Genital Herpes

Everything you need to know about genital herpes

Herpes is not simply an infection. Many people suffer silently fearing even to reach out to their healthcare providers. There are few conditions where the patient controls so much of the care they receive but for that to be done correctly, it takes time. Time must be dedicated to education and to formulating a plan that is directed by the patient and under the control of the patient.

You can control your outbreaks.

Most doctors would be hard pressed to name a condition where the patient’s directives are more central to the plan for care than herpes. Medication is available—and it works extremely well—but how it is used and when it is used can never be more precisely applied than when a person uses the guidance of experts to craft the ideal, personalized plan.

That is what we are here to do. With the education we provide below, you will be able to decide how best to utilize all the tools at your disposal. But the key is to read and learn as much as you can and make informed decisions that help you achieve your goals and gain the kind of independence you may not have realized is possible.

We realize it is a lot of reading but it may provide some recent information you have not yet found. Nothing is sugar coated because we feel you deserve the information you need to live your life the way you want. Read it all along with the package insert and the information in the PDR.

We are here to make your life better, not to give you more challenges in finding the care you need. And don’t forget, contact us if you need us.

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What is genital herpes?

Herpes is a virus. The herpes virus can barely be considered alive. It is little more than a strand of DNA (Deoxyribonucleic Acid), the code of life, safely hidden inside a shell of protein. On its own, a herpes virus cannot reproduce or do much of anything—until it infects us. When the herpes virus comes in contact with areas that are receptive, like the genitals or mouth, the virus invades the epithelial cells (skin cells) in that region. Then, the DNA of the herpes virus is released into the skin cell. At that point, it quite literally takes over.

It directs the cell to make more herpes virus and, when they have made enough copies to damage the cell so severely that it bursts, millions of the newly formed viruses are released infecting more cells, eventually causing an ulcer.

In the United States, genital herpes caused by HSV-2 (Herpes Simplex Virus Type 2) is extremely common and the most frequent cause of genital ulcer disease. Yet, the people who have symptoms represent the smallest number of people infected. In fact, 80% of the people who have genital herpes do not know it. That means for every person with symptoms who takes the step to be treated as you have, there are 4 people who are infected but totally unaware.

Herpes hides in your nerve cells.

While the virus is infecting skin cells and causing pain and ulcers, it also begins to attack the nerve cells in the same area. When the virus enters the nerve cell, it not only reproduces but it moves up the nerve to a bundle of nerves in the neck region of the spine called the dorsal root ganglion. Once it is in the nerves, it is essentially protected from being attacked by the body’s immune system. Nerve cells can never be replaced.

That is why when nerves in the spine are damaged people become paralyzed. Since nerves cannot reproduce themselves easily, the body is careful not to bombard them with all the weapons it has to clear infections. All the inflammation that is caused by the battle to eliminate infections elsewhere would be disastrous if that occurred with nerves. There is no sense clearing an infection if nerve cells that could never be replaced are destroyed in the process.

The herpes virus is essentially protected from an attack by our immune system as long as it hides out in the nerves.

Unfortunately, that leaves the virus in a perfect position to sneak back out when the immune system is suppressed in any way. That is how the virus can cause recurrent infections, especially during times of stress, illness, or any condition or circumstance that makes our immune system less vigilant.

How common are HSV-1 and HSV-2?

Worldwide (in 2012) nearly one half billion people were infected with HSV-2 between the ages of 15 and 49—and the number rises with age and the number of life partners. More women than men have herpes (14.8% versus 8% global prevalence, respectively). In the US, the number of people infected has been dropping. The percentage of people with a positive blood test for HSV-2 has declined. In people age 14 to 49, 21% were positive in the early 90s. By 2010, that number dropped to about 16%. Unfortunately, the improvement has been seen mostly in the white population “with stable rates in black populations, resulting in worsening racial disparities such that for every one white man, four black men are infected, with similar ratios for women.”

The reasons for this might be that access to information, education—and the medication that can reduce the risk of transmission—has not been made available to all equally.

In the United States, the prevalence of HSV-1, which accounts for the vast majority of oral herpes, has dropped 29% among 14–19 year olds, from approximately 42% to 30%, over the past 30 years. As a result, adolescents and young adults may experience their first exposure to HSV-1 with the initiation of sexual activity, including oral sex.

How can it be that some people do not have symptoms?

Approximately 80% of people with an infection have no symptoms they recognize. For those who experience severe or frequent outbreaks, that is difficult to understand.

The fact is most people have an immune response that holds the disease at bay—in terms of causing symptoms, that is. They are still infected and still able to transmit the disease, but the symptoms either do not occur or are so subtle that they go unnoticed or undiagnosed. Herpes can cause such minor complaints that they are ignored.

Also, the symptoms may disappear so quickly that they are dismissed, or never seen in time by a doctor, or a doctor does not recognize how minor herpes can be even when seen. This is true of oral and genital herpes.

Nevertheless, the people who have what we call asymptomatic herpes can still transmit the disease. They can do this because they can still “shed” the virus from the skin even without having a sore or a symptom that they recognize as herpes. Asymptomatic shedding occurs from the mouth in those with oral herpes, from the anal and genital region in those with genital herpes, and even from tears in people who have had herpes of the eye.

Symptoms of an genital herpes outbreak

HSV-2 is the leading cause of genital ulcers in the United States and throughout the world. We know that because a very accurate test called a PCR test, which is far more sensitive than a culture, has found herpes in 60% of genital ulcers. Remember that most people with herpes found by blood testing have had no symptoms of herpes. What follows is a description of herpes as it appears in those who experience symptoms, in people who are seen by doctors with lesions.

First Outbreak or Primary Outbreak

For patients who have symptoms, the first outbreak can be the worst. During primary infection, patients may experience multiple genital ulcers that can cover larger areas of skin. It can be on both sides of the groin and be quite painful. They often experience burning during urination in addition to the local pain. They can have fever, headaches, muscle and joint pain, and their lymph nodes in the groin can be swollen and painful as well. With no therapy, the lesions will clear and heal without scarring (typically) in about 21 days. Therapy can shorten that period significantly. The reason an initial outbreak can be so severe is that there are no antibodies to herpes when the virus first enters the body, (though a prior history of herpes type 1 can give someone antibodies to HSV-1 that may make an HSV-2 outbreak a bit less severe.)

An initial outbreak can be caused by Herpes 1 and in developed countries like the US the most common cause of genital herpes is actually herpes 1. Most people do not realize that someone infected with oral herpes from type 1 can perform fellatio (oral sex on a male partner) or cunnilingus (oral sex on a female partner) and transmit herpes 1 from their mouth to their partner’s genitals. If you think about it, why not? The problem is that many people don’t know they have oral herpes.

Nevertheless, herpes 1 and herpes 2 on the genitals do not behave identically in terms of recurrences. Herpes 1 is more “at home” in the oral region and has developed ways to deal with that environment. When on the genitals, it can cause all the same symptoms and can still be transmitted, but it has a milder course than when herpes 2 infects the genitals.

Understanding how herpes can remain in the body, yet be kept at bay to some degree, is pivotal. Herpes enters the sacral plexus of nerves during an initial infection. As discussed above, the virus remains safe from attack by antibodies and the immune system as long as it is tucked away in the nervous system. That little trick, entering the nervous system where it neither damages the nerves nor can be attacked, makes herpes a particularly stubborn infection. It can slide down the nerves that go from the sacral plexus to the skin and cause more outbreaks in the future. These are called recurrences.

Recurrences occur in a milder version than the initial outbreak because the body is no longer completely defenseless. Once the virus enters the body, antibodies are formed making it more difficult for the virus to exit a nerve and cause lesions. It is the ongoing battle between the herpes virus’ ability to stay safe in the nervous system and the body’s ability to mount a defense with antibodies that determines if symptoms will appear or not. In most people, the battle is a stalemate in terms of symptoms.

Most people never have an outbreak or, if they do, they are so mild they are not noticed.

It is in the ways herpes remains active in those who are infected, and able to spread to those who are not, that makes herpes such a difficult infection to control in terms of preventing outbreaks and preventing transmission.

However, control is possible—and that is the key.


While the immune system for the vast majority of people makes recurrences far less severe than a primary outbreak, periodic recurrences occur in genital HSV infections. They are also quite different in character. First, since herpes is in the nerves of the patient, as the virus becomes more active and begins to travel down the nerve to the skin, a person may get symptoms that tell them an outbreak on the skin is about to appear. They may get leg pain, back pain, a tingling sensation, burning, or itching. They might notice less specific symptoms like increased urination, but symptoms like fever or muscle aches are much less common than with an initial outbreak. These symptoms collectively are known as a prodrome. It is very variable but patients begin to recognize their pattern, their unique prodrome.

The outbreaks themselves are much milder. They tend to occur on one side of the body, to cover a smaller area, and are less painful. Swelling of the lymph nodes is uncommon and all the symptoms resolve much more quickly, lasting just 3–5 days.

Recurrent outbreaks can occur on the buttocks, the thigh, or anywhere in the anal and genital regions. Recurrences in areas other than the genitals (e.g., thigh) have a similar pattern to those that occur on the genitals.

Also, while herpes tends to improve over time, people can get outbreaks at any point that their immune system is challenged. This can happen when another illness occurs, with cancer or cancer treatments, or with such simple changes as life stress due to divorce, moving, changing jobs, or death of a family member, as examples. Excessive friction, sunburns, exhaustion, poor sleep patterns can also deplete a person’s immune system. In fact, anything that makes you less healthy or is a challenge to the system can make an outbreak more likely to occur. Over time patients not only recognize their prodromes, but they also recognize the circumstances associated with an outbreak.

Genital HSV-2 recurs far more often than genital HSV-1. In the first year after primary infection with genital HSV-2, patients average about 5 recurrences. That drops by approximately 2 outbreaks per year in the following year. In the first year after a genital HSV-1 infection, the recurrence rate is just 1.3 outbreaks/year. That drops to a mere .7 outbreaks/year in the second year.

Those statistics can be misleading, however. Some patients have no outbreaks and others can experience 9 or more outbreaks per year. It is incredibly variable.

Remember, these statistics are all about symptoms. People often wonder why someone who had symptoms or who knew they had herpes, and who had outbreaks, would have sex when they had an outbreak and could transmit the disease. The problem is that herpes is shed from the skin even when people who get outbreaks feel perfectly well. Also, even the people who have no history of herpes, but in whom we know herpes is present (by blood tests), shedding of the virus from the skin occurs silently and the potential to transmit the virus exists.

This is called asymptomatic shedding and occurs in anyone who has herpes—whether they have symptoms or not.

Asymptomatic shedding

When a genital herpes outbreak occurs, the virus can be cultured for about 11 days with an initial outbreak and for about 4 days with a recurrence. Yet, the question is whether the virus can be found on the skin even in between outbreaks.

As it turns out, the herpes virus becomes active and can be “shed” from the skin on days when patients who have recurrences of genital HSV-2 feel perfectly well and in people who have only a positive blood test for HSV-2 and have never had an outbreak. In a pivotal study, women with symptomatic genital herpes Type 2 collected cultures from the cervix, vulva, and the rectum every day for over 3 months. They kept track of their symptoms with a daily diary, as well.

Shedding occurred without symptoms on 2% of the days in women with HSV-2 genital herpes. They shed more frequently in the 7 days prior to or following an outbreak. Shedding lasted fewer days when they were free of an outbreak but still accounted for one-third of all the days they shed the virus.

But what is the case for the over 80% of HSV-2-seropositive persons in the United States who are not aware that they are infected with HSV-2? Using a very advanced test called PCR (Polymerase Chain Reaction), samples from patients who had herpes type 2 but who had never had symptoms were compared to patients with genital HSV-2 who had symptoms in terms of shedding the herpes virus. The patients who had a history of symptoms shed the virus when they had no symptoms on 13% of days while those who only had HSV-2 by blood testing shed on 9% of days. What is interesting is that the amount of virus shed when no symptoms were present was essentially the same in both groups.

The precise rate of genital HSV-1 shedding in between outbreaks is not known but it is suspected it is far less than genital HSV-2 herpes. One small study using cultures, and not the much more sensitive PCR test, found shedding on only 1 out of every 200 days. Unfortunately, we know that HSV-1 also sheds asymptomatically from the mouth and in developed countries like the US, it is responsible for most of the new infections of genital herpes.

Some things are associated with a risk for shedding and some things are not. With genital herpes, time of the month in relation to menstruation, sexual orientation, and sex were not. Having a history of prior outbreaks, especially a history of more than 8 outbreaks/year, and being Caucasian, are a risk for an increase in asymptomatic genital shedding, as well as an increase in overall shedding (Symptomatic and Asymptomatic shedding combined).

Duration of Asymptomatic Shedding

Another factor associated with asymptomatic shedding is how long a patient has had the infection. The first year after acquiring genital HSV is the most difficult symptomatically—and it makes sense that would be the year with the most shedding of the virus. In one study, the shedding rate declined from one-quarter of days in the first year to 13% in the years that followed; however, the rate never seems to drop to 0. Even in people with HSV-2 who had the disease for 20 years, shedding still occurred on more than 10% of days.

Herpes Transmission

It has become clear that people who have antibodies in their blood to Herpes Type 2 shed the virus from their skin whether they have a history of outbreaks or not. Basically, if someone has antibodies to herpes, they are capable of transmitting the disease. In one study that followed the course of 144 couples in which one partner was infected and the other not infected, transmission occurred in 14 couples. In 9 of those cases, the person who transmitted the disease was completely free of symptoms—no outbreak, not even a prodrome (a warning that an attack was coming). The other 5 transmissions happened when the person who was infected had a prodrome or developed lesions near the time the infection was transmitted. This makes sense. Shedding of the virus frequently occurs within 7 days of an outbreak, either before or after.

In another study of a vaccine that was totally ineffective, 155 people acquired herpes from their partner. Only 57 people who became infected had any symptoms of herpes. That means 99 people acquired the infection and only knew about it because they were in a study and had a very accurate blood test that confirmed the infection. This is consistent with what we know, which is that the disease is most often transmitted by asymptomatic shedding (when people have no symptoms) and that the people who become infected most will have no symptoms (yet will be capable of transmitting the disease).

How does Roman treat genital herpes?

Our doctors prescribe Valacyclovir to be used to limit outbreaks and reduce the risk of transmitting herpes by taking one pill every day. One of the most important advances in herpes treatment came with the knowledge that transmission from an infected person to their uninfected partner could be reduced by the use of daily Valacyclovir. Valacyclovir not only reduces the number of outbreaks a person experiences when using the medication every day but it reduces the number of days that someone sheds the virus asymptomatically (shedding of the herpes virus from normal skin when a person feels completely well). Asymptomatic shedding is how most transmissions occur. Reducing asymptomatic shedding results in fewer uninfected partners catching herpes. If a condom is worn and the medication used, the chances are cut in half compared to using a condom alone. Fewer outbreaks and fewer episodes of asymptomatic shedding means fewer people become infected.

In one study that followed the course of 144 couples in which one partner was infected and the other not infected, transmission occurred in 14 couples. In 9 of those cases, the person who transmitted the disease was completely free of symptoms—no outbreak, not even a prodrome (a warning that an attack was coming). The other 5 transmissions happened when the person who was infected had a prodrome or developed lesions near the time the infection was transmitted. As noted, the key to preventing transmission isn’t just limiting outbreaks but reducing asymptomatic shedding. Valacyclovir, taken daily, reduces the number of outbreaks a person experiences and the number of days that someone sheds the virus asymptomatically.

To reduce the number of outbreaks an infected person experiences and to reduce the risk of transmission to an uninfected partner (by up to 50%), the PDR recommends the infected partner take Valacyclovir 500 mg/day. The study measured results “in monogamous, heterosexual relationships when combined with safer sex practices.” The data are strong but refer to patients with 9 or fewer outbreaks each year. Also, the study ran only for 8 months.


An Important Point about transmitting herpes.

Herpes can be transmitted to a partner despite best efforts like using a condom and using antiviral suppression therapy. Patients should never engage in sex without a condom or when they have an outbreak or a prodrome. Also, as asymptomatic shedding is more common in the seven days following an outbreak, it is prudent to avoid sex during that period, as well.

Preventing Future Outbreaks

If you are just trying to abort outbreaks, make a note of everything you think may have made you more susceptible to an outbreak. Was there more irritation to the area? Did anything affect your immunity like another infection (e.g., a cold) or did you change something in your lifestyle that could have weakened your immune system (e.g., lack of sleep, stress, increased alcohol consumption)? No change is too small to note.

This is important because it will help you maintain the patterns that make herpes less likely to appear and makes it less likely you will need medication. For you, it may be a lack of sleep over a few consecutive nights that spurs most outbreaks. It might be excessive sun exposure or too much alcohol consumption. It could happen only when you are sick or just run down.

Whether oral or genital, people can take medication when their specific prodrome tells them an outbreak is on the horizon. The medication will stop an outbreak cold (often) and when it does not, it can shorten a milder outbreak than they might have had otherwise.

Other Ways To Use The Medication

Some patients ask if they can take the medication to prevent an outbreak when they least want to have one. The classic examples are a bride or groom on their wedding day when first engaging in sex with a new partner, or going on that long planned and much-needed vacation with your partner or spouse. You don’t need to be getting married or about to rendezvous for a much-anticipated tryst to want to prevent a herpes outbreak at particular times. It could be that an outbreak would be uncomfortable during the holidays or at any time you determine.

That is what we mean when we say you have control. At one point in life, a person may choose to abort outbreaks when they feel them coming on, at another point they might choose suppression therapy, but that may change, too. Circumstances change; only you will be able to know how your circumstances affect which option you choose. That is why learning all you can is so important. It gives you independence. Things change and how you choose to use Valacyclovir may change.

To Suppress Outbreaks For An Extended Period

Another way patients can take the medication is when they know they absolutely would like to do all they can to reduce their chance of having an outbreak at a pivotal time. The classic example would be during a honeymoon but taking medication to suppress outbreaks on a daily basis can be prudent when going on vacation, starting a new job, in a new relationship, or at any time a patient feels it is how they want to approach their condition. And that’s the key.
How medication is used is completely in your hands. Learn everything you can and do not worry about using the medication in the way that suits you best. That may change as your circumstances change, or as the condition changes, or even as your mind changes.

To Prevent Transmission to An Uninfected Partner

One of the most important advances in herpes treatment came with the knowledge that transmission from an infected person to their uninfected partner could be reduced by the use of valacyclovir. Valacyclovir not only reduces the number of outbreaks a person experiences when using the medication every day but it reduces the number of days that someone sheds the virus asymptomatically. That results in fewer uninfected partners catching herpes. If a condom is worn and the medication used, the chances are reduced at least in half compared to using a condom alone. Fewer outbreaks and fewer episodes of shedding means fewer people become infected.

Using your prescription

With Roman, you will be prescribed 30 pills of the 500 mg size of Valacyclovir every month. You should always have medication on hand, so renew your prescription well before you run out. As long as valacyclovir proves effective and you are free of significant side effects, you should never have to worry about having access to what you need.

You can always drop a note to your doctor, the pharmacist, or the care team with any questions, issues, or changes you want to consider. There is no “extra” visit charge or cost if you just want to ask questions and learn more about how you can manage your condition.

Lastly, if you would like to switch to intermittent therapy, you can always hold back on getting more Valacyclovir delivered.

This may be a new situation for you but as long as the medication works without causing you difficulties of any sort, you are in control.

Learn more about Valacyclovir

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