Keywords
HymenHymenoplastyCarunculaeVaginal introitusInner introitusVirginityVirgin
Closing the entrance does not mean being a virgin again.
For many cultures the hymen and its preservation have been very important; it is a symbol of virginity and purity.
Although nowadays we live in a more open society, where men and women are being mostly regarded as equals, male and female roles are not as strongly implanted in our heads.
However, when talking about sex, gender stereotypes come afloat and the ideal taught for women to remain virgin until they find “the one.” This is imposed on many little girls through religion and family values, so losing her virginity is a “big deal” even today. In some cultures, if the bride is not a virgin, the marriage agreement is not valid anymore, bringing shame to the girl and her family. That’s why hymenoplasty is still something frequently sought for in our practices.
Although being such a simple procedure to perform, we must always help the patient understand that a hymenoplasty is really about blocking the entrance, not a tightening of vaginal walls. In order to actually go back to being a real virgin , as surgeons, we would need to do more than just a hymenoplasty; we would need to also perform a vaginal tightening procedure.
When a girl has not had any sexual intercourse, her vagina feels tighter, but her hymen may or not be intact.
The urban myth stating that every virgin has to bleed on her first sexual intercourse is not necessarily true. As doctors, we all know that some hymens can be flexible and not rupture during the first penetration; to some patients, the hymen itself can rupture with sports, the use of a big vaginal speculum for vaginal tests in a young girl, and other traumatic activities; even the use of tampons can also cause it to rupture. Keep this in mind always when talking about this procedure with your patients.
Anatomy
The hymen is part of the female genitalia; it’s composed by a vaginal mucosa extension on the vaginal opening. This structure is located at the inner introitus , partially blocking the vagina’s entrance, being itself an organ that constantly produces mucus and secretions, that must not stay inside the female body, as they can cause secondary infections.
Also, during puberty, girls begin their menstrual cycle and with it a regular mucosa uterus exchange that causes vaginal bleeding during every cycle.
An imperforate hymen, something that could randomly happen in nature, must be perforated with surgery to prevent this patient from becoming ill.
Once the hymen is perforated by natural causes such as sexual intercourse, sports, or other activities and/or surgically, the woman is left with hymen remains at the inner introitus , as evidence that this female had a complete hymen before. These remains are also known as carunculae.
Carunculae remains
Assessment
When assessing a woman’s inner introitus , we should be able to see hymen remains. These are mucosa extensions on the vaginal entrance that vary in size and shape from woman to woman. Typically, they can be easily found in young girls; for postmenopausal women, vaginal mucosa tends to reduce lubrication after hormonal changes; this can promote carunculae shrinkage to a point where it’s not visible anymore.
For those patients which carunculae can clearly be seen, hymenoplasty can be an easy to perform procedure, while for those which remains are not visible, the case can be more challenging. As surgeons, we can surely plan flap advancements of inner vaginal introitus to simulate hymen remains and proceed with a hymenoplasty, but any scarring tissue formed at the vaginal entrance can cause future pain with friction during sexual intercourse; therefore, it is advisable to avoid aggressive flap advancements in this area.
The best advice when planning a hymenoplasty is to first listen to your patient and understand what and WHY she wants it; second, examine her carunculae ; and third, explain what you can and cannot achieve and the consequences of each different surgical options.
What will the patient tell me?
“I need to be a virgin again to be accepted as a good wife.”
“I need to have a hymenoplasty to not bring shame to my family.”
“My religion states I must be a virgin in order to get married.”
“I feel so devastated, I thought he was the one, the person I was going to live with for the rest of my life, that’s why I gave him my virginity and now he just doesn’t want to be with me anymore, what am I going to do!?”
“I feel used, he just wanted me for sex, I feel now. I need my virginity back.”
“I wish I had been a virgin for my boyfriend, could I just recreate that dream?”
“Since I’m having a vaginal tightening, why not go all the way and have a hymenoplasty done as well!?”
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