Women's Health Update: Genital Herpes

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Women's Health Update: Genital Herpes

The prevalence of genital herpes in the United States has increased by more than 30% between 1978 and 1991. There are six members of the herpes virus family that infect humans: HSV type 1 (HSV-1) and HSV type 2 (HSV-2), varicella zoster virus, human cytomegalovirus, Epstein-Barr virus, and herpesvirus type 6. Today, HSV-2 is the leading cause of genital ulcer disease in the US and as many as one in five are infected with HSV-2, the type more closely associated with genital herpes. HSV-1, the type associated with infections of the mouth, lips, pharynx, and eyes, is believed to be responsible for 10% to 50% of new cases of genital herpes.( 1) The highest annual incidence of genital herpes among women occurs at 20-24 years of age and is estimated to be 210 per 100,000 women.

There are three distinct herpes syndromes: primary herpes, first-episode nonprimary herpes, and recurrent herpes. The severity of symptoms vary in extent and duration according to whether the episode is the first infection with either HSV-2 or HSV-1 (primary herpes); initial genital infection in a woman who has already had an infection with the other HSV type (initial, or first episode nonprimary herpes); or a recurrence of a genital infection with either type.

A woman's first episode of genital herpes, (primary herpes), is usually the most severe form of the disease. Symptoms usually start appearing within a week after infection if they are going to appear at all. However, symptoms can start one day and up to 26 days after exposure to the virus. Typically, it is characterized by extensive, multiple clusters of painful lesions involving the genitals, anus, perineum, or surrounding areas. Primary genital herpes is usually the most severe form of the disease, but symptoms and lesions vary in severity, extent, and duration. The classic lesion begins as a red papule, evolving within 2 to 3 days to a vesicle containing clear fluid, and then progressing to a pustule. A tender ulceration occurs when the surface breaks open which may explain the burning pain. Lesions ulcerate more rapidly in moist areas than on dry skin, so that painful genital ulcerations are more apt to occur on the external vulva area. Several successive lesions may appear in the first 3 to 4 weeks of primary herpes. The lesions may heal in 1 to 6 weeks.

In more than two-thirds of women, primary herpes is accompanied by systemic symptoms that may include fever, malaise, body aches, headaches, and nausea. Stiffness of the neck and a sensitivity to light are also common. Nearly three-quarters of women will also suffer from herpetic cervicitis, with vaginal discharge and intermenstrual spotting. Swollen lymph nodes in the groin area are also a common finding. Discomfort with urination is also common. A clinical definition of primary genital herpes includes the presence of at least three of the following features:

- Multiple, genital sores or eruptions with severe local pain and inflammation

- Persistent genital eruptions

- Simultaneous presence of herpes lesions at non-genital sites (fingers, mouth)

- Two or more systemic symptoms such as fever, headache, body aches, or malaise.

A practitioner can often make a diagnosis of herpes based on the medical history and inspection of the area. Laboratory testing to confirm the diagnosis is indicated for most people who are having their initial genital eruption. Viral cultures are the most sensitive, and commonly available test for confirming the diagnosis of genital herpes. Cultures permit viral typing. Other testing methods include direct fluorescent antibody test, techniques that detect herpes viral DNA, and blood tests for HSV antibodies. Most of these additional methods do not adequately distinguish HSV-1 from HSV-2.

Some women already have oral herpes or herpes in some other non-genital site, and then acquire their first-episode of genital herpes. (non-primary genital herpes). These are most often caused by HSV-2 in women with a history of HSV-1 infection, often dating back to as far as childhood. These cases of genital herpes tend to have fewer eruptions than primary herpes, and healing time occurs in 1 to 3 weeks. Systemic symptoms are generally not seen.

About half of the women who sustain a first episode of genital herpes will have another episode within 6 months, and more than 80% will have a recurrence within a year. In the first year following symptomatic primary genital herpes, women experience an average of five recurrences; about 40% will have six or more occurrences and about 20% will have 10 more outbreaks. Recurrent outbreaks are usually milder and shorter, resolving within 10 days. Systemic symptoms are rare but may be accompanied by prodromal symptoms of local tingling or burning, itching, or pain a few hours to a few days prior to an eruption.

One of the most frustrating areas of herpes infections is the uncertainty of knowing when the individual is contagious. Many outbreaks of herpes, and in fact probably a majority, occur with no apparent warning, without symptoms prior to the onset of the eruption. In the prodromal states, virus can be shed and it is easy to infect another individual during sexual contact. Shedding of the virus without any apparent symptoms is commonplace in the majority of individuals who have had herpes for some time. It is important that individuals learn to recognize even subtle symptoms that may warn of an outbreak. The safest method of protecting a sexual partner is to use some sort of barrier method to prevent genital contact.

The most serious and feared complication of genital herpes is the transmission from an infected pregnant mother to her newborn child. Viral cultures late in the pregnancy may be advised and consultations about a delivery by Cesarean section may be justified. Other complications include meningitis, urinary or rectal dysfunction, infection in the eye and erythema multiforme.

The impact of genital herpes on a person's psychological and sexual health can be quite intrusive and profound. Many people withdraw from interpersonal relationships because of stress related to their infection or fear of spreading the disease. Disruption of one's sexual life can manifest as reduced sexual pleasure or reduced interest in sex. Many people also worry that they will be rejected by future partners and become pessimistic and even despondent about the possibility of establishing a sexual relationship. It is important that patients also understand that the primary infection may have been asymptomatic and that even an initial outbreak may be a reactivation of an infection acquired months or even years previously.

A susceptible host plus exposure to the herpes simplex virus is the key to acquiring the disease. Improving the health of the host and enhancement of the immune system is essential in preventing and controlling herpes. There is some evidence that a defect in the immune system is present even in otherwise healthy individuals who have recurrent HSV infection. Support of the immune system, dietary factors, stressors, skin health, and preventing and treating other non-herpes infections, are all avenues for using natural therapies in reducing the likelihood of contracting herpes and in reducing the frequency and intensity of recurrent herpes infections.

Alternative Treatments

Fundamental to good health and an optimal immune system is a health-supportive diet. Although biochemical differences may require some individualization of our diet, a health supportive diet is generally a diet with some commonalities: fruit, vegetables, whole grains and legumes, reduce fat, eliminate refined sugar and refined carbohydrates, reduce exposure to food additives, coloring agents, pesticides, and herbicides, and reduce salt and alcohol. More specifically, a dietary approach that reduces our arginine food intake and increases our lysine food intake for preventing recurring herpes outbreaks has become quite popular. This concept arose out of two findings. Firstly, the replication of the herpes simplex virus requires the manufacture of proteins rich in arginine, and arginine itself may be a stimulator of HSV replication. Secondly, laboratory research has shown that lysine has antiviral activity by blocking arginine.( 2) Theoretically, reducing the intake of arginine foo ds and increasing the intake of lysine foods should be effective in reducing HSV replication. High arginine foods include chocolate, peanuts, almonds, cashews, and sunflower seeds. Foods high in lysine include most vegetables, beans, fish, turkey, and chicken.

Scientific studies on the effectiveness of lysine supplementation have not shown consistent results. One study that did show positive results was done in 52 patients with recurrent oral or genital infections, or both.( 3) Subjects received L-lysine 1 gram 3 times daily or a placebo. They also avoided nuts, chocolate, and gelatin. After 6 months, 74% of those who received the lysine rated their treatment as either effective or very effective, compared to 28% of those receiving placebo. The lysine group also reported milder symptoms and fewer outbreaks. Another study was done giving 41 patients a daily dose of 1248 mg of lysine.( 4) I advise patients with recurrent herpes to follow the dietary recommendations and take 1 gm of lysine daily for maintenance and take 1 gm 3 times daily during acute outbreaks. Lysine is also being used in topical ointments to be applied directly to the lesion. Although I am not aware of any studies to prove their effectiveness, they seem to be effective in reducing the symptoms.

Vitamin C supplementation may have value in the treatment of recurrent external genital herpes: 600 mg of vitamin C and 600 mg of bioflavonoids three times daily for 3 days after the initial onset of prodrome symptoms was found to be the optimal dosage for the most rapid disappearance of symptoms.( 5)

Topical vitamin E applied to the lesion may provide relief of pain and discomfort. Although clinical observations have been made in only four published cases and in oral primary herpes, not genital, it would seem logical that vitamin E applied to genital eruptions may also provide similar benefit. Dry the area around the lesion with warm air and apply vitamin E oil with a Q-tip. Leave in place for 15 minutes at which time relief should be evident.

Zinc supplementation has been observed to reduce the frequency, duration, and severity of genital herpes eruptions. A compound of 25 mg of zinc and 250 mg of vitamin C was given twice daily for six weeks. In some cases the eruption was completely suppressed, and in others the eruptions disappeared within 24 hours.( 6)

Lemon balm ointments have been used as topical agents in Germany for oral cold sores and are now available in the US. The German cream is a concentrate of 70:1 lemon extract. Several clinical studies have shown impressive results. One such study demonstrated that when the lemon balm cream was used on patients with an initial herpes infection, not a single recurrence occurred. Not one patient using the cream developed another cold sore. The cream was also shown to be effective in cases of genital herpes in reducing the healing time.( 7) The cream should be applied two to four times a day during an active eruption.

Traditional herbal uses of licorice, myrrh and goldenseal for the healing of sores, wounds, inflammations and ulcerations of mucus membrane tissues warrant its use both internally and topically for herpes eruptions. Additional botanicals have the ability to provide immune support through various mechanisms. The antiviral activity of St. Johns Wort has been demonstrated in laboratory studies that have shown that two constituents in St. Johns Wort, hypericin and pseudohypericin, exhibit strong antiviral activity against herpes simplex virus I and II.( 8) Botanicals such as echinacea, thuja, lomatium and astragalus have been used traditionally by Naturopathic Physicians, herbalists, and other health care practitioners to support the body's immune system and to defend against the effects of diseases caused by viral infections. These herbs are typically administered in liquid extracts, capsules or tablets, or teas.

Women with recurrent genital herpes infections may need to seek more aggressive or individualized care from a licensed alternative health care practitioner than the therapies discussed in this article. Homeopathy, additional herbal/nutritional combination products, or Chinese medicine may be more effective in an individual case.

Conventional Medicine Treatments

Many patients prefer to use antiviral therapy to suppress infections and to reduce recurrent episodes. The primary goals of antiviral therapy are to limit the severity of the infection and give the patient a sense of control over the disease process. Antiviral therapy is offered to normal immunocompetent patients with either primary or non-primary genital herpes. In the vast majority of cases, oral antiviral therapy is sufficient, although more severe cases may require hospitalization and intravenous acyclovir.

The value of episodic therapy is debatable because the reductions in healing time and symptom duration are of relatively minor benefit. Patients who have a clearly identifiable prodrome are better candidates for episodic therapy. Patients who desire continuous suppressive therapy need to discuss with their physician, the advantages and disadvantages of this regime. Medical considerations, psychosocial needs and cost are all factors influencing the wisdom of such a regime. The most effective class of agents possessing antiviral activity are the nucleoside analogs: acyclovir, famciclovir, and valaciclovir. Herpes simplex viruses may develop resistance to antiviral agents although this seems to be rare in normal immunocompetent patients who receive acyclovir for episodic treatment or suppression of herpetic eruptions. Immunocompromised patients who receive antiviral therapy for extended periods of time, may be at risk for developing resistance and judicious use of antiviral agents is advisable.

Some women may choose to use conventional pharmaceutical antiviral therapy. This is largely based on personal choice rather than an actual medical need. There are cases of primary or nonprimary genital herpes when antiviral therapy is indicated for immunocompromised individuals. Cases where symptoms and complications are sufficiently severe enough to warrant hospitalization may require intravenous antiviral therapy.

References
(1.) Wild D, Patrick D, Johnson E, Berzon R, Wald A. Measuring health-related quality of life in persons with genital herpes. Qual Life Res 1995;4:532-539.

(2.) Griffith R, DeLong D, Nelson J. Relation of arginine-lysine antagonism to herpes simplex growth in tissue culture. Chemotherapy 1981;27:209-213.

(3.) Griffith R, et al. Success of L-lysine therapy in frequently recurrent herpes simplex infection. Dermatologica 1987;175:183-90.

(4.) McCune M, Perry H, Muler S, O'Fallan M. Treatment of recurrent herpes simplex infections with L-lysine monohydrocholoride. Cutis 1984; 34:366-373.

(5.) Terzhalmy G, Bottomley W, Pelleu G. The use of water-soluble bioflavonoid-ascorbic acid complex in the treatment of recurrent herpes labialis. Oral Surgery 1978;45(1):56-62.

(6.) Fitzherbert J. Genital herpes and zinc. Med J Australia 1979;1:399.

(7.) Wolbling R, Leonhardt K. Local therapy of herpes simplex with dried extract from Melissa officinalis. Phytomed 1994;1:25-31.

(8.) Muldner V, Zoller M. Antidepressive wirkung eines auf den wirkstoffkomplex hypericin standardisierten hypericum-extrakes. Arzneim Forsch 1984;34:918.

Townsend Letter for Doctors & Patients.

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By Tori Hudson

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