strains involved in
cancer development.[44]

2.4

Contraception

Several methods of contraception involve the cervix.

Cervical diaphragms are reusable, rm-rimmed plastic
devices inserted by a woman prior to intercourse that
cover the cervix. Pressure against the walls of the vagina
maintain the position of the diaphragm, and it acts as a
physical barrier to prevent the entry of sperm into the
uterus, preventing fertilisation. Cervical caps are a similar method, although they are smaller and adhere to the
cervix by suction. Diaphragms and caps are often used
in conjunction with spermicides.[33] In one year, 12% of
women using the diaphragm will undergo an unintended
pregnancy, and with optimal use this falls to 6%.[34] Efcacy rates are lower for the cap, with 18% of women
undergoing an unintended pregnancy, and 1013% with
optimal use.[35] Most types of progestogen-only pills are
eective as a contraceptive because they thicken cervical mucus making it dicult for sperm to pass along
the endocervical canal.[36] In addition, they may also
sometimes prevent ovulation.[36] In contrast, contraceptive pills that contain both oestrogen and progesterone,
the combined oral contraceptive pills, work mainly by
preventing ovulation.[37] They also thicken cervical mucus and thin the lining of the uterus enhancing their
eectiveness.[37]

Clinical signicance

Potentially precancerous changes in the cervix can be

detected by cervical screening, using methods including a Pap smear (also called a cervical smear), in which
epithelial cells are scraped from the surface of the cervix
and examined under a microscope.[44] The colposcope,
an instrument used to see a magnied view of the cervix,
was invented in 1925. The Pap smear was developed by
Georgios Papanikolaou in 1928.[45] A LEEP procedure
using a heated loop of platinum to excise a patch of cervical tissue was developed by Aurel Babes in 1927.[46]
In some parts of the developed world including the UK,
the Pap test has been superseded with liquid-based cytology.[47]
A cheap, cost-eective and practical alternative in poorer
countries is visual inspection with acetic acid (VIA).[39]
Instituting and sustaining cytology-based programs in
these regions can be dicult, due to the need for trained
personnel, equipment and facilities and diculties in
follow-up. With VIA, results and treatment can be available on the same day. As a screening test, VIA is comparable to cervical cytology in accurately identifying precancerous lesions.[48]
A result of dysplasia is usually further investigated, such
as by taking a cone biopsy, which may also remove
the cancerous lesion.[44] Cervical intraepithelial neoplasia is a possible result of the biopsy, and represents dysplastic changes that may eventually progress to invasive
cancer.[49] Most cases of cervical cancer are detected in
this way, without having caused any symptoms. When
symptoms occur, they may include vaginal bleeding, discharge, or discomfort.[50]

3.2

Inammation

Main article: Cervicitis

Inammation of the cervix is referred to as cervicitis.
This inammation may be of the endocervix or
ectocervix.[51] When associated with the endocervix, it
is associated with a mucous vaginal discharge and the
sexually transmitted infections such as chlamydia and
gonorrhoea.[52] Other causes include overgrowth of the
commensal ora of the vagina.[42] When associated with
the ectocervix, inammation may be caused by the herpes
simplex virus. Inammation is often investigated through
directly visualising the cervix using a speculum, which
may appear whiteish due to exudate, and by taking a Pap
smear and examining for causal bacteria. Special tests
may be used to identify particular bacteria. If the inammation is due to a bacterium, then antibiotics may
be given as treatment.[52]

3.3

Anatomical abnormalities

Cervical stenosis refers to an abnormally narrow cervical canal, typically associated with trauma caused by removal of tissue for investigation or treatment of cancer, or
cervical cancer itself.[42][53] Diethylstilbestrol, used from
1938 to 1971 to prevent preterm labour and miscarriage,
is also strongly associated with the development of cervical stenosis and other abnormalities in the daughters of
the exposed women. Other abnormalities include vaginal
adenosis, in which the squamous epithelium of the ectocervix becomes columnar, cancers such as clear cell adenocarcinomas, cervical ridges and hoods, and development of a cockscomb cervical appearance.[54]

4 History
The name of the cervix comes from Latin: cervix (neck)
from the Proto-Indo-European root ker-, referring to
a structure that projects. Thus, the word cervix is
linguistically related to the English word "horn", the
Persian word for head (sar), the Greek word for head
(Greek: koryphe), and the Welsh word for deer (Welsh:
carw).[57][58]
The cervix was documented in anatomical literature in at
least the time of Hippocrates, although there was some
variation in early writers, who used the term to refer to
both the cervix and the internal uterine orice.[59] The
rst attested use of the word to refer to the cervix of the
uterus was in 1702.[57]
Cervical cancer has been described for over 2,000 years,
with descriptions provided by both Hippocrates and
Aretaeus,[45] although the causal role played by HPV for
cervical cancer was only elucidated in the late 20th century by Harald zur Hausen, who published a hypothesis
in 1976, and whose hypothesis was conrmed in 1983
and 1984.[60] Based on work done by Jian Zhou and Ian
Fraser, a vaccine for four strains of HPV was released in
2006.[61]

5 Other mammals

Female marsupials have paired uteri and cervices. Most

eutherian (placental) mammal species have a single cervix
and single, bipartite or bicornuate uterus. Lagomorphs,
rodents, aardvarks and hyraxes have a duplex uterus
and two cervices.[62] Lagomorphs and rodents share
many morphological characteristics and are grouped together in the clade Glires. Anteaters of the family
myrmecophagidae are unusual in that they lack a dened
cervix; they are thought to have lost the characteristic
Cervical agenesis is a rare congenital condition in which rather than other mammals developing a cervix on more
[63]
the cervix completely fails to develop, often associated than one lineage.
[55]
with the concurrent failure of the vagina to develop.
Other congenital cervical abnormalities exist, often associated with abnormalities of the vagina and uterus. The 6 References
cervix may be duplicated in situations such as bicornuate
uterus and uterine didelphys.[56]
[1] Human Papillomavirus (HPV) Vaccines. National Cancer Institute. Bethesda, MD. 29 December 2011. Retrieved 18 June 2014.

3.4

Other

Cervical polyps, which are benign overgrowths of endocervical tissue, if present, may cause bleeding, or a benign
overgrowth may be present in the endocervical canal.[42]
Cervical ectropion refers to the horizontal overgrowth of
the endocervical columnar lining in a one-cell-thick layer
over the ectocervix.[52]

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babies during childbirth. NICE. September 2007.

External links
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Cervix Source: http://en.wikipedia.org/wiki/Cervix?oldid=662643353 Contributors: AxelBoldt, Kpjas, The Anome, Taw, Mark, Ed Poor,
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