[Question #78] Determining whether to be tested for HSV or not

97 months ago
Dr. Handsfield,

I have read many of your posts on medhelp.org, read the information on this page and watched the videos you have developed. I truly appreciate the work you do to help inform the public about HSV.

My situation is as follows:
I am a 29 year old female and have had 13 sexual partners. I do not believe I have been tested for HSV since I was about 16 years old- that test was requested by myself based on information I had about a boyfriend taking Valtrex- we did not have intercourse but I was fearful based on genital contact- the tests came back negative.

I provide the above information in relation to my current situation. I am tested routinely for the standard STD panel in Chicago- HIV, Chlamydia, Gonorrhea, and sometimes Syphilis and have always had negative tests. However, I have not since had a Herpes test as it is not part of the standard protocol and I have never had any symptoms that led me to believe I should request it. Regardless, I am aware that it is possible that I do have HSV based on my number of partners and the fact that while I always use condoms now, I didn't always when I was younger, along with the high percentage of people who do not know they have it.

Nine days ago I had vaginal/oral sex with a new partner. We used condoms, although a few were a bit short given his size- they did not break or slip.  We saw each other again three days ago. Prior to having sex again I asked him if I should be concerned about any STDs. He revealed he has HSV-2. He indicated that he takes suppressive therapy, has not had any outbreaks for two years post starting medication, and has had two girlfriends since that had negative tests post their relationships ending. We did not proceed with vaginal sex during this encounter but did have oral sex. 

I have read your commentary on medhelp and realize that my risk from this single evening exposure is extremely low given the precautions on both sides (multiple times in one evening, but regardless). I am not particularly concerned about exposure from this encounter, but what would you guess is my risk from this encounter? I have not had any symptoms yet- besides anxiety causing hyper focus of my genital area- itching, tingling- likely due to excessive friction as I do not have sex often. 

Assuming I do not develop any symptoms, I am struggling with whether I should be tested.
What is your personal view on testing for herpes if one knows they have been exposed, but all precautions were in place and there are no symptoms? My biggest fear is that perhaps I already have the infection from a previous encounter, but it is asymptomatic. Because I know this person certainly has herpes I feel torn about the obligation to test for it-even though I am probably safer in this circumstance than previous ones due to his knowledge.
If i have asymptomatic herpes, I will need to live with the psychological impact- my biggest concern, but not really be able to do much about it. Do doctors prescribe suppressive therapy for asymptomatic HSV 1 or 2 cases? And if they generally don't, what is the value of knowing besides being able to tell future partners?

What is your general opinion on testing for asymptomatic genital HSV1 or 2? 
If someone has an asymptomatic case, and gives it to someone else, it depends on the receiver's immune system to determine whether it will be asymptomatic in that person, correct?
Given my circumstances, do you feel it is necessary or valuable to have testing in the event I do not develop symptoms?

I am trying to do the right thing- but also selfishly concerned about my mental health knowing my low tolerance.

Thanks in advance for your help.

H. Hunter Handsfield, MD
97 months ago
Welcome to the forum and thanks for your questions. Other viewers should understand that normally questions about herpes are answered by Terri Warren, regardless of requests directly to me or Dr. Hook. But in this case you have not only requested my opinion but refer back to comments I have made elsewhere. So here I am!

I'll start congratulations on a sober, objective slant you apparently have on herpes and its prevention, and on STD prevention and sexual health in general. And also with the observation that you are correct that over time your risk of genital herpes is not zero. However, the odds probably are against it. Also, half of all new genital herpes is HSV1, which typically causes few outbreaks and probably is quite rarely transmitted to partners -- a very different scenario versus HSV2. And even HSV2 is controllable from the standpoints of both symptoms and protecting partners. Despite high anxiety about GH among many sexually active persons, in fact it typically has a lot less impact on partnerships, romance, and sexual health than people fear it will. I'm not suggesting you be cavalier about it. But at the same time, be careful it doesn't loom larger than necessary in your psyche.

Your risk of HSV2 from the particular encounters described? Under 1 chance in a several thousand. Even without a condom, and if he were not taking anti-herpes suppressive therapy, the risk probably would have been roughly 1 in a thousand. (That comes from the research on valacyclovir prevention, the approximate risk per unprotected vaginal sex exposure to a known-infected partner in the placebo group.) You could have been at risk for oral HSV2 from performing fellatio, but also in the same very low range.

My views on testing for HSV2? In the circumstances described, I wouldn't recommend it. In fact, I would rarely ever recommend HSV blood testing after any single sexual exposure in  someone who didn't develop symptoms of new herpes. The main exception might be if the exposure were particularly high risk, such as sex during an overt outbreak, especially during the partner's initial HSV infection.

My views on HSV blood tests have been evolving over time as we learn more about the limitations of the currently available tests. Suffice to say I don't recommend it as frequently as I once did. You certainly could consider periodic routine testing (e.g. yearly?), but only if prepared for the not insignificant risk of an uncertain or confusing test result.

Asymptomatic infections:  Suppressive therapy indeed is often prescribed for asymptomatic infections with HSV2, to help protect partners. Treatment is not limited to simply preventing symptomatic outbreaks. This is one of the arguments in favor of testing asymptomatic persons if at sufficient risk. However, suppressive treatment rarely is useful for asymptomatic genital HSV1. The transmission risk is low and most people have few recurrent outbreaks, so there isn't much benefit in preventing either symptoms or transmission.

Finally, the reasons are unknown why some people with new HSV infections develop symptoms and others do not. It is not obviously related to the uninfected person's immune system. The dose of virus, vigor of inoculation, and perhaps unknown difference in virus strains all may have a role. But for practical purposes, it appears to be random and is unpredictable.

I think those comments pretty well cover your questions. Let me know if I missed anything or if you need clarification.

Best wishes--   HHH, MD

97 months ago
Dr. Handsfield,

I am grateful and relieved you have taken the time to thoroughly evaluate my personal circumstance.
It is interesting how human beings ultimately react to a major fear coming to fruition- I am ultimately bothered by this individual's presumption he had the right to evaluate my risk for me, but at the same time understand why he would want to. I rationally understand the low impact of this condition on relationships and sexual health, but am having trouble reconciling my emotional reaction due to society's tendency to catastrophize it and the impact that would have on my future relationship because of these views, despite my own. The situation has certainly given new perspective on casual relationships prior to emotional connection- the risk might certainly be worth it in a committed relationship.

I have just a few follow up questions:
When would you say I could be at ease in regards to developing symptoms in the extremely rare case I have acquired HSV-2? It has now been 10.5 days since our vaginal encounters.

In regards to periodic routine testing, given my anxiety related to this issue, I don't feel I am prepared for the not insignificant risk of an uncertain or confusing test result. Would you encourage routine testing regardless for the sake of health concerns? Do you feel I am at sufficient risk to argue in favor of asymptomatic testing?

Best regards and many thanks. 

H. Hunter Handsfield, MD
97 months ago
Your partner should have told you of his herpes status before having sex, not after. That said, it's easy to understand his reasoning, and the risk genuinely was extremely low. I wouldn't be too hard on him.

The large majority of new HSV infections cause symptoms in under 10 days, usually within 5 days. Rarely it can take up to 3 weeks, but for practical purposes you're out of the woods.

There are no hard and fast guidelines about routine testing. But based on your own statements, both my impressions of your sexual lifestyle and your self-described anxieties, I think your decision is correct.

97 months ago
Dr. Handsfield,

Thank you for your reply. I apologize I have my final question. 
I woke up last night to some intense itching in my vaginal area that has lasted about 24 hours-I do not get this often but sometimes a bit before my period (I am on BC and took the morning after pill after this encounter due to not taking the pill as I should- despite using condoms for all encounters-possibly hormonal fluctuations?). I do not see any symptoms in the vaginal area- assuming this is being caused by a yeast infection and due to my recent frequent evaluations- despite no discharge. 

Because of the vaginal itching, I examined my rectal area and noticed a few pimple like pustules near my anus- on both sides. I believe they are in a hair region but it is very difficult for me to examine the area- a few weeks ago I did shave this area and noticed immediate irritation.  Upon pressing on both fairly hard, not intending extract anything- very thick, white pus was extracted from both- no fluid- and I did squeeze the remainder out- which was a good amount.  One side you can now barely notice the bump, the other larger side where more pus was extracted, there is still a red bump/irritation, as would be expected. Neither is sensitive to the touch- a bit irritated due to excessive examination. 

Needless to say I do not normally analyze this region so closely. Should I be concerned?


H. Hunter Handsfield, MD
97 months ago
This doesn't sound like herpes, and from all we've discussed up to now, there is little chance you were infected. By far the most common cause of genital area itching and irritation in women is vaginal yeast infection and I'm guessing that's what you have. The peri-anal bumps with white material might be an entirely separate problem, perhaps garden variety small sebaceous cysts. In any case, herpes also doesn't cause that sort of thing. And of course any time you manipulate any skin lesion, a "red bump" almost always will be apparent.

You could try an over the counter yeast medication -- any cream with active ingredient ending in "azole" (miconazole, clotrimazole, etc), or single dose oral fluconazole (Diflucan). Prompt (2-3 day) improvement in the itching will tend to confirm yeast as the cause. Or see your doctor about it.

In the long run, I hope you can get beyond what seem to be very inflated fears about herpes. If it continues to dominate your thinking, counseling may be something to consider. I suggest it from compassion, not criticism.

Best wishes and good luck!