Appearance of the hymen in adolescents is not well documented
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7183.605 (Published 27 February 1999) Cite this as: BMJ 1999;318:605
- Emma Curtis, Senior registrar. (emma.curtis{at}ncl.ac.uk),
- Camille San Lazaro, Senior lecturer in paediatric forensic medicine.
EDITOR—As forensic paediatricians, we concur with Rogers and Stark's emphasis on the need for education about the nature of the hymen in postpubertal women.1 Ten of the 20 women described by Logmans et al had been sexually abused.2 The appearance of the hymen before puberty and its appearance after sexual abuse has been well described; the appearance of the hymen in adolescents is not well documented. The study by Emans et al3 is an exception.4
In 1997 we surveyed 126 consultants at district general hospitals (68 paediatricians, 54 obstetricians and gynaecologists, and four consultants in genitourinary medicine). We wanted to establish the frequency with which they examined the hymen in adolescents and how confident they felt about the clinical findings.
Altogether 91/126 examined the genitalia of adolescents less than five times each year. Only 28/75 routinely assessed the hymen on genital examination. There was uncertainty regarding the significance of findings. A total of 35 out of 75 clinicians did not know if a complete cleft might be an expected finding in adolescent girls who were not sexually active, and 34/75 did not know if it might be expected in sexually active girls. One respondent thought that complete absence of the hymen might be a common finding in girls who were not sexually active; eight respondents thought that it might be a common finding in sexually active adolescent girls. The frequency of congenital absence of the hymen has been found to be <0.03%.5 When asked if they thought that frequent sexual activity resulted in ongoing loss or damage to the hymen, 19 consultants thought that it did, 44 indicated that they did not know, and three said that it did not.
In our experience of examining more than 1000 adolescents who had experienced vaginal penetration the most common appearance of the hymen was of indeterminate disruption to the free edge. Complete clefting or significant gaps in hymenal tissue is unusual.
In the prepubertal girl, because of the relative size of the structures, penetration occurs through the hymenal tissue and causes tearing; in the adolescent girl and adult woman consensual penetration occurs into the orifice which thus stretches and yields, resulting in spreading and indeterminate disruption. We agree with Rogers and Stark that so called rupture and bleeding of the hymen is not to be routinely expected after first sexual intercourse.