Last week I saw a sixteen year-old patient who complained of painful sores on her outer vagina after recently becoming sexually active. She explained that she was in a serious relationship with an eighteen year-old boy and after much thought and consideration, had lost her virginity to him. They had used condoms but not during every encounter. On examination it was clear that she had a primary outbreak of herpes. She and her mom were understandably quite upset about this.
Herpes is a scary word and I realized when talking with my patient that most people don't have a clear understanding of what herpes is and how to treat the symptoms.
Herpes is a viral infection that is transmitted through intimate contact. Herpes simplex Type I is usually oral and sores break out around the lips and in the mouth. Herpes simplex Type II is usually in the genital area and sores can be found around the vaginal opening, on the labia, between the opening and anal area or on the buttocks. A primary herpes infection is the very first outbreak a person experiences. The sores usually appear 2-14 days after the person is infected. The primary infection is the worst infection a person will ever experience. It may be accompanied by low-grade fever, muscle aches, swollen lymph nodes, fatigue and other flu-like symptoms. A primary outbreak generally has more lesions and they are more painful than subsequent episodes. Treatment for herpes outbreaks includes antiviral medications like Valtrex, Famvir and Acyslovir and supportive care such as Tylenol, Motrin or prescription pain relievers.
One of the reasons that herpes is so easily transmitted is that the virus can live under normal skin and be shed with no outer lesions present. This is called asymptomatic shedding and is an important factor in the transmission of the virus. If one person in a relationship has herpes and the other does not, each year they are together there is about a 10% chance that the uninfected person will catch herpes even with condom use. For this reason, many patients with herpes take daily antiviral medication to suppress the virus and decrease their chance of infecting their partner. Suppressive daily therapy can also decrease the chance of recurrences. It is important to note that women with a history of herpes must take antiviral medications in the final month of pregnancy to prevent transmission to the baby.
Perhaps the worst aspect of genital herpes is that after the primary infection one can experience a recurrence of that herpes outbreak anytime. This is because after infection the virus can live in the nerve roots and cause recurrent outbreaks without any other exposure. An average person will have four to five recurrences in the year following their initial infection. The recurrences usually have fewer lesions and those are generally less painful. Most patients describe them as annoyances, but they can certainly be emotionally debilitating.
Over 45 million people in the U.S. have herpes but only 10% of the people infected are aware they have it. In the case of my sixteen year old patient, her boyfriend denied ever having any previous genital sores and had never been diagnosed with any sexually transmitted disease (STD). However, since he was her first partner and she broke out 2 weeks after having intercourse with him, there is little doubt that he infected her even though he was never aware of any symptoms and indeed never had had any.
One of the most difficult parts of dealing with the disease is the emotional burden that patients carry when learning they have herpes. There is a terrible stigma associated with having an STD that cannot be cured. Between 20-25% of people in our country have herpes, though most are unaware of it. The reality is that everyone knows multiple people infected with herpes but no one ever discusses it.
I think of it as an incredibly minor medical condition and really not of any health consequence at all unless the patient is pregnant. Herpes does not turn into any other disease, does not make you more at risk for any other disease and is basically just a nuisance. Over time the recurrences diminish and eventually completely stop. The most prudent way to prevent getting herpes is to only be in a monogamous relationship with an uninfected partner. However, we must realize that just because someone says they are uninfected does not necessarily mean that they are. If you are experiencing recurrent genital sores please make an appointment with your doctor to discuss possible therapies and also so your doctor can reassure you that this is common and easily dealt with.
As for my sixteen year-old patient, hopefully she is better educated about her diagnosis and how to manage her symptoms and will come to realize that having herpes doesn't have to be who you are, it's just something you have.
Until next time . . .
Carol Swindle, M.D.
