So You Have an STD: The Herpes Edition -The Toast

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herpesThis is the second in a three-part series. Part I, on HPV, can be found here.

Name: Herpes Simplex Virus, HSV-2, genital herpes

Science Facts: a double-stranded DNA virus

Prevalence: 15-16% of adults in the US (around 25% in women, 12% in men)

Symptoms: a prodrome (meaning a period before symptoms show up when you can feel local pain), during which you can have itching or burning of the skin around the genitals. This will be followed by an eruption of one or more vesicles, which are blister-like bumps filled with yellow or clear fluid, with red skin underneath. Over a few days, these vesicles will burst, causing the bump to turn into an ulcer, which is still painful.

What’s The Worst Case Scenario? The Most Common Scenario: This is what a typical herpes infection looks like.


You’ll have a prodrome, which is where you’ll have localized burning or itching for a few days before you start noticing some raised bumps. These bumps typically look like blisters, filled with yellow fluid, with the skin underneath them looking red. All the yellow fluid is herpes virus, so DON’T POP IT because that fluid is very infective. These vesicles will often burst on their own, leading to small ulcers. During this time period, both during the prodrome, as well as during the lesions and ulcers themselves, you are very infectious and should refrain from all sexual contact.

The bad news: Herpes cannot be cured. Unlike a bacteria, which we can wipe out with antibiotics, or a virus like HPV, which the immune system usually clears on its own, HSV has a nasty habit of migrating into neurons & living there forever.

The Super Worst Case Scenario: Herpetic encephalitis, a very rare complication where herpes can get into the bloodstream and cause disseminated infection. If this infection gets into your brain, it can cause brain swelling (called encephalitis), which can cause seizures and death. This is so unlikely I feel kind of guilty for telling you about it. It’s much more likely in newborns who were born vaginally to mothers having a very severe first-time outbreak, because newborns have no immune system. You can pass it along even when you aren’t having an outbreak. This is called ‘asymptomatic shedding’, and occurs most frequently in the first year you have herpes.

The worst time to get herpes for the first time is during pregnancy, specifically in the third trimester. Newborns are at a very high risk of getting HSV if they pass through a vagina that has any herpetic lesions because again, the lesions are very infectious. In newborns, who have little to no immune system, it’s much easier for herpes to spread to the brain and cause encephalitis or meningitis, which can kill newborns. This is why it’s important to let your OB/GYN know if you have any remote history of herpes, no matter how long it’s been since outbreaks. Your OB will do a thorough pelvic exam to check for current lesions, and if you have any history of prodrome or lesions, we’ll put you on antiviral therapy as you get close to delivery to prevent any outbreaks. But even if you do come in pregnant with herpes lesions, we can mitigate the risk to baby by doing a C-section, so the baby doesn’t come in contact with the infectious lesions. The worst case scenario is a primary outbreak that happens right after delivery—meaning the baby was exposed before the lesions had a chance to develop and is at very high risk. I have, very unfortunately, seen this happen, with some tragic outcomes. If you, or your partner, have ANY remote history of HSV, let your obstetrician know!

What’s the Treatment? Luckily, we have several drugs to suppress herpes and stop you from having an outbreak, as well as decrease the frequency and amount of virus shed in genital secretions, which makes you less infectious. There are three drugs we use, all in the same family–acyclovir, vancyclovir, and famciclovir. You can take them as needed, meaning just when you have a prodrome and feel symptoms coming on or have onset of lesions. If you are with a partner who is HSV negative and want to avoid passing the virus back and forth, you can also take these drugs as daily suppressive therapy to stop outbreaks and decrease viral shedding, decreasing the likelihood that you can transmit HSV to your partner. HSV can still be passed in genital fluids even when you are asymptomatic, without prodrome or lesions, so use a condom. HSV can have skin-to-skin transmission, like HPV, so a condom is not a 100% guarantee that you won’t get herpes. To reduce risk to your partner, definitely avoid sex when you have an active outbreak, take daily immunosuppressive therapy, and use protection.

Nicole, Please Reassure Me, I Feel Horrible: I’m here for you. I worked in a herpes lab for three years and got lectures on herpes daily. The herpesvirus has been around, evolutionarily speaking, as long as there have been human beings. There are actually eight types that infect humans (also there are herpesviruses that infect almost every species in which we’ve looked for it!), and my boss—a man who had spent his entire 30+ year career working with herpes—was convinced that most humans had been exposed to all of them, including HSV-2, the one that causes genital lesions. HSV is so common that having a positive blood test isn’t very useful, because you can become exposed and develop antibodies without ever having a primary outbreak. Herpes, like HPV, is nearly ubiquitous—if you go by blood tests. By some estimates, more than 90% of the world is seropositive for HSV, because herpes is a very clever virus that has coevolved for millions of years to live in humans. However, a positive blood test for HSV often doesn’t correlate with what we actually mean when we say ‘genital herpes’—the itchy, painful, infectious bumps. This is both bad and good news, because that means you can have herpes and pass it along without ever knowing you had it because you never developed symptoms. Some people can have a primary infection that presents with one or two lesions, or some itching and burning, and not the dozens of little bumps you see in the picture above. The lesion can happen inside the vagina, on inner labia or vaginal wall, where you can’t see it and would never notice. And often health care providers don’t routinely test for it, because the antibody test being positive isn’t a good indicator of clinical status.

This picture sounds pretty bleak, I know! “Nicole, you’re telling me that I can have herpes without knowing it, that I can pass it along without knowing it, and that I might not ever get tested for it even if I ask?!” And I’m afraid the answer is yes. However, there’s a reason we go by clinical status with herpes infections. If you haven’t had a bad outbreak, chances are you can’t pass on a virus to your partner that causes a bad outbreak. Just like there are different strains of HPV, there are different strains of HSV with different clinical courses. If you do become infected with a type that produces an infection so subclinical that you don’t know you have it, the chance that you pass it along to someone else means they will likely get the same type of infection—one that is so small, and asymptomatic, that they won’t even know it’s there. The age old puzzle of “if you have a disease but no symptoms, do you really have a disease?” is brought up every time someone has a positive HSV blood test but no history of symptoms. On the other hand, if you have a primary infection that is very symptomatic, with many lesions, lots of burning and itching beforehand, then the type of infection you’ll pass to your partners could be just as symptomatic.

Here’s some good news: the first infection is the worst. Most people get one outbreak of herpes during the primary infection, which can present with painful lesions pictured above, and then the immune system clears that infection and the virus lives latent in your nerve cells. You can have outbreaks again because that virus in your nerve cells can become active, reproducing and traveling down to the skin where it causes symptoms, but over time that virus generally becomes less active. The first six months of infection is the most high-risk time, both for reactivation (secondary lesions erupting on the skin) and for shedding (the virus will be present in genital secretions). Many people have a primary outbreak and never develop symptoms again. Even if you only have one outbreak in your life, you still have herpes and can still pass it along to partners, so it’s important to disclose every time. But over time, most outbreaks become less severe or stop entirely. You’ll be able to go years without an outbreak.

The most important thing to tell you is that 99% of the problems caused by herpes are social. This virus is not damaging to your body. It will not cause cancer, it will not kill you. It will just live inside your cells, hanging out with you, for the rest of your life. For most people, herpes is just an annoyance, a couple days of itching and no sex before it goes away on its own. It won’t make your genitals fall off, it won’t cause infertility or harm your family for generations to come. With suppressive regimens, you can stop outbreaks before they even happen. In medical terms, herpes is not a big deal. Herpes is harmful because of the social stigma attached to it, because in a sex negative society where STDs are treated like a punishment instead of a disease, herpes is visible and doesn’t go away.

Heres the Etiquette:

  1. Tell your partners. Most STDs are easily curable and the ones that aren’t curable can be very well controlled or suppressed with medication. Only by not telling someone are you putting them at increased health risk. If you don’t want to tell them, talk to your health care provider, because STDs diagnoses are reportable to local health officials. If you can provide a list of partners, then the health department can call those individuals and let them know anonymously that they have been exposed to someone with an STD and need to see their doctor.
  2. There’s often a window after diagnosis & treatment when you should avoid having sex, because it takes some time for the infection to clear from your system. You don’t want to pass it along during that window to someone who could keep giving it back to you (we call this ‘ping-pong infection’).
  3. If you get one STD, we highly recommend co-testing for other STDs, including HIV. The risk factors are the same for all of them. All, including HIV, syphilis, trichomonas, crabs, lice, scabies, and bacterial vaginosis, can be cured or medically managed.
  4. Be considerate. Use condoms with your partners every time.


If you want to buy a stuffed herpes toy, you can do so here.

Nicole Nolan is in medical school. Someday she will be a gynecologist, and then her entire job will be NSFW.

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