Everything You Need to Know About Herpes
Welcome to the Sensate Health blog! While I am a physician, this blog is for educational purposes only and does not constitute medical advice or a doctor-patient relationship. Please see your healthcare provider for any medical concerns.
Whoever started the marketing campaign for herpes stigma clearly knew what they were doing. From scare-tactic sex education to high-profile celebrity scandals, herpes has been unfairly targeted as a source of shame. While it’s outside the scope of this article to unpack how we got here, the reality is that herpes is an incredibly common virus, and for the majority of people the symptoms are a minor inconvenience at most. The CDC states that half of adults (48.1%) have herpes type 1, while 12.1% or 1 in 8 adults have herpes type 2. Despite being so common, the combination of mild symptoms and lack of consistent testing means that a whopping 87.4% of people with herpes type 2 have never actually received a herpes diagnosis from a healthcare professional.
Perhaps you’re part of the smaller percentage of people with herpes who have had symptoms or received a diagnosis, and that’s why you’re seeking out this article. Or maybe someone you care about has herpes, and they asked you to read this article to learn more about it. Whatever your background or relationship to herpes, in this article I’ll break down exactly what you need to know in order to demystify this diagnosis and take better care of yourself and others.
What Exactly Is Herpes?
Oral herpes (“cold sores”) and genital herpes are caused by two subtypes of herpes viruses: herpes simplex virus (HSV) 1 and 2. Many people are surprised to learn that there are multiple other subtypes of herpes viruses that are extremely common. Did you have chickenpox as a kid, or do you know someone who did? That was human herpesvirus 3, also called varicella zoster. Shingles, a rash that usually affects older adults, is a reactivation of that same virus that occurs after it lies dormant in the nerves for years. Epstein-Barr virus, or human herpesvirus 4, is the typical cause of infectious mononucleosis or “mono.” Have you ever heard someone say their life was over because they got mono, chickenpox, or shingles? Probably not. Herpes simplex virus 1 and 2 aren’t any more serious than these other subtypes, but they have been targeted for ridicule simply because they are more likely to be transmitted sexually. The truth is that all of these subtypes are transmitted through human contact, and none of them are “clean” or “dirty.”
Herpes simplex is a virus that lies dormant in the nerves and sometimes causes skin symptoms. Once acquired, it is a lifelong infection. Most of the time, the body’s immune system keeps it inactive within the nerve roots that supply the area of skin where the virus first entered the body, but when herpes “reactivates” it sheds the virus back to the skin. Shedding may be accompanied by symptoms, i.e. tingling and blisters, and other times it may be completely asymptomatic. Herpes prefers thin, moist parts of the skin, so it commonly affects the mouth and anogenital area and rarely affects other parts of the body. HSV-1 used to be referred to as “oral herpes” because it was thought to primarily affect the mouth, while HSV-2 was referred to as genital herpes. However, an increasing number of herpes infections in the anogenital area are actually caused by HSV-1, often transmitted from the mouth to the genitals during oral sex. The symptoms of HSV-1 and HSV-2 in the anogenital area may look exactly the same, so the best way to tell which virus type is present is to have the area swabbed and tested while symptoms are present.
How is Herpes Transmitted and Diagnosed?
Herpes is transmitted from person to person through direct contact (kissing or oral, vaginal, or anal sex) with the affected area of skin or associated fluids like saliva and genital secretions. Transmission to a partner only happens if the following three conditions are met: 1) the partner is susceptible to herpes, i.e. they don’t already have the same HSV subtype, 2) the person with herpes is shedding the virus at the time of physical contact, and 3) the susceptible partner’s mouth or genitals come in direct contact with the virus. The risk of the partner contracting herpes is higher if they have a tear or cut in the skin, because this makes it easier for the virus to enter the body. There is no way to know if asymptomatic shedding is occurring, but we’ll talk about a way to lower the frequency of shedding later on. Lastly, it’s important to note that herpes isn’t transmitted by surfaces like toilet seats and bed sheets, but it can be transmitted through sharing sex toys!
Once the virus enters the body of a susceptible person, it will take around 2 to 12 days to notice any symptoms. It will then cause a “primary” episode, which may include flu-like symptoms from the body’s immune response and a painful, blistering rash at the site where it entered the body (this can occur inside the vagina or rectum as well). However, many people with a new herpes infection will be asymptomatic, so the most common symptom is no symptom! For those with pain or discomfort, you can apply an ice pack, take over-the-counter pain relievers, and for anogenital symptoms take sitz baths and drink lots of water to dilute your urine (pouring water over the area while you urinate can also help). It is unlikely but possible to transmit the virus to other parts of the body, so be sure to wash your hands after touching the affected area. Herpes can also cause rare cases of meningitis or urinary retention, so if you have bothersome headaches or are unable to urinate, please seek a medical evaluation.
It’s very important to see a healthcare provider as soon as you notice the blisters or bumps. The provider should perform a PCR swab of the area to confirm if your symptoms are due to herpes, and if so, whether it is type 1 or 2. The virus type will be important in determining if your current or future partners are susceptible or not. You may also be offered an antiviral medication like valacyclovir (Valtrex) to help shorten the duration of your symptoms. Even with medication, it may take several weeks for the blisters to fully heal, and you should avoid sexual contact during this time both for your comfort and also because this is when transmitting the virus to someone else is most likely. Processing a herpes diagnosis can be difficult, but having a sex-positive healthcare provider and trusted friends or partners to support you through it can make a huge difference. It’s common to go through a wide range of feelings from sadness to anger to hopefulness. This is all part of the process, so be patient with yourself and don’t hesitate to reach out for help.
Once your symptoms resolve, the virus goes into what is called the latent period, where it is sequestered in the nerve roots and is not actively shedding. From time to time, it may reactivate and lead to recurrent symptoms. Triggers for a recurrence include illness, stress, sunlight, and fatigue. Recurrences are often preceded by prodrome symptoms, usually itching or tingling at the site, or a shooting pain down the leg in the case of anogenital infections. Prodrome symptoms indicate that the virus is already being shed, so it’s important to avoid sexual contact during this time and until resolution of any subsequent rash that develops. Fortunately, recurrent symptoms are usually shorter and much more mild than the initial episode, and the frequency of recurrences may decrease over time. Another factor in recurrences is that HSV-1 in the genital area tends to cause far fewer recurrences than HSV-2. As mentioned previously, it is common to shed virus even without symptoms, and we’ll discuss this more in the next section.
What Does Herpes Mean For Your Sex Life?
In case you need to hear this - yes, you absolutely can and should have sex after getting herpes! As mentioned above, you’ll want to wait for your initial symptoms to completely resolve, and even then you may not feel like having sex right away. Take your time and go at a pace that feels comfortable for you. You may find that many of your concerns around having sex after a herpes diagnosis pertain to the risk of transmitting it to a partner. To address this, we’re going to revisit the conditions that must be present for transmission to occur, but this time we’re going to focus instead on steps you can take to reduce that chance.
Disclose Your Herpes Status
Most people with new herpes infections got the virus from someone who didn’t know or didn’t disclose their status. As it turns out, simply telling your sexual partner you have herpes reduces their chances of contracting the virus from you by about half. Not only is disclosing your status a protective step for your partner, you’re also giving them the opportunity to give informed consent and creating a culture of sex-positivity! You may be surprised to find that they also have herpes, or maybe they don’t have herpes but are still very informed and accepting. If you’re reading this and you don’t have herpes, the message here for you is that you are less likely to get herpes from someone who tells you they have herpes than from someone who doesn’t know their status!
I recommend opening your disclosure conversation by sharing your most recent STI test results and asking about their tests in return. Not only will this give you insight into their sexual health knowledge and practices, but the STI conversation is just as much about protecting yourself as it is about protecting them! Having a herpes diagnosis puts you at higher risk of contracting other STIs like HIV, so your partner needs to be just as committed to your health as they are to their own if they’re going to be worthy of your time and trust. After discussing recent testing, you can share your diagnosis (calmly and unapologetically if possible!) and ask if they have questions and if they’d like to discuss what safer sex would look like if you decide to become intimate.
There’s a lot of discussion online about handling “rejection,” but it doesn’t mean you were rejected if your partner declines to move forward. A “no” is simply a no, and it has nothing to do with your worth and everything to do with their background, experiences, and comfort level. “Rejection” makes it about you; “no” makes it about them. It’s still perfectly okay to feel sad and disappointed when a new connection ends for any reason, and it can be particularly upsetting if it triggers your own negative thought patterns about yourself. Challenge your negative thoughts and seek out support from friends or a trusted professional if you’re finding it hard to move forward.
Discuss Your Partner’s Status
Your partner may already know their HSV status, but if not, they may want to get tested to get more information about whether other protective steps are necessary. If they have antibodies to the same subtype of herpes you have (i.e. you both have HSV-2), it means they already have the virus, and the immunity provided by the antibodies means they’re unlikely to develop new symptoms through sexual contact with you. That being said, you should still avoid sexual activity when symptoms are present. As we discussed before, the most accurate way to test for herpes is to swab a blister, but if your partner has never had symptoms, they can still get a herpes antibody blood test to see if they have the virus.
These antibody tests aren’t perfect - IgG antibodies may take up to four months to develop after the infection occurs, so you can’t test for new infections with this method. Furthermore, it is possible to get a false positive result, where it says you have the virus when you actually don’t. Higher antibody levels are more likely to represent a true positive result, whereas lower levels could be a false positive. Consult with a trusted healthcare professional if you need help interpreting the results of your test. The last notable limitation of these tests is that a positive antibody doesn’t necessarily tell you whether the infection was oral or genital. The CDC states that HSV-2 antibodies can be assumed to represent a genital infection, but HSV-1 antibodies could represent an infection in either location. If you and your partner have different subtypes, for example if you have HSV-2 and they have HSV-1, you are each still susceptible to your partner’s subtype. There are still other steps you can take to lower the chance of transmission, so keep reading!
Understand Viral Shedding
Shedding is highest when skin symptoms (rash) or prodrome symptoms are present, so sexual activity should always be avoided during those times. However, shedding can still occur even without symptoms, which is referred to as asymptomatic shedding. Research has shown that most HSV-2 transmissions actually occur during asymptomatic shedding, but don’t be confused into thinking this means the risk of transmission is higher without symptoms. This discrepancy is likely because people know to avoid sexual activity when symptoms are present and conversely are less likely to take precautions when asymptomatic.
So how common is asymptomatic shedding, and how can you lower your chance of transmission? In one study of genital HSV-2, people who were diagnosed after having symptoms were shown to have asymptomatic shedding on 13.1% of the days of the study, while those who had never had symptoms (and were diagnosed with antibody testing) had asymptomatic shedding on 8.8% of study days. As for reducing the frequency of shedding, the most convenient and well-researched medication is valacyclovir. One study found that taking daily valacyclovir reduces the chance of HSV-2 transmission by about half, with the additional benefit of reducing the frequency of recurrent symptoms. Lifestyle measures that support a healthy immune system are likely to be helpful as well, but there isn’t robust research evidence to support this just yet. Based on what we know at this time, combining valacyclovir with a barrier method as discussed below provides the most effective protection.
Use Barrier Methods
Before we talk about the effectiveness of condom use, I want to discuss the differences in transmission rates of HSV-2 between men and women in heterosexual couples. In one study that followed 528 mostly heterosexual couples for a year and a half, transmission occurred in 9.7% of the couples where the male partner had herpes and only 1.9% of the couples where the female partner had herpes. The rate of transmission from men to women was 8.9 transmissions per 10,000 sexual encounters, while the rate of transmission from women to men was only 1.5 transmissions per 10,000 sexual encounters. While this may seem unfairly skewed for female partners of men with herpes, this is where condoms can really be a game-changer. A study examining the effectiveness of condoms found that condom use was 96% effective in preventing transmission from men to women but was less effective in preventing transmission from women to men. Because the rates of transmission from women to men are already very low, the transmission rates between the sexes become comparable with the addition of condom use.
Last but certainly not least, with the rising numbers of genital herpes infections that are caused by HSV-1, it is important to consider the possibility of transmission during oral sex if one partner has oral HSV-1 and the other partner tests negative. While the effectiveness of dental dams or condoms for prevention of anogenital HSV-1 is unclear, these partners may want to consider their own comfort levels and whether they would like to use barriers when receiving oral sex from a partner with oral herpes. As with any herpes infection, it’s especially important to avoid direct contact (including kissing) when a partner with oral herpes is experiencing prodrome or recurrent symptoms.
Special Note on Herpes and Pregnancy
A pregnant woman whose partner has a history of HSV-1 or HSV-2 should use the appropriate barrier method (condoms or dental dams) during the first and second trimester and then avoid any sexual contact with the partner’s affected area (mouth or genitals) during the third trimester. This is because herpes can be transmitted to the infant during vaginal delivery, and the risk of transmission is highest for new maternal infections. A woman who already has genital herpes may need to take an antiviral medication near the time of delivery to help prevent transmission. Please discuss your individual situation with your healthcare provider.
Conclusion
I hope you’ve found it helpful to learn more about this incredibly common and very manageable virus called herpes! It’s completely normal to feel some anxiety when receiving a herpes diagnosis for you or your partner, but there are a number of steps you can take to reduce the chance of transmission. Once you’ve disclosed your status and established if your partner is susceptible to herpes by performing antibody testing, the most effective ways to reduce transmission are to avoid sexual activity when symptoms are present, take valacyclovir daily to reduce asymptomatic shedding, and use condoms or other barrier methods.
If you have questions about your own sexual health, as of the time of this publication you can schedule a free 15-minute coaching consultation with me here. You can also check out my in-depth article on how to disclose an STI to a potential partner!
Here’s a Recap of What We Discussed:
About Herpes
Herpes simplex is a virus that lies dormant in the nerve roots and sometimes causes skin symptoms
Half of adults have herpes type 1, and one in eight adults have herpes type 2
Most people with HSV-2 have never received a diagnosis
Herpes Symptoms and Diagnosis
Herpes most commonly affects the oral and anogenital areas
While it sometimes causes a blistering rash, it is also often asymptomatic
Herpes can periodically reactivate and shed virus to the skin, with or without accompanying symptoms
The most accurate way to diagnose herpes is with a PCR swab while a blister is present
Antibody testing can be done, but antibodies can take several months to develop, false positives are possible, and an antibody to HSV-1 does not indicate whether the infection is oral or anogenital
Sex After Herpes
You can absolutely still have sex after a herpes diagnosis!
Reducing Transmission
Disclosing your herpes status to your partner reduces your chance of transmitting the virus to them by about half, allows them to give consent, and provides an opportunity for them to get antibody testing to see if they are susceptible
Taking daily valacyclovir is a way to reduce shedding and recurrent symptoms and also reduces your chance of transmission by half
Condom usage is highly effective (96%) in preventing transmission from male to female partners but is less effective in preventing transmission from female to male partners. However, because transmission from female to male partners is much less common, the rates of transmission between the sexes become comparable when using condoms.
A person who does not have HSV-1 may want to use barrier methods when receiving oral sex from a partner with oral HSV-1 due to the possibility of transmission to the genital area
Herpes and Pregnancy: Women whose partners have herpes should take precautions during pregnancy to avoid a new infection which could pass to the infant during delivery. Women who have genital herpes may need to take antiviral medication near the time of delivery.
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