Genital herpes in women is a persistent infection caused by HSV–1, 2 and occurring with a specific lesion of the mucous membranes of the genitals. It is manifested by periodic vesicular rashes in the urogenital tract, which are accompanied by erosion, exudation, burning sensation and soreness. General well-being is often disturbed: there is subfebrility, malaise, sleep disturbance. Diagnosis of genital herpes in women is based on laboratory indication of the herpes simplex virus (PCR, HSV isolation on cell culture), its antigens (PIF) or antibodies to it (ELISA). Treatment of herpes infection is carried out with antiviral and immunomodulatory drugs.
Genital herpes in women is a form of herpetic infection in which local manifestations are localized mainly in the urogenital tract. It refers to sexually transmitted diseases, which gives grounds to consider it both from the standpoint of gynecology and venereology. It is characterized by the lifelong presence of the virus in the body, recurrent course, progressive development. In the structure of STIs, genital herpes is in third place in prevalence, second only to gonorrhea and other specific urethritis. About 20 million people are registered in USA every year. new cases of genital herpes.
Women are infected with genital herpes 2 times more often than men, even with the same number of sexual contacts during their lifetime. The highest peaks of morbidity are observed in the age periods of 20-24 years and 35-40 years. The reproductive system of 25% of women of the reproductive period is infected with herpesvirus infection, but the true situation is unknown due to the high frequency of unrecognized or latent forms. At the same time, even asymptomatic genital herpes in women poses a threat to reproductive health, often causing miscarriage, intrauterine infection of the fetus, perinatal mortality, severe congenital deformities.
According to research, more than 70% of cases of genital herpes are caused by HSV type 2 and about 30% by HSV type 1. The carrier and distributor of genital herpes is an infected person, both with manifest and latent course. Infection is mainly carried out sexually: with genital, oral-genital, anal-genital contacts. Contact (through a shared bathroom and hygiene items) and medical routes of infection (through medical staff gloves, reusable tools) are less common. There may also be cases of self-infection when the virus is transferred from the oral cavity to the genitals and transplacental infection of the fetus from a sick mother. The entrance gates for HSV are the mucous membranes of the genitals.
The most significant risk factors for infection of women with genital herpes are the onset of sexual activity in adolescence, unprotected sexual intercourse, a large number of sexual partners. During sexual intercourse with a patient with a manifest form of genital herpes infection occurs in 75-80% of cases. Genital herpes in women is often associated with other STIs, primarily gonorrhea. In addition, the presence of ulcers and micro-lesions of the mucous membranes facilitates the transmission of HIV infection.
After replication at the site of primary invasion, the herpes virus transneurally or hematogenically reaches the paravertebral ganglia of the lumbosacral spine, where it persists throughout life. Under the influence of triggering factors (stress, colds, insolation, fatigue, menstruation, and others), the latent virus is reactivated. HSV migrates along the axons of peripheral nerves to the epithelial cells of the genital organs, which is accompanied by the resumption of the genital herpes clinic in women.
Taking into account the clinical situation and the nature of the course , there are:
- primary genital herpes – at the time of diagnosis, extragenital manifestations of herpes have never occurred in the patient; there are no antibodies to HSV type in the blood;
- the first episode of genital herpes – at the time of diagnosis, the patient had extragenital manifestations of herpes; At to HSV are present in the blood, but genital herpes occurs for the first time;
- recurrent genital herpes – symptoms of genital herpes in a woman occur repeatedly;
- asymptomatic viral discharge – the patient has no genital manifestations of herpes, but this does not exclude the possibility of infection of the sexual partner.
The severity of the course of genital herpes in women is determined taking into account the frequency of exacerbations: with a mild degree, exacerbations occur 1-3 times a year, with an average – 4-6 times a year, with a severe degree – every month.
Depending on the localization and prevalence of genital herpes, there are 3 stages:
- the skin of the perineum and the mucous membrane of the external genitals (herpetic vulvitis) are affected
- affects the vagina, vaginal portion of the cervix, cervical canal, urethra (herpetic vulvovaginitis, urethritis, colpitis, endocervicitis)
- affects the uterus, fallopian tubes, bladder (herpetic endometritis, salpingitis, cystitis). In addition to the genitourinary system, the anus and rectal ampoule may be involved in the infectious process.
Primary genital herpes
During primary genital herpes in women , there are five periods: 1) incubation, 2) prodroma, 3) rashes, 4) reverse development, 5) healing.
The incubation period preceding the clinical manifestation of infection can last from 2 to 14 days. At this time, due to the minimal replication of the virus, there are no symptoms.
During the prodromal period, general and local manifestations gradually increase. Malaise occurs, subfebrility appears, chills and myalgia are possible. Of the local symptoms, the most typical are itching and paresthesia in the area of the external genitals, whiteness, dysuria.
The period of rashes is characterized by the appearance of pathognomonic herpetic vesicles on the mucous membranes. Herpetic vesicles with a diameter of 2-3 mm with transparent contents are located in small groups on erythematous areas. Periodically, new elements are added. With the appearance of a rash, the general symptoms become less pronounced, but local manifestations (itching, burning, swelling, pain) persist. Against this background, the patient’s sleep is disturbed, nervousness appears. The duration of this phase of genital herpes in women is up to 7-10 days.
During the period of stabilization and reverse development of the rash, the bubbles become cloudy, open, forming wet erosions. Sometimes irregular ulcers up to 1 mm deep form in place of vesicles. Single erosions can merge into a continuous erosive surface. Erosions and ulcers are painful, do not bleed, but may be covered with a purulent coating.
The healing period is characterized by the subsiding of local and general symptoms. Erosive and ulcerative elements dry out, become covered with a thin crust, under which epithelialization processes occur. After the crust falls off, the scar does not form, but hyperemia or pigmentation remains for some time. Taking into account the last two periods, each of which lasts 2-3 weeks, the total duration of the primary episode of genital herpes in women is 5-7 weeks.
Recurrent genital herpes
Recurrent genital herpes in women can occur in a typical (manifest) and atypical clinical form. At the same time, the typical form implies the presence of vesicular erosive herpetic rashes in the area of the external genitals. The duration of repeated episodes is shorter than the primary form – 7-10 days.
Atypical forms can be represented by edematous, itchy, abortive and subclinical variants.
- The predominant symptoms of the edematous variant are diffuse edema and hyperemia of the vulva.
- With an itchy variant, deep, poorly healing cracks and pronounced itching of the mucous membrane are mainly bothered.
- The abortive variant of genital herpes develops in women who have previously received vaccination or antiviral therapy. In this form, some stages of infection are absent, itchy papules regress within 2-3 days.
- The subclinical variant of herpes occurs with microsymptomatics (itching, surface cracks) or without clinical manifestations.
Various atypical forms may be accompanied by persistent genital tract bleaching, vulvodynia, cervical pathology (pseudoerosion, cervical leukoplakia), vulvar and vaginal condylomas, pelvic ganglioneuritis. Genital herpetic infection can be complicated by sacral radiculopathy, ischuria, meningitis, hepatitis, disseminated infection with damage to several organs. Women suffering from genital herpes are at risk for developing cervical cancer.
Laboratory and instrumental examination includes assessment of the patient’s anamnesis and complaints, examination by a gynecologist, analysis of biological secrets. To confirm the herpetic etiology of infection, virological diagnostics is carried out: detection of virus DNA by PCR, isolation of the virus on cell culture, detection of HSV antibodies in blood serum (ELISA) and antigens in the test material (PIF). The object of the study may be blood, vesicle contents, scrapings from the urogenital tract, prints from erosions, etc.
During gynecological examination in the acute period, rashes and ulceration are found in the area of the external genitals. Genital herpes in women is differentiated with dermatitis, scabies, lichen planus, pemphigus, contagious mollusc, streptococcal impetigo, STIs (syphilis, venereal granuloma).
To date, there is no drug that can eliminate HSV. Therefore, drug therapy is aimed at reducing the number of relapses, reducing the duration and severity of clinical manifestations of genital herpes in women. Examination and treatment of a sexual partner is mandatory.
Etiopathogenetic therapy involves the use of antiviral drugs (acyclovir, valacyclovir, famciclovir). The dose and regimen of the drug is selected taking into account the form and severity of genital herpes. Additionally, local treatment of the affected areas with antiviral gels, creams, ointments, aerosols is prescribed. Cracks and erosions can be treated with antiseptics and aniline dyes.
Immunomodulators (thymus preparations, meglumin, interferon alpha-2b, etc.) are used to stimulate the formation of antibodies and the production of endogenous interferons. Patients with recurrent genital herpes are vaccinated with a herpetic vaccine. The introduction of antiherpetic immunoglobulin (passive immunization) is indicated only for people with immunodeficiency: pregnant women, patients with generalized infection, etc. Plasmapheresis sessions allow to increase the duration of remission and reduce the titer of antibodies to HSV. The prevention of genital herpes in women is common with the prevention of all STIs.