Genital herpes 101

Top things to know

• Genital herpes is the second most common STI in the United States of America
• Some people with herpes get recurrent blisters and ulcers on their genital areas
• Many people with herpes have no symptoms, but still are able to continue spreading the disease
• There is no cure for herpes, but outbreaks and symptoms can be managed

What is herpes?

Genital herpes is a very common sexually transmitted infection (STI) caused by the herpes simplex virus type 2 (HSV-2) and less commonly, by herpes simplex virus type 1 (HSV-1) (1).

Historically, these two different type of herpes viruses were known for where they caused infection—oral as HSV-1, and genital as HSV-2—but this is no longer true. HSV-1 can cause blisters on your mouth (“cold sores”) and on the genitals through oral sex. This means that both HSV-1 and HSV-2 can cause genital herpes.

What are the symptoms of herpes?

Genital herpes infections are very common, but many people don’t even know they have them. This is because many people don’t have any physical symptoms from the herpes infection—that is, their infections are asymptomatic (2,3).

Symptoms of genital herpes differ for everyone, and many people may not have classic symptoms or any symptoms at all. Some people may suspect that their symptoms are caused by another type of infection (2).

Herpes symptoms, for those who experience them, are often unpleasant. The initial herpes outbreak can be shocking and the most severe outbreak.

The first outbreak (primary infection)

After contracting the herpes simplex virus, symptoms may start to appear around 2 to 10 days later (4). This first infection is known as the primary infection.

The classic symptoms of genital herpes involve the skin: clusters of small raised bumps develop, which progress to fluid or pus-filled blisters (4,5).

Next, these blisters crust over or ulcer (turn into open wounds). They eventually regress, leaving the skin and mucous membrane to heal over (4,5).

These blisters are often painful, itchy, can cause tenderness, and may be accompanied by painful urination (5).

In women and people with female reproductive tracts, herpes lesions can appear on the vulva, perineum, buttocks, anal area, cervix, and inside of the vagina (6), and some people may experience spotting and vaginal discharge (7). This means that people with vaginas may not be able to “see” any herpes blisters because they are inside the vaginal canal. The first outbreak may also be accompanied by full body symptoms, such as fever, body aches, and swollen lymph nodes (3,6).

The first outbreak of genital herpes lesions usually lasts between two to four weeks long (4). While skin symptoms are present, a person is very contagious, as herpes viruses are present in the blister fluid and over the entire infected area (5).

Additional outbreaks (non-primary infections)

People with genital herpes who are infected with HSV-1 can also contract HSV-2 in their genitals (or vice versa). This is called a non-primary infection, and is often not as severe in presentation as the primary infection (5).

After the initial outbreak (recurrent infections)

Herpes outbreaks can keep coming back rather unexpectedly. This is because the herpes virus takes up permanent residence in nerve roots, and can never truly be eliminated (7).

Genital herpes outbreaks that occur after the primary infection are called recurrent infections (1). These can include the same symptoms from the primary infection, but are usually less severe, or can be asymptomatic, so that a person doesn’t even know that they are having a recurrent infection (2,3,5,7).

Fever and general feelings of being unwell are not usually present with recurrent infections (4). The number of recurrent outbreaks decreases over time (4).

During recurrent infections, something called viral shedding occurs, meaning that a person is contagious and can pass on herpes virus to another partner (2,4).

This means that even if you can’t see any herpes lesions on you or your partner’s genitalia, you are not safe during these times. The best way to avoid transmitting herpes if you know you have it is to always use a condom or another barrier method.

Most people who have recurrent infections have less severe lesions for a shorter period of time, compared to the primary infection (5). Some people may even be able to “feel” when a recurrent herpes outbreak will occur—this is called a prodrome—noticing symptoms like tingling, itching, or leg pain anywhere from 30 minutes to five days before the skin symptoms start (3,4).

How is genital herpes transmitted?

Genital herpes is spread through direct sexual contact of mucous membranes (the soft moist skin present at the openings of your genitals and mouth), herpes lesions and fluids, as well as through genital fluids and saliva (1,7).

Viral shedding occurs when someone is contagious and able to pass on the virus.

If herpes blisters are present, viral shedding will occur, making the person very contagious (8). If no blisters are present, this does not not mean that they are not contagious. Viral shedding can still happens in absence of active lesions, which means a person can still pass on the genital herpes virus to an unsuspecting partner (2,8,9,10,11).

How common is genital herpes?

Genital herpes is a very common STI, but since many people are asymptomatic or are in a phase between visible outbreaks, it is perceived as less common than it actually is.

Genital herpes caused by HSV-2 is estimated to the second-most prevalent STI in the United States of America, affecting almost 24 million people between 15 and 49 years of age (12).

But this estimate only accounts for people with the HSV-2 virus. Since genital herpes is increasingly being caused by HSV-1 (13), the amount of people with genital herpes infections is likely even higher.

Worldwide, a range of 274-678 million people aged 15 to 49 years old are estimated to be living with HSV-2, with a global prevalence of around 1 in 10 people having HSV-2 (14).

More women than men are affected by HSV-2 (14); this is because herpes is more easily transmitted to the female partner during sex (3).

Since genital herpes cannot be cured, the number of infected people in a population can only grow as more and more people become infected. The only way to reduce genital herpes within a population is through prevention.

Oral herpes caused by HSV-1 can also be a source of genital herpes. Across the world, it is estimated that 2 out of 3 people under 50 years of age—around 3.7 billion people—are infected with HSV-1 (3).

How can I prevent contracting or spreading genital herpes?

Always use a condom and/or barriers

Being sexually active puts people at risk for contracting an STI. Practicing safer sex and using condoms can moderately reduce the risk of contracting genital herpes (15).

People who use condoms every time they have sex have are 30% less likely to contract genital herpes (15).

Condoms should be used before any genital or sexual contact begins—not just during ejaculation. Since outbreaks and viral shedding may occur in areas not covered by a condom, total protection—even with perfect and consistent condom use—cannot be guaranteed (15).

Do a visual scan

People with outbreaks (herpes blisters present in the genital area) should abstain from sexual activity until the sores have fully healed.

The risk of transmission of genital herpes is highest during outbreaks, when viral shedding is at its greatest.

If a person with genital herpes feels prodrome symptoms—they sense that a herpes outbreak will happen soon—then sexual intercourse should be avoided until after the outbreak has subsided, and all of the blisters and ulcers have completely healed.

Ask about sexual history

Ask all partners whether they’ve been tested recently for STIs before sexual contact. Limiting the number of sexual partners you are exposed to will also decrease your risk of contracting genital herpes and other STIs.

If you've had unprotected sex, or if you experience symptoms of genital herpes, visit your healthcare provider or local STI clinic for an STI screenings.

If you have genital herpes, be open with your partner and talk about the risks of transmission.

Douching should be avoided, as this may actually increase chances of contracting an STI (16).

Researchers are working towards the development of other preventative strategies, such as an HSV vaccine and topical microbicides to help prevent the spread of herpes (3).

How is genital herpes diagnosed?

To diagnose a genital herpes infection, a healthcare provider will inspect the lesions and discuss sexual history and (if applicable) previous herpes outbreaks. The provider may run lab tests of the lesions, or blood tests to detect the virus (17).

How is genital herpes managed?

The herpes simplex virus cannot be cured, but it can be managed using antiviral medications to help control outbreaks. These medications help to prevent the outbreaks from happening as often and to reduce the symptom severity and duration (3).

There are two different treatments for people with genital herpes: suppressive therapy and episodic treatment.

• In suppressive therapy, antiviral medications are taken daily to reduce the frequency of herpes outbreaks (4). Having less frequent outbreaks means fewer episodes of painful genital lesions and less viral shedding, which will help reduce the risk of giving herpes to a partner.
• Episodic treatment may be better suited for people with infrequent outbreaks. Antivirals are dosed at the onset of symptoms to help ameliorate symptoms and shorten the duration of the outbreak (17).

If you have genital herpes, talk to your healthcare practitioner to determine which management option is best for you.

For people with herpes blisters inside the vagina, using tampons or menstrual cups during menstruation may be painful or irritating, making pads or menstrual underwear a better option during outbreaks.

What are the potential complications of genital herpes?

Pregnancy and herpes

It is possible to transmit a genital herpes infection from mother to the baby during birth (4,17).

The rate of transmission depends on whether or not herpes lesions are present at the time of delivery. If no genital herpes lesions or prodromal symptoms are present at the onset of labor, then a mother with a known herpes infection can still deliver a health baby vaginally.

But if a herpes outbreak is present at the time of delivery, or if the mother has recently just acquired genital herpes near the time of delivery, then a caesarian section will be performed to help reduce the risk of herpes transmission to the baby (17).

If you are pregnant and you don’t have genital herpes, avoid sex with anyone who you know or suspect has genital herpes, especially in the third trimester (17).

Neonatal herpes

If a newborn infant is exposed to the herpes virus, the consequences can be severe and even fatal (3,18). Infants can develop infections in their skin, eyes or mouth, in their central nervous system, or even throughout their body, affecting multiple organ systems at once (18).

HIV and genital herpes

Having HIV puts a person at greater risk of contracting genital herpes, and having genital herpes puts a person at greater risk of contracting HIV.

Immunocompromised people (including people with HIV) often experience longer and more severe genital herpes outbreaks, and have increased herpes virus shedding (17). The open sores caused by herpes make transmission of both HIV and the herpes simplex virus more likely (CDC).

It's estimated that people with genital herpes are three times more likely to contract HIV when exposed (19).

Other impacts of genital herpes

It's important to also remember that there are mental and social impacts of having an incurable STI. Many people with recurrent genital herpes symptoms may feel stigmatized or fearful of pursuing sexual relationships. But people should remember, while genital herpes is not curable, it is manageable, and the outbreaks often decrease over time.

Most people live healthy happy lives with genital herpes (3).

Download Clue to track your sex life and herpes symptoms using custom tags.