Introduction

Genital herpes is one of the most common sexually transmitted infections (STIs), also referred to as sexually transmitted diseases (STDs). Herpes virus infections actually don’t often lead to a disease, though: Up to 90 out of 100 people who are infected will have either no symptoms or hardly noticeable symptoms.

If symptoms arise, they can be painful and distressing. A painful rash develops in the genital area and people often also feel sick and feverish. The symptoms usually go away by themselves after 1 to 2 weeks. But there are treatments that can relieve the symptoms and shorten the outbreaks. After infection, the herpes viruses stay in your body for the rest of your life. If you’ve had herpes once, it usually keeps coming back. The good news is that herpes outbreaks become milder and less frequent over time.

But being diagnosed with genital herpes is still quite distressing for many people and brings up a number of questions: Where was I infected? How will I tell my partner – and who else should I even tell? Will I transmit the infection to my child if I’m pregnant?

At a glance

• Genital herpes can lead to a painful rash in the genital area.
• It is caused by herpes viruses that are transmitted during sex.
• Many people never notice the infection, while the symptoms keep returning in other people.
• Medications can relieve the symptoms.
• A number of things can be done to avoid infection in the first place.

Symptoms

In genital herpes, the skin in the genital area can become inflamed and painful, and small blisters may develop. The blisters occur in small clusters, and can tear open and weep. They often form scabs when they heal. The skin may also itch or burn. Women often have pain when urinating (peeing).

Where genital herpes occurs and what it looks like

The symptoms typically affect the penis, foreskin and scrotum in men, and the labia, vagina and cervix in women. The blisters may also occur in the anal region, on the buttocks or on the inner thighs. Some people notice that an outbreak is starting through a tingling sensation in their genitals or pain in their bottom, hips or legs.

The very first outbreak of genital herpes often causes more severe symptoms than later outbreaks. In addition to the typical skin problems, these include fever, headache, general exhaustion and muscle pain, and often swollen lymph nodes in the groin area. Further outbreaks are usually milder.

If you already have a different herpes virus in your body, you may already have a certain amount of immunity to herpes viruses. Then the symptoms may be milder during the first outbreak than in people who haven’t yet come into contact with the virus. If – on the other hand – your immune system is weakened, the symptoms could be more severe and last longer.

Causes

Genital herpes is caused by herpes simplex viruses. There are two different types:

• Herpes simplex virus type 1 (HSV-1)
• Herpes simplex virus type 2 (HSV-2)

Genital herpes is mainly caused by HSV-2. Cold sores on lips are also caused by herpes viruses, but usually by HSV-1. But there are exceptions. For example, if somebody has cold sores on their lips and touches another person's genital area with their mouth during oral sex, they can pass on the virus. That person can then develop genital herpes from HSV-1 viruses.

Herpes viruses that have settled in nerve cell clusters (ganglia) at the lower end of the spine can cause genital herpes. If these viruses multiply in the nerve cell clusters and move along the nerves to the outer layers of the skin, they can lead to genital herpes. The blisters contain a large amount of herpes viruses, which can be passed on to other people through direct skin contact during sex. They can also be transmitted through shared sex toys. But they’re highly unlikely to be transmitted through things like towels, bedsheets or toilet seats.

Pregnant women can transmit herpes viruses to their child during birth, but that is rare.

Risk factors

Genital herpes is transmitted during sex. But the risk isn't the same for all sexually active people. It is generally more likely that you will have sex with somebody who is infectious if you have frequently changing sexual partners.

Herpes infections often can't be seen. Because people can be infectious without having noticeable symptoms, they can unknowingly pass the herpes viruses on.

It is thought that women are generally more vulnerable to infection than men. The risk also increases if you don't use condoms.

Not everyone who is infected by the herpes virus also goes on to develop genital herpes. No one really knows why some people do and some don’t.

There is hardly any research on possible triggers of recurring outbreaks of genital herpes. Some evidence suggests that constant emotional stress could make them more likely. Other possible triggers are thought to include sunlight, common colds, physical exertion, skin injuries, menstruation, and wearing clothes that are tight or made from rough fabrics.

Prevalence

Genital herpes is one of the most common sexually transmitted infections. It is estimated that 10 to 15 out of 100 people in Germany have the viruses in their body. About 10 to 30% of those people develop genital herpes. This is somewhat more common in women than in men.

Outlook

People may have their first outbreak of genital herpes months or even years after being infected by the virus. The first time you have genital herpes, it takes an average of 20 days for it to go away if left untreated. Later episodes are milder, though, and generally go away within 10 days. People who have had genital herpes once will usually keep getting it.

The type of virus will determine how often it recurs:

• HSV-1 causes an average of one further outbreak within one year in about 20 to 50% of people who have the virus.
• HSV-2 causes at least one further outbreak – but an average of four further outbreaks – within one year in about 70 to 90% of people who have the virus.

The outbreaks usually become less frequent and less severe over time.

Effects

Genital herpes can lead to more severe symptoms and complications, especially the first time you have it. This risk is also higher for people who have a weakened immune system.

The possible complications include vaginal yeast infections (“thrush”), bladder problems with trouble urinating, and – in rare cases – meningitis. In very rare cases, a herpes infection may lead to larger rashes elsewhere on the body or it may affect the eyes.

It is very rare for newborn babies to become infected, but if they do there is a risk of the herpes infection spreading across their whole body, which can be life-threatening.

Frequently changing sexual partners and not using condoms also increase the risk of other sexually transmitted infections. People who have genital herpes are at greater risk of being infected with HIV because the HI viruses can enter the body more easily through open sores.

Diagnosis

In order to diagnose genital herpes, the doctor takes a sample of cells from the affected area of skin. This sample is tested for herpes viruses in a laboratory. Depending on the situation, the type of virus can sometimes be determined as well.

It’s often not possible to get a definitive diagnosis of herpes based solely on the symptoms and appearance of the skin. The typical symptoms don’t always occur. What’s more, genital herpes may occur at the same time as other skin conditions or sexually transmitted infections. Herpes symptoms are sometimes similar to those caused by yeast infections or chlamydia, or by other skin conditions such as psoriasis.

It is more difficult to diagnose a herpes virus infection in people who don't show any symptoms. Then a test for herpes antibodies can be used to check whether there are antibodies in the bloodstream. If HSV-2 antibodies are found, then the person could develop genital herpes. If there are HSV-1 antibodies, it's difficult to predict what part of the body might be affected if symptoms occur.

The tests usually can't offer any information about when you first became infected. But if someone has genital herpes for the first time and no antibodies are found, then they were probably infected recently.

Prevention

Because a lot of people have the herpes virus in their body, anyone who is sexually active can be infected with it. But the risk of infection can be reduced significantly.

People who have genital herpes are advised to avoid sex as soon as they notice signs that an outbreak is starting. This is because the risk of transmitting the virus is greatest during an outbreak.

But the virus can also be transmitted by people who don’t have any symptoms. Condoms can reduce the risk of infection during symptom-free periods. They also protect against other sexually transmitted diseases. That is also true of condoms for women (femidoms) and dental dams.

If you have genital herpes, it’s a good idea to talk about it with your partner. Particularly if you are in a long-term relationship or have regular sexual partners, you can discuss whether a blood test for antibodies might be a good idea. This allows you to find out who is infected, what type of herpes viruses you have in your bodies, and whether there's a risk of infection. A partner who has HSV-1 could still become infected with HSV-2, for example.

People who have genital herpes can somewhat lower the risk of infecting others by taking antiviral medication. These medications include acyclovir, famciclovir or valacyclovir. They must be taken daily for a long period of time, though. Using them as a cream or ointment does not provide any protection. If you already use condoms for contraception, it's not clear whether taking antiviral medications can lower the risk of infection even more.

Pregnant women who have an outbreak of genital herpes shortly before birth are a special case. A Cesarean section is often recommended because the child could get infected during natural birth and become seriously ill.

Treatment

The very first outbreak of genital herpes can cause more severe symptoms than later outbreaks, and sometimes complications as well. So it’s normal to take antiviral medications containing the active ingredients acyclovir, famciclovir or valacyclovir the first time you have herpes. These tablets can reduce the severity of symptoms and shorten the length of the outbreak by a few days. Creams or ointments containing antiviral drugs aren’t effective against genital herpes.

In later outbreaks, the symptoms are typically less severe. Treatment is then not absolutely necessary. If you take antiviral medication for later outbreaks, you won’t need to use it for as long. It’s important to start the treatment within the first 24 hours – ideally, as soon as you notice the first signs of an outbreak. This is easier to do if you always have tablets at home or take them with you when you travel.

Preventive treatment with medication may be considered if someone has severe or very frequent herpes outbreaks. Then the medication is taken over a longer time period – during symptom-free phases, too. This can greatly lower the likelihood of outbreaks.

If genital herpes is causing severe pain, painkillers can help. Many women who have pain when peeing find that sitting in warm, shallow water (a sitz bath) can help.

There has hardly been any research on other treatments like laser therapy or applying warmth to the area, so it isn’t clear whether they are effective.

Everyday life

Knowing that you have genital herpes can be very distressing. Many people find it hard to talk about it with their partner if the first outbreak occurs during a long-term relationship. It can be difficult to talk about the disease and also have to discuss subjects like sex before or outside of the relationship. Others may wonder whether they were infected by their partner.

Speaking openly about the disease and finding information together can help. That can overcome mistrust because it's often not really possible to tell who you were infected by, or when. The virus can already have been in your body for months or years.

It can also take a lot of effort to tell purely sexual contacts or a new partner that you carry herpes viruses. Some people worry that they might then be rejected.

Further information

When people are ill or need medical advice, they usually go to see their family doctor first. In our "Health care in Germany" topic you can read about how to find the right doctor – and our list of questions can help you to prepare for your appointment.

The Centers for Disease Control and Prevention (CDC) also provide information about sexually transmitted infections and how to protect against them here.

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