Definition

Imperforate hymen is a rare congenital condition where the hymen completely covers the vaginal opening. The term "imperforate" means the absence of a normal opening.

The hymen, also known as the vaginal membrane, is a thin, small membrane located at the vaginal opening. Typically shaped like a crescent, the hymen allows menstrual blood to flow out of the vagina. The hymen has a similar color to the skin surrounding the vagina. It is a remnant of tissue that remains when the vagina forms during fetal development.

The hymen can change over time due to factors such as hormones, physical activity, or the insertion of objects like tampons into the vagina. The function of the hymen is not yet fully understood, but it is believed to help prevent bacteria from entering the vagina.

In cases of an imperforate hymen, the membrane does not spontaneously rupture during fetal development. This condition is the most common cause of vaginal obstruction, occurring in approximately 1 in 1,000 female births worldwide. Because the hymen still completely covers the vaginal opening, menstrual blood cannot flow out. This condition is usually discovered when a girl reaches puberty and experiences her first menstrual cycle.

Causes

An imperforate hymen is a congenital abnormality present from birth. The exact cause of this developmental anomaly during fetal development in females remains unknown.

Normally, the hymen opens and ruptures at around 22 weeks of gestation. In cases of an imperforate hymen, the hymen fails to open due to a failure in cell degeneration within the hymen.

Risk Factor

Although the exact cause of this condition in some females is unknown, experts suspect it may be related to some cells in the developing hymen failing to die as they should. There are also cases where imperforate hymen runs in families, suggesting a possible genetic component.

Symptoms

Although an imperforate hymen is present from birth, girls usually do not experience any symptoms until puberty, when menstruation begins. Symptoms arise because menstrual blood cannot exit the body normally due to the blockage by the hymen, causing blood to back up into the vagina and abdomen.

Symptoms of an imperforate hymen may include:

• Amenorrhea, the absence of menstruation despite the presence of secondary sexual characteristics such as breast development and pubic hair growth
• Abdominal or pelvic pain, recurring monthly pain due to menstrual blood accumulating and unable to flow out
• Back pain
• Bloating or a feeling of fullness in the lower abdomen. This can persist for days due to the buildup of menstrual blood
• Difficulty urinating or painful urination. This can occur because the accumulated blood presses on the urinary tract
• Digestive issues such as constipation
• Problems with urination, especially during the first menstrual cycle
• Digestive difficulties

Additionally, if a doctor detects an imperforate hymen in a newborn, they may notice a bulge in the hymenal membrane.

If you are interested in knowing more about the amenorrhea, you can read it here: Amenorrhea - Definition, Causes, and Risk Factor.

Diagnosis

The appearance of an imperforate hymen varies depending on the patient's age, the severity of the blockage, and the clinical symptoms. This condition can be detected at birth or after puberty. In girls under 10, it is often discovered accidentally. For example, a newborn with an imperforate hymen might have a small bulge on the genitalia, although this bulge might not always be visible.

Generally, a doctor will ask about symptoms and perform an examination based on the complaints. During a genital exam, the hymen may appear swollen or bulging. The hymen might also appear blue due to the accumulation of menstrual blood in the vagina. During a physical examination, healthcare professionals may notice the absence of an opening in the vagina because the hymen completely covers it.

An ultrasound (USG) may be performed next to obtain a clearer view of the tissue. An ultrasound can also confirm the diagnosis if the condition is indeed an imperforate hymen and not caused by another condition. An MRI can help evaluate findings from the ultrasound examination.

Management

The primary treatment for an imperforate hymen is a minor surgical procedure called a hymenectomy. This procedure involves cutting and removing the extra tissue from the hymen to allow menstrual blood to flow out. The surgery can be performed with a scalpel or laser, and once the hymen is cut, the accumulated blood is drained. The patient will be under general anesthesia during the procedure.

Typically, the incision on the hymen is made in an “X” shape, or a small slit is made on the hymen. This type of incision can help alleviate symptoms caused by obstructed menstrual blood flow. The surgical procedure is done to prevent the hymen from closing again completely. In infants, the procedure is usually performed once the child has reached puberty.

Pain relief medications may be prescribed to manage postoperative pain. Antibiotics may also be given to prevent infection. In some cases, you may be advised to use a vaginal dilator to prevent the surgically created opening from closing again after surgery.

There are no long-term complications associated with a hymenectomy. Most females recover without any problems. In the majority of cases, there are no issues with menstruation, sexual activity, pregnancy, or childbirth.

Complications

Many teenage girls are unaware they have an imperforate hymen until their first menstruation. Complications can arise if too much menstrual blood accumulates in the vagina.

If not detected and treated early, an imperforate hymen can lead to infections in the vagina, kidney problems, fertility issues, and endometriosis (a condition where the lining of the uterus grows outside the uterus).

A hymenectomy procedure usually does not cause complications, and patients can resume normal activities after recovering from surgery. However, there are still risks associated with a hymenectomy, including:

• Swelling or inflammation
• Heavy bleeding
• Infection in the reproductive organs
• Scar tissue formation
• Allergic reactions to medication

Prevention

It is impossible to prevent an imperforate hymen, as it is a congenital condition that occurs during fetal development. The cause is still unknown. However, since some cases show a family history of an imperforate hymen, it is advisable to be aware if any close family members have had this condition.

When to See a Doctor?

It is recommended to consult a doctor if you or your child:

• Have not started menstruating yet
• Have developed secondary sexual characteristics such as pubic hair and breast enlargement
• Are experiencing any of the symptoms mentioned above

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