What are the symptoms to be aware of? An imperforate hymen can be painful if there is an attempt to place a tampon, speculum, finger, or penis through a too tight opening. However, if there is an imperforate hymen, the hymen or the areas around the hymen (the vulvar vestibule) should not be tender when they are touched with a cotton swab.

During the female embryo stage, two types of tissue meet to form the vagina and vulva. The vagina, cervix and uterus are formed from tissue known as Mullerian tissue, and the vulva is formed from tissue called the primitive urogenital sinus. The two different types of tissue meet and form a thin membrane called the hymen.

During the latter stages of female fetal development the central cells of this membrane die in a process known as aptosis. After the central cells die, what is left is the hymenal ring.

However, infrequently the cells in the center of the hymenal membrane do not die and the membrane persists. This condition is known as an imperforate hymen. Often this condition is not known until a woman begins to menstruate. If the hymen is completely imperforate (no opening at all), then menstrual blood will collect in the vagina (called hematometra) and the hymen will bulge out and appear to be a dark blue or brown mass coming out of the vagina.

If this condition is not corrected with a hymenotomy, the menstrual blood “back up” in the uterus (called hematocolpos) and flow out the fallopian tubes and into the abdomen. This unfortunately can lead to endometriosis, a condition where the cells that are usually in the uterine cavity start to grow in the pelvis.  More commonly, the hymenal membrane is only partial imperforate and the menstrual blood escapes, but the hole in the membrane is too small to allow for tampon insertion.

When is it appropriate to perform a hymenotomy?

When there is a completely imperforate or almost completely imperforate hymen.

When is appropriate to perform a hymenectomy?

Should an imperforate hymen be painful?

An imperforate hymen can be painful if there is an attempt to insert a tampon, speculum, finger, or penis. However, if there is an imperforate hymen, the hymen or the areas around the hymen (the vulvar vestibule) should not be tender when they are touched with a cotton swab.

Many gynecologists incorrectly make the diagnosis of an imperforate hymen or thickened hymen instead of a condition known as vulvar vestibulitis syndrome. In vulvar vestibulitis syndrome, the vestibule and the hymen have too many nerve endings and are very tender when touched lightly with a cotton swab. In my opinion, since the diagnosis of imperforate or thickened hymen is so frequently incorrectly made, I suggest that any women considering a hymenectomy or hymenotomy get a second opinion from a vulvar specialist prior to surgery.

How is a hymenectomy performed?

The procedure can be done as an office procedure under local anesthesia; however, as most young women are understandably anxious about the procedure, I have found it best to perform the procedure under conscious sedation in an ambulatory surgery hospital. After sedation has been achieved, I inject a local anesthetic (Marcaine) in the hymenal membrane. If there is a hematocolpos is present, I make a small incision in the membrane and insert a suction catheter to remove all of the blood. The hymenal opening is then enlarged by making either a circular incision following the lines of the normal hymenal ring. Alternatively, a star shaped incision can be made to open up the imperforate hymen. Then the vaginal epithelium then is sutured to the hymenal ring to keep the hymenal ring opened.

Don’t you loose your hymen when you loose your virginity?

No, the hymenal ring may tear the first time you have intercourse and the opening will may get larger, but there always will be a hymenal ring, even after childbirth.

(Much has been written on the Vibrance Associates Bulletin Boards about hymenectomy ---the most of any other topic on the board.  The interesting thing is information women are getting from their health care providers.)

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