As most of you know there are 2 kinds of herpes infections:
Herpes 1 (HSV-1), which when activated causes sores on the lips, gums and even the eyes. (It used to be called the herpes above the waist.)
Herpes 2 (HSV-2) or genital herpes, which can appear on the labia, vagina cervix (obviously in men in different genital areas…) and all sorts of places on the lower body (inner thighs, buttocks, back)….this is the one we are most concerned about.
A recent postgraduate Obstetrics and Gynecology publication gives an excellent synopsis on herpes and I thought it would be appropriate to go over some of the facts that were presented in this review.
HSV is a DNA virus and is classified as either 1 or 2 by its glycoproteins (i.e. not by where it infects but what is in its molecular structure). It’s transmitted though direct contact with mucosa or abraded skin. That’s the official wording…. when it comes to HSV-1 in “lay” expression you get it from kissing, or oral contact including oral sex. When it comes to HSV-2, transmission is through genital contact…. pretty easy to imagine how it can occur with intercourse, but those lesions women often get on their buttocks, back or thigh can occur via post coital contact (spooning, or getting close to a member that is shedding the virus…. member here usually refers to a penis).
Once transmitted, the virus incubates for 2 to 12 days and then replicates in the layers of the skin causing inflammation and ulceration. But that’s not all…. the virus then enters the sensory neurons and then travels to their root (or ganglia) where it then becomes dormant. Weeks, months or years later it can become reactivated, spread back down along the nerve root to the skin and cause a recurrent ulcer-like lesion or simply shed from the skin without a visible sore or irritation. Antibodies to the virus develop within several weeks of the infection. The initial infections tend to be more severe than recurrent ones; there may be swelling of adjacent lymph nodes and the lesions may last 3 to 6 weeks. Recurrent infections are usually mild and last 3 to 10 days. The frequency of recurrences can vary…. they are more likely to occur when your resistance is diminished, i.e. you are sick, have a fever, or are physically or emotionally stressed. After the first infection, about 50% of individuals will have a recurrence in 6 months.
The estimate of how many of us have had HSV-1 or HSV-2 is based on antibody testing which if positive is termed seroprevalence. The seroprevalence of HSV-2 in the US is 16.2% but women are at higher risk with a rate of 20.9%. The amazing fact is that only 19% of adults who are HSV-2 positive (and hence can spread the virus) are aware or their diagnosis! (I have frequently seen patients who come to my office with a complaint of “something down there” but deny any previous history of herpes…they may have had similar symptoms in the past but thought they were due to yeast infections or friction and never had these checked or diagnosed. Now… I am telling them that they have herpes. (And of course, the recriminations begin.) In most cases, especially if they are abstinent or have been with the same partner for years, it’s a recurrent infection. Remember that the virus can also be transmitted from the skin without a viable lesion. This is an STD that is chiefly spread without knowledge that it was there in the first place.
So what is the best way to diagnose HSV? When a “classic” group of vesicles (blisters) or ulcers occur, a culture of the lesions can be done. Especially in primary (first) infections, the culture will be positive in 48 to 72 hours. The sensitivity of the culture decreases the longer the lesion has been present. A positive culture is evidence of herpes, but a negative one doesn’t mean it’s not there, it simply means it was too late to find it or that the culture wasn’t sensitive enough. So ultimately the way to definitively diagnosis herpes and to distinguish between types 1 and 2 is with antibody testing…in a blood test called HerpesSelect 1 and 2. It can usually detect antibodies within 2 to 3 weeks of infection.
The treatment is usually oral with an antiviral medication. The generic and oldest form of medication is acyclovir. The dose for a primary infection is 400mg tablets three times a day for 7 to 10 days. There are 2 other antiviral medications that have somewhat better absorption and longer half-lives than acyclovir but essentially are converted to the same substance in the body. These are valcyclovir (Valtrex) and famcyclovir (Famvir). These are generally more expensive. The dose for Valtrex in a primary infection is 1 g twice daily, again for 7 to 10 days. For Famvir it’s also 1g twice daily…..in recurrent infections, less is needed (and works best if started with the very first sign of infection, such as local tingling or pain). Acyclovir is given in a dose of 400mg, 3 times a day for 5 days, Valtrex, 500mg, twice a day for 3 days and Famvir two tabs of 500mg twice a day for just one day. And for suppression (it’s not complete but may decrease viral shedding and transmission to a partner) the prescribed dose is 500 mg of Valtrex daily or 250 mg of Famvir twice daily. (I know this is getting very specific, but so many women ask for prescriptions, I thought I should include dosing.)
What should be done if herpes occurs during pregnancy? How great is the risk for neonatal infection? About 1200 to 1500 babies are born in the US each year with neonatal herpes. The most likely cause for their infection is through contact with the active virus in the lower maternal genital tract during vaginal delivery. The majority of the infected babies are born to women who had no history of HSV infection (i.e. they acquired a new infection before delivery) and one third of the cases are caused by HSV-1. Only 3% of the infections are among women with recurrent clinically evident HSV-2 infection. A primary genital herpes outbreak is associated with a higher risk of perinatal transmission than a recurrent outbreak, presumably because the mother has no preformed antibodies that are transferred to the fetus. Neonatal herpes can be serious; 30% of seriously infected babies die and up to 40% of survivors have serious neurological problems. In the past, many women underwent C-section just because they had a history of herpes even though they didn’t have any active lesions at the time of delivery. (This falls into to the “you never know, let’s be safe” category.) But it’s the women who are seronegative (have no antibodies) and who get infected in the last trimester that are the most likely to pass the virus to the baby during delivery. Nor is it completely “safe” for women with active vaginal lesions to deliver vaginally. The current recommendations are:
During pregnancy all symptomatic infections (primary or recurrent) should be treated with a 7-day course of antiviral medication.
All women who have had recurrent herpes or a new infection in pregnancy should be given prophylactic antiviral medication beginning at 36 weeks (And if at risk for a preterm delivery, this should be started earlier.)
C-section is indicated in any women with active perineal (in and around the vagina and labia) lesions or prodromal symptoms (sense that a herpes lesion is starting).
C-section is not indicated in women with a history of HSV without active lesions or symptoms at the time of labor,
C-section is not indicated for nongenital lesions (if there is a lesion on the thigh or buttock in can just be covered with a bandage.)
Bottom line: Many of us have herpes. No, we don’t have a vaccine but short courses of antiviral therapy or daily medication will help diminish recurrence of lesions and spread of the virus. Recurrences should be treated during pregnancy and at 36 weeks prophylactic antiviral medication may help prevent the need for C-section. If, however, an active lesion is present at time of labor, C-section is advised.