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A.D. is a 21 year old patient of mine who came in for a routine exam and birth control pill refill 3 months ago. She also was complaining of painful intercourse.
She explained that intercourse has always been somewhat painful, which she attributed to her partner being “large” and some difficulty with lubrication. The pain is located at the opening of the vagina. Coitarche was 2 years ago and she’s had only infrequent intercourse since then, with one partner.
I examined her and found that her hymen was mostly intact, but very stretchy. Immediately external to the hymen, the skin was reddened, and when I touched those reddened areas with a Q-tip, that duplicated the pain she’s experienced.
I told her she had vulvar vestibulitis, which some have attributed to a chronic unruptured hymen. Normally, the hymen tears at first intercourse, but for those hymens that are unusually stretchy, rather than tear, they stretch. But the stretching isn’t necessarily a good thing, because whenever she has intercourse, the surrounding tissues are tugged on, leading to a chronic inflammation and painful intercourse.
If the symptoms are relatively mild, then using extra lubrication during intercourse may make the problem tolerable enough. But the definitive solution is to surgically create the tears that normally would occur during first intercourse. This is called a hymenotomy and is a simple office procedure.
I first dabbed on some Hurricaine gel to provide some topical anethesia, then injected some 1% lidocaine into the base of the hymen, making it completely numb. Next, I used a hemostat to clamp across the hymen in several locations before using scissors to snip the hymen. In this case, I made incised the hymen at 2, 4, 6, 8, and 10 o’clock. Pre-clamping with the hemostat crushed the tissue I was about to incise, so there was no significant bleeding.
Vulvar vestibulitis presenting with reddened tender areas immediately external to the hymen.
I recommended she wait several days before attempting intercourse again, and ideally a week in order to give the tissues plenty of time to heal. Then, I asked her to return in 3 months to see how she has done.
This surgical approach is simple and usually effective. Other surgical approaches include a hymenectomy, or removal of the entire hymen. This can also be effective, but is a much bigger operation and probably not suitable for performing in an office setting.
A variety of medications have been tried to treat this condition, without much success, including steroids, antibiotics, and anti-inflammatories.
Three months later, she is completely cured and appreciative that sex no longer hurts.
