Joanne Poje Tomasulo, M.D., ACOG
Herpes simplex is a virus that causes blisters and sores. There are two types: herpes simplex virus 1 (HSV-1) and herpes simplex virus 2 (HSV-2).
HSV-1 is usually associated with the cold sores or fever blisters people frequently get on the mouth, lips or nose, but in some cases HSV-1 can also cause genital herpes. HSV-1 infection of the genitals can be caused by oral contact with the genitals or genital-to-genital contact with a person infected with HSV-1. Only 5 to 10 percent of genital herpes is caused by HSV-1, according to the National Institutes of Health (NIH).
Most genital herpes cases are caused by HSV-2 infection, which is spread through sexual contact (vaginal, oral or anal) with an infected partner. It can be spread even if the infected person is not experiencing symptoms. Genital herpes is one of the most common sexually transmitted diseases in the United States. The Centers for Disease Control and Prevention (CDC) estimates that 1 million Americans become infected each year with genital herpes.
HPV-1 infection is by far more common. An estimated 90 percent of the U.S. population has been exposed to HSV-1, and 25 percent of young adults (ages 25 to 45) have been exposed to HSV-2, according to the NIH.
Many people with genital herpes experience no symptoms. When present, early symptoms include itching or burning in the genital or anal area and flu-like symptoms. Later symptoms include blisters or sores and vaginal discharge.
If a woman is experiencing sores, genital herpes may be diagnosed during a gynecological examination. Laboratory tests, such as viral cultures (tests performed by placing a tissue sample in a container where a virus can grow) or blood tests, may be performed to confirm diagnosis.
There is no cure for herpes as the herpes simplex virus remains in an individual’s body for life. However, antiviral medications can ease symptoms, reduce the number of outbreaks and help prevent transmission of the virus.
Using a latex condom during vaginal, oral or anal sex can help prevent the spread of the virus. However, abstinence from sexual activity or maintaining a monogamous relationship with an uninfected person is the most effective way of reducing the risk of herpes.
Herpes is the general term for a group of viruses that cause blisters and sores. There are two types of herpes simplex viruses: herpes simplex virus 1 (HSV-1) and herpes simplex virus 2 (HSV-2).
HSV-1, the more common form of the virus, causes cold sores or fever blisters that appear on or around the mouth, lips or nose. Many people experience cold sores at some point in their lives. HSV-1 can cause genital herpes but it is less likely than the second form of the virus, HSV-2.
HSV-1 infection of the genitals can be caused by oral contact with the genitals or genital-to-genital contact with a person infected with HSV-1. Between 5 to 10 percent of genital herpes is caused by HSV-1, according to the National Institutes of Health (NIH). Genital herpes is more commonly caused by HSV-2, a sexually transmitted disease that causes sores in the genital area. It may be transmitted through vaginal, oral or anal sex.
Herpes viruses can live outside the body for up to several hours in a warm, damp place. It is possible for HSV-1 to be transmitted by an individual with a cold sore through kissing or by touching contaminated objects such as towels, bedding, utensils, toothbrushes or toilet seats. However, according to the NIH, there are few, if any, cases of genital herpes being spread through contact with contaminated objects.
HSV-1 and HSV-2 live in nerve cells. After the virus infects the body, it travels to the sacral ganglion (a sensory nerve root at the base of the spinal column). It can remain there in a 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 a sore. When this occurs, it is called an outbreak. The nerves in the genitals, upper thighs and buttocks are connected. As a result, a person can experience outbreaks in any of these areas.
Between outbreaks, the virus remains in the sacral ganglion, where the body’s immune system cannot destroy it. People with genital herpes develop antibodies (proteins used by the immune system to identify and neutralize foreign objects such as bacteria and viruses) in response to infection. But the antibodies cannot completely protect against different strains of the virus or reactivation of the dormant virus.
An estimated 90 percent of the U.S. population has been exposed to HSV-1, and 25 percent of the population ages 25 to 45 has been exposed to HSV-2, according to the NIH.
The U.S. Centers for Disease Control and Prevention (CDC) estimates that 45 million people ages 12 and older in the United States (one out of five adolescents and adults) have been infected with genital herpes. Between the late 1970s and the early 1990s, the number of Americans with genital herpes infection increased 30 percent. The infection rate remained stable over the 1990s.
In 1999, the estimated prevalence of genital herpes was 19 percent among the general population in the United States aged 14 to 49 years old.
Genital herpes is more common in women (about one out of four women is infected) than in men (almost one out of five). This is probably because transmission from men to women is more likely than women to men.
The herpes virus can be transmitted regardless of sexual orientation. For instance, it can be transmitted from woman to woman if a sore from one woman comes into contact with the oral mucosa (moist tissue that lines certain organs and body cavities) or the genital mucosa of her female partner.
Rarely, genital herpes can be passed during childbirth from a mother to a baby as it passes through the birth canal. This occurrence is uncommon because mothers pass antibodies to their babies during pregnancy. A woman who acquires genital herpes during the third trimester of pregnancy, however, is more likely to transmit the virus because she has not had time to build up antibodies.
Transmission of the virus to an unborn fetus can lead to premature birth. A baby born with herpes can also experience serious health problems, such as encephalitis (inflammation of the brain), severe rashes and eye problems. Herpes may also be life-threatening to an infant. According to the National Institute of Allergy and Infectious Diseases (NIAID), half of all babies infected with herpes either die or suffer from nerve damage.
Although genital herpes can be uncomfortable, the disease is not considered a dangerous condition in adults. It does, however, increase the risk of acquiring and transmitting human immunodeficiency virus (HIV) by providing a point of entry or exit for HIV. In addition, HIV-positive people who are not being treated because their immune system is suppressed often have severe herpes outbreaks.
In addition to the two herpes simplex viruses, the family of herpes viruses includes varicella zoster, which causes chickenpox and shingles, and Epstein-Barr virus, which causes mononucleosis.
Risk factors and causes of herpes
Genital herpes can be caused by exposure to herpes simplex virus 1 (HSV-1), but most cases are caused by exposure to herpes simplex virus 2 (HSV-2). HSV-1 and HSV-2 can be found in and released from the sores that the viruses cause, but may also be released from skin that does not appear to be broken or have sores. The virus is secreted from oral or genital mucosa (moist tissue that lines some organs and body cavities) and may be transmitted through exchange of bodily fluids. Most skin is thick enough to serve as a barrier for the virus.
Genital herpes is most easily spread through having vaginal, oral or anal sex with another person who is infected with the HSV-2 virus and having an active outbreak. In addition, the disease is also easily transmitted during the few days prior to an outbreak. This period is known as prodrome.
It was once believed that transmission could occur only if the virus was active and causing symptoms, but this has since been proven false. There may be occasions, known as asymptomatic reaction or asymptomatic shedding, in which a person infected with herpes can transmit the virus without the presence of sores or other visible symptoms.
Genital herpes can also be transmitted when a person infected with HSV-1 has oral sex with another person. The virus can live outside the body for several hours, and it is possible to transmit the virus by sharing items such as towels or utensils. However, there are few, if any, cases of genital herpes being spread through contact with contaminated objects, according to the National Institutes of Health (NIH).
Scientists do not know what causes the virus to become active. Some people report having an outbreak when they are sick, under stress or have been exposed to the sun. Some women also report having outbreaks during menstruation. In addition, poor diet, fatigue, friction, surgical trauma and steroid medications (e.g., asthma medications) may also trigger outbreaks. Some patients will never have a subsequent outbreak and others have frequent recurrent outbreaks.
Risk factors for genital herpes include:
- Multiple sexual partners. Having sex with more than one person results in a greater risk of acquiring genital herpes.
- High-risk partners. Having sex with a person who has multiple sexual partners or one who is infected with the HSV-2 virus puts a person at a higher risk of acquiring genital herpes.
- Unprotected sex. Having sex without using a condom. Condoms reduce, but do not eliminate, the risk of spreading the HSV-2 virus. Areas not covered by the condom can transmit the virus.
- Gender. More women acquire genital herpes than men. Women also tend to have more severe and longer-lasting symptoms.
- An impaired immune system. People infected with human immunodeficiency virus (HIV) or other diseases that affect the immune system are more likely to acquire genital herpes because of a decreased ability to fight off infection.
Signs and symptoms of herpes
Many people who have genital herpes experience no symptoms. If symptoms appear during the first outbreak, however, they can be severe. Symptoms may appear within days of contracting the virus, or it may take weeks, months or years. The first outbreak usually occurs within two weeks after the virus is transmitted and typically lasts two to three weeks.
Early symptoms (prodromal phase) of an outbreak may include itching or burning in the genital or anal area. Other early symptoms may include:
- Fever, muscle aches, swollen glands and other flu-like symptoms
- Pain in the legs, buttocks or genital area
- Vaginal discharge
- A feeling of pressure in the area below the stomach
Within a few days, sores appear near where the virus entered the body, such as the mouth, vagina or penis. They can also occur inside the vagina and on the cervix in women and in the urinary passage (urethra) in men.
The sores appear as small red bumps that may become blisters or painful open sores. Over time, the sores crust over and usually heal without scarring within two to 12 days.
Later symptoms may include those listed above, as well as:
- Painful urination (dysuria)
- Swollen glands in the genital area
Some people experience mild symptoms that are often mistaken for insect bites, yeast infections, razor burn, ingrown hairs or hemorrhoids. In fact, the American Social Health Association estimates that as many as 90 percent of people with genital herpes are unaware that they have it.
Because the virus remains in the nerve cells, people with genital herpes can have future outbreaks. Most people who experience a first episode of genital herpes have several more within a year, although symptoms tend to be less severe and last only a week.
The frequency of outbreaks experienced by people with genital herpes over the course of a lifetime varies. Some people have one outbreak and never experience another. Some have outbreaks several times a year. According to the American Social Health Association, the average number of outbreaks is four to five a year. In general, the frequency of outbreaks tends to decrease over time.
Diagnosis methods for herpes
Genital herpes can be difficult to diagnose because signs and symptoms vary widely among individual patients.
The condition may be diagnosed during a gynecological examination if sores are visible to the naked eye. However, laboratories tests will be needed to confirm a diagnosis or if symptoms are not present.
A viral culture is one such laboratory test. To perform a culture, a sample is obtained by swabbing or scraping a new sore. The sample is placed in a culture that also contains healthy cells. When examined under a microscope after several days, the cells show changes that may indicate the presence of the herpes virus.
However, the specimen must be collected from a new sore, usually within 48 hours after it appears. After 48 hours, the test is not reliable because the sores begin to heal and there may not be adequate virus on the skin to make a diagnosis.
Blood tests have recently become a more popular test because they do not require the presence of sores. The test is conducted on a small amount of blood taken from the arm or finger. The tests look for specific antibodies, which are substances used by the immune system to identify and destroy foreign objects such as bacteria and viruses. Although the results may not be available for several weeks, they can identify whether a person has herpes simplex virus 1 (HSV-1) or herpes simplex virus 2 (HSV-2). However, a blood test cannot distinguish between an acute or active infection or one that has occurred in the past.
The U.S. Food and Drug Administration (FDA) has recently revised rules that could make herpes virus tests less costly and more widely available. The FDA also is proposing to reclassify herpes tests to a class that has fewer regulations. In doing so, more medical facilities and offices could offer the tests due to lower training requirements of personnel. In addition, companies may be able to develop and market new tests for the virus.
Treatment options for herpes
There is no cure for genital herpes. Once the virus has infected the body, it cannot be eradicated and remains in the body. However, there are several prescribed antiviral drugs that can reduce the intensity of symptoms at the time of outbreaks as well as reduce the frequency of outbreaks. One antiviral drug (Valtrex), has been approved by the U.S. Food and Drug Administration (FDA) to prevent transmission of genital herpes.
Topical creams have been proven to be ineffective. Intravenous (I.V.) treatment may be used to treat people with suppressed immune systems, such as those who have been infected with human immunodeficiency virus (HIV).
There are several treatment regimens including:
- Episodic therapy. Taking medication when symptoms appear. This involves taking a daily dose of a medication, usually for a week, until symptoms subside. The medications, which are safe and 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 symptoms.
- Suppressive therapy. For patients who experience frequent recurrences. This involves taking daily medication, even when symptoms are not present. It reduces the number of outbreaks and the chance of transmitting the virus to a sexual partner.
- Episodic suppressive therapy. Designed for patients who wish to prevent outbreaks when it is important, such as while on vacation.
During outbreaks, a number of steps can be taken to speed healing and prevent spread of the infection to other parts of the body and other people. They include:
- Keeping the infected area clean and dry
- Trying not to touch the sores
- Washing the hands if sores are touched
- Avoiding sexual contact from the time symptoms are noticed until they have healed
In addition, there is a number of self-care measures a person can take to relieve the symptoms associated with a herpes outbreak. Applying cool cloths to the affected areas may provide relief. People experiencing an outbreak should also avoid wearing tight or irritating underwear or clothing. Over-the-counter pain medication, such as acetaminophen and ibuprofen, can also be taken to help relieve the pain of genital sores.
Pregnant women may be put on suppressive therapy if the virus is active late in their pregnancy. The goal is to prevent transmission to the baby, which, though rare, can have very serious or fatal consequences. Women with sores detected in or near the vagina at the time of labor may be given Caesarean sections (the surgical delivery of a baby through the mother’s abdomen).
If a newborn is infected, early treatment with antiviral therapy can greatly improve the baby’s health. Early detection and treatment can reduce the more serious complications of neonatal herpes.
Although genital herpes is a common and manageable condition, living with herpes can be distressing, inconvenient and, in some cases, painful. The period after diagnosis may be an especially emotional time, with many people experiencing feelings of shame and fear. As a result, people with genital herpes may benefit from seeking counseling or attending a support group.
Prevention methods for herpes
The best way to prevent genital herpes is to abstain from vaginal, oral and anal sex or to be in a long-term, monogamous relationship with a partner who has been tested and is known to be uninfected.
For those who are sexually active, using a latex condom during vaginal, oral or anal sex can prevent spread of the virus. For vaginal sex, a latex male condom or female polyurethane condom should be used. For anal sex, a male condom should be used and, for oral sex, a dental dam (rubbery material placed over the anus or vagina) should be used. It should be noted that condoms are not 100 percent effective in preventing the spread of genital herpes because sores can occur outside the area protected by the condom.
For those who have sex with an infected partner, the risk of transmission is greatest when an outbreak occurs but can occur even if no symptoms are present. Also, the possibility of spreading the virus is greatest during the first six months after first being infected. It is best to avoid sexual contact when symptoms are present and to use condoms in between outbreaks. Because herpes can be passed to the genitals from oral contact, it is best to abstain from oral sex if a cold sore is present.
In addition, there are a number of steps a person with herpes can take to reduce the frequency of outbreaks they experience. Frequency of herpes outbreaks may be reduced through stress management, getting plenty of rest, exercise and proper nutrition.
Ongoing research regarding herpes
Scientists continue to study herpes to gain information about causes, treatment and prevention of the disease.
Some of the most current research is focused on the following areas:
- Existing drugs. A number of studies and clinical trials are attempting to determine the best way to use existing drugs.
- Biology of the virus. Scientists are studying the biology of the herpes virus, including the genes and enzymes that the virus depends on. This may potentially lead to the development of more effective treatment methods.
- Vaccines and microbicides. Some research is aimed at developing vaccines and topical microbicides (microbe-killing gels, creams or lotions) to control transmission of the virus.
Questions for your doctor regarding herpes
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions about genital herpes:
- What is the difference between HSV-1 and HSV-2?
- What tests will be used to diagnose genital herpes?
- How often can I expect to experience outbreaks?
- Is there a way to prevent outbreaks?
- What is the best treatment for my herpes?
- Should I use medications continually or only when I suspect an outbreak?
- Do I need to use a condom during sex even when there are no symptoms?
- What is the best way to prevent transmitting the virus to my partner?
- If I’m diagnosed with genital herpes, do I need to inform my past sexual partners?
- How will genital herpes affect my pregnancy and delivery?
- Are there any clinical trials that are appropriate for me?
- Can you recommend a genital herpes support group?