Genital herpes is not always easy to diagnose because signs and symptoms vary greatly. Some studies show that as many as two-thirds of all people infected with genital herpes will experience either no symptoms or will have symptoms so mild or atypical that they will not notice them or will mistake them for something else, like a yeast infection. Recent research has shown that after receiving health education about symptoms of genital herpes, many people who were thought to have asymptomatic infection (infection with no symptoms) were able to recognize symptoms.
The first episode of genital herpes is referred to as the primary outbreak, an episode occurring within a week or two after exposure. When it produces symptoms, the primary outbreak is characterized by lesions at the infection site and can be accompanied by flu-like symptoms, including headache, fever, painful urination and swollen glands in the groin. Usually, small red bumps appear first, develop into blisters and then become painful open sores. Lesions can occur on the pubic hair area, vulva and perineum, inside the vagina and on the cervix in women, on the penis in men, or at the rectum or the urethral opening of women and men. These lesions usually heal within two to four weeks. Scabs may form on skin surfaces, such as the penis, but not on mucosal surfaces such as the vagina. Not all individuals who are exposed to the virus will experience a primary episode directly following exposure, or the symptoms may be so mild that they go unrecognized.
Almost immediately after HSV infects your body and before symptoms appear, the virus travels to a sensory nerve root at the base of the spinal column called the sacral ganglion. It remains there in a latent or dormant stage indefinitely. In some people the virus reactivates and travels back to the skin, where it multiplies until it erupts at the surface in the form of a sore. An itching, tingling, or burning sensation in the genital area or buttocks often signals an upcoming episode. These warning symptoms are called the prodrome.
Most people who have primary infection will experience periodic outbreaks, or recurrences. For many, symptoms will reappear an average of four or five times a year lasting about five to 10 days. Between outbreaks, the virus retreats to the sacral ganglion in the spine where it is protected from the body's immune system. Infected people develop antibodies in response to genital herpes infection but, unfortunately, HSV antibodies cannot completely protect a person against different HSV types nor against reactivation of the dormant virus. Periodic outbreaks tend to become less frequent and less severe over time. Eventually outbreaks may disappear altogether.
Not all outbreaks have symptoms, and yet the virus may continue to be transmitted from a variety of sites in the genital area or in genital secretions or from lesions that are hidden or too small to notice.
The trigger for these recurrences is not known. Stress, menstruation, infections and emotional distress may contribute. However, research has shown that episodes can recur when these factors are absent.
Although sores may be visible to the naked eye, laboratory tests may be needed to distinguish herpes sores from other infections. For several years, the most common method of diagnosis has been the viral culture. A new sore is swabbed or scraped, and the sample is added to a laboratory culture containing healthy cells. When examined under a microscope after several days, the cells show changes that indicate growth of the herpes virus. A major disadvantage of viral culture is that the specimen must be collected from a lesion or sore; when the lesion begins to heal, the test becomes unreliable.
Blood tests have become more popular because they can detect evidence of infection even when sores are not present. These tests can be done on a small amount of blood taken from the arm or finger and, in some settings, results may be available immediately. Because they detect antibody (made by the body in response to the infection) they may not be positive until several weeks after exposure. As opposed to culture tests, blood tests for HSV can be type-specific, meaning that they test for HSV-1 and HSV-2 specifically. Because most HSV-2 is genital, a positive blood test for HSV-2 usually indicates genital herpes. Because so many people in the United States have cold sores due to HSV-1, it is not routinely done. However, because genital herpes may be caused by HSV-1, a negative test for HSV-2 does not rule out genital herpes infection due to HSV-1. Interpretation of test results should be done by a clinician. A major advantage of the HSV-2-specific test is that it can be done when no sore is present. It may, therefore, detect infection in people who have not had recognized symptoms.
Counseling at the time of diagnosis and ongoing support is important for everyone with genital herpes. Such support may be especially important for those who are diagnosed but have no symptoms. Although treatment and counseling are similar for genital herpes, whether caused by HSV-1 or HSV-2, knowing the type of HSV may be helpful for the health care professional. For example, genital herpes caused by HSV-1 usually presents with milder symptoms and less frequent outbreaks.
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Author: Editorial Staff of the National Women's Health Resource Center