Herpes expert H. Hunter Handsfield, MD explains the basics about genital herpes, including the difference between genital HSV-1 and HSV-2 infection, testing options and the importance of knowing virus type, and the three-prong strategy for prevention. See more herpes videos at sexualhealthTV.com.
Have a question about herpes you’d like Dr. Handsfield or our other experts to answer? Visit our Ask the Experts page to learn how.
Herpes is a common and usually mild infection caused by the herpes simplex virus (HSV). It can cause cold sores on the mouth or face (called oral herpes) as well as symptoms around the genitals, butt and thighs (called genital herpes). Anyone who has ever kissed can get oral herpes. Anyone who has ever had any type of sex can get genital herpes.
Below are some common questions and answers about herpes.
According to the Centers for Disease Control and Prevention (CDC), about 12% (one in eight) persons ages 14-49 in the United States has genital HSV-2 infection; however, as many as 90 percent are unaware that they have the virus. There are many reasons people do not know they have herpes (see the section on Signs and Symptoms for more).
Anyone who is sexually active can contract genital herpes. Some groups are at higher risk, however.
- Male-to-female transmission of genital herpes is easier than female-to-male transmission. That’s why more females (21%) have HSV-2 than males (11.5%).
- Communities of color are also at higher risk. For example, genital herpes is more common among non-Hispanic blacks (39.2%) than non-Hispanic whites (12.3%). These differences, which are true even among those with the same number of lifetime sexual partners, are the result of poverty, lack of access to health care, and many other social factors. (For more on this subject, see ASHA’s position statement on Race, Ethnicity, & Sexually Transmitted Diseases.)
Oral herpes (around the mouth, sometimes called cold sores or fever blisters) can be passed on through kissing or oral sex. If a person with oral herpes performs oral sex, it is possible to pass along the infection to the partner’s genitals. If a person with genital herpes has sex, it is possible for his or her partner to get genital herpes. Any person who is sexually active can get genital herpes.
Genital herpes can be transmitted sexually both when symptoms are present and sometimes when symptoms are not present. There are several days throughout the year (called asymptomatic reactivation, asymptomatic shedding, or subclinical shedding) when the virus may be on the surface of the skin, but there are no symptoms. Herpes can be passed through sexual contact during this time.
There are no documented cases of a person getting genital herpes from an inanimate object such as a toilet seat, bathtub, or towel. Herpes is a very fragile virus and does not live long on surfaces.
Here’s how it works: once HSV gains a foothold, the virus begins making copies of itself and spreading. This can lead to a range of signs and symptoms, everything from subtle symptoms that go unrecognized to severe illness. In response, the immune system mobilizes its forces for an assault and limits HSV’s spread.
Whether there are severe symptoms or not, the virus will stay in the body. To avoid the immune system, HSV will retreat along the nerve pathways, hiding in a nerve root called a “ganglion.” In cases of genital herpes, HSV retreats to the sacral ganglion, located at the base of the spine. In oral or facial herpes (cold sores), HSV finds its way to the trigeminal ganglion, at the top of the spine. In the ganglion, the virus remains inactive (“latent”) for an indefinite period of time.
The phenomenon of latency is similar to a sleep cycle. Basically, the virus returns to a safe haven and sleeps, sometimes for long periods. Unfortunately, while HSV is latent, various biological events can cause it to become active and begin traveling the nerve pathways back to the skin. There it can cause signs and symptoms again, though it doesn’t always do this.
How often the virus “wakes up” is a complicated question. It used to be thought that all of the HSV’s “waking times” were marked by outbreaks—-an irregularity in the skin (defined as a “lesion”) such as a pimple, for example, or else some kind of symptom like an itch. Then researchers learned that the virus could wake and become active without causing noticeable signs or symptoms: no itch, no pain, no pimples, no blisters. This phenomenon has been called a number of things, including “asymptomatic shedding,” “asymptomatic reactivation,” and “subclinical shedding.”
Asymptomatic shedding applies to the following situations: 1) some lesions are overlooked because they occur in places we simply never look or can’t see; 2) some are mistaken for something else—an ingrown hair, for example; and 3) some can’t be seen at all with the naked eye. The point is that when herpes “wakes” and travels to the surface of the skin or mucous membranes, it is often subtle and hard to recognize, even for a healthcare provider, and sometimes impossible to spot. Also, even if you’re a person with recurring signs and symptoms that you can usually recognize as herpes, there are almost certainly days when you won’t be aware that the virus has reactivated and traveled to the skin or mucous membranes.
Because signs can vary a great deal, we recommend that an individual see a healthcare provider to be tested if they have a lesion of any kind. This can be swabbed for a culture test or for other sensitive tests.
A person may show symptoms within days after contracting genital herpes, or it may take weeks, months, or years. For this reason, it can be difficult for people to know when and from whom they may have contracted the virus.
The “classic” symptoms that most people associate with genital herpes are sores, vesicles, or ulcers – all of which can also be called “lesions.” (The scientific literature on herpes uses the term “lesion” to describe any break or irregularity in the skin.) These classic lesions of genital herpes often resemble small pimples or blisters that eventually crust over and finally scab like a small cut. These lesions may take anywhere from two to four weeks to heal fully. During this time, some people will experience a second crop of lesions, and some will experience flu-like symptoms, including fever and swollen glands, particularly in the lymph nodes near the groin. Headache and painful urination also sometimes accompany full-blown symptoms of first episodes.
But for many other people, herpes lesions can so mild that they may be mistaken for:
. . .and other conditions. In other words, the signs go unrecognized as being caused by genital herpes. Also, signs and symptoms can be found: on the penis and vulva; near the anus; on the thigh; on the buttocks – virtually anywhere in the genital area.
Treatment with antiviral drugs is standard during first episodes and can speed healing significantly. If you haven’t already, you may want to discuss treatment with your healthcare provider at this time.
But what if you don’t see any lesions nor have other symptoms? In some studies, people with herpes were completely unaware of lesions about one third of the time that the virus was found to be active in the genital area. While recognizing lesions and other symptoms is important, this cannot always tell you when the virus is active.
The amount of outbreaks someone has varies from person to person. The average number of outbreaks for a person with genital HSV-2 is four to five per year. The average for genital HSV-1 is less than one outbreak per year. Usually, there are more outbreaks during the first year, and many people find that outbreaks tend to lessen in severity and frequency with time.
Early in the phase of reactivation many people experience an itching, tingling, or painful feeling in the area where their recurrent lesions will develop. This sort of warning symptom—called a “prodrome”— often precedes lesions by a day or two. To be on the safe side, it’s best to assume virus is active (and, therefore, can be spread through direct skin-to-skin contact) during these times.
Herpes triggers (what leads to an outbreak/recurrence) are highly individual, but with time, many people learn to recognize, and sometimes avoid, factors that seem to reactivate HSV in their own bodies. Illness, poor diet, emotional or physical stress, friction in the genital area, prolonged exposure to ultraviolet light (commonly for oral herpes, such as a beach trip or skiing weekend), surgical trauma, and steroidal medication (such as asthma treatment) may trigger a herpes outbreak. The frequency of outbreaks can often be managed through effective stress management, and getting adequate rest, nutrition, and exercise.
Since one in five persons is thought to have herpes and the majority of people don’t know, if a partner has ever been sexually active, it is possible that she or he could unknowingly have the virus too. Accurate blood tests are available to determine whether a person has antibodies for HSV. Knowing a partner’s status can help a couple make a joint decision about whether they need to take steps to reduce the risk of transmitting HSV.
If one or both partners have herpes, it is important to become educated about herpes, to understand the basics of herpes prevention, and to make decisions together about which precautions are right for you. If someone has signs or symptoms around the genital or anal region (genital herpes), he or she should not have sexual activity until all signs have healed. When there are no symptoms present, there is still the possibility of asymptomatic reactivation. Using latex condoms between outbreaks for genital-to-genital contact can reduce the risk of transmission. While condoms don’t always cover the potential sites of viral shedding, they offer useful protection against the virus by protecting or covering the mucous membranes that are the most likely sites of transmission. Furthermore, keep in mind that condoms also help reduce the risk of acquiring another STD.
One antiviral medication for herpes, valacyclovir, has been shown to reduce the risk of herpes transmission. When a person with a history of recurrent genital herpes takes 500 mg of valacyclovir daily, it can reduce the risk of transmission to a partner who does not have the virus by 50%. It’s likely that a combination of suppressive valacyclovir and condoms provides greater protection than either method alone.
We do not recommend regular use of the spermicide nonoxynol-9 (“N-9”) as it can cause irritation in the genital area, making it easier for some STDs to be transmitted. If a spermicide is used, it should be used with a condom, not in place of one.
If you share your sex toys with a partner, you should put a condom on the sex toy, remove it after use on one partner, and thoroughly clean the toy before using it on a different person or location (mouth versus anal or vaginal area).
If someone has a symptom around the mouth (oral herpes), she or he should not perform oral sex until all signs have healed. When there are no symptoms present around the mouth, using a barrier (such as a dental dam) or condom when performing oral sex can reduce the risk of contracting genital herpes. By performing oral sex on someone who has genital herpes, it would be possible to contract oral herpes – but this is rare. Most cases of genital herpes are caused by HSV-2, which rarely affects the mouth or face. Also, and even more importantly, most adults already have oral HSV-1, contracted as a child through kissing relatives or friends.
Three antiviral medications (in pill form) are approved by the Food and Drug Administration (FDA) for the treatment of herpes: acyclovir, famciclovir, and valacyclovir. All of these medications, which are taken orally, work by attacking the herpes virus and disrupting its ability to multiply.
Each of these medications can be used during a recurrence (outbreak) to help speed the healing process of an outbreak.
All three drugs are FDA-approved for daily, suppressive therapy to help reduce the frequency of outbreaks. Acyclovir is also available in the form of an ointment, but the medication has been proven to be much more effective for genital herpes when taken orally as a pill. Valacyclovir, when taken daily (suppressive therapy) by a person with recurrent genital herpes, can reduce the risk of transmission to a partner.
According to the manufacturers, the most common short-term side effects reported are nausea and headaches. A large volume of research suggests that the medications are safe and have few or no side effects. These medications have never been noted to cause any long-term side effects.
Using medication to treat genital herpes is not required. However, if a person would like to use antivirals, speaking with a health care provider can help determine which treatment may be right for them.
Over-the-counter creams and/or ointments are not recommended for genital herpes, since they can interfere with the healing process in a number of ways, causing genital outbreaks to last longer. Keeping the area clean and as dry as possible and allowing the area to get air can help to speed the healing process.
For more information on treatment and alternative therapies, see the treatment page.
It is rare for infants to contract herpes.
Twenty percent to 25 percent of pregnant women have genital herpes.
Less than 0.1 percent of babies contract genital herpes.
A mother helps the baby by passing her antibodies to the infant during pregnancy.
Women who acquire genital herpes before becoming pregnant have a low risk of passing the virus to their baby.
A woman who contracts genital herpes during the third trimester of pregnancy is at a higher risk of passing herpes to the baby because she has not had time to build up antibodies to the virus.
Most mothers with genital herpes have normal vaginal deliveries.
The doctor should do a thorough visual exam at the onset of labor.
If a woman has symptoms at the time of delivery, a Caesarean section is recommended.
If an infant does contract herpes during delivery, the symptoms tend to show within two to three weeks after birth.
Herpes can be life threatening to an infant, but medication may help prevent or reduce the lasting damage to an infant if treated early.
After birth, herpes can be passed to a baby by receiving a kiss from someone with a cold sore on the mouth (oral herpes).