Normal Hymen Variants

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When performing a vaginal exam on a prepubertal girl, it is important to be familiar with normal variants of hymen anatomy. The most common hymenal variants are crescentic, annular, cuff-like, fimbriated, and septate.

Look For

The absence of the hymen in a neonate has never been reported. On average, the width of the hymenal ring tissue is approximately 3 mm. A study of prepubertal girls done by Pugno reports that average transhymenal diameter is 2.3 mm in an infant with a 1 mm increment with every year of age.

An annular hymen completely surrounds the hymenal opening and is the most common configuration.

A cuff-like hymen has an annular shape with a slightly anteriorly placed orifice when compared with an annular hymen.

A fimbriated hymen has redundant hymenal tissue at its periphery appearing as folds, so the edge has a ruffled appearance.

A crescentic hymen appears as a “crescent” of hymenal tissue with absence of the upper portion of the hymen, so it appears to be attenuated between 11 o’clock and 1 o’clock.

A septate hymen has one or more bands of tissue that bisects the vaginal opening, creating 2 or more openings. The hymen will appear normal at the periphery and have concentric continuity. This has been found in 1–2% of prepubertal girls. It is an incidental finding for most pre-pubertal girls.

An estrogenized hymen in pubertal girls will appear to be thicker.

Patients can have normal, non-specific findings that include hymenal tags, papules or “mounds,” labial adhesions, notches or clefts in the anterior portion of the hymen between 9 o’clock and 3 o’clock, vaginal discharge, erythema, perianal skin tags, anal fissures, and anal dilatation. Findings concerning for sexual abuse, but not diagnostic, include notches or clefts in the posterior portion of the hymen, condylomata acuminata, marked and anal dilatation, or anal scarring. Physical findings that are diagnostic of penetrating trauma include laceration or ecchymosis of the hymen, absence of the inferior portion of the hymen, healed hymenal transection, deep anal laceration, or pregnancy.

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