#TBT - 14 things you never knew about the hymenal ring

One of my most popular posts makes a comeback for this week's Throwback Thursday (#TBT). Enjoy!...

14 Things You Never Knew About the Hymenal Ring

First let's start with the obvious: what is the hymenal ring, and why should we know about it? I will begin with very brief definition of the hymen itself, as a full posting about the anatomical, physiological, socio-cultural, religious, and sexual aspects of the hymen deserve a separate post.According to Anne Frye in Healing Passage, page 52:

"The hymen is a thin, circular or crescent-shaped fold of mucous membrane located just inside the introitus... The hymen is absent in some women."

If a vagina-owner has a hymen, each is shaped differently, and thus, breaks differently. Variation of shapes are displayed in the picture below:

If a hymen is present, when the hymen breaks, which may or may not happen, it may break during exercise, tampon use, masturbation, or sexual activity. It breaks, but does not disappear. The pieces that remain are referred to as the hymenal ring. The one-sentence description I found of the hymenal ring?

"It consists of tags of firm, fibrous scar tissue on either side."

As the hymen itself may have been "located just inside the introitus at a depth that varies between 0.5 to 2cm," so such is also the location of the remaining hymenal ring. Healing Passage, Anne Frey, p. 52.

The following clinical scenarios occurred recently that have led me to ponder the hymenal ring:

• Notable tension during fetal head descent and crowning specifically at the hymenal ring, with vaginal tissue and skin around the introitus without the same tension
• A woman with vulvodynia, specifically with pain around the area of the hymenal ring
• Discomfort with the speculum exam, for multiple women only to the point of the hymenal ring, and a prior preceptor who regularly encouraged spending as little time as possible applying pressure to the area of the hymenal ring during speculum and bimanual exams
• Dyspareunia and concern about "tags" in the vagina causing pain during sex
• A recent assessment of bladder prolapse, the degree of which was measured by proximity to, or passing of, the hymenal ring

Consequently, I have had many questions about the remnants of tissue left from the hymen, and what the research has to say. Thus, I went searching for more information. Facts to know:1. Hymen comes from the Greek word hymen, meaning membrane. Wikipedia, hymenorrhaphy.2. "Remnants of the hymen are referred to as carunculae myrtiformes, or hymenales but are most commonly referred to as hymenal tags." Healing Passage, Anne Frye, p. 52.3. Varney's Midwifery does not have the word 'hymen', in the glossary. I found discussion of the hymenal ring in three sections. The first, "Inspection of the External Genitalia": "Inspect the vaginal introitus for (1) the hymen or its remnants (myrtiform caruncles), an intact hymen is normal unless tight and rigid or imperforate; myrtiform caruncles are also normal (p. 1173). The second in the section "Procedure for Speculum Examination": "Insert the speculum into the vagina at an oblique angle past the hymenal ring" (p. 1177). In this section, a rationale for the oblique angle of the speculum is provided, but no detail is given as to why "past the hymenal ring" is advised. The third section, "Principles and Thoughts About Episiotomy and Laceration Repair": "Good functional results also include not creating functional problems during the process of repair, for example... not creating sexual problems by placing stitches in the hymenal ring... all of which can cause dyspareunia" (p. 1284).4. The hymenal ring is used as a landmark in assess pelvic organ prolapse (POP), in the most-often used Pelvic Organ Prolapse-Quantification (POP-Q) method. Each of the six quantification points are assigned in relation to the hymenal ring as the stationary vaginal landmark.5. The hymenal ring, and tags present at the site, should be differentiated from "normal configurations of the hymen," which may include "mounds, notches, and tags... If the hymenal edges are smooth and without interruption in the inferior half, the hymen is probably normal." Bates' Guide to Physical Examination and History Taking, p. 828-829. NB: As should be noted with all things deemed "normal," the vagina, and its parts, including hymens and their rings, likely have incredible variation, and beauty.6. "[The hymen] is composed mainly of elastic and collagenous connective tissue, and both outer and inner surfaces are covered by stratified epithelium... The edges of the torn tissue soon re-epithelialize. In pregnant women, the epithelium of the hymen is thick, and the tissue is rich in glycogen. Changes produced in the hymen by childbirth are usually readily recognizable." Williams Obstetrics, p. 17.7. Hymenotomy refers to the cutting of hymenal tissue during birth. "The hymenal ring will usually tear during the first term birth. [You will often note a trickle of blood during crowning as this occurs (insert from page 474)]. As a rule, this happens easily, but occasionally the tissue is tough and resistant. Some practitioners find that snipping a tough hymen down to the center, flush with the yoni wall, will direct the tearing and prevent ragged skin tags with difficult-to-repair deviations. It may also invite a straight tear down to the perineum just as a clitorotomy would do. You will have to use your judgment regarding the ethics of cutting prophylactically and the expected helpfulness of a hymenotomy in a particular case." Healing Passage, Anne Frye, p. 253. 8. Bleeding during first intercourse does not necessarily indicate breaking of the hymen. The concept of "first bleed" could be caused by tense vaginal muscles, inadequate lubrication, rushed entry, or vaginal abrasions not related to hymenal tears. Thus, a lack of bleeding on first intercourse does not necessarily mean that the hymen did not break, or that there was no intact hymen to be broken. Thus, hymenal tags may be the normal hymen state, damage to the hymen, or complete breaking of the hymen. From general reading and seemingly logical information.9. "Past neonatal stage, the diameter of the hymenal opening (measure within the hymenal ring) widens by approximately 1mm for each year of age." Wikipedia, Hymen. 10. The hymenal ring is an anatomical reference for vulvar pain diagnosis: "Chronic vulvar pain that has no clear etiology is called vulvodynia. When the pain is confined to the outer edge of the hymen and the interior edge of the inner surface of the labia minora, it is termed vestibulodynia." Teri Stone-Godena, "Vulvar Pain Syndromes: Vestibulodynia," JMWH, Nov/Dec 2006, p. 502.11. The hymenal ring is an anatomical reference for levator ani muscle strength in pessary fitting: "Pelvic floor strength is assessed by asking the patient to perform a Kegel exercise. The examiner palpates the levator ani muscle in the posterior vagina 2 to 4 cm above the hymenal ring." J.M. Maito, et al., Predictors of Successful Pessary Fitting and Continued Use in a Nurse-Midwifery Pessary Clinic, JMWH, Mar/Apr 2006, p. 78. 12. The Feminist Women's Health Collective in the 1970s defined many structures as clitoral, and thus able to be stimulated and included in arousal tissue, including the hymen (referred to in the referenced article). NB: the sensation of the clitoral basis would logically continue to remaining hymenal structures, including carunculae myrtiforms and remaining hymenal ring tissue. Aileen MacLaren, Primary Care for Women: Comprehensive Sexual Health Assessment, JMWH, Mar/Apr 1995, p. 104. 13. The hymenal ring is a landmark during the repair of vaginal tears after birth. "See how much space there is between your anchor stitch and the hymenal ring... If the hymen is deeply placed, plan your last stitch to be in front of it. If the hymen is relatively shallow (as most are), plan your last stitch to be behind it... Never sew through the hymenal tags themselves and don't attempt to reconstruct the hymenal ring. This will cause extreme pain and is totally unnecessary. Be sure not to strangle the hymenal tags as you secure each stitch." Healing Passage, Anne Frey, p. 506.14. Hemenorrhaphy, or hymenoplasty, is the restoration of hymenal tags into a form similar to the originating hymen, the optimum result of which may cause bleeding during intercourse. In societies where virginitiy may be assessed by the presence of an intact hymen versus hymenal tags, possibly assessed by bleeding during first intercourse with a new partner, this procedure is discussed in limited literature regarding the role of gynecologists in performing the procedure, including here.Despite cellular definitions of hymenal tissue and remaining tag structures, little is known about the continue physiologic role of the hymenal ring or carunculae myrtiformes in vaginal anatomy, sensation, interrelationship with neighboring tissues and organs, and support for women who experience pain in the area of the fibrous hymenal ring. Clearly, however, its recognition is not missed as an anatomical reference point, its palpable difference to surrounding tissue, and pain- and pleasure-sensing points.Lessons learned? The hymenal ring is different for everyone, vascular, sensitive, and an area of vaginal anatomy that likely could use additional research as to its vaginal elasticity related to estrogen supply, elasticity during childbirth, involvement with dyspareunia or vestibulodynia, and varied positioning in regards to a landmark structure for pelvic organ prolapse and suturing.Do you know anything, or can link to any research, about the hymenal ring not listed here? Would love to know more!