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Female Genital herpes: a Complete Guide to HSV in Women

Learn everything about HSV with this complete guide: genital herpes in women: symptoms, signs, early diagnosis, and scientifically proven treatment.
A couple at risk of genital herpes

What is genital herpes?

Genital herpes, caused by the herpes simplex virus (HSV) is a common and highly contagious sexually transmitted infection (STI). The term herpes is derived from the Greek language meaning “to creep or crawl” and dates approximately 2000 years ago, in reference to the spreading nature of herpetic (blisters or ulcer) skin lesions. The virus can cause fluid-filled bumps, that may break open and ooze a clear fluid. They can be found in any area of the genital region. However, many of individuals that have contracted genital herpes do not have any symptoms.

How common is genital herpes?

According to the Centers for Disease Control and Prevention (CDC), approximately 776,000 new cases of genital herpes infection occurs in the United States annually. 

The CDC believes that the rate of genital herpes may be even higher than what has been reported and this is because of the increasing number of cases of genital herpes caused by HSV-1. 

The World Health Organization (WHO) estimates that more than 3.7 billion people worldwide under the age of 50 (67%of the population) have the HSV-1 infection and approximately 417 million people worldwide aged 15-49 have been infected by the HSV-2 infection (WHO, 2017). They go on to state that the presence of HSV-2 in the human body increases your risk of acquiring and transmitting HIV infection.

What does genital herpes look like?

A person infected from exposure to the herpes virus can be asymptomatic (no symptoms) or can have mild symptoms that go unrecognized. If you suspect that you may have been exposed, you should be aware of what to look for. A genital herpes outbreak can be characterized by one or more blisters or ulcers. These blisters can be painful and if they ruptured, may ooze clear fluid. They can be located on the genitalia, perineum, buttocks, upper thighs. In addition, newly infected individuals often have symptoms that include fever, body aches, and swollen lymph nodes.

Types of genital herpes

Today, there are 100 known herpes viruses but only eight can infect humans. 

Genital herpes can be transmitted to any sexually active person and can be caused by two different herpes viruses. These viruses are known as herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2).

Herpes simplex virus type 1

For decades, herpes simplex virus type 1 (HSV-1) was the primary cause of oral herpes only. However, during the last decade, the number of cases of genital herpes caused by HSV-1 has increased significantly. Many researchers believe that this is due to the fact that HSV-1 infection that is typically contracted in early childhood, has been on the decline. Because of this, many sexually active adults are now susceptible to HSV-1 induced genital herpes. 

Genital herpes caused by HSV-1 can be asymptomatic or can even have mild symptoms that can be unrecognized. Many infected people report experiencing a tingling, itching or burning sensation before the appearance of any sores. When these sores do appear, they are characterized by one or more genital or anal blisters/ulcers that can be very painful. If these blisters open, they can ooze clear fluid and then develop a “crust-like” covering. After an initial genital herpes outbreak, symptoms may recur. Fortunately, with genital herpes caused by HSV-1, subsequent recurrences are milder and much less frequent.

Herpes on the skin

Herpes simplex virus type 2

Many times, the first episode of a genital herpes outbreak is clinically indistinguishable between HSV-1 and HSV-2. The presentation of the blisters or ulcers looks the exactly the same. Unlike HSV-1, HSV-2 may cause frequent, symptomatic genital ulcers. Recent studies have demonstrated that the HSV-2 virus is frequently shed from the genital surfaces even in the absence of signs or symptoms of clinical disease. They have also found that this virus can be transmitted during these periods of shedding.

HSV-2 shedding can also be detected throughout the genital tract and may be associated with genital tract inflammation. These researchers believe that this likely contributes to an increased risk of acquiring HIV.

What causes genital herpes?

Genital herpes is caused by the herpes simplex viruses (HSV). Herpes simplex viruses are pathogens, having the ability to adapt to their host’s conditions (your body) and can cause a wide variety of medical conditions.

HSV infection is not fully understood. A study published in the British Medical Journal states that the number of persons that contracted the herpes virus were exposed equally to HSV-1 as were HSV-2. During this study, the researchers followed 29 subjects infected by HSV-2 for one year to try to determine why some healthy individuals experience more serious symptoms than others.

They concluded that the immunological mechanism underlying recurrent symptomatic HSV infection is not fully understood, but they found that the severity of the symptoms was directly related to the aggressiveness of the individual’s immune response. The greater the initial immune response, the greater the likelihood that symptoms will recur.

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How is genital herpes transmitted?

Genital herpes can be transmitted by the HSV-1 or HSV-2 virus and is a lifelong condition. The average incubation period for an initial herpes infection is 4 days after exposure, but may range from 2 to 12 days. 

During this time, the newly infected person has no symptoms of the virus. In a number of countries (e.g., the USA, Western Europe, Australia and New Zealand) studies have shown evidence that the proportion of first episode genital herpes that is due to HSV-1 has increased and that it is believed to be caused by an increase in oral sex among populations that do not feel that they are at risk of contracting an STI.

Herpes simplex virus (HSV)-2 is characterized by viral cells that shed off of the infected genital area. HSV-2 shedding consists of approximately 14 episodes per year. 

The majority of the times that HSV-2 is transmitted, the infected partner is asymptomatic and passes the virus on.  Studies consistently report the majority of patients with genital HSV infection are unaware of its presence. 

A couple in love

Genital herpes symptoms in women

The clinical features of genital herpes in women can include: 

  • Blisters on the genitalia, vaginal opening, perineum, buttocks, upper thighs, or perianal areas. 
  • In moist areas, blisters may rupture, leaving painful ulcers
  • The vaginal tissue can become red and swollen. 
  • General symptoms may include fever, body aches, swollen lymph nodes, or headaches.
  • Cervicitis (inflammation of the cervix)
  • Dysuria (difficulty urinating). 
  • Pain with urination

Genital herpes test for women

There are several different ways that genital herpes can be diagnosed in women and it depends on the stage of the exposure. A blood test is available for diagnosis and can be completed prior to any physical symptoms appearing. If physical symptoms do appear, an evaluation can be done by a general health provider or gynecologist.

Genital herpes is usually diagnosed based on a physical exam and the results of laboratory tests, including:

  • Blood test
  • Viral culture
  • Polymerase chain reaction (PCR) test

Genital herpes treatment for women

Is there a cure for genital herpes?

Unfortunately, there is no cure for HSV-1 and HSV-2.

Because of this, you should be aware of how to prevent, identify, and treat outbreaks. Prevention is the biggest key when it comes to avoiding the infection and the possible complications associated with herpes simplex virus. If you or your partner is infected or thinks that they may have been exposed to herpes simplex, you should take precautions. If there is a current outbreak (oral or genital), skin-to-skin contact should be avoided. This includes kissing, and any unprotected sex, including oral sex. If you or your partner know that they are infected with herpes simplex, even without visible symptoms, the virus can be passed to the other person. Because of this, you should take precautions every time you engage in sex.

The easiest way for women to protect themselves from genital herpes is to:

  1. Insist that your partner wears a condom during sex.
  2. Make sure that you and your partner are in a committed relationship, are tested for HSV, and you are aware of the results prior to engaging in any unprotected sex.
  3. Limit your number of intimate partners.
  4. Currently, vaccines are being developed.
Genital herpes treatment

What does genital herpes do to your body?

Women that are infected by genital herpes are at a greater risk of contracting HIV.

Herpes simplex virus (1 & 2) infection involves a complex cycle of events. Herpes simplex viruses are considered latent infections, a type of persistent viral infection that lasts for the life of the person and is usually passed through sexual contact. The virus enters the body through the genital or oral mucosal tissues or sores of the skin and replicates. Following the incubation period, one or more lesions may appear.  This is considered the primary infection.

While the blisters form, rupture, crust over, and finally disappear, the virus is making its way into a group of nerve cells (ganglia) near the spinal cord that supply the nerve fibers in the primary infected area. Here the viral DNA can remain silent (dormant or latent) unless the body is stressed. When this happens, the virus reactivates, begins multiplying again, and travels through the nerve fibers back to the skin. This reaction causes eruptions of blisters in the same area of skin that was previously affected. This is referred to as a secondary infection. When all has calmed down the virus can become latent again, sometimes for months or years, and then the cycle starts all over. 

The herpes virus can infect different parts of the human body. Once inside the body, it can affect various organs and tissues. Particularly if the infected person has a compromised immune system.  

The herpes simplex viruses can cause inflammation and infection in the following body systems:

Respiratory

  • HSV-1 can cause pneumonitis (inflammation of the lungs) in individuals that do and do not have a compromised immune system.
  • HSV pneumonia (viral infection of the lungs) is usually associated with individuals that have a compromised immune system (e.g., AIDS). Generally, this infection is due to herpes simplex virus type 1. Pneumonia due to herpes simplex virus type 2 is extremely rare.

Genitourinary 

  • Acute urinary retention (not being able to completely empty your bladder) caused by herpes simplex is usually due to the presence of irritation and swelling during active outbreaks. This condition is typically caused by HSV-1.
  • Pelvic inflammatory disease can result from herpes simplex. As stated previously, the herpes virus can cause inflammation and tissue changes when it attacks the cervix. A study published in 2015 also identified a significant correlation between HSV and ectopic pregnancies.

Skin

  • Disseminated herpes simplex virus 2 affects multiple regions of skin. 
  • Oral lesions caused by HSV-2 have been identified, usually secondary to oral sex.
  • Neonatal infection can happen when an infected mother passes the virus onto a baby during delivery. 

Brain and Nervous System

  • Aseptic meningitis. This is a condition that can be caused by HSV and results in swelling of the protective membranes that surround the brain and spinal cord. A study published in 2016, presented a case study of a woman that experienced aseptic meningitis several times after being diagnosed with HSV-2. The last reported occurrence was 11 years after the previous treatment.
  • Encephalitis. HSV can travel to the brain. This infection (called herpes encephalitis) begins with confusion, fever, and seizures and can be fatal.
  • Alzheimer’s disease (AD). Recent studies have suggested a that there is a connection with HSV-1 and AD. These studies support provide additional support of the idea that repeated reactivation of latent HSV-1 found in the brain may contribute to the symptoms associated with AD. Three recent studies examined the link between Alzheimer’s disease and herpes. The suggested that an infection by the HSV may increase the likelihood of developing AD.

How to treat genital herpes

Antiviral drugs are available by prescription only. There are numerous drugs available on the market, but no current antiviral treatments can eliminate an HSV infection. Early treatment is very important with the first oral or genital infection. You need to be aware though, that treatment will not prevent the virus from moving into the nerves and causing chronic (long-term) infection. It may, however, decrease the severity of the symptoms and shorten the length of time of the outbreak. Alternative treatments include topical treatments and intravenous therapy for severe cases. One thing to remember though is that taking antiviral drugs do not prevent infected people from passing it to their partner. Always use protection when you or your partner is infected or if you just don’t know.

Agyemang, E., Magaret, A. S., Selke, S., Johnston, C., Corey, L., & Wald, A. (2018). Herpes Simplex Virus Shedding Rate: Surrogate Outcome for Genital Herpes Recurrence Frequency and Lesion Rates, and Phase 2 Clinical Trials End Point for Evaluating Efficacy of Antivirals. The Journal of infectious diseases. 218(11), 1691-1699. https://doi.org/10.1093/infdis/jiy372. 
Anderson, P. (2018). More evidence herpes virus strongly tied to Alzheimer’s. Medscape Medical News, Retrieved from https://www.medscape.com/viewarticle/903703?nlid=125655_4502&src=wnl_dne_181022_mscpedit&uac=143690SJ&impID=1776604&faf=1

Ashshi, A. M., Batwa, S. A., Kutbi, S. Y., Malibary, F. A., Batwa, M., & Refaat, B. (2015). Prevalence of 7 sexually transmitted organisms by multiplex real-time PCR in Fallopian tube specimens collected from Saudi women with and without ectopic pregnancy. BMC infectious diseases, 15(1), 569. https://doi.org/10.1186/s12879-015-1313-1
Biskup, U. G., Ursic, T., & Petrovec, M. (2015). Laboratory diagnosis and epidemiology of herpes simplex 1 and 2 genital infections. Acta Dermatovenerologica, 24, 31-35. doi: 10.15570/actaapa.2015.9
Centers for Disease Control and Prevention (CDC). (2017). Genital herpes - CDC fact sheet. Retrieved from https://www.cdc.gov/std/herpes/stdfact-herpes.htm
Clifton, S., Mercer, C. H., Sonnenberg, P., Tanton, C., Field, N., Gravningen, K., ... & Johnson, A. M. (2018). STI Risk Perception in the British Population and How It Relates to Sexual Behaviour and STI Healthcare Use: Findings From a Cross-sectional Survey (Natsal-3). EClinicalMedicine, 2-3, 29-36. https://doi.org/10.1016/j.eclinm.2018.08.001
Costa, C., Sidoti, F., Saldan, A., Sinesi, F., Balloco, C., Simeone, S., ... & Cavallo, R. (2012). Clinical impact of HSV-1 detection in the lower respiratory tract from hospitalized adult patients. Clinical Microbiology and Infection, 18(8), E305-E307. https://doi.org/10.1111/j.1469-0691.2012.03882.x
Franzen-Rohl, E., Schepis, D., Atterfelt, F., Franck, K., Wikstrom, A., …. Gains, H. (2017). Herpes simplex virus specific T cell response in a cohort with primary genital infection correlates inversely with frequency of subsequent recurrences. Sexually Transmitted Infections, 93, 169-174. 
http://dx.doi.org/10.1136/sextrans-2016-052811.

Fukuoka, T., Nakazato, Y., Miyake, A., Tamura, N., Araki, N., & Yamamoto, T. (2017). A case of urinary retention in the early stages of herpes simplex virus type-1 encephalitis. Clinical Neurology and Neurosurgery, 157, 17-18. https://doi.org/10.1016/j.clineuro.2017.03.011

Gnann Jr, J. W., & Whitley, R. J. (2016). Genital herpes. New England Journal of Medicine, 375(7), 666-674. DOI: 10.1056/NEJMcp1603178 

Gottlieb, S. L., Giersing, B., Boily, M. C., Chesson, H., Looker, K. J., Schiffer, J., ... & WHO HSV Vaccine Impact Modelling Meeting Working Group. (2017). Modelling efforts needed to advance herpes simplex virus (HSV) vaccine development: key findings from the World Health Organization Consultation on HSV Vaccine Impact Modelling. Vaccine. https://doi.org/10.1016/j.vaccine.2017.03.074
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Itzhaki, R. F. (2017). Herpes simplex virus type 1 and Alzheimer’s disease: possible mechanisms and signposts. The FASEB Journal, 31(8), 3216-3226. https://doi.org/10.1096/fj.201700360

Johnston, C., & Corey, L. (2016). Current concepts for genital herpes simplex virus infection: diagnostics and pathogenesis of genital tract shedding. Clinical Microbiology Reviews, 29(1), 149-161. DOI:10.1128/CMR.00043-15. 

Looker, K. J., Magaret, A. S., May, M. T., Turner, K. M., Vickerman, P., Gottlieb, S. L., & Newman, L. M. (2015). Global and regional estimates of prevalent and incident herpes simplex virus type 1 infections in 2012. PloS One, 10(10), e0140765. https://doi.org/10.1371/journal.pone.0140765.

Luginbuehl, M., Imhof, A., & Klarer, A. (2017). Herpes simplex type 1 pneumonitis and acute respiratory distress syndrome in a patient with chronic lymphatic leukemia: a case report. Journal of Medical Case Reports, 11(1), 329. https://doi.org/10.1186/s13256-017-1495-9.

Nakamura, Y., Nakajima, H., Kano, Y., Unoda, K., Ishida, S., & Kimura, F. (2016). Herpes simplex virus type 2-associated recurrent aseptic meningitis (Mollaret's meningitis) with a recurrence after 11-year interval: a case report. Rinsho shinkeigaku= Clinical Neurology, 56(11), 785-787. Retrieved from https://europepmc.org/abstract/med/27773908

Shey, M. S., Garrett, N. J., McKinnon, L. R., & Passmore, J. A. S. (2015). The role of dendritic cells in driving genital tract inflammation and HIV transmission risk: Are there opportunities to intervene? Innate Immunity, 21(1), 99-112. https://doi.org/10.1177/1753425913513815.

World Health Organization (WHO). (2017). Herpes simplex virus. Retrieved from http://www.who.int/news-room/fact-sheets/detail/herpes-simplex-virus

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