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confirmed oral hsv2, do I have genital too?
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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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confirmed oral hsv2, do I have genital too?

Hi,

3 weeks ago, I was diagnosed with oral hsv2 by a swab test.  4 days after an encounter with a guy I had never been with, I got sores all over my mouth and throat.  My doctor said it looked like herpes and he took a swab which came back positive for hsv2.  The encounter consisted of 10 minutes of me giving him oral sex and then 10 minutes of protected vaginal sex.  I have not yet had any genital symptoms at all.  The guy has now admitted to having hsv2, and my only other partner in the last 4 years tested negative yesterday.  So I know I got it from this encounter.  

My doctor said that since I didn't get genital symptoms and I did get severe oral symptoms, I only have an oral infection and I don't have to worry about transmitting the virus genitally.  I was relieved until I read on this forum that pretty much everybody who has oral hsv2 will have genital hsv2 as well!

1. If I only was infected orally, will the virus somehow travel to my genitals?  I don't get how else everybody with oral hsv2 also has genital hsv2?

2. Is my doctor's theory correct that I would not have had oral symptoms without genital symptoms if I was also infected genitally?  He said that the chances of getting infected in 1 encounter are really small, so the chances of getting infected in 2 places at once is basically 0.  Is he right?

3. I read about a guy who had hsv2 outbreaks on his chest, and he was told anybody with a positive hsv2 blood test always has it genitally.  He said he got infected through a cut on his chest and never had genital symptoms.  But they told him he should assume he has it genitally even without genital symptoms.  Is it possible to have hsv2 only in a non-genital location?

4. I asked my doctor if there was any way to confirm if I have genital hsv2.  He said no, b/c a blood test will come back positive for hsv2 regardless.  He said just watch to see if anything pops up in the genitals.  If not, I am probably not infected there.  Is that all I can do?
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239123_tn?1267651214
Welcome to the STD forum.  Sorry to hear about your bad luck.  Oral HSV-2 isn't common, but it does happen from time to time -- and swab tests for the virus are very reliable, so for sure you have it.  You ask some very good questions.  I'll try to help sort it out for you.

1) HSV-2 doesn't travel through the body.  Therefore, your doctor is exactly right:  your infection probably is limited to the oral area.  If so, that is where it will stay.  Most people with new oral HSV-2 also have it genitally because both areas are exposed, i.e. with both unprotected genital and oral exposure during the same sexual episode.  In this case, the condom did what it was supposed to do:  it apparently protected you from genital infection.  The virus takes hold only where there is direct contact with a partner's infection.  It is possible you were infected genitally as well, without symptoms, but unlikely.  With the obvious and undoubtedly painful oral symptoms you experienced, the same usually would happen if you had been infected in the genital area.  Hooray for condoms!

2) I wonder if you misunderstood your doctor.  All else you say suggests he is very knowledgeable about herpes.  However, as just discussed, it's not rare for people to simultaneously acquire oral and genital HSV-2.

3) The vast majority of HSV-2 infections are genital, probably well over 99%. When there is oral involvement, it's usually in addition to genital.  Therefore, if the blood test is used to determine how many people in a community have HSV-2 (a pretty common kind of research), it can be safely assumed that just about all persons with positive results have genital herpes.  In truth, a very small number of such people may not have genital infection.   Some, like you, may have only oral.  Others might have been exposed as babies, during birth if mom had active genital herpes at the time.  But these cases are rare.

In other words, from here on out you're one of those relatively rare persons who has purely non-genital HSV-2.  I'm not so sure about the guy with herpes on his chest, however.  Without a detailed clinical and sexual history, I won't speculate on whether he might also have an asymptomatic genital infection.

4) Your doctor also is correct on this point.  If you ever develop genital blisters/sores, that will be the best evidence you were infected genitally.  Or if you have an unexplained itch or soreneess, examine yourself closely, maybe even with a magnifying glass.  If something shows up, return to your doc ASAP, preferably the same day, for testing of the lesion.  But my bet is that this won't happen.  You may well have oral recurrences, but most likely not genital ones.

Having said all that, your situation is unusual enough that I'm going to discuss it with some first class herpes experts, researchers who know more than I do.  I'll get their perspective on the likelihood you have genital as well as oral infection.  I'll let you know what they say.

I hope this helps.  Best wishes--  HHH, MD
9 Comments
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Avatar_n_tn
Thanks for the information, Doctor.  It is very helpful.  I have been scouring the internet looking for information about similar cases without any luck, that's why I mentioned the guy with the chest herpes.  I very much look forward to hearing from your colleagues as well.

Just 2 clarifying points if I could:

1.  The idea of looking with a magnifying glass sounds good, but what exactly would microscopic herpes look like?  Discoloration?  Redness?  Tiny blisters?

2.  With regard to what my doctor said about the odds of contemporaneous oral and genital transmission, he noted that I was probably particularly susceptible to oral infection at the time of exposure because I had a new canker sore at the time.  (And for sure it was a canker sore.  I've gotten them since I was a kid, and I know all about the difference between canker and cold sores.  I don't have hsv1).  He said that just because I was susceptible orally does not mean I was also susceptible genitally.  Undoubtedly, the guy was shedding the virus, but he said that does not automatically mean I would get infected everywhere I was in contact with the virus.  I guess he didn't say "almost 0," I may have optimistically added that.  

Thanks again!
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239123_tn?1267651214
You're welcom. Glad to help.

The magnifying glass is icing on the cake; a mirror is more important.  If you develop a sore or itchy spot, take a look at it.  If herpes, you should at least see an obvious red bump, a day later a blister, and a day or two after than it would become an open sore or become scabbed.  Don't go looking at all if there are no symptoms.

I suppose a preexisting canker sore might increase the risk of HSV if exposed, but it certainly isn't necessary and I doubt it made any real difference.  The far greater likelihood for infection at one site but not the other is the condom.  Is there some reason you and your doctor are skeptical about that explanation?  To me it is far and away the obvious one.

That you did not have prior HSV-1 could be predicted from your clinical story.  Your symptoms are classical for a true primary infection, i.e. the first HSV infection in someone not previously infected with either type.
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239123_tn?1267651214
By the way, you're unlikely to have frequent recurrent oral herpes.  HSV-2 doesn't reactivate often in the oral area; and asymptomatic oral shedding is uncommon too, so most likely you will never infect anyone by either kissing or oral sex.  Not zero risk, but quite low.

Finally, can you say more about your partner and his history of herpes?  And not telling you about it?  I hope he has learned a lesson that he will use in protecting future partners.
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Avatar_n_tn
I have been examining myself nonstop with a mirror, although the magnifying glass is a new weapon in my arsenal.  Any possible symptoms (in terms of itch or soreness) have been extremely minor if they exist at all.  

No doubt the fact that I was protected was critical if in fact i did not get infected genitally.  I used a female condom so that may have helped too.  I (and my doctor in trying to answer my questions) were just trying to come up with explanations for how I could have been so "lucky" as to only get oral hsv2.  Lots of people use condoms.  
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Avatar_n_tn
My partner is an idiot.  I have no idea what his history is.  First he claimed he didn't have it, then when I pressed him, he claimed he has had some symptoms but didn't know what they were, finally he claimed he just got tested and was surprised to learn he is hsv2 positive.  

Based on what he said, I suspect he is lying and knew all along, but I don't know for sure.  I understand lots of people don't know so maybe he didn't.  I doubt I will ever talk to him again to find out.  
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239123_tn?1267651214
Well, as I said, you weren't "so lucky" to not acquire genital HSV-2.  It was the condom, not luck.  Period.  That's what condoms are for, and they work.  Of course "lots of people use condoms", but lots don't.  Genital herpes occurs mostly in the ones who don't.

Your partner indeed sounds like a jerk.  I hope he will inform future partners.  But you've dont your part and it's now his responsibility.
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Avatar_n_tn
Any word from the first class herpes experts?

Also, I was told on another board that I could do daily pcr swabbing to test for the virus.  Does this suggestion have merit?  
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239123_tn?1267651214
The one I most want to hear from is on vacation; I'll let you know when I get her perspective.  Two others agree exactly with my responses above, including Terri Warren, the herpes forum moderator.

I would recommend against PCR testing.  Negative results are never proof that shedding isn't happening; if someone has, say, 10 negative swabs, it is never possible to know whether the 11th (or 50th) would be positive.  Terri is the country's primary proponent of that method; I didn't ask her about it, but think she would agree on this.  Also PCR is so sensitive that false results can result from unimaginably small contamination.  Since you have oral HSV-2 and would need to handle the swabs, vials, etc in order to collect vaginal specimens, it might be difficult to be certain whether a positive result reflects genital shedding or contamination.  Still, if more than one swab were strongly positive, it would confirm you have genital HSV-2.  But the chances of that are so low that it just doesn't seem worth the time and money -- at least not to me.

You could contact Terri's clinic (Westover Heights Clinic, Portland, OR; website westoverheights.com) and get their opinion.  Or ask for Terri's opinion directly on the herpes forum.  (In either case, ask her or her clinic staff to review this thread to see my concerns about it.)  In any case, I suggest you not proceed down that path until my other colleague gives her opinion on all this.
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A related discussion, Statistics on Oral HSV2 transmission was started.
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