Genital herpes: The painful facts about a tricky virus

There are two main types of herpes simplex virus (HSV) infections, HSV-1 and HSV-2. Generally speaking, HSV-1 is responsible for those annoying cold sores that can pop up during times of stress or lack of sleep. Genital sores are usually caused by HSV-2. Many people don't realize that HSV-1 can cause genital ulcers as well, though these tend to be less severe and less likely to recur.

It can take as little as a few days and up to a week after a person has been exposed before any herpes symptoms appear. First, there will be redness and tingling, followed by small painful bumps that progress to fluid-filled "blisters." Eventually, these burst to form shallow skin ulcers which then crust over, with gradual healing over a couple weeks. An initial genital herpes infection can be very painful, also cause fever, body aches and fatigue. Recurrent outbreaks tend to cause less severe symptoms. Rarely a genital herpes infection can cause inflammation of the membrane that covers the brain (meningitis).

You can only get genital herpes if your partner has an active infection with sores, right? Wrong

A person can be exposed to the virus and pass it to someone else without ever having symptoms. It happens more often than you'd think. That's because the virus can exist in genital fluids even without any ulcers. This is called "asymptomatic shedding of virus." Although there is a lot more active virus when there are sores, asymptomatic shedding is probably how most people get herpes. What's more, only one out of four people who tests positive for genital herpes actually knows that they have the virus. That's a lot of people. Combine the two and you have many people unknowingly infecting others.

Many people who learn they have genital herpes are shocked. They often didn't see any sores on their partner (and they really looked!) or that their partner had never had any ulcers, ever. This is common and true, because people can have genital herpes and not know it.

Got Ulcers? Get Tested

A person with genital ulcers should see his or her doctor. It's important to confirm whether or not it is herpes. Genital herpes outbreaks are treated with antiviral medications. These medications can help to reduce the number of days of discomfort and have few side effects. They are most effective when taken early in an outbreak. Some people take these drugs daily to prevent outbreaks.

Once someone has had a test that confirms either type of genital herpes, future partners can have a blood test which tells them if they already have been exposed to the same strain of virus. If the person tests negative, the partner with the infection would be advised to take antiviral therapy daily, in order to help prevent infecting his or her partner. Although daily antiviral therapy decreases the chances of spreading the virus, there is no guarantee, so it's best to have a frank conversation with a new sexual partner.

No ulcers doesn't equal no herpes, so then what?

If you've never had genital ulcers and as far as you know, have never been exposed, is it worth getting tested? That's a controversial point and in fact, the widely followed official guidelines discourage screening.

Why? Many reasons: Let's say a person has a blood test that comes back positive for HSV-2. This means that the patient may have been exposed to HSV-2 at some point in their lives, somehow, somewhere. Research tells us that these folks may be periodically shedding virus particles in their genital fluids. These patients would then be diagnosed with genital herpes, encouraged to share their status with future partners, and offered daily antiviral medication to prevent possibly spreading the virus.

All of this can be a tough pill to swallow, so to speak. There is significant social stigma and shame associated with herpes. In addition, there are occasionally false-positive tests. Labeling someone with the diagnosis can be devastating to their future relationships, and asking someone to take a pill for a condition they may or may not have and may or may not spread seems unreasonable.

However, not all experts agree with the official guidelines. Except for the uncommon case of a false positive blood test for HSV-2, a seropositive test means one of three things:

1. The person has had herpes with symptoms.
2. The person has had herpes with symptoms but didn't realize the cause.
3. The person has the herpes virus and may shed virus from time to time in genital fluids. The only way to know if a person is shedding the virus is with daily tests. That's just not practical.

A lot of people fall into the second and third categories — again, that's why so many people still get the virus. People who should strongly consider getting a blood test include:

• people with any other sexually transmitted infection including chlamydia, human papilloma virus (HPV), etc.
• people in a relationship with a herpes-positive partner, especially if you are a pregnant woman or plan to become pregnant
• any person who asks to be tested.

If you are not sure about getting tested, talk with your doctor.

Adapted from a Harvard Health Blog post by Monique Tello, MD, MPH