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HSV-1 Genital Question for Dr. Handsfield

Dear Dr. Handsfield,
       I have recently been diagnosed with genital HSV-1 and with my first outbreak occurring a month ago. I was and still am devastated by my diagnosis. I am grateful it is not HSV-2 but this is still new and scary to me. I got the virus because the person I am with performed oral sex on me even though he knew a cold sore was forming. Unfortunately, he did not understand that cold sores are herpes. My first outbreak consisted of two veryyy small bumps on my labia right above my clitoris. I did have other physical side effects: flu-like, itching, distinct lower back pain and vaginal discharge. I now take Valtrex, 500mg once per day. Post-diagnosis I have a few questions moving forward:

1) I recently had sex for the first time since my outbreak and, to my extreme disappointment, two days later I started experiencing itching, vaginal discharge and a slight tingling so I immediately upped my Valtrex dosage. No bumps ever formed but I still have itching and a rather foul-smelling brownish discharge. Does this sound like a recurrent outbreak?
2) Would the sex have triggered this outbreak? I read that friction may trigger outbreaks. If so, considering that the location of the virus is undesirably around my clitoris, am I more at-risk for sex to trigger outbreaks?
3) I had a brownish vaginal discharge during my first outbreak and again now- is this common to genital herpes?
4) If it is a sign of an outbreak but no sores are present, how should I determine when an outbreak is over if there are no sores to see healed, etc? Does the discharge need to disappear completely?
5)     Since the person I am with now is also infected with HSV-1 do we need to use condoms every time? Obviously, I would be smart to never have sex during an outbreak but during other times is the risk extremely low since he already has the virus?

Thank you very much for you time. I am looking for any hopeful advice you might have.
10 Responses
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239123 tn?1267647614
MEDICAL PROFESSIONAL
1) If genital to oral HSV-1 transmission ever occurs, it is very rare.  In theory it is possible, but your potential partner(s) are not at significant risk.  Anyway, half of all adults in the US already have HSV-1; all of them are immune to catching it again (which we also discussed above).

2) "Always" is too strong.  Generally the first outbreak is the worst and most recurrent ones are milder, or at least no worse.  If you have another episode, it may not be in the same spot as your original one --- but all outbreaks after that likely will be in more or less the same place, give or take an inch or so.

You are way overthinking all this.  Please read my replies above.  As we discused, with genital HSV-1, you may have no further outbreaks at all -- and mostly likely will have one or two and then no more.  Don't spend a lot of energy worrying about exactly what it will be like or exactly where it might occur.  And please re-read and study my comments above about potential transmission to future partners, which should be reassuring.

That's all for this thread.  Take care.  


Helpful - 0
300980 tn?1194929400
MEDICAL PROFESSIONAL
I'm moving this question over as a follow-up.  I have informed Floridagal200 that I was doing this and that she should not have startred a new thread.  EWH

Dear Dr. H,
    I'm trying to get a complete grip on my HSV-1 diagnosis and have a couple more questions (I was diagnosed with HSV-1 by a culture). I feel that your extensive experience with this disease can give me a better feel for "how likely" things are to occur based on what you've seen.

1) Should I refrain from receiving oral sex from future partners who do not have type 1? I understand I pose NO threat by giving oral sex as I do not have oral herpes but since I carry HSV-1 and the site of preference for this virus is the mouth, does this make it easier for me to transmit it genital to oral?

2) Is it true that the first outbreak is always the worst? If I only experienced two very small bumps with my first outbreak, is that the most I can expect in the future? And will the outbreaks occur in the same place?

Thank you again for your very helpful advice.
Helpful - 0
239123 tn?1267647614
MEDICAL PROFESSIONAL
I was responding to a deleted comment you can't see.  However, I did forget to address my reply to that person, but now have gone back to do that.  Thanks for the heads-up.
Helpful - 0
239123 tn?1267647614
MEDICAL PROFESSIONAL
You may not ask a new question in an existing thread, even if it's on the same STD or topic.  I deleted it.  You'll need to start your own thread.  Click on the Post a Question link near the top of the page.
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Avatar universal
Dr. Handsfield, I think you might have misread Florida Gal's last question. I think her concern was whether she could give HSV-1 to a partner who performed oral sex on her (rather than whether she herself was vulnerable to another infection).
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239123 tn?1267647614
MEDICAL PROFESSIONAL
As I already said, people are immune, or at least highly resistant, to new infections with the HSV type they already have.  That means infection anywhere on the body.  You're never going to get another HSV-1 infection.  However, you remain susceptible to HSV-2 if you have sex (oral or genital) with an infected partner.
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Avatar universal
Thank you again for your great responses.  I have one last question, which is a clarification of a previously asked question. I will be sure to use condoms with future partners and understand that I cannot give anyone herpes from oral sex as I do not have oral herpes myself but do you suggest I refrain from receiving oral sex? In your extensive experience, have you seen individuals get oral HSV-1 from someone who have genital HSV-1. Thank you!!
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239123 tn?1267647614
MEDICAL PROFESSIONAL
Thanks for the clarifications.

"I find a lot of my stress from this diagnosis comes from the thought of dealing with this with future partners."  I could use this comment to teach medical students; in fact, maybe I will.  That is exactly what research shows to be the single most frightening thing about genital herpes, the main reason people most fear it most of all STDs except HIV -- even though it's a much less serious or dangerous infection than things like chlamydia, gonorrhea, or syphilis.  But HSV-1 is a much lesser concern than HSV-2.

If you had no oral symptoms during the first infection, you can be quite certain your herpes is limited to genital, not oral.  The virus doesn't travel through the body, so you can assume you cannot transmit the infection by kissing or oral contact with a partner's genitals.  Any risk will come from vaginal or anal intercourse.

And that risk probably will be low.  As discussed in those many other threads,  most patients with gential HSV-1 have infrequent outbreaks or asymptomatic viral shedding.  In my 30+ years in the STD business, I have never seen a case of genital HSV-1 that seemed to result from genital exposure -- only oral.

That said, a few people with genital HSV-1 might be efficient transmitters.  But if you go a few months -- preferably a year -- and have had no confirmed recurrent outbreaks, you can then be pretty certain you will have few or none, and that you are unlikely to transmit the infection.  Being more confident about this is exactly why you should avoid Valtrex for now, so you can have an accurate picture of the potential for recurrence and transmission.
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Avatar universal
Dear Dr. H,
    Thank you very much for your response. A little more on my diagnosis- I got a positive HSV-1 result from a genital culture. I also requested a blood test that included testing for many other STD's which all came back negative.
   It is reassuring to know that sex and friction cannot specifically cause outbreaks and I will take your advice to stop suppressive therapy for the next several months. I was taking it now with the thought that it not only prevents transmissions (which i know now is not an issue with my current partner) but also to prevent the frequency of outbreaks from the start. I just want to do whatever I can to have as few outbreaks as possible. I will also be sure to go straight to my Dr. if I notice any discharge or itching or other symptoms moving forward.
    I have one more question regarding transmission- assuming I do not remain with my current partner, I find a lot of my stress from this diagnosis comes from the thought of dealing with this with future partners. If I use condoms every time with new partners it seems the transmission rate is pretty low, is that true? But what about oral sex? Since I have type-1 which is probably more aggressive in the oral region- should I refrain from oral sex with any new partners in the future? It is this part of the diagnosis that seems like a life-sentence of worry...any further advice would be greatly appreciated. I will read the threads that you recommended- THANK YOU Dr!
Helpful - 0
239123 tn?1267647614
MEDICAL PROFESSIONAL
Welcome to the STD forum.  Sorry to hear of your unfortunate recent infection. But I believe you will very soon get past being "devastated".  In the long run, this should not be a very important issue in your life and loves.  In case you're not aware, genital herpes due to HSV-1 has been discussed hundreds of times on this forum.  Use the search window and enter "genital HSV-1".  Most of what you read should be quite reassuring.  (Your thankfulness it isn't HSV-2 suggests you already know some of this.)

It would be useful to know more about the diagnosis.  Did you have a positive test for the virus from a genital lesion (i.e. culture or PCR)?  Or just blood testing?

Finally, before getting to the specific questions, I suggest you stop taking Valtrex.  Most people with genital HSV-1 have few recurrences and little asymptomatic shedding of the virus, low risk of transmission to partners, and no need for ongoing treatment.  Further, taking the drug will prevent you from knowing the natural course.  For all persons with new genital herpes, I advise no suppressive treatment (i.e. treat only symptomatic outbreaks) for the first several months, so that the patient and her provider can have an idea of what sort of outbreak frequency to expect.  Over 40% of those with genital HSV-1 have no recurrent outbreaks at all.

To your specific questions:

1,2) Neither sex nor friction triggers outbreaks.  Probably they can result in earlier onset of symptoms than otherwise would occur, i.e. if an outbreak was on the verge of starting.  But an outbreak is unlikely this soon or when taking Valtrex; and anyway, higher doses of Valtrex are not likely to be any more effective than the dose you were taking.  Itching and discharge suggest yeast is possible.  You should not make assumptions; see your health care provider promptly for proper assessment.

3) The first episode of herpes often includes infection of the cervix, which can cause abnormal discharge -- sometimes bloody or brown.  Recurrent herpes usually doesn't cause cervicitis, although it is possible.  Recurrence at this time makes me concerned about the possibility of other STDs in addition to herpes -- another reason you should be professionally evaluated.

4) The way to know whether subtle symptoms are due to outbreaks is to be examined by a knowledgeable provider for at least a couple of episodes, often with testing for the virus.  As mentioned above, this is why it usually is best to not take suppressive antiherpes drugs right from the start.

5) Couples do not "ping pong" their shared HSV infections back and forth.  Once infected with HSV of either type, people are immune to new infections with the same type.  Your partner cannot re-catch HSV-1 from you, and you cannot transmit it back to him.  (This is another reason you do not need Valtrex at this time.  There is no need for treatment to prevent transmission if you aren't having sex with new, susceptible partners.)

I'll be happy to give a bit more advice if you want to provide the details of your diagnosis.  In the meantime, please read some of the many other threads that discuss all these issues.

Regards--  HHH, MD
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