The Hymen

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The Hymen

• C. Jill Poarch, BSN, RN, SANE-A, SANE-P

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All females are born with a hymen.

• Some study Honest!

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Types of Hymens
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Annular Hymen

• An annular hymen has hymenal tissue
  circumferentially encircling the entire vaginal
  opening.

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Annular Hymen
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Crescentic Hymen

• A crescentic hymen has a predominantly posterior
  rim with hymenal attachments at the 1 and 11
  oclock positions.

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Crescentic Hymen
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Fimbriated / Redundant Hymen

• This hymen is characterized by multiple
  projections and indentations along the edge of
  the hymen, creating a ruffled or flowery
  appearance.

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Fimbriated/Redundant Hymen
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Cuffed Hymen

• A redundant hymen which presents with abundant
  circumferential tissue that folds back on itself
  or protrudes much like the neck of a turtleneck
  sweater is sometimes called a cuffed hymen.

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Septate Hymen

• A septate is a band of tissue bisecting the
  hymenal opening. Estrogen may lyse this band,
  leaving opposing remnants.

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Septate Hymen
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Cribiform
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Imperforate
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Incidence of Hymenal Shapes

• In one study of 147 females
• 53 had annular hymens
• 29.2 had crescentic hymens
• 14.9 had redundant hymens
• 2 had septate hymens
• One had an imperforate hymen

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Hymenal Changes with Relaxation
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Hymenal Changes with Traction
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Labial TractionPull toward examiner not apart!!!

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Hymenal Changes with Position
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The child should always be examined in two
different positions, especially if there are
abnormal findings.
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Normal Variants
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Mounds or Bumps
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Hymenal Notch / Cleft

• A hymenal notch / cleft is defined as an angular
  or V-shaped indentation on the edge of the
  hymenal membrane.

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Hymenal Tags

• A hymenal tag is defined as an elongated
  projection of tissue arising from the rim of the
  hymenal membrane. They are commonly found in the
  midline at the 6 oclock position.

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Intravaginal Ridges

• Intervaginal ridges are narrow bands of mucosal
  tissue on the vaginal wall which may be attached
  to the inner surface of the hymen.

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Periurethral Bands

• Periurethral vestibular bands are support
  ligaments, which are lateral to the urethra and
  connect periurethral tissues to the wall of the
  vestibule. They are symmetrical in number and
  create semilunar spaces adjacent to the urethra.
  They may be located lateral to the hymen and
  connect to the lateral vestibular wall
  (perihymenal bands).

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Incidence of Normal Variants

• 91.8 had periurethral / perihymenal bands
• 93.8 had intravaginal longitudinal ridges
• 3.4 had hymenal tags
• 34 had hymenal bumps or mounds
• 30.6 had a hymenal opening greater than 4mm
• 15.6 had labial adhesions
• 18.3 had partial posterior hymenal clefts
• 29.5 had posterior hymenal concavity
• 0 had a complete posterior hymenal cleft
  (transection)

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• From this study, the authors concluded that the
  presence of clefts and notches posteriorly,
  concavities, narrowing of the hymenal rim,
  thickening of the hymen or irregularities, as
  well as the exposure of the intravaginal
  contents, should NOT be considered diagnostic of
  sexual abuse.

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Hymens Across the Life Span
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Normal Newborn

• Estrogen effects from Mother

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No Estrogen Period

• Translucent or nearly so
• Limited mobility
• Limited distensibility
• Very sensitive!

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3-year-old female with crescentic hymen
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6-year-old female with crescentic hymen
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Although the first sign of puberty in the female
traditionally has been considered breast budding
increasing evidence indicates that the first sign
of puberty is found in the hymen.Sexual Assault
Victimization Across the Life Span A Clinical
Guide, 2003
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Puberty

• Puberty begins in females between approximately 8
  and 13 years
• Physical changes occur in an orderly sequence
• Genital changes D/T increasing estrogen
• Vaginal epithelium increases in thickness
• Vaginal secretions increase and acidify
• Labia majora and minora become larger and thicker
• Clitoris enlarges
• The hymen becomes larger, thicker, and redundant
  and has blanched edges

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Partial Estrogenation

• Thickening
• Secretions
• Variable mobility
• Variable distensibility
• Variable sensitivity

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9-year-old with crescentic hymen
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10 year old with annular hymen
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Mature / Complete Estrogenation

• Thick
• Fully mobile
• Redundant
• Protrudes toward vestibule
• No pain with palpation

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Adolescent Hymen
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Assessment of the Estrogenized Hymen

• All edges of the redundant hymen must be viewed /
  assessed this can be challenging.
• Techniques for assessment
• Moistened swab
• Foley catheter technique

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Foley Catheter Technique

• A Foley catheter with a 30cc balloon is
  inserted gently past the hymenal opening. The
  balloon is inflated with air. Following
  inflation of the balloon, the catheter is pulled
  gently toward the examiner to expose the hymeneal
  edges.

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• The Foley catheter technique is used ONLY with
  estrogenized hymens!

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Foley catheter balloon technique for visualizing
the hymen in female adolescent sexual assault
victims by Jamie Ferrell Dec 1997 issue
Journal of Emergency Nursing
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Decreased Estrogen Changes

• 3 5 years premenopausal
• Menstrual cycle changes/ceases
• Pubic hair thins
• Loss of fatty tissue and elasticity of labia

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80 year old female
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Postmenopausal Changes

• During and following menopause
• Skin and mucosal surfaces of the vulva become
  thinner (as a result area may be more easily
  traumatized)
• Sebaceous glands produce less secretions
• Vaginal atrophy
• Epithelium of the hymen thins
• Labial folds thin
• Less lubrication
• Vaginal wall may appear light pink or pale and
  appear thin and dry. Vagina loses some capacity
  for expansion.

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Decreased estrogen increased injury
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Postmenopausal Trauma

• Genital trauma was found to be more frequent and
  more severe in postmenopausal women (43 vs. 18)
• More genital edema, abrasions, and lacerations
  were found in postmenopausal women
• Factors influencing the increased prevalence of
  trauma in the older victim included
• Connective tissue atrophy
• Lessening of soft tissue elasticity
• Atrophy of the vaginal epithelium
• Ramin et al. 1992

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Documentation re Pediatric Hymen Assessment

• Type of hymen (annular, crescentic, etc)
• Degree of estrogenation
• Transverse diameter of hymenal opening??
• Depth of posterior rim
• Presence of skin tags, notches, etc
• Presence of lacerations / tears,
• transections, abrasions, etc.

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Note degree of hymenal estrogenation No
(none) Partial Yes (complete)
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Hymenal Opening Measurements(Transverse Diameter)

• Vary with technique of examiner
• Vary with position of child
• Depend on amount of relaxation
• Difficult to measure
• Measurements are not standardized
• No longer considered a definitive indicator of
  sexual abuse

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Posterior rim of hymen lt1mm

• This finding was not seen in girls selected for
  nonabuse in four separate studies
• However, a rim estimated to be lt 1 2mm
  was found in 22 of girls selected for nonabuse
  in another study
• It is very difficult to measure the posterior rim
  of the hymen

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Resources

• Evaluation of the Sexually Abused Child by Heger
  and Emans
• A Practical Guide To The Evaluation Of Sexual
  Abuse In The Prepubertal Child by Giardino,
  Finkel, Giardino, Seidl and Ludwig
• Color Atlas of Sexual Assault by Girardin,
  Faugno, Seneski, Slaughter and Whelan

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Resources

• The Anatomy of Child and Adolescent Sexual Abuse
  by McCann and Kerns CD-ROM
• Sexual Assault Victimization Across the Life
  Span A Clinical Guide by Giardino, Datner and
  Asher

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Prepared by -C. Jill Poarch, BSN, RN, SANE-A,
SANE-P608-836-6326jpoarchwi_at_charter.netPlease
do not reproduce without permission!!
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