What is genital herpes?
Genital herpes is caused by herpes simplex virus (HSV), a common virus which, in most cases, causes very mild symptoms or none at all. In symptomatic herpes there are painful red spots mainly in the genital area. These spots change to fluid-filled sores that blister, ulcerate and heal in about 10 days. There may be associated symptoms, such as painful urination. Genital herpes is transmitted by having sexual contact (vaginal, oral or anal sex) with someone who carries HSV.
Clearing up confusion
Even when the symptoms of genital herpes are more severe, they are simple to treat and can usually be very well controlled. Most people’s perceptions of the herpes virus are based on the wide range of myths about it, rather than the facts. As a result, being diagnosed with genital herpes can often be both confusing and confronting.
This article aims to clear up any confusion, and to help those who have genital herpes to take positive steps to get their lives back to normal.
About the infection
Genital herpes is a common viral infection caused by the herpes simplex virus (HSV). There are two types of the virus, types 1 and 2 (HSV-1 and HSV-2). As well as genital herpes, HSV can infect the mouth and cause cold sores (oral/facial herpes).
HSV-1 is the usual cause of cold sores, and HSV-2 is the usual cause of genital herpes. But either type of HSV can infect either part of the body.
Up to 50% of genital herpes is caused by the oral cold-sore type of herpes simplex (by contact with the genitals, eg, oral sex when one partner has a cold sore).
HSV-1 and HSV-2 lesions look the same and can only be distinguished by laboratory testing.
Key facts about genital herpes
As many as one in three adults has the virus that causes genital herpes.
Around 80% of people infected with genital herpes do not know they have the virus, because they have very mild symptoms or none at all.
Over 50% of people who have genital herpes get it from people who are entirely unaware that they have it themselves.
The emotional impact of being diagnosed with genital herpes is often much worse than the condition and it does not deserve the upset it causes.
Oral herpes, also known as cold sores, is commonly transmitted to the genitals through oral-genital contact. Up to 50% of genital herpes is caused by the oral cold-sore type of herpes simplex.
There is effective treatment available if symptoms are problematic.
The symptoms of genital herpes vary enormously. It can show up as blisters or sores, but it can also just produce a mild rash. And whatever symptoms do appear may be on the thighs, back, fingers, and, of course, the genitals.
The virus can be passed on when there are no symptoms present.
Most people who infect others do not realise they are even putting their partners at risk.
Using condoms reduces the risk of passing on the virus, but does not eliminate it completely.
Daily medication can prevent recurrences and reduce the risk of transmission to partners.
Having genital herpes is not associated with causing cervical cancer.
What happens in a viral infection?
The herpes virus invades the human body, often through a crack in the skin or through the lining of the mouth and genital area. Once inside the body’s cells, the virus uses the material in the cell to reproduce itself (known as replication). In this process the cell is destroyed. The disruption of the host cell is responsible for the characteristic signs (blisters, etc) and symptoms (tingling, pain, etc) of herpes infections and the release of thousands of copies of the virus.
Particles of the virus also enter one of the many sensory nerve fibres which are found all over the body, and proceed to move upward to where the fibre begins near the spinal cord. This is a small cluster of cells known as a sensory ganglion.
In oral/facial herpes (cold sores), the virus settles in a large nerve centre (ganglion) at the base of the skull, known as the ‘trigeminal ganglion’. In genital herpes, the virus retreats to the ‘sacral ganglion’, situated near the tail of the spinal cord. Once the virus reaches the ganglion, it lives there for the rest of the person’s life.
Other viruses that remain in the body
Herpes simplex isn’t the only virus many people have. Anyone who has had chickenpox is host to the Varicella zoster virus, another member of the herpes virus family. This virus remains dormant for the rest of their lives; in some people, however, it can leave the nerve ganglia, travel down the nerve fibres and cause shingles. Other chronic viruses include the glandular fever virus (EBV - Epstein-Barr virus) and cytomegalovirus (CMV), for example.
Once a virus enters the body, antibodies are produced to fight it. Antibodies are the body’s natural form of defence and continue to be produced long after the initial episode.
With genital herpes, antibodies help ensure that recurrences are milder than the first episode. It is quite common to find antibodies in people who have never apparently experienced an episode of genital herpes. Either the initial infection was so mild the person was unaware it was taking place, or it was completely without symptoms and therefore went unrecognised.
How ‘viral shedding’ occurs
When the HSV reactivates in the ganglion and travels down the nerve fibres to the skin surface, particles of virus may be ‘shed’ on the surface of the skin, with or without any signs or symptoms of infection present. This is called ‘viral shedding’. Viral shedding also occurs when blistering and/or sores are present.
During these times, HSV may be transmitted to sexual partners. There is no way to tell when the virus is being ‘asymptomatically’ shed [ie, happening without obvious signs or symptoms] on the skin surface and, therefore, no way to predict when you may be infectious and at risk of transmitting the virus to a sexual partner. However, viral shedding is most prevalent just before, during, and immediately after, the presence of symptoms. Viral shedding may occur on approximately 5% of days per year.
Viral shedding does occur in association with outbreaks of genital herpes and, therefore, sexual contact should be avoided during these times. Between outbreaks, viral shedding may still occur (‘asymptomatic viral shedding’) so, as with any new relationship, it is wise to consider using condoms to reduce the chance of transmission to sexual partners.
How genital herpes is spread
You can get genital herpes by having sexual contact (vaginal, oral or anal sex) with someone who carries HSV. It used to be believed that transmission (passing it on) only occurred if herpes blisters or sores were present. However, it is now known that transmission can also occur when herpes blisters or sores are not present. This can occur in two situations:
People who have recurrent genital herpes (repeated episodes) can transmit the virus between recurrences (through asymptomatic shedding). This occurs on approximately 5% of days per year.
There are many people who are exposed to, and infected by, the virus but never develop any signs or symptoms of the infection. These people carry and may ‘shed’ the virus from time to time without showing symptoms and, in doing so, may transmit the infection to their sexual partner if they have sex at that time. Up to 80% of people get HSV from partners who have no signs and symptoms of HSV and are unaware they have the infection.
Being gay and having herpes
Obviously the herpes virus does not care what sort of sexual activity is creating the right conditions for infection, but different sexual practices create different risks.
Gay women are slightly less likely to become infected than heterosexual women, but for those who do, the impact of the virus is exactly the same.
In the past, genital herpes was much more prevalent among gay men than in heterosexuals. That is no longer the case, partly because more heterosexual couples are having oral sex and becoming infected that way. However, infection through anal sex remains more common among gay men.
It has also been shown that having the herpes virus makes men more susceptible to infection with HIV (human immunodeficiency virus).
The good news is there is less stigma attached to all STIs (sexually transmitted infections) in the gay community, safer sex practices are widely accepted, and there is a range of sexual health services specifically aimed at gay men and women.
Sites of infection
In women, the genital areas most affected are the vulva and the entrance to the vagina. Sores can sometimes develop on the cervix.
In men, sores are most common on the glans (end of the penis), the foreskin and shaft of the penis. Sometimes, sores can develop on the testicles.
Less commonly, both men and women can experience sores on the anus, buttocks and tops of the thighs.
The most serious of these other conditions are neonatal herpes and herpetic encephalitis, both of which are relatively rare but can be deadly. The causes of herpetic encephalitis are not fully understood, but having genital herpes does not seem to make you more or less likely to develop it.
The initial infection
The initial infection that causes symptoms is usually most severe as the body’s immune system has not yet come into contact with the virus.
An initial infection can last more than 20 days and it is not uncommon for someone to experience a range of generalised symptoms, such as fever, aches and pains, as well as specific genital symptoms. For others, an initial infection can be mild with minimal symptoms and often is unrecognised and undiagnosed.
How many people get symptoms?
The majority of people who acquire genital herpes will not experience any recognisable symptoms. Of those who do experience symptoms (20%), the first indication of infection usually starts between 2 and 20 days after exposure to the virus. This is referred to as the first or primary episode. The development of symptoms may take longer or be less severe in some people, especially those who have developed resistance to HSV-1 from previous cold sore infection.
What are the symptoms of genital herpes?
Symptoms can start with tingling, itching, burning or pain (these are warning symptoms also known as the ‘prodrome’) followed by the appearance of painful red spots which, within a day or two, evolve through a phase of clear fluid-filled blisters which rapidly turn whitish-yellow.
The blisters burst, leaving painful ulcers which dry, scab over and heal in approximately 10 days.
Sometimes the development of new blisters at the early ulcer stage can prolong the episode. On the other hand, the blister stage may be missed completely and ulcers may appear like cuts or cracks in the skin. Some women may also notice vaginal discharge.
Other possible symptoms
The severity and range of symptoms differ from person to person. Women frequently experience painful urination, and when this happens, it is important to avoid the problem of urinary retention by drinking plenty of fluids to dilute the urine and thereby reduce pain and stinging. Sitting in a partially filled bath when urinating also helps.
Both women and men can experience generalised fever, aches and pains, and a depressed run-down feeling.
Some people do not experience symptomatic recurrences, but for those who do, recurrences are usually shorter and less severe than the primary episode. Recurrences are often preceded by warning or prodromal symptoms such as tingling, itching, burning or pain.
As with the initial episode, there is a large variation in people’s experience of recurrences. Approximately 80% of persons having a first episode caused by HSV-2 will have at least one recurrence, while only 50% of persons with HSV-1 on their genitals will experience a recurrence.
Genital herpes caused by HSV-2 recurs on average four to six times per year, while HSV-1 infection occurs less often, only about once per year. A minority will suffer more frequent recurrences.
Recurrences are more likely to recur in the first year or two after acquiring genital herpes, but for many people these become less frequent and less severe over time.
Genital herpes can be elusive
In many people, the diagnosis of genital herpes can be hard to establish. As mentioned earlier, the severity of symptoms can vary greatly from one person to another. An initial episode can, at times, be so mild as to pass unnoticed and a first recurrence may take place some months or even years after the first infection.
Up to 80% of people who have been infected with genital herpes are unaware they have the infection. These people may, however, transmit HSV to others. Such cases can lead to confusion and bewilderment, as people are unable to understand the sudden appearance of infection and apparent transmission from someone else.
What triggers genital herpes?
A recurrence takes place when HSV reactivates in the nerve ganglion at the base of the spinal cord and particles of virus travel along the nerve to the site of the original infection in the skin or mucous membranes (eg, the skin in or around the genital area). Sometimes with a recurrence of the virus it travels down a different nerve, causing symptoms at another site, such as the buttocks or thighs (rather than the genitals).
Although it is not known exactly why the virus reactivates at various times, the cause can be separated into the physical and the psychological.
Physical: Physical factors differ among people. Being run-down, suffering from another genital infection (compromising the local skin area), menstruation (periods), drinking too much alcohol, exposure of the area to strong sunlight, conditions that weaken the immune system, prolonged periods of stress or depression, are all factors that can trigger an episode. Less commonly, friction or damage to the skin, such as may be caused by lack of lubrication at the time of sexual intercourse, can lead to a recurrence. In summary, anything that lowers the immune system or causes local trauma (damage) can trigger recurrences.
Psychological: Recent studies have shown that periods of prolonged stress may bring about more frequent recurrences. It is also common to experience stress and anxiety from having recurrences.
Transmitting the infection
People with herpes can be infectious either at the time of symptoms or sometimes when there are no symptoms present. People who experience an episode of herpes, either oral or genital, should consider themselves infectious from the first symptoms to the healing of the last ulcer.
Avoid oral sex if you have cold sores
Oral herpes lesions (cold sores) are also an important source of infection through oral sex, and this should be avoided if one partner has an oral cold sore. People worry a great deal about transmitting genital infection, but are less concerned about oral herpes (cold sores). Yet the main way women get genital infection is from cold sores, via oral sex.
Infectivity without symptoms
People with no obvious lesions can still have infectious virus present at certain times through asymptomatic viral shedding [described earlier]. Asymptomatic viral shedding cannot be predicted but is known to occur on at least 5% of days each year.
Occasionally, one partner in a long term relationship may develop symptoms of herpes for the first time. Often this is due to one or both of the partners being carriers of HSV and not knowing it. It does not necessarily imply recent transmission from someone outside the relationship.
Reducing the chance of transmission
By avoiding sex when the signs of herpes are present, and by using condoms with sexual partners between outbreaks, the chance of passing on herpes is reduced. Taking daily oral antivirals, known as suppressive treatment, as well as using condoms, makes the chances of passing on herpes extremely low
It is highly unlikely that HSV will be passed on to other people by the sharing of towels or toilet seats. Outside the body the virus cannot survive for more than a few seconds. The virus is killed by the use of soap and water.
What it means to have genital herpes
Genital herpes is essentially a minor, sometimes recurring, skin infection; ‘cold sores’ which occur on the genitals rather than the face. It does not cause long-term ill health or affect longevity of life. People who get genital herpes can, and do, lead perfectly normal lives.
As described earlier, a primary infection can be severe and involve generalised ‘flu’-like symptoms. This, combined with the pain and discomfort of the sores and, in some cases, secondary infection, can leave people feeling very run-down. Fortunately, recovery is fast once the herpes has healed.
People with recurrent genital herpes may reconsider some aspects of sexual intimacy. For example, using non-genital forms of sexual contact when skin blisters or ulcers are present.
It also means considering if, how and when you are going to tell a sexual partner. Many people do not understand what it means to have genital herpes or realise how common it is. Most people react supportively when told, and appreciate and respect your honesty.
People who choose not to tell a sexual partner risk the burden of fear, guilt and secrecy. In an ongoing relationship where both partners fully understand the chance of transmission, the use of condoms becomes less relevant.
For people who experience very frequent herpes recurrences, suppressive antiviral therapy, which reduces the frequency of recurrences, can help reduce the impact the herpes recurrences can have on sexual activity and may reduce the risk of transmission.
Genital herpes is not hereditary. HSV has no effect on fertility and is not transmitted via men’s sperm or women’s ova (eggs).
Women with genital herpes can experience a safe pregnancy and vaginal childbirth. This is especially so when a women has had a diagnosis of genital herpes prior to becoming pregnant. In the situation when the mother already has a history of genital herpes, she will have antibodies circulating in her blood which will protect the baby during the pregnancy and delivery.
Being a parent
Genital herpes in either parent does not affect babies/children and there is little risk of transmission as long as normal hygiene is ensured.
Parents should be aware, however, that HSV can be transmitted from oral cold sores simply by kissing and can cause serious, widespread (disseminated) infection in the newborn. Fortunately, by the time a baby is about six months old, the immune system is well able to cope with exposure to the virus.
Initial exposure to HSV in babies and young children, after being kissed by someone with a cold sore, can cause gingivostomatitis, an infection of the mouth and gums which goes largely unrecognised and untreated.
Original material provided by the New Zealand Herpes Foundation.