NOTE: THIS POST CONTAINS MATURE SUBJECT MATTER. ALTHOUGH IT IS NOT APPROPRIATE FOR CHILDREN, IT IS LIKELY REQUIRED READING FOR THOSE THIRTEEN AND OVER.
A teenager is seated on the exam table. Snuggled up beside her is the boyfriend – his mouth and nose covered by a yellow mask. The stated complaint on the chart is “unwell.” I read the triage note. The patient has a vaginal rash. It’s itchy, irritated, and it burns. It’s been there for a few days. She’s tried an over-the -counter cream for yeast infections – but it hasn’t helped at all. The boy has a coughing fit, and I wonder whether or not I have the right chart.
“Who’s the patient?” I say.
The boy points to his left. “It’s her,” he says. “They made me put on this mask cause I was hacking up a lung at the registration desk.”
She’s had yeast infections before – often after intercourse – and this one started the same way – a little burning and some irritation. This time, however, the anti-fungal remedy only seemed to make things worse. Now, she says, it’s so sore she can barely walk.
I ask a few more questions. She’s completely healthy, and takes no medications other than an oral contraceptive. She’s never been hospitalized, has never had surgery, doesn’t smoke, and drinks occasionally. Like her boyfriend, she’s in the eleventh grade. She’s sexually active but this boy, she says, is the only partner she’s ever had.
The boy raises one hand puts the other one on his heart. “Me too,” he says. “I swear. Nobody else.”
I give her a gown and tell her that I’ll return in a few minutes with a nurse. It’s her choice, I say, whether or not she wants her boyfriend in the room.
“It’s fine,” she says. “He can stay.”
I return with gloves, a vaginal tray, a flashlight, and a nurse. The boyfriend stands at the head of the bed and holds my patient’s hand. I only need a few seconds. I don’t need the speculum – everything I need to see is on the outside. I let her know that she can get dressed, and that I’ll be back.
The first similar case I remember seeing was just after I’d finished my training. A newlywed had just returned from a beach vacation. It was the first week of January and I was on locum in a small town, covering while a doctor and his family spent an extra week away on Christmas break. I’d had an intern with me that week – a skilled, enthusiastic young woman who became an asset during the rural ER’s long twenty-four hour shifts.
The patient was alone in the exam room, sitting on a chair, leaning forward. We entered and introduced ourselves. Her chart in hand, I asked if she worked in the area – her home address was eighty miles away. If she’d come from there, she’d have passed three hospitals and a dozen clinics on her way to me.
“No,” she said anxiously. “I took the afternoon off and came this far just to be sure I wouldn’t run into anyone I knew.” She wasted no time telling her story. “My husband and I just got married two weeks ago. We met a year ago, and I thought I could trust him, but now I’m not sure.” I felt like I was about to hear something from a tabloid’s advice column. “He told me he’d never had any sexually transmitted diseases, and I definitely know I’ve never had any. I’ve only had two other partners – both long-term relationships – and neither of them ever had any STDs.” She exhaled. “Anyway. We were in the Caribbean last week on our honeymoon. We tried some things we hadn’t tried before – some things were a little rough – and we were intimate with each other every day, sometimes several times a day.” She stood. “About mid-week, I started getting a little sore down below, but I just thought it was from all the activity. But now something’s definitely wrong. It’s all red and I can’t even pee without feeling like I’m being sliced by razor blades. The only way he could have given me an STD is if he cheated on me because we were both checked just a few months ago and we were clean.”
“Okay,” I said. “We’ll get you a gown and let you undress so we can have a look.”
I closed the door and the intern looked at me. “Do you think it’s an STD?”
“Maybe. I’d have to see it.”
“How do you approach the ethical aspect?” the intern said. “We had a case-study like this in medical school where the husband is found to be HIV positive, and he refuses to tell his wife. As the doctor, you can’t break your confidentiality agreement. And what if she’s the one who was fooling around, not him?”
“Let’s wait until we see it first.”
Moments later, we were back in the room, flashing a light toward the inflamed area. It looked terrible. And painful. Surrounding her vulva were tiny red blisters, and some of them wept fluid. No wonder it hurt to pee. It would be like pouring acid onto a burn. “Do you know what this is?” I asked the intern.
“No,” she said. “Do you?”
“Yes.” I took a swab and brushed it against one of the blisters. “We’ll send this away for confirmation.” I placed the swab into a fluid filled tube and capped it. “You can get dressed and we’ll be back in about five minutes to chat.”
“Is it an STD?” the patient said.
“Kind of. You can get dressed and I’ll be back in a sec.”
I return to the eleventh graders and tell them that although I took a swab to confirm the diagnosis, I’m ninety-nine-point-nine percent certain that it’s genital herpes.
She gasps and looks to her masked boyfriend. “Oh my god,” she says. “I swear, I haven’t been with anyone but you. You lied to me.”
“I didn’t lie,” he says. “I swear. I’ve never slept with anyone else either.” He points toward his mid-section. “Plus, you know I’ve never had any bumps or rashes down there! Don’t look at me!”
“Herpes,” she says, looking at me. “It’s a sexually transmitted disease, right? I had to get it from someone, didn’t I?”
In his book, The Night Shift, radio personality Brian Goldman recounts the tale of a twenty-year old female ER patient with the classic symptoms of a genital herpes outbreak. When informed of the diagnosis, Goldman tells, his patient doesn’t believe it, citing that she and her boyfriend didn’t “sleep around.” He explains to his patient that, perhaps, her boyfriend had a blister, and that he didn’t know what it was – and during intimacy, he transmitted the virus to her. “This version she could handle,” he writes. “I didn’t think for a second that he didn’t know. A genital herpes outbreak is not something you can pass off as a minor rash.” He goes on to suggest that “her boyfriend had passed the virus on to her uncaringly.”
Transmission, however, isn’t that simple. Her boyfriend may well have been the source of the virus, but it may have originated from something as simple as a kiss from his mother when he was a child.
I look to the teenage couple. “Okay, so you both say that you’ve only been intimate with each other, right?”
“Then let me ask you.” I look to the boy. “Do you ever get cold sores around your mouth? And if you do, is it possible that through an intimate encounter, you transmitted the herpes virus from your lips to your girlfriend?”
“Oh my God,” the girl says.
The boy lowers his mask. On the corner of his upper lip, there is a large blister – a cold sore – herpes labialis.
I ask if they learned about this form of transmission in sex-ed. No, they say – they had no idea that a cold sore could cause genital herpes.
I returned to the exam room with my intern. The newlywed was dressed, and ready to leave. I asked her a few questions and she confirmed my suspicion: her husband had developed a cold sore on the sunny beach toward the end of the week. And in the days before the cold sore appeared, there had been direct lip-to-labia contact.
I explained to her that the virus would stay with her for life. The current outbreak would settle, but then, the virus would live dormant in her nervous system forever. It could come out at any time, especially in times of physiological or psychological stress. “And if you feel any tingling, or burning down there, avoid sexual activity until the episode has settled, or your partner may get it as well.”
“You mean there’s nothing I can do to make it go away forever?”
“There’s nothing,” I said.
I turned to my intern. “This is something that needs to be taught in the seventh and eighth grades, in clear and direct language. You can get genital herpes from a cold sore. Period.”
I continue to see patients like this – not every day, or even every week, but here and there, every so often. The problem is, that once it’s there – it’s there for life. Only education and appropriate precautions can help prevent transmission.