Genital Herpes in Women: Clinical Picture, Diagnosis, Treatment
Genital herpes is a chronic viral infection that lasts for life. Two types of herpes simplex virus (HPV) can cause genital herpes: HPV-1 and HPV-2. Most cases of recurrent genital herpes are caused by HPV-2, with no detectable clinical manifestations, hence, in this case, genital herpes infection is transmitted by individuals who are not suspected of having the infection.
Clinical picture
Herpetic vaginitis (vaginal herpes) during gynecologic examination in mirrors is manifested by swelling of the vaginal mucosa, painful vesicular rash or ulcerative lesions. The lesion process is usually self-limited.
When interviewed, the patient may mention complaints suggestive of neurologic symptoms. Non-specific symptoms may also be present: fever and enlarged lymph nodes, weakness.
The course of the disease can be completely asymptomatic.
Recurrent and subclinical courses are more common with infection caused by HPV-2. Vaginitis associated with HPV-2 increases the risk of HIV infection by two to three times, so all persons with genital herpes should be tested for HIV.
Diagnosis of genital herpes
The difficulty in diagnosis is that self-limited, recurrent, painful, and vesicular or ulcerative lesions classically associated with HPV are absent in many infected individuals at the time of clinical evaluation.
If genital lesions are present, the clinical diagnosis of genital herpes should be confirmed by virologic testing for the specific type of HPV.
Serologic tests for a specific type of HPV can be used to help diagnose HPV in the absence of genital lesions.
Cytologic detection of cellular changes associated with HPV infection is a nonsensitive and nonspecific method for the diagnosis of genital lesions.
A direct immunofluorescence assay using fluorescein-labeled monoclonal antibodies is also available for detection of HPV antigen from specimens, but it lacks sensitivity and is not recommended.
Genital herpes treatment
First clinical episode of herpetic vaginitis
All patients with a first episode of genital herpes should receive antiviral therapy.The standard course of treatment is 5-7 days. Treatment can be prolonged If the therapeutic effect was not achieved, up to 10 days of therapy.
Recurrent herpetic vaginitis
Antiviral therapy may be instituted either in a suppressive drug regimen to reduce the frequency of recurrence or episodically to reduce or shorten the duration of lesions. Recurrences occur less frequently after the first episode of genital herpes HPV-1 compared with HPV-2. There are no data on the efficacy of suppressive therapy to prevent transmission of HPV-1.
Genital herpes during pregnancy
All pregnant women should be interviewed for genital herpes or genital symptoms associated with HPV infection during pregnancy. Be sure to clarify the presence of prodromal symptoms (e.g., pain or burning at the site before vesicles appear). All women should be carefully screened for herpetic rashes to allow for vaginal delivery. Women with recurrent genital herpes should be delivered by cesarean section to reduce the risk of neonatal HPV infection, but the risk of transmission of HPV to the newborn is not eliminated. Treatment is recommended starting at 36 weeks of gestation. There are no data to support the use of antiviral therapy in HPV-seropositive asymptomatic women without a history of genital herpes.
Recommended treatment regimens for genital herpes
| Clinical situation | Recommended therapy regimens | Course duration | Notes |
|---|---|---|---|
| The first clinical episode | – Acyclovir 400 mg×3 p/d – Acyclovir 200 mg×5 p/d – Valacyclovir 1 g×2 p/d – Famciclovir 250 mg×3 p/d | 7-10 days | Start within the first 72 hours. If severe, extend to 10 days. |
| Episodic therapy for relapses | – Acyclovir 800 mg×2 p/d – Valacyclovir 500 mg×2 p/d – Famciclovir 1 g×2 p/d (1 day) – Famciclovir 500 mg, then 250 mg×2 p/d | 3-5 days | Start in the prodromal period or in the first 24 hours of rashes. |
| Suppressive therapy (frequent recurrences ≥6/year) | – Acyclovir 400 mg×2 p/d – Valacyclovir 500 mg×1 p/d – Valacyclovir 1 g×1 p/d – Famciclovir 250 mg×2 p/d | Daily, long term | Reduces recurrences by 70-80%. For ≥10 recurrences/year – valacyclovir 500 mg/d may be less effective. |
| Pregnancy (from week 36) | – Acyclovir 400 mg×3 p/day – Valacyclovir 500 mg×2 p/day | Before I gave birth. | The goal is to reduce the risk of transmitting HPV to the newborn. Cesarean section for active rashes. |
| HPV-1 (rare recurrences) | Episodic therapy (similar to HPV-2) | 3-5 days | Suppressive therapy is not recommended because of the low recurrence rate. |
Prevention of genital herpes
The efficacy of male latex condoms has been established, which, when used consistently and correctly, can reduce but not eliminate the risk of genital herpes transmission. For patients with serologic evidence of HPV-2 (with combined testing if necessary) without symptomatic manifestations, neither episodic nor suppressive therapy is indicated for relapse prevention.
FAQ
1. Can genital herpes be completely cured?
2. How is genital herpes transmitted?
3. What symptoms characterize the first episode of herpes?
4. Can genital herpes occur without symptoms?
5. How is the diagnosis of genital herpes confirmed?
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