Hymen

This article is about the vaginal mucous membrane fold. For the god and other uses, see Hymen (disambiguation).

Hymen
External genital organs of female. The labia minora have been drawn apart.
Latin	hymen vaginae
Gray's	subject #270 1264
MeSH	Hymen

The hymen is a membrane that surrounds or partially covers the external vaginal opening. It forms part of the vulva, or external genitalia.^[1][2] The size of the hymenal opening increases with age. Although an often practiced method, it is not possible to confirm with certainty that a girl or woman is a virgin by examining her hymen.^[2] In cases of suspected rape or child sexual abuse, a detailed examination of the hymen may be performed, but the condition of the hymen alone is often inconclusive. In younger children, a torn hymen will typically heal very quickly. In adolescents, the hymenal opening does extend from natural causes and variation in shape and appearance increases.^[1] In children, although a common appearance of the hymen is crescent-shaped, many variations are possible.^[1] After a woman gives birth, she may be left with remnants of the hymen, called carunculae myrtiformes, or the hymen may be completely absent.^[3]

Development

The genital tract develops during embryogenesis, from the third week of gestation to the second trimester, and the hymen is formed following the vagina.

At week seven, the urorectal septum forms and separates the rectum from the urogenital sinus.

At week nine, the müllerian ducts move downwards to reach the urogenital sinus, forming the uterovaginal canal and inserting into the urogenital sinus.

At week 12, the müllerian ducts fuse to create a primitive uterovaginal canal called unaleria

At month 5, the vaginal canalization is complete and the fetal hymen is formed from the proliferation of the sinovaginal bulbs (where müllerian ducts meet the urogenital sinus), and becomes perforate before or shortly after birth.

In newborn babies, still under the influence of the mother's hormones, the hymen is thick, pale pink, and redundant (folds in on itself and may protrude). For the first two to four years of life, the infant produces hormones that continue this effect.^[4] Their hymenal opening tends to be annular (circumferential).^[5]

Resorption

Past neonatal stage, the diameter of the hymenal opening (measured within the hymenal ring) has been proposed to be approximately 1 mm for each year of age.^[6] In children, to make this measurement, a doctor may place a Foley catheter into the vagina and inflate the balloon behind the hymen to stretch the hymenal margin and allow for a better examination. In the normal course of life, the hymenal opening can also be enlarged by tampon or menstrual cup use, pelvic examinations with a speculum, regular physical activity or sexual intercourse.^[1] Once a girl reaches puberty, the hymen tends to become so elastic that it is not possible to determine whether a woman uses tampons or not by examining her hymen. In one survey, only 43% of women reported bleeding the first time they had intercourse, indicating that the hymens of a majority of women are sufficiently opened.^[1][4]

The hymen is most apparent in young girls: At this time, their hymen is thin and less likely to be redundant, that is to protrude or fold over on itself.^[7] In instances of suspected child abuse, doctors use the clock face system to describe the hymenal opening. The 12 o'clock position is below the urethra, and 6 o'clock is towards the anus, with the patient lying on her back.^[8]

Infants' hymenal openings tend to be redundant (sleeve-like, folding in on itself), and may be ring-shaped.^[8]

By the time a girl reaches school age, this hormonal influence has ceased, and the hymen becomes thin, smooth, delicate, and nearly translucent. It is also very sensitive to touch; a physician who must swab the area should avoid the hymen and swab the outer vulval vestibule instead.^[4]

Prepubescent girls' hymenal openings come in many shapes, depending on hormonal and activity level, the most common being crescentic (posterior rim): no tissue at the 12 o'clock position; crescent-shaped band of tissue from 1–2 to 10–11 o'clock, at its widest around 6 o'clock. From puberty onwards, depending on estrogen and activity levels, the hymenal tissue may be thicker, and the opening is often fimbriated or erratically shaped.^[5]

After giving birth, the vaginal opening usually has nothing left but hymenal tags (carunculae myrtiformes) and is called "parous introitus".

Anatomic anomalies

Various types of hymen

Anomalies of the female reproductive tract can result from agenesis or hypoplasia, canalization defects, lateral fusion and failure of resorption, resulting in various complications.^[6]

• Imperforate:^[9][10] hymenal opening nonexistent; will require minor surgery if it has not corrected itself by puberty to allow menstrual fluids to escape.
• Cribriform, or microperforate: sometimes confused for imperforate, the hymenal opening appears to be nonexistent, but has, under close examination, small openings.
• Septate: the hymenal opening has one or more bands extending across the opening.

Hymenorrhaphy

Main article: Hymenorrhaphy

In some cultures, an intact hymen is highly valued at marriage mainly to show virginity.^[11][12][13] Some women undergo hymenoplasty, a restoration of their hymen for this reason.^[13][14]

Womb fury

In the sixteenth and seventeenth centuries, medical researchers used the presence of the hymen, or lack thereof, as founding evidence of physical diseases such as "womb-fury" (hysteria). If not cured, womb-fury would, according to these early doctors, result in death.^[15][16]

In other animals

Due to similar reproductive system development, many mammals, including chimpanzees, elephants, manatees, whales, and horses retain hymens.^[17][18]

See also

Artificial hymen

References

1. ^ ^{a b c d e} Emans, S. Jean. "Physical Examination of the Child and Adolescent" (2000) in Evaluation of the Sexually Abused Child: A Medical Textbook and Photographic Atlas, Second edition, Oxford University Press. 61-65
2. ^ ^{a b} Perlman, Sally E.; Nakajyma, Steven T. and Hertweck, S. Paige (2004). Clinical protocols in pediatric and adolescent gynecology. Parthenon. pp. 131. ISBN 1842141996. 
3. ^ Knight, Bernard (1997). Simpson's Forensic Medicine (11th ed.). London: Arnold. pp. 114. ISBN 0713144521. 
4. ^ ^{a b c} McCann, J; Rosas, A. and Boos, S. (2003) "Child and adolescent sexual assaults (childhood sexual abuse)" in Payne-James, Jason; Busuttil, Anthony and Smock, William (eds). Forensic Medicine: Clinical and Pathological Aspects, Greenwich Medical Media: London, a)p.453, b)p.455 c)p.460.
5. ^ ^{a b} Heger, Astrid; Emans, S. Jean and Muram, David (2000). Evaluation of the Sexually Abused Child: A Medical Textbook and Photographic Atlas (Second ed.). Oxford University Press. pp. 116. ISBN 0195074254. 
6. ^ ^{a b} "Imperforate Hymen". Web MD. http://emedicine.medscape.com/article/269050-overview. Retrieved 2009-02-02. "Different normal variants in hymenal configuration are described, varying from the common annular, to crescentic, to navicular ("boatlike" with an anteriorly displaced hymenal orifice). Hymenal variations are rarely clinically significant before menarche. In the case of a navicular configuration, urinary complaints (e.g., dribbling, retention, urinary tract infections) may result. Sometimes, a cribriform (fenestrated), septate, or navicular configuration to the hymen can be associated with retention of vaginal secretions and prolongation of the common condition of a mixed bacterial vulvovaginitis." 
7. ^ Muram, David. "Anatomical and Physiologic Changes" (2000) in Evaluation of the Sexually Abused Child: A Medical Textbook and Photographic Atlas, Second edition, Oxford University Press. 105–7.
8. ^ ^{a b} Pokorny, Susan. "Anatomical Terms of Female External Genitalia" (2000) in Evaluation of the Sexually Abused Child: A Medical Textbook and Photographic Atlas, Second edition, Oxford University Press. 110.
9. ^ Encyclopedia of Jewish Medical Ethics. 2003. ISBN 1583305920. http://books.google.com/?id=aaklGZAID08C&pg=PA1115&dq=hymen. "Occasionally, the hymen is harder than normal or it is complete and sealed without there being ... This condition is called imperforate hymen and, at times ..." 
10. ^ DeCherney, Alan H.; Pernoll, Martin L. and Nathan, Lauren (2002). Current Obstetric & Gynecologic Diagnosis & Treatment. McGraw-Hill Professional. pp. 602. ISBN 0838514014. http://books.google.com/?id=9xD0inFiEIAC&printsec=frontcover#PPA602,M1. "Imperforate hymen represents a persistent portion of the urogenital membrane ... It is one of the most common obstructive lesions of the female genital tract. ..." 
11. ^ "Muslim women in France regain virginity in clinics". Reuters. 2007-04-30. http://www.reuters.com/article/wtMostRead/idUSL2532025120070430?pageNumber=2&sp=true. "'Many of my patients are caught between two worlds,' said Abecassis. They have had sex already but are expected to be virgins at marriage according to a custom that he called 'cultural and traditional, with enormous family pressure'." 
12. ^ "The Hymen". University of California at Santa Barbara. http://www.soc.ucsb.edu/sexinfo/article/the-hymen. Retrieved 2009-02-09. "The hymen can have very important cultural significance in certain cultures because of its association with a woman’s virginity." 
13. ^ ^{a b} "In Europe, Debate Over Islam and Virginity". The New York Times. June 11, 2008. http://www.nytimes.com/2008/06/11/world/europe/11virgin.html?_r=1&scp=1&sq=hymen&st=nyt&oref=slogin. Retrieved 2008-06-13. "'In my culture, not to be a virgin is to be dirt,' said the student, perched on a hospital bed as she awaited surgery on Thursday. 'Right now, virginity is more important to me than life.'" 
14. ^ Hymenoplasty is depicted in a fictional context in "Everett Poe", an episode of the television series Nip/Tuck that was broadcast in 2007.
15. ^ Berrios GE, Rivière L. (2006) 'Madness from the womb'. History of Psychiatry. 17:223-35.
16. ^ The linkage between the hymen and social elements of control has been taken up in Marie Loughlin's book Hymeneutics: Interpreting Virginity on the Early Modern Stage published in 1997
17. ^ Blank, Hanne (2007). Virgin: The Untouched History. Bloomsbury Publishing. pp. 23. ISBN 1596910100. http://books.google.com/?id=shq1AAAAIAAJ&dq=Virgin%3A+The+Untouched+History&q=toothed+whales. 
18. ^ Blackledge, Catherine (2004). The Story of V. Rutgers University Press. ISBN 0813534550. http://books.google.com/?id=f2d-11Y_u3cC&pg=PP250&dq=guinea+pig+hymen. "Hymens, or vaginal closure membranes or vaginal constrictions, as they are often referred to, are found in a number of mammals, including llamas, ..." 

External links

• Hymen gallery—Illustrations of hymen types
• Magical Cups and Bloody Brides—the historical context of virginity
• 20 Questions About Virginity—Interview with Hanne Blank, author of Virgin: The Untouched History. Discusses relationship between hymen and concept of virginity.
• All about The Hymen: To prevent Vaginismus and painful first-time sex at the Vaginismus Awareness Network
• MedPix Teaching Case Radiology (US - ultrasound) of Hydrocolpos
• Evaluating the Child for Sexual Abuse at the American Family Physician