Genital herpes in women

Genital herpes cause two serotypes of the herpes simplex virus: HSV-1 and HSV-2; most often HSV-2.

Herpes simplex virus causes the pathology of pregnancy and childbirth, often leads to "spontaneous" abortion and fetal death or causes a generalized infection in newborns. There is a connection between genital herpes and cervical cancer.

Epidemiology

Herpes is one of the most common human viral infections. More than 90% of the world's people are infected with the herpes simplex virus (HSV) and up to 20% of them have certain clinical manifestations of infection.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Causes of the genital herpes in women

The causative agent, the Herpes simplex type 1 and 2 virus (HSV-1 and HSV-2), causes an infection characterized by lifelong carriage of the virus and its periodic reproduction, leading to the development of a clinical recurrence, or proceeding asymptomatically. The frequency of recurrence of HSV-2 is very high (in 98% of patients).

Ways of transmission of genital herpes:

• contact:
  • direct contact (household, sexual);
  • indirect contact (household items, dishes, toys, medical instruments);
• air-drip;
• transplacental (from mother to fetus and passing through the birth canal);
• parenteral (transplantation of organs and tissues, artificial insemination with infected donor sperm).

About 50% of the primary genital herpes is caused by HSV-1 and transmitted with orogenital contact. Self-infection with the available HSV-1 (orolabial) is very rare. Possible asymptomatic transmission of the virus (especially HSV-2).

Among different populations of the population there is a different prevalence of this virus. From 8 to 83% of female patients have antibodies to the herpes virus (seropositive). Among prostitutes, the frequency of detection of antibodies is from 75 to 96% and among blood donors from 5 to 18%. In pregnant women, the prevalence of HSV-2, according to serological studies conducted in various countries of the world, varies from 6 to 55%, and the prevalence of HSV-1 is 50-70%. 75% of seropositive people never had any symptoms.

[11], [12], [13], [14], [15]

Risk factors

• Prostitution.
• Numerous and occasional sexual relations.
• Homosexuality.
• Rare use of barrier methods of contraception and spermicides.
• The presence of other STIs.
• Erosive-ulcerative lesions of the genitals.
• Immunodeficiency conditions.

[16], [17], [18], [19]

Symptoms of the genital herpes in women

The incubation period is from 1 to 26 days, an average of about 7 days.

Genital herpes is characterized by the periodic appearance on the skin and mucous membranes of foci of lesions with varying degrees of severity and active release of HSV, which manifests itself in the form of various clinical forms:

• manifest,
• atypical,
• abortive,
• subclinical.

The manifestation of recurrent genital herpes is characterized by the typical development of herpetic elements in the lesion. Constant symptoms of genital herpes are vesicles, erosions, sores, exudation, recurrent nature of the disease. Patients with genital herpes often complain of malaise, headache, sometimes subfebrile temperature, sleep disturbance, nervousness. Usually at the beginning of the disease there is a burning sensation, itching and pain in the genital area. The affected area slightly swells, reddens, then a group of small vesicles of 2-3 mm appears on the hyperemic ground.

Among variants of the atypical form of recurrent genital herpes, women have edematic and itchy forms. The lesion focus can be represented by deep recurrent cracks in the tissues of small and large labia, which are self-epithelialized within 4-5 days.

The abortive form of genital herpes is usually found in patients who have previously received antiviral treatment and vaccine therapy. The focus of defeat in abortive flow passes some stages characteristic of the manifest form, and can manifest as an itchy patch or papules resolving in 1-3 days.

Subclinical form of genital herpes is usually detected when examining sexual contacts of patients suffering from STDs or couples with impaired fertility. This form is characterized by microsymptomatics (a short-term appearance on the mucous membrane of the external genitalia of surface cracks, accompanied by a slight itch).

Symptoms of genital herpes are directly related to the site of the lesion, the intensity of the inflammatory process, the duration of the disease, the body's ability to protect immunological responses and the virulence of the strain of the virus.

Neonatal herpes

• A rare but serious threat to the health of the child.
• Antenatal infection is rare.
• Herpes viruses infants are more often infected during passage through the birth canal of the mother.
• In newborns born to mothers with a primary infection that occurred immediately before birth, the risk of developing the disease increases (more than 50%), regardless of whether the mother had an asymptomatic infection or had symptoms.
• The clinical picture can develop immediately after the birth of the child, but can also after 4-6 weeks after childbirth.

[20], [21], [22], [23]

Symptoms of herpetic infection in newborns

• Generalized herpetic infection with liver, central nervous system and other organs with / without skin lesions (incubation period about 1 week).
• Isolated lesion of the central nervous system without skin or visceral manifestations (incubation period 2-4 weeks).
• Lesions of skin, conjunctiva and oral mucosa without involvement of the central nervous system or internal organs (incubation period 1-3 weeks). Newborns with skin lesions can give neurological complications, so these children should receive parenterally acyclovir.
• Postnatal infection of HSV is rare, but it is possible with primary contact with the mother or someone with a herpetic infection.

Stages

Depending on the location and degree of severity of lesions in patients with genital herpes, three stages are conventionally identified:

1. I stage - defeat of external genital organs;
2. Stage II - herpetic colpitis, cervicitis and urethritis;
3. III stage - herpetic endometritis, salpingitis or cystitis.

In women, herpetic lesions are usually localized in small and large labia, in the vulva, clitoris, vagina and cervix. Herpetic vesicles form characteristic polycyclic scalloped figures. Subsequently, superficial, greyish-coated ulcers are formed according to the number of former bubbles or continuous erosion with a smooth bottom and unsintered edges surrounded by a bright red rim. The sores are not deep and do not bleed. Herpetic ulceration is sometimes very painful. Sores and erosions heal without leaving scars. Herpetic eruptions on small lips and vulva in women, in some cases, cause significant swelling of the labia. In herpetic lesions, the cervix is edematous, often eroded. Relapses occur either spontaneously, or after sexual intercourse, or after menstruation. Often the appearance of genital herpes is provoked by other infections. Herpetic recurrent infection can affect not only the area of the vulva, but also the mucous membrane of the vagina, the cervix and penetrate the ascending pathway into the mucous membrane of the uterus and tubes, the urethra and the urinary bladder, causing a specific lesion in them.

Complications and consequences

• Extragenital herpes with nasopharynx, ophthalmoherpes.
• Generalized herpesviral infection.
• In pregnant women, genital herpesvirus infection can cause a risk of neonatal meningitis in the fetus when passing through the herpetic pathogens infected by herpes.

[24], [25], [26], [27]

Diagnostics of the genital herpes in women

Methods of laboratory diagnosis of genital herpes

• Direct immunofluorescence (PIF) - the detection of virus antigens when processing material with specific fluorescent AT.
• Molecular biological methods (PCR in real time) - the detection of DNA virus.
• Isolation of the virus in the cell culture.
• Serological diagnosis (immuno-enzyme analysis (ELISA)) is not critical (about 90% of the population of Russia are seropositive). To establish the fact of primary infection in pregnant women, it is necessary to determine IgG, IgM and determine the IgG avidity index. The presence of low-grade antibodies (the avidity index is below 30%) indicates an acute, first-emerged infection.

The material for the study is the contents of the vesicles and / or detachable from the erosive ulcerative surface of the manifestations on the skin and mucous membranes, with asymptomatic forms - scraping of the urethral epithelium and / or cervical canal. For serological examination, blood is taken from the vein.

The material must be taken during the virus isolation period: with primary infection it lasts about 12 days, with relapse - about 5 days.

When complications develop, consultation of related specialists is required.

The order of the doctor's actions with the established diagnosis of genital herpesvirus infection

1. Tell the patient about the diagnosis.
2. Presentation of information about the behavior of the patient. Genital herpes is a recurrent and incurable infection. Therefore, counseling is considered a major part of patient management. All patients who have genital herpes and their sexual partners should be aware of their chronic illness.
3. Advise patients with genital herpes.
   • It is necessary to explain the nature of the disease, focusing on the recurring nature of the disease, frequent asymptomatic course and sexual transmission. The sex route of transmission is possible with asymptomatic flow, in the absence of any damage. In this case, it is necessary to discuss with the patient the measures to prevent infection.
   • Inform the patient that during the rash it is necessary to abstain from sexual activity and inform your sexual partner about the presence of genital herpes. During a sexual relationship with a new sexual partner, you must use a condom.
   • Condoms are not effective enough to prevent the transmission of herpesvirus infection, as there may be other localization of lesions or asymptomatic flow, and the risk of transmission of infection by the orogenital route is high. The patient needs to discuss other methods of safe sex.

When recommending monogamous couples to use condoms for a long time, it is necessary to weigh all the pros and cons.

• Discuss the risk of developing infection in newborns with their patients, including men. Women who have genital herpes should be advised to report this when registering for pregnancy, which will ensure observation (especially over the course of herpetic infection) throughout the pregnancy.
• Patients with a primary episode of genital herpes should be advised to conduct short-term antiviral therapy, which reduces the duration of the rash, as well as prolonged suppressive antiviral therapy that reduces the number of relapses.
• Follow-up counseling for patients with genital herpes is an important phase of patient management.

4. Gathering of a sexual anamnesis.
5. Identification and examination of sexual contacts is carried out depending on the clinical manifestations of the disease and the estimated duration of infection - from 15 days to 6 months. A patient with genital herpes should inform his / her sexual partner about the diagnosis so that he or she knows about the risk in case of infection and could help a partner in case the disease develops.

Patient education

Training of patients should be aimed at implementing measures to prevent infection of sexual partners.

[28], [29],

Treatment of the genital herpes in women

Therapy of genital herpes consists in the appointment of antiviral drugs (Aciclovir (Zovirax), Famciclovir (Famvir), Valaciclovir (Valtrex) .They:

• Accelerate the healing process of sores.
• Reduce the severity, intensity and duration of symptoms.
• Reduce the frequency of recurrence of the disease.
• Minimize the likelihood of transmission of the herpes simplex virus.

Therapy lasts from 7 to 10 days.

Prevention

Preventive measures for genital herpes are common to all STIs. To prevent the development of herpetic infection in newborns - with a primary clinically pronounced infection in the mother before giving birth (the presence of bubble rashes in the genital tract) shows caesarean section.

[30], [31], [32], [33], [34],

Forecast

In case of inadequate treatment of genital herpes, complications may develop.

[35], [36], [37],