Herpes: More Common Than You Think
A 73 year old patient presents with blisters on her vulva for the first time in her life. A 23 year old patient tells me that the sores on her vulva hurt so badly that she cannot urinate. An 83 year old patient has been complaining of burning upon urination for weeks and has been treated for a urinary tract infection twice with no relief. A 45 year old patient notices stinging around her rectum when she has a bowel movement. An 18 year old woman presents with a cold sore. What do all of these women have in common? Herpes.
Herpes is one of the most common yet misdiagnosed sexually transmitted disease in the United States. Although 50 million men and women have been diagnosed with herpes, countless others harbor the disease asymptomatically. Even if a woman presents with an active herpes leasion, a culture performed on a the site may return negative for the disease. That is why it is especially important to undergo bloodtesting. Two tests should be performed ,an HSV I IgG antibody test and an HSV II IgG antibody test. These two tests will show if you have had an infection in the past and now harbor herpes asymptomatically. I am commonly asked by patients ,”How long have I had this? and Who do you think gave this to me?”. Unfortunately, unless it is a very new infection or a first outbreak, it is nearly impossible to determine how long a patient has had herpes. Most of my patients who are routinely tested with bloodwork which returns positive have never even had an oubreak.
The most common herpes viruses are herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2). Usually HSV-1 causes cold sores while HSV-2 causes lesions below the waist, causing genital and perirectal herpes. But be aware that both HSV-1 and HSV-2 viruses can cause herpes outbreaks in either area. For instance, having oral sex with an active cold sore can spread HSV -1 to the genitals of your partner. Other common herpes infections include chicken pox and shingles, which are caused by the herpes zoster virus. Transmission is caused by close oral, anal, or genital contact, including intercourse, masturbation, kissing, or any direct skin-to-skin contact which allows for the transfer of bodily fluids.
A person is considered contagious when prodromal symptoms such as itching and burning, active sores, and healing lesions are present.
Herpes is potentially contagious when no symptoms are present. That is, a person who has genital herpes is potentially always shedding active virus.
Approximately 1 in 6 members of the general infected population is thought to shed active virus occasionally without symptoms.
Some people do not get typical blister-like sores but harbor active virus in their saliva, vaginal, or penile secretions, and can shed the virus without knowing they have herpes.
Lesions can occur deep inside the vagina and the cervix where they cannot be seen or felt, but can readily transmit the virus.
An uninfected individual has about a 75% chance of contracting herpes during intimate contact with someone actively shedding virus.
Auto-inoculation occurs when an infected individual spreads the virus to other parts of his or her body by touching an area which is shedding virus and then touching, scratching, or rubbing another susceptible part of the body. Towels are especially conducive to this, and can also transmit the herpes virus to members of a family. That is why it is so important to not share toothbrushes and towels and to line the toilet seat if one has a known herpes outbreak.
Treatment for active herpes involves acyclovir twice per day for seven days or Valtrex ™ twice per day for three days. This is not a cure for the virus but it will allow the symptoms to abate more rapidly. For patients who have more than three outbreaks per year, I suggest continuous acyclovir or Valtrex ™ therapy. This involves taking a daily pill to suppress the virus. This can stop outbreaks altogether with minimal side effects. Adverse side-effects which patients can expect on antiviral therapy include headache, nasal congestion, and upper respiratory tract infection. In practice, I have never seen one of these side-effects on continuous therapy.
Should a woman who is trying to become pregnant or a woman who already is pregnant woman concern herself with herpes? The answer is yes. There is a 30-40% transmission rate of herpes to the newborn with a first herpes episode at the time of delivery. The transmission rate falls to 4% with a recurrent outbreak. Either way, the patient must undergo a cesarean section to lessen the viral load which is transmitted to the newborn. Infected newborns may have mild symptoms at first, such as a low grade fever, poor feeding, or one or more small skin lesions. This may happen two to twelve days after exposure. Newborns can then become very ill with high fevers, seizures and lethargy (lack of energy). To prevent these infections from occurring at the time of delivery, I usually place my patient on either acyclovir or Valtrex ™ twice a day at the thirty sixth week of pregnancy until delivery. Then I continue this therapy until six weeks post-partum. These antiviral therapies are both safe with breastfeeding.
Herpes infections can often be disguised as one of many other common gynecologic infections such as a urinary tract infection, vaginitis, and yeast infections. Presenting symptoms may include itching, burning, redness, discharge, painful urination and urinary urgency and frequency. If any of these symptoms become persistent despite multiple therapies such as creams or antibiotics, please ask that you undergo herpes testing. Although you will carry this virus with you for the rest of your life, it can be controlled with proper diet and exercise to boost the immune system and by antiviral therapy if outbreaks become recurrent.
References:
Centers for Disease Control and Prevention website. www.cdc.gov, August 10, 2006
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Tara A. Solomon, MD
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