Overview

Genital herpes is a contagious infection caused by a virus known as herpes simplex virus (HSV). According to the U.S. Centers for Disease Control and Prevention, genital herpes affects about 16.2 percent of the population and approximately 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, however, 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, recent 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.

Causes of Genital Herpes

Two types of viruses cause genital herpes: the herpes simplex virus (HSV-1) and herpes simplex virus (HSV-2), which belong to the same family of viruses.

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 several 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 is more sensitive than standard culture tests at identifying the herpes virus in the urinary and genital tracts; however, it is expensive and therefore not used very often.

Blood tests have become more popular 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 after exposure. Because most HSV-2 is genital, a positive blood test for HSV-2 usually indicates genital herpes. Because so many people in the United States have cold sores due to HSV-1, it is not routinely done. However, because genital herpes may be caused by HSV-1, a negative test for HSV-2 does not rule out genital herpes infection due to HSV-1.

Interpretation of test results should be done by a clinician. A major advantage of the HSV-2-specific 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.

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 or not 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 neurologic 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.

How Can Genital Herpes Be Treated?

Treatment can reduce the outbreaks, but it cannot cure you of the herpes simplex viruses.

Medications

Antiviral drugs may help speed up the healing time of your sores and reduce pain. Medications may be taken at the first signs of an outbreak (tingling, itching, and other symptoms) to reduce the symptoms.

Home Care

Use mild cleansers when bathing or showering in warm water. Keep the infected site clean and dry. Wear loose, cotton clothing to keep the area comfortable.

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.

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 can 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.

Key Q&A

1. What is my risk as a woman of transmitting genital herpes to my male partner?

The risk of infection is based on several factors, but according to one report, in heterosexual couples in which only one partner is infected, over one year, the virus was transmitted in 10 percent of cases. In 70 percent of these couples, transmission took place when the infected person had no symptoms.

2. Does having oral herpes protect me from genital herpes?

No. Some experts have speculated that having oral herpes reduces the chances of acquiring genital herpes, but most authorities believe there is no significant cross-protection between the two types.

3. If I have no symptoms, doesn’t that mean I am less likely to transmit the virus?

Yes and no. The amount of virus produced is greatest at the time someone is having an outbreak. Yet many outbreaks occur without the person realizing it. Lesions can be so small or hidden from view that only special tests can prove one is having an outbreak. It is estimated that most people with herpes are infectious at some point in their lives when they don’t have visible symptoms.

4. How effective are condoms for preventing infection?

They are effective. The virus cannot penetrate through latex barriers. However, it is possible, although rare, to acquire infection during skin-to-skin contact if a lesion is present and not covered by a condom.

5. How is genital herpes diagnosed?

Visual inspection is the most common way of making a diagnosis. Viral cultures are also commonly used, but only when a sore is present. Blood tests also are available that can accurately determine infection and can accurately distinguish between the two types of HSV, even when no symptoms are apparent.

6. How safe are the drugs used for treating genital herpes?

All of the commonly used prescription medications are well-tolerated and have few short-term side effects. Acyclovir has been studied the longest, and its long-term safety appears to be good, both in pregnant women and in children.

7. What causes recurrent outbreaks of genital herpes?

This is an important question and hard to answer definitively. Some factors that have been studied include stress, poor diet, birth control pills, sunlight, menstruation and fatigue. However, there is no way of accurately predicting when the next outbreak will come. Keeping one’s immune system strong is important. (Persons with weakened immune systems, such as HIV-positive individuals, have more frequent and severe outbreaks than HIV-negative persons.) Experts also recommend getting emotional support, as the psychological impact of genital herpes often is more upsetting than the physical symptoms.

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