STDs Expert Forum
Genital HSV 1
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The STD Forum is intended only for questions and support pertaining to sexually transmitted diseases other than HIV/AIDS, including chlamydia, gonorrhea, syphilis, human papillomavirus, genital warts, trichomonas, other vaginal infections, nongonoccal urethritis (NGU), cervicitis, molluscum contagiosum, chancroid, and pelvic inflammatory disease (PID). All questions will be answered by H. Hunter Handsfield, M.D. or Edward W Hook, MD.

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Genital HSV 1

Dear Doctor,
I would greatly appreciate any advice on the following. I am positive by serology for HSV1. I am trying to determine if  have an oral or genital infection, since the last time I was the recipient of oral sex was about 8 years ago. I have never had any oral outbreaks as a child or adult. Many years ago, I did experience intense vaginal itching lasting more than 5 days, but no lesions/blisters/ulcers developed. So I would also say that I have not had genital outbreaks either.  
1. Does genital HSV 1 usually present with obvious symptoms/outbreaks?
2. Could I have been concurrently/simultaneously infected in both the oral and genital area by an asymptomatic shedder of oral HSV 1, and never had any obvious initial symptoms in either place?
3. Could I have the virus genitally and it have remained dormant over this 8 year period without any obvious symptoms (similar to what can happen with HSV 2)?
4.  If I have it genitally, though not having any symptoms, could I still be asymptomatically shedding? Is there a link between number of outbreaks and asymptomatic shedding? Is there any research about the course of genital HSV 1 asymptomatic shedding over many years?
5.  If I had it genitally and were to become pregnant in the future, could this result in a reactivation and/or shedding of the virus (since pregnancy suppresses the immune response)?So could neonatal herpes occur in this scenario?
6.  If I was able to find viral shedding (by PCR)in my mouth, would this be conclusive proof that I ONLY had it in my mouth given my history?

Thank you very much
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The large majority of people with asymptomatic HSV-1 infection diagnosed by blood test originally acquired the infection orally.  In the absence of symptoms it is impossible to know for sure, but it really doesn't matter in terms of sexual transmission; asymptomatic shedding of HSV-1 is rare with genital infection, and genital-genital transmission of HSV-1 is even rarer.  To answer your specific questions:

1) First episodes can be symptomatic or asymptomatic.

2) Yes, but it is a statistical improbability.  In 30 years I have never seen a case of simultaneous initial genital and oral herpes due to HSV-1.

3) That happens extremely rarely, if ever.  For practical purposes the answer is no.

4) Very unlikely; see above.

5) Neonatal herpes can occur due to HSV-1, but neonatal herpes occurs primarily when a pregnant woman first acquires genital infection late in pregnancy.  Women with chronic HSV infections, either HSV-1 or -2, rarely transmit to their babies.  If you don't have an overt, visible outbreak when you go into labor, your baby will not be at risk.

6) No, you would have to have genital testing to evaluate genital shedding.  But it would be a statistical rarity to have both, so you might find it reassuring.  But why are you planning it?  I am skeptical that oral testing by PCR or any other method will tell you anything useful.  Where HSV PCR testing is available, it probably will cost you $50-100.  If you had an oral infection at one time but are not having oral symptoms, the chance you will have shedding on any particular day is well under 1 in 100.  So even if you were to have 10 PCRs over several weeks--costing you at least several hundred dollars--it would not tell you whether or not you had oral HSV-1 infection.  And if you happen to have a positive result, it won't tell you anything you don't already know:  many (most?) people with a positive blood test for HSV-1 sometimes have oral shedding.

Bottom line:  50%-70% of people have positive blood tests for HSV-1.  You're normal and have no particular risks for either sexual or perinatal transmission.  I suggest you drop it.

Best wishes--  HHH, MD
8 Comments
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Avatar_n_tn
Thank you for your reply. I just want to get further clarity on a few points.

1.  If I understand correctly, the initial genital HSV1 may be asymptomatic. Do obvious outbreaks then occur sometime in the future as a matter of course?

2.  Do you see cases where the person is positive by serology for HSV 1, and subsequently have genital outbreaks caused by HSV 1?

3. Having never had an outbreak, can I assume I don't have genital HSV 1? Or do I need to inform a future partner of the possibility that I may have it?

Thank you very much
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239123_tn?1267651214
Clearly some initial genital HSV-1 infections are asymptomatic, but whether those infections ever break out with symptomatic recurrences in the future has never been studied.  If it happens, it is very rare.  When people get genital HSV-1 with symptoms, 40% have zero outbreaks any time in the future; another 50% have 1 or 2 recurrences in the next 1-2 years, then none.  No more than 10% have ongoing outbreaks, and asymptomatic shedding of HSV-1 from the genitals is very rare.  Your risks for all this, having never had genital herpes symptoms, are much lower.  Most people who have positive HSV-1 blood tests acquired their infections orally, usually in childhood.  The exact proportion acquired orally vs genitally isn't known.

Thus, to answer your remaining questions:

1) Very rarely, if ever, following asymptomatic infection.

2) Same answer.

3) Yes, you can assume that with some confidence.  But it doesn't matter anyway; even if you acquired your infection genitally, you aren't going to transmit it to a future sex partner or your future children.  Corollary:  People who are HSV-1-positive have no ethical obligation to inform sex partners of possible genital herpes.

As implied in my first reply, you seem to be obsessing about this far more than warranted.  Put it out of your mind; most people are HSV-1-positive, like you; it is normal.

Good luck--  HHH, MD
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Avatar_n_tn
I want to thank you for your time in responding to my posts.  I know I may come across as a bit obsessed, but I have been particularly frightened since realizing how insidious herpes is.
Add to that a great deal of confusion in trying to sort out a lot of contradictory information on the internet.  So because of this, I am trying to at last get some solid information on things that I was unsure of for such a long time.
Along this vein, I want to get a better idea of symptoms of genital infection.

1. I have read that HSV 2 symptoms may be mild or atypical e.g. a paper thin cut in the vulva, bumps in the pubic area etc.  
Are genital HSV 1 symptoms like this, or are they more of the classic blister/ulcer sort?

I ask because I have had recurrences in the past of large bumps/boils (not blisters) in my pubic hair, which produced pus then blood when squeezed hard. Squeezing out the pus only reduced the size slightly if at all.  They remained there for between a week to 2 weeks, or more sometimes. No ulceration,scab formation or anything, just stayed there and eventually went away. At the time I dismissed this as garden variety hair bumps (folliculitis), but after reading up about herpes I now question whether these were actual herpes outbreaks that I didn't recognize.

2.  Do you have any figures on the actual rate of asymptomatic shedding of genital HSV 1? Is this figure by viral culture or PCR? (I read somewhere that it was 3%).  Does it represent people with recurrences or people with no recurrences?

Thank you
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239123_tn?1267651214
Genital HSV-1 hasn't been as well studied as genital HSV-2.  It probably can be just as subtle or atypical, but it's also much less common.  There is little or no asymptomatic shedding of genital HSV-1 (if you want to look further, search for studies by my colleage Dr. Anna Wald, University of Washington).  The lesions you describe clearly aren't herpes; almost certainly folliculitis.

HHH, MD
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Avatar_n_tn
Ok so I'm new to this stuff so bear with me.  I have a number of questions.  Eight months ago my friend got genital hsv-1 through unprotected genital sex with his gf of six months.  Apparently she hadn't had an outbreak since her first one which was about two years prior.  Her bf had a cold sore on his mouth, at least that's what she said.  My friend is 22 years old he's never had a cold sore as a child or in his life and never ever had chicken pox.  So when he became infected it went away in less than 10 days. However, in about a month he developed chicken pox at 22 years old.  I want to know if there is any linkage between getting the genital hsv 1 and getting the chicken pox because he had never had either in his life.  Ok, now for the second ques:  my friend knows all about the asymptomatic shedding...he's read basically every site on the internet and he knows that it is more common in hsv-2 than hsv-1. I want to know if lets say when he first had the outbreak, the sores were just around the head of the penis and like one on the middle part...when this guy has protected sex, can he shed the virus asymptomatically at the very bottom of the penis if the condom is not fully covering that part.  In other words, the areas where the breakout first happend are covered but there is a little bit of skin that is not covered on the bottom where the sores never occured.  Also, what would you say is the asymptomatic shedding rate of genital hsv-1?  Is it really true that my friend has a chance of never getting an outbreak again?  Or after 1 -2 years then never again?  Thanks for the help.
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Avatar_n_tn
I believe I have a cold sore on my upper lip.  Yesterday I performed oral sex on my boyfriend.  I was caught in the moment and I only put his penis in my mouth once and pulled away.  I would like to know what the probability is that he will contract genital herpes. (genital HSV-1) If he did contract it, when will his symptoms occur?  I would like some statistics please.
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Avatar_n_tn
awl,

im no doctor but i would just like to say that i am a female who 2 months ago contracted Type 1 from receiving oral sex from an infected male. he had a cut on his lip and swore all it was was chapped lips that cracked in the cold weather. believable. and weve been dating for 8 months so i had never experienced any discomfort in the past with him so i didnt think anything of it...sure enough it was type 1. i would just like to say that herpes is a very common virus and its more of a mental disorder than anything else. people 'scheve' this virus b/c it pertains to kissing & sexually relations. its a social stigma & seems to many to be 'taboo' and 'dirty'. in all reality its a viral skin infection that may or may not return. and in all actuality, is less contagious than the common cold. its just the 'bad rep' "herpes" carries with it's name. i would get tested the both of you just for precautionary reasons. but if it does come back positive for the both of you, dont panic, approx. 60 MILLION americans (1 in 4 women & 1 in 5 men) have herpes of some sort. you'll blend right in. ;)

take care.
-girl05
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