Genital Herpes

Overview

What Is It?

Genital herpes is a contagious infection caused by the herpes simplex virus. Although it is incurable, genital herpes responds well to treatment.

According to the U.S. Centers for Disease Control and Prevention, genital herpes affects about one in six people aged 14 to 49.

Although the infection can be serious for newborn babies and people who are chronically ill, rarely is it fatal. While there is still no known cure, genital herpes does respond well to treatment.

There are two types of herpes simplex virus, herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2). Both types are related to the family of viruses that cause chicken pox and shingles. Both HSV-1 and HSV-2 can cause genital herpes.

"Oral herpes" causes sores and blisters on the lips and gums and in the mouth—typically referred to as cold sores. Oral herpes is very common and can be spread by kissing or oral sex. It is usually caused by HSV-1.

"Genital herpes" causes sores in the genital area. The sores it causes often are painful and sometimes itchy. Genital herpes can cause serious health problems in infants who become infected by their mothers during delivery and in people whose immune systems are weakened. Genital herpes can be caused by HSV-1 or HSV-2; it is most often caused by HSV-2.

For reasons not entirely clear, many people with genital herpes either have no visible symptoms or don't recognize the symptoms. The virus can be transmitted with or without symptoms being present. But the major concern with both oral and genital herpes is that you remain infected for life and there is no cure.

When it does cause symptoms, genital herpes can produce sores in and around the vaginal area, on the penis, around the anal opening and on the buttocks or thighs. Occasionally, sores also appear on other parts of the body where broken skin has come into contact with the virus. HSV remains dormant in certain nerve cells of the body for life, causing periodic symptoms in some people while remaining dormant for life in others. Like other genital ulcer diseases, genital herpes increases both the risk of acquiring and transmitting HIV, the virus that causes AIDS, by providing a point of entry or exit for HIV.

One of the most bewildering and frustrating aspects of genital herpes is the periodic outbreak of sores that infected people often experience. Recurrences of genital herpes can be upsetting and sometimes painful. Moreover, the emotional stress over transmitting the disease to others and disrupting sexual relations during outbreaks, as well as informing your sexual partner of your infection status, can take a toll on personal relationships. With proper counseling, improved treatments and prevention measures, couples can cope with and manage the disease effectively.

Genital herpes is acquired by sexual contact with someone who is infected. A decade ago, it was believed that the virus could be transmitted only when the virus was active and causing symptoms, such as sores and blisters. Now, it is known that the virus can spread even when there are no symptoms (called asymptomatic transmission). In addition, research suggests that a large proportion of people who appear to have no symptoms do have symptoms that they just don't recognize.

If you have oral herpes, you also can transmit the infection to the genital area of a partner during oral-genital sex. Some genital herpes infections in the United States are due to HSV-1; presumably, many of these were transmitted during oral sex. There is no documented case of herpes being spread by contact with objects such as toilet seats or hot tubs. While rare, transmission is possible from skin-to-skin contact through open sores. Prudent hand-washing and personal hygiene decrease or nearly eliminate that risk.

Diagnosis

Genital herpes is not always easy to diagnose because signs and symptoms vary greatly. Some studies show that as many as two-thirds of all people infected with genital herpes will experience either no symptoms or will have symptoms so mild or atypical that they will not notice them or will mistake them for something else, like a yeast infection. Recent research has shown that after receiving health education about symptoms of genital herpes, many people who were thought to have asymptomatic infection (infection with no symptoms) were able to recognize symptoms.

The first episode of genital herpes is referred to as the primary outbreak, an episode occurring within a week or two after exposure. When it produces symptoms, the primary outbreak is characterized by lesions at the infection site and can be accompanied by flu-like symptoms, including headache, fever, painful urination and swollen glands in the groin. Usually, small red bumps appear first, develop into blisters and then become painful open sores. Lesions can occur on the pubic hair area, vulva and perineum, inside the vagina and on the cervix in women, on the penis in men, at the rectum or the urethral opening of women and men or on the buttocks or thighs. These lesions usually heal within two to four weeks. Scabs may form on skin surfaces, such as the penis, but not on mucosal surfaces such as the vagina.

Not all individuals who are exposed to the virus will experience a primary episode directly following exposure, or the symptoms may be so mild that they go unrecognized.

Almost immediately after HSV infects your body and before symptoms appear, the virus travels to a sensory nerve root at the base of the spinal column called the sacral ganglion. It remains there in a latent or dormant stage indefinitely. In some people the virus reactivates and travels back to the skin, where it multiplies until it erupts at the surface in the form of a sore. An itching, tingling or burning sensation in the genital area or buttocks often signals an upcoming episode. These warning symptoms are called the prodrome.

Most people who have primary infection will experience periodic outbreaks, or recurrences. For many, symptoms will reappear an average of four or five times a year lasting about five to 10 days. Between outbreaks, the virus retreats to the sacral ganglion in the spine where it is protected from the body's immune system. Infected people develop antibodies in response to genital herpes infection but, unfortunately, HSV antibodies cannot completely protect a person against different HSV types or against reactivation of the dormant virus. Periodic outbreaks tend to become less frequent and less severe over time. Eventually outbreaks may disappear altogether.

Not all outbreaks have symptoms, and the virus may continue to be transmitted from a variety of sites in the genital area or in genital secretions or from lesions that are hidden or too small to notice.

The trigger for these recurrences is not known. Stress, menstruation, infections and emotional distress may contribute. However, research has shown that episodes can recur when these factors are absent.

Although sores may be visible to the naked eye, laboratory tests may be needed to distinguish herpes sores from other infections. For years, the most common method of diagnosis has been the viral culture. A new sore is swabbed or scraped, and the sample is added to a laboratory culture containing healthy cells. When examined under a microscope after several days, the cells show changes that indicate growth of the herpes virus. A major disadvantage of viral culture is that the specimen must be collected from a lesion or sore; when the lesion begins to heal, the test becomes unreliable.

A test called the polymerase chain reaction (PCR) test, which detects HSV DNA, is more sensitive and faster than standard culture tests at identifying the herpes virus in the urinary and genital tracts. Like the viral culture, it involves getting a cell sample from a sore. PCR is increasingly used, and may replace viral culture as the preferred test for diagnosis. According to the U.S. Centers for Disease Control and Prevention, viral cell culture and/or PCR are the preferred tests for individuals with active lesions.

Blood tests have become more popular for diagnosis because they can detect evidence of infection even when sores are not present. These tests can be done on a small amount of blood taken from the arm or finger and, in some settings, results may be available immediately. Because they detect antibody (made by the body in response to the infection) they may not be positive until several weeks to months after exposure. Because most HSV-2 is genital, a positive blood test for HSV-2 usually indicates genital herpes. This test cannot determine when the initial infection occurred.

Because so many people in the United States have cold sores due to HSV-1, the test for HSV-1 is not routinely done. However, because HSV-1 can cause genital herpes , a negative test for HSV-2 does not rule out genital herpes infection due to HSV-1.

A clinician should interpret test results. A major advantage of the HSV-2-specific blood test is that it can be done when no sore is present. It may, therefore, detect infection in people who have not had recognized symptoms. However, the U.S. Centers for Disease Control and Prevention does not recommend routine testing for herpes in individuals without symptoms. It may be useful if you have had multiple recurrences of genital ulcers without positive HSV cell culture or PCR testing, if your partner has genital herpes or if you want a "complete" STD exam (especially if you have multiple partners).

Counseling at the time of diagnosis and ongoing support is important for everyone with genital herpes. Such support may be especially important for those who are diagnosed but have no symptoms. Although treatment and counseling are similar for genital herpes, whether caused by HSV-1 or HSV-2, knowing the type of HSV may be helpful for the health care professional. For example, genital herpes caused by HSV-1 usually presents with milder symptoms and less frequent outbreaks.

Treatment

Although herpes cannot be cured, there are several drugs that can reduce the intensity of symptoms, as well as the number of recurrences. Acyclovir (Zovirax), valacyclovir (Valtrex) and famciclovir (Famvir) are all prescription antiviral drugs that are effective in treating genital herpes. Dosage, frequency and duration of treatment vary depending upon the individual and the type of treatment. They are taken by mouth. Topical creams are ineffective. Intravenous treatment may be used in the hospital specifically for individuals who have a suppressed immune system, that is, those who have HIV/AIDS. Since all three drugs are good, effective antivirals, decisions about which to use usually take into account convenience and cost.

Valacyclovir has been approved by the U.S. Food and Drug Administration for prevention of genital herpes transmission. However, while valacyclovir significantly decreases the risk of sexual transmission of herpes, transmission can still occur. Also, it isn't known whether valacyclovir prevents transmission of genital herpes in same-sex couples.

Treatment can be taken in different ways. "Episodic therapy" is taken at the first appearance of symptoms. This therapy involves taking daily dosages of a drug until symptoms subside, usually for a course of one to five days. The antiviral drugs are safe, have few side effects, shorten the length of first episodes and reduce the severity of recurring outbreaks, especially if taken within 24 hours of the onset of prodromal symptoms. Episodic therapy will not prevent transmission between episodes.

For those who have frequent recurrences, "suppressive therapy" can keep the virus in check indefinitely. This treatment involves daily medication, even when you have no symptoms. It can reduce the number of recurrences significantly. Suppressive therapy also reduces the chances that an infected person will transmit the virus to a sexual partner primarily because it reduces asymptomatic shedding of the virus.

As for other treatments, there is some indication that some natural remedies such as zinc, vitamins C and A, lysine, Siberian ginseng and echinacea may enhance the immune system's response to herpes. Aloe vera extract and other topical ointments may speed healing time of lesions, but experts caution that topical treatment of sores appears to have no added benefit when used in conjunction with antiviral drugs. No natural therapy has been proven to benefit people with herpes.

Treating women who develop genital herpes during pregnancy is critical to protecting newborns from acquiring the virus. Nearly half of the babies infected with herpes either die or suffer neurological damage. Babies born with herpes can also develop encephalitis (inflammation of the brain), severe rashes and eye problems. Fortunately, only a small percentage of women with HSV pass the infection onto their babies.

The risk of transmission to an infant varies greatly depending on when a woman is infected. A pregnant woman who develops a first episode of genital herpes during her pregnancy is at highest risk of passing the virus to her fetus and may be at higher risk for premature delivery. If a mother has her first outbreak near or at the time of a vaginal birth, the baby's risk of infection is high. If the outbreak is a recurrence—meaning the mother was infected before she was pregnant—the baby's risk is much lower. Overall, studies show that less than 2 percent of pregnant women with HSV acquired the virus during pregnancy.

Before much was known about how HSV is transmitted from mother to baby during birth, many pregnant women with the virus were given cesarean sections, regardless of when they became infected. Today, cesarean sections are limited to women who have detected sores in or near the birth canal at the time of labor. Women whose virus is active late in pregnancy may be put on suppressive therapy to help prevent transmission to the infant.

If an infant is infected, the antiviral medication acyclovir can greatly improve the outcome, particularly if treatment starts immediately. With early detection and treatment, most of the serious complications of neonatal herpes can be lessened. The drug acyclovir appears to be safe in pregnancy, but it should only be used when the benefits of taking the drug outweigh the risks. At this time, there isn't as much information on the safety of valacyclovir and famciclovir, but both are classified as class B agents by the FDA (no evidence of risk in humans), similar to the risk of acyclovir.

Comprehensive treatment should include education and counseling. Referrals to support groups as well as online resources may help people with genital herpes adjust to this recurring condition.

Prevention

Any type of unprotected vaginal, anal or oral-genital sex can transmit herpes. Until a vaccine is developed or research proves that antiviral drugs can stop transmission, the only effective means of preventing herpes is abstinence or consistent and correct condom use. However, even condoms are not risk-free because lesions can occur outside of the area protected by condoms.

The risk of transmission is greatest when an outbreak occurs. As a rule, experts say it is best to abstain from sex when symptoms are present and to use condoms between outbreaks. Since oral herpes can be passed to the genitals from oral contact, it is prudent to abstain from oral sex if a cold sore is present.

Couples in long-term monogamous relationships in which one partner is infected must weigh the risk of infection against the inconvenience of always having protected sex. Most infections take place fairly early in a relationship and research indicates that a person may become less infectious over time.

Women can use dental dams or plastic wrap to cover the vulva and help protect their partners from contact with body fluids during oral sex. The only dental dams approved by the FDA for oral sex are Sheer Glyde dams. Because transmission can occur even when no lesions are present, always place a latex barrier between you and your partner's genitals and anus. Again, couples should abstain from sex during outbreaks, until the skin is fully healed.

Lesbians or bisexual women should be aware that the herpes virus can be transmitted when a lesion from one woman comes into contact with the oral mucosa or the genital mucosa of her female partner.

If you experience an outbreak, whether primary or recurrent, you need to follow a few simple steps to improve healing and avoid spreading the infection to other parts of your body or to other people:

• Keep the infected area clean and dry to prevent secondary infections from developing.
• Avoid touching sores, and wash hands after contact with sores.
• Avoid sexual contact until sores are completely healed (that is, scabs have fallen off and new skin has formed over the site of the lesions).

People with early signs of a herpes outbreak or with visible sores should not have sex from the development of the first prodromal symptom until the sores have healed completely.

Several clinical trials have looked at both prophylactic and therapeutic vaccines. The goal of prophylactic vaccines is to prevent acquisition of the virus. To date, vaccines for preventing infection have been found to be ineffective. Therapeutic vaccines would help people already infected with HSV, with the goal to decrease viral shedding and the number of outbreaks experienced. Research efforts continue with the goal of development of effective prophylactic and therapeutic HSV vaccines.

Facts to Know

1. Some studies show that most people infected with genital herpes don't know they are infected because they have no visible or no recognized symptoms.

2. Although transmission to infants is rare (only a small percentage of women with herpes pass the infection on to their babies), genital herpes causes death or neurological damage in nearly half of untreated newborns who become infected at birth.

3. Some genital herpes infections are caused by HSV-1 (oral herpes), probably resulting from oral-genital sex.

4. As many as half of infected persons who have recurrent episodes will experience localized tingling and irritation at the site of infection, usually 12 to 24 hours prior to an outbreak. Recurrences average two to six per year but vary widely.

5. Preventive therapy may decrease the frequency and severity of recurrent outbreaks by up to 90 percent. However, therapy doesn't significantly reduce the frequency of recurrences once it is stopped. Recurrence also tends to lessen in intensity and duration over time.

6. Without treatment, recurrent infections usually last five to 10 days.

7. The first episode of infection, called the primary outbreak, is usually the most severe.

8. Although herpes vaccine research is being conducted, no vaccine is currently available.

Questions to Ask

Review the following "Questions to Ask" about herpes so you're prepared to discuss this important health issue with your health care professional.

1. How, what and when should I tell my partner about my infection?

2. Does my partner need to be tested?

3. Does having genital herpes mean I can't or shouldn't get pregnant?

4. How will I be monitored for outbreaks once I am pregnant?

5. Do I have to be careful about passing the virus to my children through casual contact?

6. How can I predict when I'm going to have another outbreak?

7. When am I at greatest risk for transmitting the virus to my partner?

8. Is there a cure for herpes? How can drug treatments help me?

9. How do I decide whether I need drugs to control recurrences?

10. How do I choose among the drugs available for treating herpes and preventing recurrences?

11. What can I do to make herpes outbreaks less painful?

12. Are there any support groups for people with herpes? Where can I find someone to talk to who understands how I'm feeling?

Key Q&A

Lifestyle Tips

1. Talk to your date about herpes

If you have herpes and are planning to become sexually active with someone new, you owe it to them and to yourself to be honest about your own infection. You can spread the infection even if your virus is dormant and you have no open sores. Try practicing telling with a trusted friend or in front of a mirror. And stay calm. Keep your words simple and clear, and be prepared to answer any questions. In general, those with herpes find that with time and a better understanding of the disease, telling new partners becomes easier. They also discover that herpes doesn't affect their intimate relationships and sex lives as much as they originally feared.

2. Take precautions for oral sex

Unprotected oral sex is no guarantee of protection against sexually transmitted diseases. Most sexually transmitted diseases can be spread via oral sex. To protect yourself, make sure your partner uses a condom if you're performing oral sex; if he's performing oral sex on you or if you're having oral sex with a woman, use a dental dam, a flat piece of latex, to cover the vulva. You can get them in some medical supply stores. They provide a barrier between the mouth and the vagina or anus during oral sex. Household plastic wrap or a split and flattened, unlubricated condom can also be used if you don't have a dental dam. Also, don't brush or floss your teeth right before having oral sex. Either may tear the lining of your mouth, increasing your exposure to viruses.

3. Practice the best protection

The best protection against any type of sexually transmitted disease is a latex condom. However, it doesn't provide 100 percent protection against STDs––only abstinence does. If you use a condom, make sure you use it properly. Human error causes more condom failures than manufacturing errors. Use a new condom with each sexual act (including oral sex). Carefully handle it so you don't damage it with you fingernails, teeth or other sharp objects. Put the condom on after the penis is erect and before any genital contact. Use only water-based lubricants with latex condoms. Ensure adequate lubrication during intercourse. Hold the condom firmly against the base of the penis during withdrawal, and withdraw while the penis is still erect to prevent slippage.

4. Get tested for STDs

No one test screens for all STDs. Some require a vaginal exam; others a throat or rectum swab or a blood or urine test. Just because you have a negative test doesn't mean you don't have the disease. Chlamydia, for instance, may travel far up into your reproductive tract, so your health care professional is unable to obtain a culture. Or your body may not have developed enough antibodies to a virus like HIV or HSV to turn up in a blood test. Still, it's important to ask your health care professional to regularly test you for STDs if you're sexually active in a nonmonogamous relationship (or have the slightest concern about your partner's fidelity). You can get tested at your health department, community clinic, private physician or Planned Parenthood. Or call the national STD hotline at 1-800-227-8922 or the Centers for Disease Control and Prevention at 1-800-CDC-INFO or 1-800-232-4636 for free or low-cost clinics in your area.

5. Know whether you have an STD

While some STDs may present with symptoms such as sores or ulcers or discharge, most, unfortunately, have no symptoms. Women are even more likely than men to have STDs without symptoms. Women are also more likely to develop serious complications from STDs. You can't always tell if you or a partner has an STD just by looking. Don't rely on a partner's self reporting and assume that will prevent you from acquiring an STD; many infected persons do not know they have a problem. They may think symptoms are caused by something else, such as yeast infections, friction from sexual relations or allergies. Educate yourself about your own body and, in turn, learn about your own individual risk for contracting an STD. One way to do this is to schedule an examination with a health care provider who can sit down with you and help you learn the principles for staying safe and sexually healthy. Don't allow fear, embarrassment or ignorance to jeopardize your future.

6. Talk to your children about STDs

Sexually transmitted diseases are particularly common among adolescents. And it's an issue kids are concerned about. As a parent, you can play a large role in your adolescent's behavior, both in terms of the behavior you model yourself and in terms of the communication between you and your teen. Make sure your daughter has regular visits with a competent gynecologist, and that your son sees a medical professional who specializes in adolescent health at least once a year, if for nothing else than some plain talk about STDs and pregnancy. And talk to your kids. Study after study proves that when parents talk to their kids about sexual issues, their kids listen. Don't worry that talking about sex is the same as condoning it; hundreds of studies dispute that theory. In fact, studies show that when parents talk about sex, children are more likely to talk about it themselves, to delay their first sexual experiences and to protect themselves against pregnancy and disease when they do have sex.

Organizations and Support

For information and support on coping with Genital Herpes, please see the recommended organizations, books and Spanish-language resources listed below.

American College of Obstetricians and Gynecologists (ACOG)
Website: https://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Social Health Association (ASHA)
Website: https://www.ashasexualhealth.org/
Address: P.O. Box 13827
Research Triangle Park, NC 27709
Hotline: 1-800-227-8922
Phone: 919-361-8400
Email: info@ashastd.org

CDC National Prevention Information Network
Website: https://www.cdcnpin.org
Address: P.O. Box 6003
Rockville, MD 20849
Hotline: 1-800-458-5231
Phone: 404-679-3860
Email: info@cdcnpin.org

Guttmacher Institute
Website: https://www.guttmacher.org
Address: 1301 Connecticut Avenue NW, Suite 700
Washington, DC 20036
Hotline: 1-877-823-0262
Phone: 202-296-4012
Email: info@guttmacher.org

National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
Website: https://www.cdc.gov/nchhstp
Address: Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30333
Hotline: 1-800-CDC-INFO (1-800-232-4636)
Email: cdcinfo@cdc.gov

National Family Planning and Reproductive Health Association (NFPRHA)
Website: https://www.nationalfamilyplanning.org/
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
Phone: 202-293-3114
Email: info@nfprha.org

Planned Parenthood Federation of America
Website: https://www.plannedparenthood.org
Address: 434 West 33rd Street
New York, NY 10001
Hotline: 1-800-230-PLAN (1-800-230-7526)
Phone: 212-541-7800

Sexuality Information and Education Council of the United States (SIECUS)
Website: https://www.siecus.org
Address: 90 John Street, Suite 704
New York, NY 10038
Phone: 212-819-9770

Books

Controlling Herpes Naturally: A Holistic Approach to Prevention & Treatment
by Michele Picozzi

Herpes Simplex (Experience of Illness)
by T. Natasha Posner

Sexual Health Questions You Have...Answers You Need
by Michael V. Reitano, Charles Ebel

Sex: What You Don't Know Can Kill You
by Joe S. McIlhaney, Marion McIlhaney

Understanding Genital Herpes (Women's Health Care)
by Gilles R. G. Monif

Spanish-language resources

Medline Plus: Genital Herpes
Website: https://www.nlm.nih.gov/medlineplus/spanish/ency/article/000857.htm
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Center for Disease Control
Website: https://www.cdc.gov/std/spanish/herpes/stdfact-herpes-s.htm
Address: CDC Info
1600 Clifton Rd
Altanta, GA 30333
Hotline: 1-800-232-4636
Email: cdcinfo@cdc.gov

American Academy of Family Physicians, FamilyDoctor: Genital Herpes
Website: https://es.familydoctor.org/condicion/infecciones-de-transmision-sexual-sti/