Genital Herpes:
What You Need To Know
October 16, 2002, Acurian
Source: U.S. Food and Drug Administration
by: Linda Bren
What is Genital Herpes?
Genital herpes, a sexually transmitted disease (STD), is an infection caused by the herpes simplex virus (HSV). HSV is in the same family of viruses that causes chickenpox, shingles and mononucleosis.
There are two types of HSV: HSV-1, which infects 80 percent of the U.S. population, usually appears on the lips in cold sores; HSV-2 is usually found in the genital area. However, if a person with HSV-1 oral herpes (cold sores) performs oral sex, it is possible for the partner to get HSV-1 genital herpes. And HSV-2 can infect the mouth through oral sex.HSV can cause sores, or lesions, to appear in and around the vaginal area and within the cervix in women, and on the penis and scrotum in men.
Both males and females may also get lesions in the urinary tract, around the anal opening, on the buttocks or thighs, and sometimes on other parts of the body.The First Episode Symptoms of genital herpes can vary in appearance and intensity.
Some people have no symptoms or such mild symptoms that they don't suspect they have an infection. For others, the first episode of herpes (primary infection) can cause one or more very painful lesions to erupt on the skin.
For many people, this primary infection may be more severe and have more generalized symptoms than recurrent episodes. During a first episode, the lesions may be accompanied by flu-like symptoms such as fever, headache and muscle aches. Some people experience painful or difficult urination and swollen glands in the groin area. Women may also have a vaginal discharge.
Genital herpes lesions usually appear within two to 10 days after being exposed to the virus, and can last from two to four weeks.
First to appear are small red bumps, which develop into blisters. Then the blisters become open sores, which later dry up, crust over, and heal without leaving a scar. Sometimes a second crop of lesions appears.
Recurrent Episodes
Once HSV infects a person, the virus travels through the nerves and settles at the base of the spine. During this inactive phase, the virus is dormant.
But it may wake up later, travel along the nerve paths to the surface of the skin, and cause another outbreak of lesions.
This recurrence of HSV usually causes lesions to appear around the same area of the first outbreak.Some people have only one or two recurrences in a lifetime, while others have them frequently.
"The recurrence rate is far lower in HSV-1 than HSV-2," says Rhoda Ashley, Ph.D., director of the University of Washington's diagnostic virology laboratory at the Children's Hospital and Regional Medical Center in Seattle.
Most people diagnosed with HSV-2 affecting the genital area typically have four or five symptomatic recurrences the first year. After the first year, most people have fewer and milder recurrences, lasting a week or less.
Many people get warning signals of a recurrence, known as prodrome
. With prodrome, there may be a tingling or itching in the genital area, or pain in the buttocks, down the legs, or in the lower back.
Sometimes these symptoms go away and no lesions appear.Phinney's outbreaks were so frequent that they made him irritable, he says.
"I would get an outbreak, and as that outbreak was fading over a week or so, suddenly a new one would crop up. As a result, I was really only 'clear' for as little as one week a month.
"Researchers don't know why recurrences happen, or why their frequency and severity vary.
Some people report that recurrences are triggered by stress, illness, poor nutrition, menstruation, and friction in the genital area, such as that caused by vigorous sex. However, many of these supposed triggers have no scientific basis, says Ashley.
"You can't say stress is a trigger. It's like the chicken and the egg. Which came first--the herpes or the stress?"
Nevertheless, for many people, trying to avoid their triggers seems to work for them, says Ashley.Stress is a "huge factor" in triggering outbreaks for Pat Adams of Washington, D.C., Adams has had genital herpes for about 20 years.
"Anything I can do to calm myself down during a stressful period and take better care of myself can help," says Adams. She finds that a good diet and exercise help her to keep the virus in check.Asymptomatic Shedding In many instances, people with genital herpes know the virus is active because they have symptoms, such as lesions.
But this isn't always the case.The herpes virus can become active without causing symptoms.
During these times, small amounts of the virus are present on the skin, often at the place of first infection. This reactivation without symptoms, known as "asymptomatic shedding," may also occur in rectal tissue or in fluids from the penis and vagina.
"Even if you're asymptomatic, you can transmit the virus," says Stanka Kukich, M.D., a medical team leader in the FDA's Center for Drug Evaluation and Research.
In fact, studies have shown that most people get HSV from sexual contact during times of asymptomatic viral shedding.
Researchers have found that people with HSV-2 genital herpes tend to have more shedding than those with HSV-1.
In addition, people with new infections are more likely to shed the virus than those with an infection more than a year old. Those with frequent recurrences may also shed the virus more often, but this is still an area being studied
Diagnosing Genital Herpes
Herpes can be detected by a viral culture of a lesion, if one is present, or a blood test. Ashley recommends both methods.
With a viral culture, a doctor swabs a lesion to pick up cells, puts the swab in a special solution, and sends it to a lab for growing and analyzing.Although a doctor may recognize a herpes lesion by examining it, a viral culture will confirm the presence and type of HSV, says Ashley.
Once they know whether they have HSV-1 or HSV-2, people have a better idea of how often they will have recurrences.
But viral cultures do have their drawbacks. If the lesion has started to heal (usually 48 hours after its appearance), the swab may not pick up enough virus and the culture result will be a "false negative." (False positives in cultures are rare.)A blood (serology) test can be used to confirm a negative culture.
It can also be used to diagnose herpes in a person who has no symptoms, who has genital irritation but isn't sure it's herpes, or who has a sexual partner with herpes and wants to find out if he or she has already become infected.
"Diagnosing whether someone has herpes or not is quickly done by a serology test because once you've become infected, an immune-competent [healthy] individual will develop antibodies to the herpes that is infecting them," says Thomas Simms, a biologist in the FDA's Center for Devices and Radiological Health.
Herpes antibodies will usually show up in the blood several weeks after a person first becomes infected. Some blood tests can determine the type of herpes infection, but cannot indicate whether the herpes is oral or genital.
So people without symptoms may not know for certain if their herpes is oral or genital.In the past several years, the FDA has cleared three blood tests that accurately determine if a person is infected with HSV-1 or HSV-2.
The HerpeSelect ELISA Kits and the HerpeSelect Immunoblot Kit made by Focus Technologies of Herndon, Va., detect both types. The POCkit Rapid Test made by Diagnology Inc. of Cary, N.C., detects HSV-2 only.
Another blood test is the Western Blot. Although not 100 percent accurate, the Western Blot is considered the "gold standard" of blood tests and is used to determine the accuracy of other herpes blood tests that are developed.
The University of Washington is the premier institution for performing and interpreting the test.
Many older FDA-cleared blood tests for herpes are still on the market, and many labs use these tests because they are widely available and inexpensive.
Although they may be labeled type-specific (can determine whether the infection is HSV-1 or HSV-2), they are not reliable, says Simms.But it's difficult for people to make sure they are getting one of the newer, accurate tests, says Wald. Doctors and even lab workers may not know what test they're using.
"The patient needs to ask, but it's a very tall order. It will take a significant amount of work on their part and phone calls to the lab themselves."This is where a herpes support group can help, says Adams, who facilitates a group called HELP of Washington.
"We keep a list of doctors who are up to speed, knowledgeable, and know what the right tests are.
