Genital herpes

Genital herpes symptoms

The first infection with genital herpes simplex is called the primary infection. This may, or may not, cause symptoms (described below). Following a primary infection, the virus is not cleared from the body but lies inactive (dormant) in a nearby nerve. In some people, the virus 'activates' from time to time and travels down the nerve to the nearby skin. This causes recurrent symptoms of genital herpes (if the primary infection was in the genitals) or recurrent cold sores (if the primary infection was around the mouth).

How long can you have herpes without knowing?

Most people never develop any symptoms when they are infected with the virus or they only have a short bout of very mild symptoms which is not recognised as genital herpes (for example, a slight itch or small red area). At least 8 in 10 people with genital herpes simplex virus (HSV) do not know that they are infected. In such people, the virus stays inactive in the root of a nerve that supplies the genitals, but never causes recurrent episodes of symptoms.

However, even people who do not develop symptoms may, on occasions, have the virus in their genital area and therefore be infectious to sexual partners. In fact, this is how many genital herpes simplex infections are passed on. This can occur weeks, months or even years after the first infection.

A first episode of symptoms

It usually starts with feeling unwell with a mild fever and aches and pains (flu-like symptoms). Groups of small, painful blisters then appear around the genitals and/or back passage (anus). They tend to erupt in crops over 1-2 weeks. The blisters soon burst and turn to shallow, sore ulcers.

Recurring episodes of symptoms

After the first episode, further episodes of symptoms occur in some people from time to time. This is called recurrent infection. It is not clear why the dormant virus erupts from time to time. Recurrences tend to be shorter and less severe than the first episode. It is more usual to have 7-10 days of symptoms with a recurrence, unlike the longer lasting symptoms that may occur during the first episode.

Most people do not develop a fever and do not feel particularly unwell during a recurrence. A tingling or itch in the genital area for 12-24 hours may indicate a recurrence is starting. The time period between recurrences is variable.

Recurrences tend to become less frequent over time. In people who have recurrences, their frequency can vary greatly. Some people have six or more a year. For others it is less frequent than this. On average, people tend to have 1 to 4 recurrences per year during the first two years after the first episode. Some people do not have recurrences at all after a first episode of symptoms.

Some people can identify things that may trigger a recurrence. Such triggers include sunlight, physical illness, excess alcohol, or stress. If a trigger can be identified, it may be helpful to try to avoid this in the future, if possible.

What does genital herpes look like?

Genital herpes - woman

By Me, CC BY-SA 3.0, via Wikimedia Commons

Genital herpes - man

No author listed, CC0, via Wikimedia Commons

The glands in the groin may swell. Women with genital herpes often have pain on passing urine.

In women, a vaginal discharge may occur. Women may also have blisters and ulcers on the neck of the womb (cervix) at the top of the vagina. The inside of the back passage may also be affected. The ulcers and blisters can last up to 10-28 days and then gradually heal and go without scarring.

Sometimes there may just be a small red or itchy area with one or two blisters.

It is not clear why some infected people develop symptoms, some don't and some have their first episode of symptoms months or even years after first being infected. It may be due to the way the immune system reacts to the virus in different people.

How long does genital herpes last?

The symptoms of a first infection with genital herpes will usually last up to three or four weeks. The blisters appear in crops. After the symptoms go away the virus is still present in a nearby nerve, but is no longer active. This is sometimes called being dormant. It is usual to have repeated outbreaks of genital herpes symptoms over time. The recurrence symptoms usually last around 6-12 days.

How do you get genital herpes?

Genital herpes is an infection of the genitals (penis in men, vulva and vagina in women) and surrounding area of skin. It is caused by the herpes simplex virus. The buttocks and anus may also be affected. There are two types of herpes simplex virus (also known as HSV):

• Type 1 herpes simplex virus is the usual cause of cold sores around the mouth. It also causes around half of cases of genital herpes.

• Type 2 herpes simplex virus usually only causes genital herpes. It can sometimes cause cold sores.

Genital herpes is usually passed on by skin-to-skin contact with the affected area of someone who is already infected with the virus; this is usually during sex. Vaginal, oral or anal sex can pass on the herpes virus. It is a sexually transmitted infection (STI) but does not require penetrative intercourse for the virus to be passed on.

The moist skin inside the mouth, genitals and back passage (anus) is the most susceptible to infection. This means that the virus is most commonly passed on by having vaginal, anal or oral sex, or just close genital contact with an infected person. For example, if you have a cold sore around your mouth, by having oral sex, you may pass on the virus that causes genital herpes.

Condoms have been found to prevent infection passing from a man to a woman in 96 out of 100 cases but only prevent the virus from passing from a woman to a man in 65 out of 100 cases. Dental dams have not been found to be effective at reducing the risk of transmitting the HSV virus during oral sex.

You are not likely to re-infect yourself with your own virus through accidental touching, or to catch back your own virus from an infected partner, on a different part of your own body.

Who should I see if I think I have genital herpes?

If you suspect that you have genital herpes or any other STI then see contact your local genitourinary medicine (GUM) clinic. You can go to the local GUM clinic without a referral from a GP. You can look for a GUM clinic near you in the UK by searching the 'Find a sexual health clinic service'. Your general practice would also be able to advise you where your nearest clinic is.

Search for your local GUM / sexual health clinic here.

Genital herpes test

A blister can be swabbed by a doctor or nurse to obtain a small sample to send to the laboratory. This can confirm the infection is due to the herpes simplex virus. It may also find out which type of herpes virus has caused the infection. Tests to look for other STIs may also be done at the same time.

These swab tests are best carried out in a GUM clinic. Most GPs cannot offer this specific test and will therefore normally advise attending a GUM clinic as soon as possible. Blood tests are unreliable.

Genital herpes treatment

General measures that may help to ease symptoms when they occur

• Painkillers such as paracetamol may help to ease pain.

• If it is painful when passing urine, it is often less painful to pass urine whilst sitting in a warm bath or shower (with water flowing over the area).

• A numbing (anaesthetic) ointment that can be bought at pharmacies, called lidocaine 5% gel, may relieve itching or pain. Some people also apply ointment about five minutes before passing urine if this is painful. Note: some people are sensitive (allergic) to anaesthetic ointments, and the ointment then makes skin symptoms worse. Applying Vaseline® before passing urine may be a helpful alternative to anaesthetic ointment.

• Ice wrapped in a tea towel (an ice pack) placed over the sores for 5-10 minutes may be soothing. Do not put ice directly on to skin, as this may cause an 'ice burn'.

• Have plenty to drink. This can help to make the urine less strong and less concentrated. This may make passing urine less painful.

• Do not use scented soaps, bubble bath, etc, as these may irritate the skin. Gentle cleaning of the open sores with just cotton wool and plain or salt water is best. Gentle drying with a hairdryer on its lowest setting may be more comfortable than with a towel.

• When resuming sexual activity after an episode has cleared, a lubricant may help, as some people find the friction of having sex may trigger a recurrence.

Other points:

• It is important to avoid having sex until the sores and blisters have cleared.

• It is best to be honest and tell a sexual partner if you have been diagnosed with genital herpes. If they have not got the infection, the doctor or nurse at the GUM clinic will explain ways to reduce the chances of passing it on to them. The doctor or nurse will also help explain that because of the way the virus works, it is not possible to tell how long ago you acquired the infection. Sometimes people are scared to tell their partners in case their partner thinks they have been unfaithful or they are worried their partner has been unfaithful and given them the infection. Because there is often a long time lag, this is often not the case. A GUM clinic doctor or nurse will be able to advise further.

Genital herpes cannot be cured. The symptoms are improved by taking the antiviral medicines but medicine cannot clear the virus which will remain in the body permanently.

Antiviral medication

There are three antiviral medicines that are currently usually used to treat genital herpes:

• Aciclovir.

• Famciclovir.

• Valaciclovir.

They all come in different brand names. They work by stopping the herpes virus from multiplying. If an antiviral medicine is started early in an episode of symptoms, it tends to reduce the severity and duration of symptoms during an episode of genital herpes.

These medications all appear to be as effective as each other; one is not better or quicker than another at clearing symptoms.

Antiviral medication for a first episode of genital herpes

An antiviral medicine is commonly prescribed for a first episode of genital herpes. (A first episode of genital herpes is also called a primary episode.) A five-day course of treatment is usual but this may be extended by a few days if blisters are still forming. With a first episode of genital herpes, the sores and blisters may last from about 10 days up to 28 days. This is usually much reduced if an antiviral medicine is started within five days of the onset of symptoms. The earlier the medicine is started, the better the chance of easing symptoms.

Antiviral medication for recurrent episodes of genital herpes

Further episodes of symptoms (recurrences) tend to be milder and usually last just a few days, typically 7-10 days of symptoms rather than the 10-28 days with the first episode. Antiviral medication is often not needed for recurrences. Painkillers, salt baths, and local anaesthetic ointment (such as lidocaine) for a few days may be sufficient to ease symptoms. However, an antiviral medicine may be advised for recurrent episodes of genital herpes in the following situations:

If you have severe recurrences

Starting an antiviral medicine as soon as symptoms start may reduce the duration and severity of symptoms. A supply of medication may be prescribed to have ready at home to start as soon as symptoms begin. This kind of 'as needed' treatment tends to be prescribed for people having severe attacks of genital herpes fewer than six times a year. There are a number of different options of courses of treatment to take, ranging from one to six days in length, and with different daily regimes.

If you have frequent recurrences

An antiviral medicine every day may be recommended for people who have more than six recurrences a year. In most people who take medication every day, the recurrences are either stopped completely, or their frequency and severity are greatly reduced. A lower maintenance dose rather than the full treatment dose is usually prescribed. A typical plan is to take a 6- to 12-month course of treatment and then stop the medication to see if recurrences have become less frequent. This type of continuous treatment can be repeated if necessary.

For special events

There is no evidence that short courses of medication help to prevent a recurrence.

To avoid transmission

Condoms should always be used when having sex with someone who has genital herpes. Sex should be avoided entirely when there is an active recurrence of infection (in other words, when there are blisters visible on the genitals) but condoms should be worn at other times as the virus can shed and be passed on even when there is no outbreak. Anti-viral medication has been shown to reduce the risk of transmission; in studies of heterosexual couples, if the person with the HSV infection took one tablet a day, the risk of passing it on to their sexual partner was significantly reduced.

Are there any side-effects from antiviral medicines?

Most people who take antiviral medication do not get any side-effects or the side-effects are very minor. The most common side-effects are:

• Feeling sick (nausea).

• Being sick (vomiting).

• Diarrhoea.

• Tummy (abdominal) pain.

• Skin rashes (including photosensitivity and itching).

Read the leaflet inside the medication packet for a full list of possible side-effects.

Can genital herpes be cured?

Genital herpes cannot be cured. The symptoms are improved by taking the antiviral medicines but medicine cannot clear the virus from the body.

Genital herpes in pregnancy

A specialist will normally advise about what to do if the first genital herpes is during pregnancy or if someone with recurrent genital herpes becomes pregnant. This is because there may be a chance of passing on the infection to the baby.

A first episode of genital herpes whilst you are pregnant

The risk of passing on the virus to the baby is highest if the first episode of genital herpes occurs within the final six weeks of pregnancy or around the time of the birth,. In this situation there is about a 4 in 10 chance of the baby developing a herpes infection. The baby may develop a very serious herpes infection if he or she is born by a vaginal delivery.

Therefore, in this situation a caesarean section delivery is usually recommended. This will greatly reduce the chance of the baby coming into contact with the virus (mainly in the blisters and sores around the genitals). Infection of the baby is then usually (but not always) prevented.

However, in women who choose to opt for a vaginal delivery despite having active genital herpes, an antiviral medication (usually aciclovir) will usually be given into the veins (intravenously) during labour. An antiviral medication will also often be given to the baby after he or she is born.

If there are eight weeks or more between the first episode of genital herpes and giving birth, a normal vaginal delivery is likely to be safe for the baby. This is because there will be time for the mother to produce protective proteins called antibodies which will be passed on to the baby through the placenta to protect it when it is being born.

An obstetrician may advise treating with an antiviral medication at the time of infection to help the sores to clear quickly. They may also advise taking antiviral medication in the last four weeks of pregnancy to help prevent a recurrence of herpes at the time of childbirth. Antiviral medicines such as aciclovir have not been found to be harmful to the baby when taken during pregnancy.

If you have recurrent genital herpes and become pregnant

In women with recurrent episodes of genital herpes, the risk to the baby is low, even if there is an episode of blisters or sores during childbirth. This is because some antibodies and immunity will be passed to the baby during the final two months of pregnancy.

For most women with recurrent genital herpes, it is felt to be safe to have a normal vaginal delivery. However, an obstetrician will help individuals weigh up the pros and cons of vaginal delivery vs caesarean section.

Often antiviral medication will be advised in the last four weeks running up to childbirth. This may help to prevent a recurrence of blisters during childbirth.

In summary

A first episode of herpes around the time of birth can be serious for the baby and a caesarean section is usually advised. In any other situation - an earlier primary infection or a history of recurrent episodes - the risk to the baby is low and a specialist will advise on possible options.

How can genital herpes be prevented?

There is not yet a vaccine to protect against the herpes virus and therefore prevent genital herpes. There are a number of things to consider which may reduce the risks of getting genital herpes or of passing it on to others. These include:

• Consider the use of condoms always, even in established relationships. This is because a person can carry the herpes virus for a very long time and pass it on without ever being aware of it. Condoms do not completely protect against herpes but they reduce the risk.

• The more sexual partners, the greater the risk of picking up any STI, including herpes. So avoiding having a large number of partners will cut reduce the risk.

• Avoid having sex with somebody with an active genital herpes infection (ie somebody with visible genital sores or blisters).

• Also avoid oral sex with a person who has a cold sore.

• If you have an active herpes infection yourself, avoid having sex with anyone else in order to prevent passing it on.

• If one partner finds out they have herpes, it is wise to tell the other. This can reduce transmission rates.

• If a person knows they have recurrent herpes, taking a regular antiviral medicine can reduce the risk of passing on the virus.

• In particular, a pregnant woman should avoid having sex with somebody with active herpes, because of the extra risk to the baby during delivery

Should I have sex if I have genital herpes?

When you have symptoms (during a primary episode or recurrence)

Herpes simplex virus is very contagious when blisters are present. There is a high chance of passing on the virus during sex. You should not have sex from the time symptoms first start until they are fully over. If you do have sex, using a condom may not fully protect against passing on the virus, as the condom only protects the area that is covered.

When you do not have symptoms (which is most of the time)

It is less likely that you will pass the virus on when you have sex. However, some virus will be present on the genital skin surface from time to time, although infrequently. So, there is still a small chance that you may pass on the virus when you have sex when you do not have symptoms. It is best to discuss things with your sexual partner. Using a condom each time you have sex is thought to reduce the chance further. However, using a condom cannot completely stop the chance of passing on the virus.

Taking antiviral medication long-term to prevent recurrences (suppressive treatment) also reduces the risk of passing on the virus. However, very few people need to take this treatment all the time.