Herpes: It’s Not the Plague

I was a teen in the 80s, and I remember a Time Magazine cover from 1982 that referred to herpes as the modern “Scarlet Letter.” Many of my younger patients don’t recall the intense stigma associated with herpes. Heck, they don’t recall that HIV used to be a death sentence. Times have changed, thank God!

Over 50 million Americans have herpes, and there are 1 million new cases every year. An even more surprising statistic: Only 1 in 10 people knows they carry this virus. To quote the CDC, “Most genital herpes infections are transmitted by persons unaware that they have the infection.” (2015)

Not a week goes by that I don’t diagnose a woman with Herpes Simplex Virus, which I will refer to as HSV. This diagnoses often leads to tears, confusion, blame and anger.

Below are answers to the questions so many patients have asked me in that upsetting moment.

“How can a person not know they have herpes?!!”

Although the “classic” symptoms are pretty obvious–painful ulcers and sores on one’s genitalia–most people’s symptoms are much more subtle and often attributed to other things. Perhaps that sore is from shaving or scratching oneself. That frequent prickly itching is recurrent yeast, even though the symptoms do not go away with anti-yeast medications. Maybe that itching near one’s anus is hemorrhoids  . . .

Herpes is the great imitator and is often self-diagnosed as something else. This is why so many people do not know they carry the virus.

“But my partner told me he/she was checked for STIs and was all clear . . .”

If your parter told you they’ve been checked for STIs, they’re probably being honest. Most providers do not routinely check for HSV when screening for STIs, unless someone is having symptoms or knows they’ve been exposed to the virus. These providers are following the recommendation of the US Preventative Task Force (USPTF), which claims that the harms of regular HSV screening outweigh the benefits.

Confession: Until recently, I also followed this recommendation. More than 50% of adults will show a history of exposure to HSV on blood testing, and many of these individuals simply have cold sores. Why open Pandora’s box?

My thinking has changed because I now see HSV Type I and Type II as separate entities.

“What is the difference between HSV I and HSV II?”

Both can lead to genital sores. The difference is that HSV I is often acquired during childhood, something as innocent as swapping spit on a playground via a shared toy. When this toddler becomes an adult, they have the capacity to transmit this to any orifice, even if they have no visible sores. This is called asymptomatic shedding.  If their new partner also has been exposed to HSV I and has antibodies, then nothing happens. But if their new partner had a helicopter mom that did not allow sharing of spit-covered toys, then they can get a genital infection with HSV I. But I digress a little.

If a person gets an outbreak caused by HSV I, there is good news and bad news. First the bad: you have genital herpes. Now the good: since it was caused by HSV I, chances are you will not get recurrent outbreaks and if you do, they will be mild. Approximately 30% of new herpes cases will be HSV I.

“Why offer testing for HSV II, but not HSV I?”

I went to a conference last year where the lecturer simply asked, “If you had HSV II, wouldn’t you want to know?” Yes, I would.

HSV II is more debilitating, with frequent recurrences and thus more shedding. Whereas >50% of adults have antibodies to HSV I, a smaller but significant proportion of people–roughly 15%–carry HSV II. Because this is a smaller subset, it is less likely that their partners will also be carriers and more likely that they will transmit HSV to someone susceptible.

If a person knows they have HSV II and is sexually-active, they should probably take anti-viral medication, use protection, and let their partner know. The partner should be tested and if they do not demonstrate immunity, then the person should continue anti-virals and the couple should avoid unprotected sex.

“I just had sex without protection and now I am worried I have HSV. When should I get tested?”

Serum (blood) antibodies appear as early as 3 weeks after exposure and as late as 3 months. If you have sores on your genitalia, a test called “PCR” is widely available and is a direct swab of the lesions. If the infection is “Primary” (recent) the PCR will often be positive and the blood tests negative. It takes a while for one’s immune system to mount a response.

“What are other symptoms of Herpes?”

  • Swollen lymph nodes in the groin, on the crease between the thigh and abdomen, also known as the “inguinal” region.
  • Feeling flu-like, with headache, fever, aches, etc.
  • Vaginal or penile discharge (hence the erroneous self-diagnosis of yeast)
  • Burning with urination, especially if it just seems to be on the outside and not deep in the bladder

“Will HSV go away? Is there any treatment to get rid of it permanently?”

No and no. The virus can be dormant for years in the nerves that supply the genitalia. The virus then travels sporadically to the surface, especially in times of stress or trauma, including rough sex.

Although I am describing genital lesions, a more accurate distribution is “boxer shorts”–HSV can be evident on buttocks, upper thighs and even lower abdomen. I will admit that I did not know this earlier in my career, and I remember misdiagnosing a few cases of butt-herpes.

But the good news is that anti-viral medications such as Acyclovir and Valtrex are effective at minimizing the intensity and duration of an infection, and they are very well-tolerated. I have prescribed these medications hundreds of times and I have not seen one true allergic reaction, just a couple of patients that swore the medication gave them headaches. Anti-virals also can be used daily for suppression and prevention of transmission, as mentioned above.

I hope this post is somewhat informative and maybe even reassuring. If you have herpes, you are not alone and you probably are in good company. As I tell my patients, you probably have many friends with HSV, but it is not something posted as a status update on Facebook.

This is all skimming the surface and whole books have been written about HSV. An excellent resource for more information is The Herpes Handbook from Westover Heights Clinic: https://www.westoverheights.com/wp-content/uploads/2014/08/Updated-Herpes-Book.pdf



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