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Genital Herpes: Intimate Conversations

with Terri Warren, RN, ANP

This blog has been retired.

Friday, August 22, 2008

Testing: IgG – Good, IgM – Bad

The good news about herpes testing is that more and more clinicians are learning about blood testing that can identify those who are infected but don’t know it. The bad news is that they are often ordering a poor test called IgM blood antibody testing. The IgM test, with other viruses, comes up early in the infection and goes away when another antibody, called IgG comes up subsequently.

However, with herpes, there are significant issues with the IgM test. It can’t accurately distinguish type 1 from type 2, so a person could be told they have brand new genital herpes when all they have is old cold sore infection. It also can’t accurately distinguish herpes simplex virus from other herpes viruses, like chicken pox. And about a third of people infected with HSV 2 make new IgM with a recurrence, so it really can’t tell old from new infection, which is often why clinicians order the test.

PLEASE, if you’ve been diagnosed with herpes by a blood antibody test, get a copy of your results, and make sure they are IgG results, not IgM results. If you were positive by IgM and not by IgG, and at least 3-4 months have passed since your test, ask for an IgG test. If its negative, then the IgM was wrong.

And when you do this, let your clinician know the IgM is not a reliable test for herpes antibody. If it were me, I wouldn’t pay for that test, period. Be proactive about your herpes status – be certain your diagnosis is correct.

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Posted by: Terri Warren, RN, ANP at 8:00 am

Thursday, August 14, 2008

Who Gave What to Whom?

I very frequently see a patient who has had only one partner for a long time, and they have newly diagnosed genital herpes. Their first question is, “Has my partner been cheating on me?” They often have read somewhere on the internet that symptoms show up within 2-10 days of new infection, and they KNOW they’ve never had these symptoms before so this must be new!

But the reality is, 90% of those with HSV 2 infection don’t know it, so most people completely miss their first infection. Many times, new symptoms aren’t new infection, but infection that’s been there for years and symptoms are just newly recognized, not newly present.

Do you see the difference there? A person could have genital herpes for 40 years and never know it, and then, for some reason, the symptoms become noticeable, and they immediately blame their current partner for infecting them.

So if you have new genital herpes symptoms, there are some ways to sort it all out.

If you have a positive swab test from a lesion for HSV 2, for example, and you have a negative HSV 2 IgG antibody test, then you have new HSV 2 infection – you have virus present on your skin, but not enough time has passed for you to have made antibody.

If you have a positive swab test from a lesion, and a positive HSV 2 antibody test, you’ve been infected sometime in the past. However, if you wait 3 weeks from the first time you notice the sore until you get a blood test, you could have made antibody during the 3 week period, so it could get confusing. But if you have an antibody test right away when you notice the sore, and it is positive, then it is very likely an old infection.

If all you get is an antibody test, make sure it is an IgG test. If it is positive (at greater than 3.5), then you have old infection.

If your partner gets an antibody test, and they are negative for HSV 2 and you are positive for HSV 2 on an IgG antibody test, then you didn’t get it from them.

If your partner gets an antibody test and they are positive for HSV 2 and you are negative for HSV 2, then they didn’t get it from you.

There are many possibilities, and you may need help sorting out the combinations and permutations of antibody and swab testing, but I hope this helps a little.

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Posted by: Terri Warren, RN, ANP at 4:19 pm

Thursday, March 13, 2008

Sex, STDs, Safety and Your Teen

A recent study by the CDC suggests that 1 in 4 teenage girls have a sexually transmitted disease. This may include the genital wart virus, chlamydia, or trichomoniasis, among others. This doesn’t surprise me at all. Sex in teenagers in incredibly common – by age 15, about half of teen girls have had intercourse, and probably more have given or received oral sex. And it often isn’t with committed partners; it may be quite casual or fit into the category “buddies with benefits”, friends having sex without a romantic attachment at all.

But where are the parents in all of this? Are we doing a decent job of talking with our kids about sex? I don’t think so. If you have a teenager, let me ask you this: how often have you talked to your child about giving and receiving oral sex? Its the big thing now, kids have lots of oral sex so they can preserve their virginity and feel like they really haven’t had sex. And anal sex is the same – if you’ve had anal sex, they will tell you, you are still a virgin. Interesting thinking, wouldn’t you agree? I have 16-year-old female patients who have had lots of anal sex so they can still be virgins and 45 year old men who would give their right arm to have anal sex once in their lifetime. Its boggles my mind sometimes.

But teens are vulnerable and desperately need frank and honest information. Yes, abstinence would be my preference too, at least for a while, but this really isn’t our choice. It is their choice, it is their body, and no matter how much we talk and lecture and pray and hope, they will do what they do, and often that’s have sex. They are curious and want pleasure and sometimes drugs and alcohol impair their judgment. Does this sound familiar to you?

How old were you when you first had sex? I made the dubious decision to tell my youngest daughter when that was for me, and at that age, she told me that she first had sex then, too, so it must have been OK. That’s a decision I might revisit with my granddaughters someday! But she and I talked a lot about sex – about the risk of getting herpes from a cold sore and oral sex, about the damage that chlamydia can do to fallopian tubes, what HPV can do to the cervix. We talked about all the behaviors that could put her at risk, and we made the discussion a casual, regular thing we talked about because I knew it was on her mind. Her friends sought me out for birth control and STD testing and free condoms and information. I felt mixed, but mostly incredibly glad that they did, that they trusted me and knew they could count on me for straight answers. These teens are very dear, just beginning to explore their worlds, and they need their parents to be the ones who they can turn to for these discussions.

But the truth is not all parents can do it, so it would be good to have a back up person in mind to talk the talk. Teens who are having sex need STD screens, and they need reminders about condom use and they need to hear that mutual masturbation holds no risk and oral sex and anal sex ARE sex and do present some risks of their own. And they need to know their parents love them, even if they are sexually active. Because no matter how uncomfortable we are, their safety and their future fertility and sexual health is what’s important, right?

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Posted by: Terri Warren, RN, ANP at 4:38 pm

Thursday, January 17, 2008

STD Testing – Who is at Fault?

I wonder how many times I’ve heard someone say to me as I’m diagnosing them with an STD, “But I asked my partner before we had sex and they said they were clean!”

On one hand, its good that the topic of sexual health came up at all. But on the other, how do people really know if they are “clean” anyway? And do you think that we could use some other term for not being infected with an STD? Because the opposite of “clean” is “dirty” and I would really love to see THAT concept go away somewhere and never return. Is it any wonder STDs are stigmatized in our society when that’s how we define someone who is infected?

STDs spread largely because people don’t know they have them. If someone knew, for example, that they had chlamydia, a bacterial STD, they would get it treated and it would not be spread to anyone else. But about 2/3 of women who have chlamydia don’t know they have it, and perhaps a third of men, so it just keeps moving from person to person, not because anyone is “dirty” but because the bacteria stays inside people, unrecognized, even for years, until someone diagnoses it and treats it.

The same is true with genital herpes. Ninety percent of those infected with herpes have no clue. They infect someone else who notices, and then all hell breaks loose – who gave what to whom and how dare you! But its nowhere near that malicious.

Perhaps the irresponsible part relates more to not getting tested before having sex with a new partner. If people did get tested for STDs more often, there would likely be less of them. So whose fault is that? I think the blame falls on both clinicians and sexually active people. Spur of the moment sex with a new partner is hot and interesting and fun, but it really doesn’t allow for the time it takes to sort out STDs, does it? Is there a middle ground somewhere in there?

And clinicians – how receptive are they to patients requesting full STD screening? And how good are they at including all the possible STDs that someone might reasonably have? They are notoriously not great about including herpes testing in an STD screen, and that’s the most prevalent STD in the US!

I think the burden must fall on the sexually active person who holds off on penetrative sex until testing has been done or least uses condoms for everything until testing can be done.

Or maybe its me. Maybe if I could figure out how to make testing hot and interesting and fun, people would do it more! But that’s a whole different blog.


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Posted by: Terri Warren, RN, ANP at 6:25 pm

Friday, September 7, 2007

Herpes Stigma

So there’s good news and bad news about the social stigma associated with herpes. In a recent phone survey of about 2,000 people in the US, 3/4 without herpes and 1/4 with herpes, a slight majority of both groups felt that the topic of genital herpes was not taboo. But when ranking the social stigma associated with any STD, herpes ranked only behind HIV – but hey, let’s face it, there is stigma associated with any STD – it does involve genitals, after all, and we, as a society just aren’t comfortable about our genitals.

Another piece of good news was that for people who had herpes, the biggest issue was bothersome symptoms of herpes outbreaks. That was listed way ahead of being bothered by stigma. Outbreaks can be treated or mostly prevented with medicine but there’s no prescription for feeling stigmatized by your herpes.

The bad news is that a majority of people who didn’t have herpes said they would avoid having a relationship with someone with herpes or break up with a partner who had herpes. Now that is truly stunning to me. This is 2007, folks! Of all of the things that can go wrong in a relationship, herpes is so far down the list, its almost not detectable. I’ll bet if you surveyed discordant married couples – that is, couples where one person has herpes and the other doesn’t, they would tell you that sex, money, in-laws, household chores and inability to talk to each other cause way more problems than herpes ever could.

It makes my heart very sad to think of the wonderful, quality people that I know, and know really well, who have been turned down for relationships because they have herpes. I used to think that people who did that were scumbags, that they didn’t have a good sense of ethics or of what’s important in life or that they would be unreliable in future hard situations. But I think a bit differently about that now. Now, I think that often they are just unreasonably afraid, that they know too little about the real experience of herpes, that they are just afraid of the reputation, not the actual disease and that they will never be able to know the “real” herpes.

I also think that people who count a lot on their sexuality for their identity are less likely to take any risk of getting herpes. It’s like if you are a pianist, you take extra care with your hands or if your job is to model toenail polish, you take extra care with your feet. If much of your identity is tied up in your ability to be sexual, then you will be less willing to take risks with that part of you. And lest you are thinking, “yea, see, they are scumbags, they are oversexed weirdos”, I would say that isn’t necessarily true. They just may feel good about the way they look or the things they can do sexually and may not have built up their confidence about themselves in other areas at the same rate as the sexual confidence. We all feel strong in some areas, but not in others, right?

Another group of people who just can’t seem to deal with herpes in a partner is people with obsessive compulsive disorder, and this is more common than you night think. And it comes in mild, moderate and severe cases. The severe case is the person who comes into my office and won’t touch the doorknobs – they wait for someone else to walk into our suite to let them in, then we have to open and close the exam room and bathroom doors for them because they cannot touch the knobs.

The moderate is the person who is unreasonably fearful about transmitting or getting STDs – like “if my daughter digs through my laundry basket for her pink socks can she get herpes on her hands if I had a pair of jeans in there that she touches” (undies would always be kept separate, of course, and never within reach of the daughter). The moderate might also do lots of hand washing, far more than necessary.

The milder is the person who asks lots and lots of questions about germs and presents several scenarios about getting an STD – like “so if I touch a guy’s penis through his jeans, but there is a little wetness from pre-cum on his jeans and I do it without gloves on, can I get herpes under my fingernails?” True, lots of people ask questions about transmission, but if someone leans toward OCD tendencies, the questions have a different feel, are more “out there”, are more troubling for the asker.

Another reason someone might not take the risk of getting herpes is simply that they don’t know the person who has herpes well enough to take that risk, and that is completely understandable. That’s why, when you have herpes, and you meet someone at a party, you don’t say, “Hi, I’m Terri, and I have genital herpes.” You wait until they know you better, have more invested in you, have more reason to be willing to take some risk. But this discussion must happen before having sex, of course, so they have an opportunity to make the decision about risk for themselves.

The survey also deals with the fact that many people with herpes admit to NOT disclosing their herpes status to sexual partners. But that’s another blog.

I’m sure you can think of more reasons why people are reluctant to take the risk of getting herpes, but think of this: do you think it is in one’s best interest to chose or not chose a life partner based on whether they have a virus on their genitals that can be well controlled with medicine and causes infrequent symptoms that can also be successfully and easily treated? Are there not more important qualities for a partner to have or not have that will sustain a relationship over time? I think the answer is quite clear. The trick is having people think it through carefully and being brave and sensing what is truly important in a partner.


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Posted by: Terri Warren, RN, ANP at 10:50 am

Friday, July 6, 2007

Itches, Rashes and Discharge Have More Than One Cause

Let’s see – a patient presents with itching, burning, cracking and irritation of the genitals. Is it herpes? Is it yeast? It is a bacterial infection? It could be any of those things, but the herpes option strikes the most fear into patients. That’s probably because of the stigma and the lack of knowlege about the subject. But indeed, many things can mimic herpes symptoms in the genital.

Herpes itches but so do lots of things, primarily yeast. Herpes can cause blisters in the genitals, but so can staph infections. Herpes can cause a discharge, but so can gonorrhea and chlamydia and bacterial vaginosis and trich. My point is, if genital symptoms are present, they aren’t always herpes, and that’s true even with the person who has a diagnosis of herpes. That’s why is is important for people who have herpes who have symptoms that are constant, are unresponsive to antivirals or that are outside of the “normal” pattern of herpes to have those symptoms evaluated by a clinician rather than assuming that they are herpes.

Of course, the reverse is also true, and probably happens more often. A person has symptoms like pain with urination. They present to the clinician’s office where urine is dipped for white cells (pus). White cells are found, so the person is put on antibiotics. But when the urine sample is sent to the lab to grow bacteria, none is found. That’s because what the person really had was herpetic urethritis, herpes lesions in or at the urethra. These lesions cause pain with urination because urine, which is acidic, is passing over open sores, which hurts. And there are pus cells in the urine because the lesions have pus in them. But the symptoms get better, so the patient and the clinician believe it was a bacterial UTI. Really, time just passed and the lesions resolved.

There are a few problems with that, as you might imagine. The first is that people are taking medicine for things they don’t have. That’s an issue because they might have allergies to those medicines or the medicines might cause side effects, like antibiotics cause yeast infections. As if having first episode herpes wasn’t bad enough, now that same person has a yeast infection or more serious complications from the antibiotics. It’s a vicious circle, for sure.

Here’s the bottom line: Symptoms need careful evaluation by a clinician who knows genital herpes and takes a good history and does good lab work. Nothing should be assumed.

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Posted by: Terri Warren, RN, ANP at 3:30 pm

Monday, February 26, 2007

Can Pap Smears Test for Herpes?

For all you women out there getting annual exams with pap smears: you need to be very careful. There is a bad thing happening out there – a pap with a herpes PCR test built in. This is sometimes called a “silver pap”. It often includes tests for chlamydia, gonorrhea, and herpes.

Here’s the problem: If you get a pap and the PCR HSV test portion is negative for herpes, does that mean you don’t have herpes? Of course not. It means that there was no herpes virus present at the moment the pap was taken, but that certainly does not mean that you don’t have herpes!

The bacterial infections gonorrhea and chlamydia are always present until they are treated. They aren’t there intermittently, and so the “silver pap” that includes only gonorrhea and chlamydia is legitimate. But in order to test for herpes, an antibody test needs to be done, not a swab test (PCR or culture) and certainly not a pap.

Herpes virus is present only intermittently and so looking at one point in time for VIRUS is not accurate, not legitimate, and a total waste of money in the asymptomatic individual. It gives false reassurance about lack of infection to patients who have no idea how to interpret these results. Clinicians are confused enough about testing that they don’t seem to get it either.

Testing for herpes with a pap test is like someone did a pap looking for sperm and found none and saying, therefore, this person never has sex. It just isn’t valid!

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Posted by: Terri Warren, RN, ANP at 4:24 pm

Tuesday, December 5, 2006

Who should be tested for herpes?

This is a question I am often asked, and my opinion may not match everyone’s on this topic, but here it is anyway.

If you’ve had a partner in the past who has had herpes, you might want to find out if you got infected and didn’t know it.

If your current partner has herpes, and you are wondering how to reduce the risk of transmission, the first step is to determine that you are indeed, not infected! Why go to all the trouble to reduce transmission risk when you may already have the virus, and would need to make no changes in your sexual practices to accommodate your partner’s herpes?

If you have had lesions or sores or breaks in the skin in the past, and they have been swabbed for herpes and you’ve had negative swabs, you need a blood test to confirm that you are actually not infected. Swab tests often have false negative results, and you can take the extra step to find out that you actually are or are not infected.

If you have new symptoms, and you want to know if this is actually your first infection or reactivation of an old one, you can use a combination of swab test and blood test to sort that out. If you have a positive swab test for HSV 2, let’s say, and a negative antibody blood test for HSV 2, that tells you this is your first infection. You’ve got virus present on the skin, but have not yet had a chance to develop antibody to the virus – it is too soon, because this is your very first infection.

If you’ve had a clinician look at your genitals and tell you by physical exam that you have genital herpes, you may wish to get an antibody test to confirm that diagnosis and/or determine whether you have HSV 1 or HSV 2 – you can’t tell from a look.

If you are pregnant, you may wish to know if you have herpes or not. This test is not usually included in pregnant screening – this is a topic to raise with your OB provider, if you wish. If you are starting a new relationship or coming out of an old one and would like to know which, if any STDs you bring to the table, so to speak, antibody testing for HSV is important to be comprehensive, and often isn’t included in routine STD screens.

So there are a few ideas for you about who may benefit from antibody testing for herpes. Be certain you get IgG testing, not IgM testing, and that it is truly type specific – there are good and not good blood tests for herpes. Feel free to post on the message board if you have questions about antibody testing.

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Posted by: Terri Warren, RN, ANP at 12:36 pm

Monday, November 27, 2006

It’s not always herpes

Sometimes when a person gets diagnosed with genital herpes, they start recognizing symptoms in the genital area. That’s a good thing, because most herpes is unrecognized but not asymptomatic.

However, don’t assume that all symptoms in the genital area are herpes symptoms. People with herpes get yeast infections, they get bacterial infections, they get genital warts, they get molluscum, they get scabies, they get urinary tracts infection and they get other STDs like Chlamydia and gonorrhea.

It’s important that herpes not become a dumping ground for all symptoms. On my WebMD message board, I get lots of questions from people who are having continuous symptoms — non-stop itching or irritation and they report that their antiviral medicines “aren’t doing anything”.

Antiviral medicines, acyclovir, Valtrex and Famvir, are all very effective and reduce outbreak frequency by about 70%. In healthy adults who have fully functioning immune systems, these medicines always improve symptoms. But they improve symptoms that are related to herpes. So if no improvement is seen in symptoms, then they are likely caused by something else. It worries me that some people get so stuck on their herpes diagnosis that they miss getting appropriate diagnoses and treatment for other infections.

If you have herpes, and antiviral medicines “aren’t doing anything” to improve your symptoms, think other types of things going on and get that sorted out.

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Posted by: Terri Warren, RN, ANP at 1:00 pm

Thursday, April 27, 2006

HSV Testing in Pregnancy: Just DO it!

After speaking a lot with OB/GYN providers in the past few weeks, I would like to vent about HSV testing in pregnancy. There are so many reasons given for not testing in pregnancy, but to me NONE of them hold a candle to the value of testing.

If the statistics are true that about 1 in three women in their 30′s have HSV 2, and 90% of them don’t know, ASKING pregnant women if they have genital herpes is almost worthless. Yes, you will catch a few, but miss 90% of those infected!

If you believe the research that shows that people who test positive for HSV 2, but have no outbreaks shed asymptomatically at the same rate as those having 1-12 outbreaks, then wouldn’t it be useful to know who is infected, rather than basically playing Russian roulette with the pregnancy?

If you believe that viral suppression treatment for women with herpes at the end of pregnancy is the right and valuable thing to do, would you not then want to know who all the infected women are? If you believe that the woman who gets new herpes in the third trimester has a 30-50% chance of infecting her baby, would you not want to know which women are vulnerable and which of their partners is infected?

Pregnant women are routinely tested for syphilis, gonorrhea, chlamydia, rubella, HIV (in many states), and their pap smears hopefully look for HPV. Why, then, we would not test for herpes?

In my next blog, I will share with you the reasons I am given for not testing. Some of you will be amazed, others of you will not be surprised. Suffice to say, in preview, we are letting social stigma and emotional upset guide testing decisions. This is not true for all clinicians, but many. Perhaps testing for HSV in pregnancy will need to come from patients, driving clinicians to test. But it should be the other way around, I think.


Related Topics: Are You Sex-Smart?, Vaginal Gel Blocks HIV, Herpes

Posted by: Terri Warren, RN, ANP at 1:44 pm