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Frequently Asked Questions About Herpes

What is herpes?

Genital herpes is an infection caused by the herpes simplex virus. There are two types of herpes simplex viruses: herpes simplex type I and herpes simplex type II. Both can be transmitted by vaginal intercourse, oral sex and rectal intercourse.

Herpes simplex infections are characterized by three phases: an initial infection; latency, when the viral infection shows no symptoms; and recurrence. Recurrences are when an individual has repeated outbreaks, often at a substantial time after the initial infection occurs.

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Where does the herpes virus live in the body?

The herpes simplex viruses are latent. After the initial infection, the virus gets into the nerve roots and spreads to the sensory nerve ganglia. The ganglia are the nerve junctions in which nerves from different parts of the body come together. For the genital area, the ganglia are adjacent to the spinal cord in the lower back. For orofacial herpes (cold sores), the ganglia are located behind the cheek bone.

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How common is genital herpes?

Genital herpes is caused by herpes simplex type II. According to the Centers for Disease Control (CDC), approximately 40 to 50 million adults in the United States have genital herpes. HSV II infection is more common in women, but also is common in persons who have had more than five sex partners. Most people with HSV II do not know they have it, because it is asymptomatic and shows no symptoms.

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What if I don't have lesions?

Most people with genital herpes don’t have lesions. Typical lesions with herpes are vesicles (little blisters) which then progress to genital ulcers (open sores). Many people don’t realize they have genital herpes and often find out when they have a serological exam.

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Can I spread genital herpes?

Individuals infected with HSV I and HSV II genital infections can spread it to their sex partners. Typically, the likelihood of spreading the infection from one partner to another is highest when genital ulcers or blisters are present. However, transmission during the asymptomatic period is extremely common as well. It is estimated that one to three percent of individuals with asymptomatic genital herpes are shedding the virus at any particular time. If you have sexual intercourse with an individual during that period, you have the risk of transmitting or acquiring the infection.

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What are the symtoms of genital herpes?

The symptoms of genital herpes are typically non-specific and quite mild. In the classic case, individuals have grouped blisters or genital ulcers. These burn and can be painful. Often–prior to the development of the lesions–patients describe a prodrome. A prodrome is a burning sensation in the area where the lesions will develop. This can be accompanied by a burning sensation during urination, itching or discomfort in the genital area.

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I had lesions when I was evaluated, but my culture was negative. Does this mean that I don't have herpes?

One of the biggest problems in diagnosing genital herpes is test sensitivity. There are a number of reasons why cultures can be negative, one being that the disease may be caused by something other than herpes. Cultures also can test negative if the samples are not taken appropriately, if there is a long transport time between the clinic and the laboratory, or if cultures were taken late in the course of the lesions. Lesions that occur early in the course of a herpes outbreak are much more likely to have positive cultures than cultures taken after the lesions crust over.

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What are the different types of herpes?

There are two types of herpes simplex virus: HSV I and HSV II. HSV I is the cause of oral herpes, or cold sores. This is usually acquired as an upper respiratory tract infection during early childhood. HSV II is the cause of most cases of genital herpes. However, it is possible for HSV I to cause genital herpes and HSV II to cause oral herpes.

Clinicians cannot tell the difference between the two types by physical examination alone. The importance of understanding the different types, however, is in the area of prognosis. For example, genital herpes caused by HSV II is much more likely to cause recurrence later. This diagnosis can be helpful in establishing a health-care plan for an individual patient.

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Can herpes be transmitted by oral sex?

Genital herpes can be transmitted by oral sex and can be caused by HSV I or HSV II. The transmission of herpes can occur in the absence of lesions and during asymptomatic shedding. This is one of the reasons why the population of patients with genital herpes caused by HSV I is thought to be increasing.

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Can herpes be transmitted to other parts of my body?

If you have genital herpes or orofacial herpes, you cannot transmit the infection to another part of your body after the initial infection occurs. If you have genital HSV II, you will not get HSV II at another site in your body. The body produces antibodies that protect other parts of your body from infection. However, there are cases where an individual has multiple site infections from the same virus. This is usually acquired at the time of the initial infection. For example, if an individual has oral and genital sex with an infected partner, they can acquire the infection at both sites because they are susceptible at that time.

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Can genital herpes be treated?

Genital herpes can be easily treated with drugs that inhibit viral replication. Commonly used medications are acyclovir, famciclovir and valacyclovir. Treatment can reduce symptoms, the number of outbreaks and viral replication. Treatment does not cure the virus.

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Can treatment help prevent multiple herpes outbreaks?

Suppressive therapy can provide coverage for individuals who have frequent outbreaks. During therapy, an individual with frequent outbreaks takes a small dose of anti-herpes medication every day. It has been proven that suppressive therapy can reduce the number of outbreaks by over 90 percent. Patients have taken suppressive therapy for long periods of time, but in most cases, patients can be weaned from it.

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Are there any side effects from the medications?

The medications used to treat herpes have extremely low side effects. There are no major complications associated with these medications.

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Can the drugs be used safely during pregnancy?

The medications used to treat genital herpes have been safely used during pregnancy. The Centers for Disease Control (CDC) conducted a study of over 800 pregnant woman and their infants. The study found that women who were on medications early in their pregnancy had no increased incidence of fetal abnormalities or side effects.

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Can I be treated to prevent transmission to my partner?

If a couple is dichotomous–one partner is documented to have herpes and the other partner is documented to be uninfected–then therapy can be used to prevent transmission. By treating the infected partner with suppressive therapy, transmission of symptomatic herpes can be prevented in over 90 percent of cases. This is an option for couples who are interested in having unprotected sex or who are planning to become pregnant.

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Can I get herpes sores on other parts of my body?

Patients with genital herpes have infection of the nerve roots that supply those areas. The same nerve roots, commonly called L-4, L-5 and S-1, are located at the base of the spinal cord. They also innervate the rectal area, buttocks and lateral aspect of the thigh. In some cases, patients with genital herpes will have lesions and outbreaks at any of these areas, which are not a result of direct inoculation of the virus. These outbreaks can be part of the typical herpes outbreak.

Occasionally, patients can get herpes lesions at distant parts of their body. This is more common in immunocompromised patients. Outbreaks can occur in the trunk, arms or legs. This is a very serious condition called disseminated herpes and should be addressed immediately with your health-care provider.

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Is herpes related to shingles?

Shingles is also called herpes zoster. It is caused by the varicella zoster virus (VZV), which causes chickenpox earlier in life. The natural history of varicella zoster infection is similar to genital herpes infection in that VZV also becomes latent in the sensory nerve roots. Later in life the virus may exit, causing a recurrence.

Recurrences in shingles are typically characterized by appearance of vesicles and blister lesions in a single dermatome. This is a distribution in the nerve roots supplied by that segment of the spinal cord and is usually seen on one side of the body. Shingles is not a sexually transmitted infection and is independent from genital herpes.

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Is herpes infection related to HIV?

Herpes and HIV are caused by different viruses; however, patients infected with these viruses are more likely to transmit either disease to their sexual partners. Patients with herpes are more susceptible to acquiring HIV. Individuals newly diagnosed with herpes should be tested for HIV infection and other sexually transmitted infections.

Herpes and HIV are caused by different viruses; however, patients infected with these viruses are more likely to transmit either disease to their sexual partners. Patients with herpes are more susceptible to acquiring HIV. Individuals newly diagnosed with herpes should be tested for HIV infection and other sexually transmitted infections.

Patients who are infected with both herpes and HIV also may have higher HIV viral loads related to the interaction between the herpes virus and the HIV virus. When an individual becomes immunosuppressed from HIV, they may be more likely to shed herpes simplex virus asymptomatically.

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I have cold sores in my mouth. Can I still get genital herpes?

Cold sores are usually caused by HSV I. Individuals who have HSV I are susceptible to becoming infected with HSV II, the common cause of genital herpes. If you have cold sores, you are still at risk for getting genital herpes from HSV II.

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This is the first outbreak I've had of genital herpes. When did I become infected?

This is a difficult question. Initial outbreaks are often asymptomatic for most individuals. The only way to differentiate whether this is your first outbreak or if this is a recurrence of a prior asymptomatic infection is to perform a serological test. However, if the serology indicates that you have become infected in the past, it cannot tell you at what point in time you became infected.

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I'm worried about recurrences.

Patients with genital HSV II infection often have recurrences. Patients can detect the beginning of a recurrence because they develop symptoms, such as burning or itching. When an individual suspects a recurrence, they begin taking anti-herpes medications that alleviate symptoms and decrease the duration of the recurrence. Women often report that recurrences are most common immediately before they get their period.

Recurrent genital herpes is most common in the first year after the initial infection and decreases as time goes on. In many cases, patients may be candidates for suppressive therapy.

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Are condoms protective?

Condoms have been proven to prevent transmission of herpes simplex between partners in over 90 percent of cases where they are used consistently.

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Do I have to use condoms forever?

If you want to prevent transmission of herpes simplex between partners, we recommend that condoms be used 100 percent of the time. Many patients will shed the virus asymptomatically. Careful studies have shown that asymptomatic shedding occurs between one and three percent of the time in patients who have had previous HSV II genital infections. A large portion of new herpes infections occur from partners who are shedding the virus asymptomatically. Because of this, it is highly recommended that patients have protected sexual intercourse.

Condoms may not be an attractive option for monogamous couples or for couples who desire to become pregnant. Couples may opt to have serological tests that will determine whether or not both partners have asymptomatic infection. In close monogamous relationships, the risks of transmission can be weighed against other relationship issues such as intimacy. Couples may decide that the risk of transmission may be something that they want to consider.

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What do I tell my partner?

If you are entering into a relationship and are aware that you have herpes simplex infection, you owe it to your partner to notify them prior to initiating sexual intercourse.

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Is there any resistance?

Medications that are used to treat herpes are acyclovir, famcyclovir, and valacyclovir. Resistance to these drugs–even after 20 years of use–is very rare. Generally, resistance occurs in situations where the patient is profoundly immunosuppressed and has been treated with these drugs for a prolonged period of time. While there is very little resistance in the community, an individual's response to treatment may vary. In some cases, patients may need more drugs to suppress their viral outbreaks than others.

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I'm thinking about becoming pregnant. What should I do?

Pregnancy is a major concern for all women who have herpes. The major risk is transmitting herpes to the newborn infant, which can cause neonatal herpes. In understanding the risk of transmission, there are several principles which are important.

  1. Transmission of herpes from a mother infected with herpes simplex type II prior to pregnancy to a newborn infant is extremely rare and occurs only when there are visible lesions at the time of delivery.
  2. The greatest risk of transmission of herpes from the mother to the baby is when a primary herpes infection occurs during the last trimester. Based on these principles, there are several strategies which are available, depending on the status.
    1. If the mother is previously known to be infected with herpes simplex type II infection, then the risk of transmission is related to presence of lesions at the time of delivery. No additional intensive screening of the mother or newborn is required. If there are open visible herpes lesions at time of delivery, then the recommendation is for caesarian section. Otherwise, normal vaginal delivery is recommended.
    2. If the mother continues to have herpes simplex recurrences during her pregnancy, then anti-viral treatment during pregnancy can be used. Acyclovir is extremely safe during pregnancy. A large CDC registry study conducted in cooperation with the manufacturer found that women who used acyclovir early in their pregnancy had no increased incidence of fetal abnormalities or side effects.
    3. If the mother has no history of HSV, but her husband/partner does, then there is major concern over whether transmission would occur from the infected male partner to the woman during pregnancy. It is important to document the serological status of both partners during the pregnancy. Sexual activity can continue during pregnancy; however, if discordance is demonstrated, (i.e. the male partner is HSV II seropositive and the pregnant mom is seronegative), then measures to limit transmission during pregnancy need to be implemented. These can include:
      1. Abstinence during pregnancy
      2. 100 percent condom use
      3. Preventive therapy to prevent transmission, such as treating the male partner with antiviral medications in order to prevent transmission

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I have herpes simplex, but my partner does not. Can I do anything besides use condoms in order to prevent transmission?

In this case, there is an option to take suppressive therapy in order to prevent transmission. A large study demonstrated that in discordant couples, treatment of the infected partner–even when that partner was asymptomatic–reduces transmission of symptomatic herpes to the uninfected partner by over 90 percent.

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