The Prepubertal Hymen
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CLINICAL The prepubertal hymen Anne Smith consequences of an incorrect diagnosis of sexual Not so long ago, some doctors believed that they could determine, on the basis abuse can be as serious as a missed diagnosis. of examination of a girl’s genitals, whether or not the girl had engaged in sexual intercourse. Even today, ‘virginity checks’ are conducted by doctors in some countries. Do all prepubertal girls have a Some Australian doctors still believe that it should be possible to determine, on the basis hymen? of examination findings, whether a child has been sexually abused. This article sets out Yes, with very rare exception. Population based to describe some of the common variations in hymenal anatomy in order to dispel myths and misperceptions surrounding genital examination findings in young girls. cohort studies of newborn girls support the contention that all girls are born with a hymen.2–4 Keywords: physical examination, medicolegal/jurisprudence, child abuse Intersex conditions occasionally cause confusion about gender and rare congenital abnormalities of the genital tract can also alter the appearance of external genitalia. Most general practitioners would immediately refer any prepubertal child who they What does the normal suspected may be the victim of sexual abuse prepubertal hymen look like? to a specialist centre for assessment and The shape of the prepubertal hymen can change support. Given the consequences for doctors over time.5 It is a structure with a width and and patients when mistakes occur in the depth. The width is the distance from the hymenal medicolegal arena and the potential risk of edge (which defines the hole which forms the secondary trauma, this cautious approach entrance to the vaginal vault) and the vaginal rim. seems wise. However, there are several The depth is the distance from the outer surface other presentations in young girls that would facing the observer to the inner surface inside the appropriately prompt the GP to conduct a vaginal vault. genital examination. For example, in the By convention, most girls are examined in absence of an allegation or suspicion of sexual the supine frog leg position (lying on their backs abuse, symptoms of genital itch, redness, with legs flexed, hips abducted and feet opposed pain or discharge would usually warrant or placed apart). The hymen is described with examination. reference to a clockface, 12 o’clock being the most anterior aspect nearest the urethra and 6 There are two distinct challenges for GPs in o’clock being the most posterior aspect nearest conducting genital examinations in prepubertal girls. the anus. The first is ensuring that the girl and her caregiver are In most newborn girls, the hymen has an relaxed and comfortable during the examination so annular appearance (Figure 1). The ring shape that the process does not create unnecessary anxiety. extends all of the way around the vaginal rim. The second challenge is understanding what is and Oestrogen can cause the hymen to thicken isn’t normal so that the GP knows exactly what they (increase in depth) and also to increase in width. are looking at. It can become folded and fimbriated; taking on Tips for conducting the examination can be found a ‘frilly’ appearance that often obscures the elsewhere.1 This article aims to inform GPs about hymenal opening. Typically there are two stages common variants in hymenal anatomy and offers in a girl’s life when the hymen is affected by advice for interpretation of examination findings. This oestrogen; the first phase occurs from birth may reduce incorrect attribution of normal findings through the first year or so of life, and the second to trauma or sexual abuse. This is important as the phase occurs when puberty commences and Reprint from AUSTRALIAN FAMILY PHYSICIAN VOL. 40, NO. 11, NOVEMBER 2011 873 CLINICAL The prepubertal hymen continues throughout the reproductive years. septal remnants forming hymenal bumps or tags. between the shape of a girl’s hymen and the Clefts (areas of hymen that appeared to be of These findings are not caused by sexual abuse. likelihood of conviction of an alleged perpetrator lesser width than surrounding hymen) were noted of child sexual assault. What does it mean if I cannot see in Berensen’s 1993 study in the anterior half of the the hymen? What rare hymenal abnormalities hymens of newborn girls, but not in the posterior 3 might raise suspicion about child half. The most common reason for the hymen and sexual abuse? During the preschool and early primary school vaginal vestibule to be obscured from view is the years the hymen is commonly observed to have presence of labial adhesions. These can extend One finding that may indicate possible sexual a cresentic shape (Figure 2). The reduction in almost the entire length of the labia or they can abuse (specifically, repeated penetrative trauma to hymenal width is usually seen in the anterior be relatively localised. They are not of forensic the hymen) is a very narrow rim of hymen between hymen, sometimes to the extent that the hymen significance. 3 o’clock and 9 o’clock.11 This ’narrow posterior appears to be absent between 11 o’clock and rim’ must be present when the girl is examined Is a large hymenal opening 1 o’clock. in the prone knee chest position (buttocks in the evidence of previous penetration? The literature abounds with reports and air, knees beneath her buttocks and chest on the opinions about the possible significance of No. The size of the opening in the hymen can bed). In many situations, an apparently narrow hymenal bumps, clefts, vasculature and hymenal be affected by a number of factors including the posterior rim hymen ’unrolls’ or ‘falls down’ under opening size.6 Findings that were previously tension within the surrounding musculature, the influence of gravity, appearing to have a much believed to have been caused by injury, such the examination position and the examination greater width when the girl is examined in the as adhesions, clefts and hymenal thickenings technique. The size of the hymenal opening has no prone position. It is not appropriate to diagnose or bumps, are now known to have no forensic forensic significance.7 a ‘narrow posterior rim hymen’ unless the girl is significance. examined in the prone knee chest position. 8 Bumps (local thickenings of the hymen) Common hymenal variants Repeated traumatic hymenal penetration is a in prepubertal girls are often the hymenal A hymenal septum is noted in approximately possible cause of a narrow posterior hymenal rim, continuation of intravaginal ridges caused by 5% of genital examinations of prepubertal but it is not the only possible cause. underlying longitudinal muscle. Some girls have girls (Figure 3). The septum of hymenal In rare circumstances a laceration (tear) or tissue is typically (but not always) oriented transection (laceration of the entire width of anteroposteriorly. The hymenal openings can the hymen) might be seen following penetrative be eccentric, uneven in size and located in hymenal trauma. Deep clefts or defects around asymmetric positions. If a hymenal septum is the 6 o’clock position (inferior hymen) should present, it is important to inspect for a vaginal arouse suspicion regarding possible sexual abuse, septum, although this is uncommon. although rarely, accidental penetrative hymenal Less commonly, in some girls the hymenal trauma may result in a transection or deep opening is located more anteriorly than average, hymenal cleft. resulting in a vase-like shape (the hymen is Petechiae, bruises, abrasions and lacerations thickened and wider than average at 6 o’clock). might be seen following recent sexual assault. Sometimes the hymen protrudes forward as Unexplained genital injury, hymenal laceration, Figure 1. Annular hymen a sleeve might protrude forward over a hand deep cleft in the inferior hymen, or the presence (sleeve-like hymen) and some hymens appear to of a narrow posterior rim hymen warrant referral roll inward into the vaginal vault. to a specialist centre for assessment regarding Some girls have hymens that appear to have possible sexual abuse. tiny openings (microperforate hymen) or (rarely) Do small red dots on the hymen more than two openings (cribriform or ‘pepper indicate injury? pot’ shape). Probably. The most common cause of small red What does the hymen of a dots on the hymen are petechiae. Petechiae are sexually abused girl look like? pinpoint bruises usually caused by mechanical Most sexually abused girls have normal hymens. forces (often penetrative trauma). Other causes of Normal genital examination findings such as small red hymenal dots include congenital naevi those described have been found in girls who and inflammation. A specialist opinion from a Figure 2. A crescentic hymen is shaped like a have clearly described penetrative sexual forensic expert is recommended as this finding crescent moon. It is usually widest inferiorly 9,10 assault. There appears to be no correlation could have forensic importance. 874 Reprint from AUSTRALIAN FAMILY PHYSICIAN VOL. 40, NO. 11, NOVEMBER 2011 The prepubertal hymen CLINICAL Summary of important points medical care of children who may have been sexually • If there is any suspicion of sexual abuse, abused. J Pediatri Adolesc Gynaecol 2007;20:163– 72. GPs should refer to a specialist centre for 9. Adams JA, Harper K, Knudson S, Revilla J. assessment and support. Examination findings in legally confirmed child sexual abuse: it’s normal to be normal. Pediatrics • GPs may need to examine the genitalia 1994;94:310–7. of prepubertal girls for other clinical 10. Boos SC, McCann J. The paediatric hymen. In: presentations and should understand the Current Practice in Forensic Medicine. Gall J, Payne- James J, editors. Wiley-Blackwell, 2011. normal anatomical variants. 11. Pillai M, Genital findings in prepubertal girls: what • There is significant variation in the appearance can be concluded from an examination? J Pediatr of the normal prepubertal hymen.