(52) Examination of Hymenal Variant Diagnoses Pre- and Post-Evaluation by Pediatric and Adolescent Gynecology

Background: Imperforate hymen is a congenital anomaly of the female genitalia wherein the opening to the vagina is completely obstructed by hymenal tissue and affects 1/2000 patients. Several other hymenal variants, including septate and microperforate hymen, may mimic the presentation of imperforate hymen. This may lead to misdiagnosis of hymenal variants by providers who are less familiar with examination and diagnostic methods for proper diagnosis of congenital anomalies of the female reproductive tract. The objective of this study was to review how an initial diagnosis of hymenal variants may change after referral to pediatric and adolescent gynecology (PAG) specialists.

Methods: A retrospective chart review of patients who underwent a hymenectomy procedure from 2018-2023 was performed on the basis of CPT codes. IRB approval was obtained from our institution. Medical records were reviewed by two researchers. Data regarding age, sociodemographics, reason for referral, and specialty of the initial examining provider were collected. Descriptive statistics were performed. Comparisons were made between initial diagnosis and final diagnoses of hymenal variants among patients who underwent a hymenectomy.

Results: 143 patients were included in our study population. Average age of presentation was 14.2 years (SD=2.4 years). 104 patients were referred to PAG from outside specialties: Pediatrics (71.2%), Adult Ob/Gyn (9.6%), Emergency Medicine (5.8%), Self-referral/unknown (7.7%), Other subspecialties (5.8%). Reasons for referral included difficulty with tampon insertion/removal (38.5%), abnormal uterine bleeding (8.4%), dysmenorrhea (6.3%), and other reasons/asymptomatic (16.8%). Notably, when patients underwent initial evaluation by a non-PAG provider, the initial and final diagnoses differed 44% of the time after referral to a PAG specialist.

Conclusions: Misdiagnosis of hymenal variants occurred nearly half of the time when patients were initially seen by non-PAG providers in this study. PAG providers offer unique expertise in gynecologic examination and appropriate diagnostic work-up of pediatric patients. Our study highlights a disparity in appropriate gynecologic care of pediatric patients with complex gynecologic conditions, as well as a need for early involvement of PAG-trained providers in the assessment of congenital anomalies of the reproductive tract. Increased availability of PAG providers may improve rates of misdiagnosis, delayed diagnosis, and inappropriate surgical management of these complex gynecologic conditions.