What are varicose veins?
Varicose veins, also known as varices or varicosities, are bulging, twisted veins that usually appear in the legs and are a form of chronic venous disease. Clinically, a varicose vein is defined as a dilated vein 3 mm in diameter or larger, as measured in the upright (standing) position.[1] The two veins most commonly affected are the greater saphenous vein and the small saphenous vein, both of which are found in the leg; varicose veins in other parts of the body, such as the pelvis, are less common. Varicosities can occur in one or several veins and may change in size or appearance over time. They may cause discomfort, but serious complications are rare. Without treatment, they do not go away.
What are the main signs and symptoms of varicose veins?
While the appearance of varicose veins can be cosmetically concerning, they rarely cause serious complications and may even be asymptomatic. When symptoms do occur, the most common are aching, tightness, burning, itching, tingling, throbbing, tenderness, and swelling in the legs. These symptoms are often worse at the end of the day, especially after prolonged sitting or standing, and may resolve with leg elevation. Restlessness, heaviness in the legs, and nocturnal leg cramps are also symptoms of varicose veins. Less common but more serious complications can include vein infections and blood clots.[2][3]
How are varicose veins diagnosed?
Varicose veins are diagnosed by consideration of symptoms (when present) in combination with a physical examination to identify the presence, location, and severity of varicose veins. The exam may be done in a standing position to better assess venous dilation, and often includes checking pulses and looking for skin changes. In some cases (especially symptomatic ones), an imaging test called a duplex venous ultrasound may be completed to more closely evaluate the veins. An ultrasound can determine how well blood is flowing through the veins and where there may be improperly working valves that are causing blood to flow backwards (called venous reflux). This test is painless and noninvasive. Varicose veins are clinically classified using the class, etiology, anatomy, and pathophysiology (CEAP) system, which ranks the presence and severity of chronic venous disorders on a continuum from no venous disease to active venous ulcers.[1]
What are some of the main medical treatments for varicose veins?
Medical treatments vary depending on the severity of the condition and patient preferences. People without symptoms or cosmetic concerns may not require any treatment. Mild to moderate cases may respond to conservative management, which includes using compression stockings (or socks) and certain lifestyle modifications, like avoiding prolonged standing or straining, performing exercise, wearing nonrestrictive clothing, reducing cardiovascular disease risk factors, losing weight, and elevating the affected leg(s). The goal of these strategies is threefold: to improve blood flow in the veins and prevent blood from pooling; to reduce venous swelling and inflammation; and to compress dilated veins. While conservative management may reduce symptoms, it usually does not drastically change the appearance of the veins. For example, a 2021 systematic review on the use of compression stockings as a first-line treatment for varicose veins found that stockings improved symptoms but did not reduce the progression or recurrence of the disease.[4]
There are some medications that can help people with varicose veins. Diosmiplex (Vasculera) is a medical food derived from orange rinds and is used in the treatment of varicose veins. Topical steroid creams or ointments may be used to treat rashes that are secondary to varicose veins.
People with persistent symptoms, severe complications, or cosmetic concerns may opt for interventional treatments, like thermal ablation (endovenous or radiofrequency ablation), sclerotherapy, and surgery to remove affected veins. While each of these is effective, thermal ablation and sclerotherapy are less invasive and may be initially preferred over other surgical procedures.[5]
Have any supplements been studied for varicose veins?
Phlebotonics are broadly characterized as a group of venoactive compounds that are used to treat varicose veins and other chronic venous disorders. They include natural flavonoids extracted from plants and synthetic compounds with flavonoid-like properties. Many work by increasing venous tone, decreasing the permeability of capillaries, fighting inflammation, improving lymphatic drainage, or making blood less viscous. Some examples are aminaftone, calcium dobesilate, Gotu Kola (Centella asiatica), diosmin, hidrosmin, French pine bark extract (Pycnogenol), grape seed extract, and rutosides. A systematic review from 2020 concluded that there was low to moderate-certainty evidence that phlebotonics may reduce edema, pain, cramps, restless legs, and lower-leg swelling.[6] The evidence for most phlebotonics is limited, but horse chestnut seed extract[7] and French pine bark extract[8] are two phlebotonics that may be effective for treating signs and symptoms of varicose veins.
How could diet affect varicose veins?
The direct effect of diet on varicose veins has been insufficiently studied. A Mendelian randomization study concluded that higher genetically-predicted iron levels were associated with an increased risk of varicose veins, while calcium, magnesium, and zinc were inversely associated with varicose vein risk. The risk for varicose veins was increased with higher alcohol consumption and decreased with higher coffee consumption.[9] The following dietary patterns have been reported among patients with venous leg ulcers: Lower intakes of omega-3 fatty acids, vitamins A and D, and zinc; a higher omega-3:omega-6 ratio; an excessive intake of sodium, saturated fat, and sugar; and an inadequate intake of fruits and vegetables.[10][11] While a diet low in fiber and high in refined carbohydrates has been linked to the risk of varicose veins, this relationship is not well-established.[12][13]
Are there any other treatments for varicose veins?
There is data to support the effectiveness of a variety of exercise programs in improving both the function of varicose veins and overall quality of life. Exercise improves endothelial function and circulation in people with varicose veins, even when physical activity levels are initially low and exercise capacity is reduced.[14] Indeed, structured exercise training improves calf muscle pump function in people with varicose veins (chronic venous insufficiency).[15] Balneotherapy and aquatic exercise also improve quality of life, pain, edema, and functional parameters (i.e., venous function) among varicose vein patients.[16][17] For post-surgical varicose vein patients, treadmill exercise improves microvascular endothelial function,[18][19] although therapeutic exercise (i.e., stretching, ankle-strengthening exercises, foot and ankle flexion/extension) may not improve quality of life in this population.[20]
Because overweight and obesity are associated with an elevated risk for varicose veins, people with these conditions may experience a reduction in symptoms with weight loss.[21][22][23][24] However, there are no studies directly investigating the effect of weight loss on quality of life, symptoms, or functional measures among people with varicose veins. Avoiding prolonged standing and reducing cardiovascular disease risk factors, such as high blood pressure, may also reduce varicose vein symptoms.[2]
What causes varicose veins?
Varicose veins are caused by a combination of genetic and environmental factors that ultimately lead to venous dysfunction. Normally, healthy veins return blood to the heart with the help of skeletal muscle pumps (which are activated during muscle contraction) and one-way valves (which prevent blood from flowing backward).[25]
In people with varicose veins, these mechanisms do not work properly, often due to high blood pressure, insufficient one-way valve function, or structural/functional changes to the walls of the veins. Consequently, blood begins to flow backwards (venous reflux), increasing venous blood pressure. Over time, this leads to weaker blood vessel walls, dilated (stretched) blood vessels, and dysfunctional one-way valves. The result is the appearance of large, discolored, and twisting veins in the lower extremities.
High blood pressure and altered blood flow patterns in the veins also elevate levels of inflammatory cytokines, lymphocytes, neutrophils, monocytes, macrophages, and other growth factors, which further contribute to venous remodeling and structural damage.[26] All of these processes are enhanced in the presence of risk factors, such as obesity, pregnancy, tall height, a family history of varicose veins, age, smoking, and occupations that require prolonged standing or sitting.[26]
Examine Database: Varicose Veins
Frequently asked questions
Varicose veins, also known as varices or varicosities, are bulging, twisted veins that usually appear in the legs and are a form of chronic venous disease. Clinically, a varicose vein is defined as a dilated vein 3 mm in diameter or larger, as measured in the upright (standing) position.[1] The two veins most commonly affected are the greater saphenous vein and the small saphenous vein, both of which are found in the leg; varicose veins in other parts of the body, such as the pelvis, are less common. Varicosities can occur in one or several veins and may change in size or appearance over time. They may cause discomfort, but serious complications are rare. Without treatment, they do not go away.
While the appearance of varicose veins can be cosmetically concerning, they rarely cause serious complications and may even be asymptomatic. When symptoms do occur, the most common are aching, tightness, burning, itching, tingling, throbbing, tenderness, and swelling in the legs. These symptoms are often worse at the end of the day, especially after prolonged sitting or standing, and may resolve with leg elevation. Restlessness, heaviness in the legs, and nocturnal leg cramps are also symptoms of varicose veins. Less common but more serious complications can include vein infections and blood clots.[2][3]
Varicose veins are diagnosed by consideration of symptoms (when present) in combination with a physical examination to identify the presence, location, and severity of varicose veins. The exam may be done in a standing position to better assess venous dilation, and often includes checking pulses and looking for skin changes. In some cases (especially symptomatic ones), an imaging test called a duplex venous ultrasound may be completed to more closely evaluate the veins. An ultrasound can determine how well blood is flowing through the veins and where there may be improperly working valves that are causing blood to flow backwards (called venous reflux). This test is painless and noninvasive. Varicose veins are clinically classified using the class, etiology, anatomy, and pathophysiology (CEAP) system, which ranks the presence and severity of chronic venous disorders on a continuum from no venous disease to active venous ulcers.[1]
Medical treatments vary depending on the severity of the condition and patient preferences. People without symptoms or cosmetic concerns may not require any treatment. Mild to moderate cases may respond to conservative management, which includes using compression stockings (or socks) and certain lifestyle modifications, like avoiding prolonged standing or straining, performing exercise, wearing nonrestrictive clothing, reducing cardiovascular disease risk factors, losing weight, and elevating the affected leg(s). The goal of these strategies is threefold: to improve blood flow in the veins and prevent blood from pooling; to reduce venous swelling and inflammation; and to compress dilated veins. While conservative management may reduce symptoms, it usually does not drastically change the appearance of the veins. For example, a 2021 systematic review on the use of compression stockings as a first-line treatment for varicose veins found that stockings improved symptoms but did not reduce the progression or recurrence of the disease.[4]
There are some medications that can help people with varicose veins. Diosmiplex (Vasculera) is a medical food derived from orange rinds and is used in the treatment of varicose veins. Topical steroid creams or ointments may be used to treat rashes that are secondary to varicose veins.
People with persistent symptoms, severe complications, or cosmetic concerns may opt for interventional treatments, like thermal ablation (endovenous or radiofrequency ablation), sclerotherapy, and surgery to remove affected veins. While each of these is effective, thermal ablation and sclerotherapy are less invasive and may be initially preferred over other surgical procedures.[5]
Phlebotonics are broadly characterized as a group of venoactive compounds that are used to treat varicose veins and other chronic venous disorders. They include natural flavonoids extracted from plants and synthetic compounds with flavonoid-like properties. Many work by increasing venous tone, decreasing the permeability of capillaries, fighting inflammation, improving lymphatic drainage, or making blood less viscous. Some examples are aminaftone, calcium dobesilate, Gotu Kola (Centella asiatica), diosmin, hidrosmin, French pine bark extract (Pycnogenol), grape seed extract, and rutosides. A systematic review from 2020 concluded that there was low to moderate-certainty evidence that phlebotonics may reduce edema, pain, cramps, restless legs, and lower-leg swelling.[6] The evidence for most phlebotonics is limited, but horse chestnut seed extract[7] and French pine bark extract[8] are two phlebotonics that may be effective for treating signs and symptoms of varicose veins.
The direct effect of diet on varicose veins has been insufficiently studied. A Mendelian randomization study concluded that higher genetically-predicted iron levels were associated with an increased risk of varicose veins, while calcium, magnesium, and zinc were inversely associated with varicose vein risk. The risk for varicose veins was increased with higher alcohol consumption and decreased with higher coffee consumption.[9] The following dietary patterns have been reported among patients with venous leg ulcers: Lower intakes of omega-3 fatty acids, vitamins A and D, and zinc; a higher omega-3:omega-6 ratio; an excessive intake of sodium, saturated fat, and sugar; and an inadequate intake of fruits and vegetables.[10][11] While a diet low in fiber and high in refined carbohydrates has been linked to the risk of varicose veins, this relationship is not well-established.[12][13]
There is data to support the effectiveness of a variety of exercise programs in improving both the function of varicose veins and overall quality of life. Exercise improves endothelial function and circulation in people with varicose veins, even when physical activity levels are initially low and exercise capacity is reduced.[14] Indeed, structured exercise training improves calf muscle pump function in people with varicose veins (chronic venous insufficiency).[15] Balneotherapy and aquatic exercise also improve quality of life, pain, edema, and functional parameters (i.e., venous function) among varicose vein patients.[16][17] For post-surgical varicose vein patients, treadmill exercise improves microvascular endothelial function,[18][19] although therapeutic exercise (i.e., stretching, ankle-strengthening exercises, foot and ankle flexion/extension) may not improve quality of life in this population.[20]
Because overweight and obesity are associated with an elevated risk for varicose veins, people with these conditions may experience a reduction in symptoms with weight loss.[21][22][23][24] However, there are no studies directly investigating the effect of weight loss on quality of life, symptoms, or functional measures among people with varicose veins. Avoiding prolonged standing and reducing cardiovascular disease risk factors, such as high blood pressure, may also reduce varicose vein symptoms.[2]
Elevated BMI increases the risk for varicose veins.[9] Women (especially postmenopausal women) with overweight or obesity are more likely to develop varicose veins,[23] but less consistent associations are observed in men, suggesting that pregnancy may be a confounding factor. Nonetheless, there’s some evidence that the prevalence of obesity is higher in people with varicose veins/chronic venous disease, but the direction of this relationship (i.e., whether the obesity or varicose veins appeared first) is not established.[12]
Despite the association between BMI and varicose veins, there are no studies investigating the effect of weight loss per se on the presence, symptoms, or development of varicose veins.
People with varicose veins may have impaired calf muscle pump function, poor lower-extremity venous valve function, and reduced endothelial function. Exercise improves calf muscle pump function, and aerobic exercise training (i.e., treadmill walking) can improve endothelial function in postsurgical varicose vein patients.[19] Conversely, there is limited evidence to support the benefits of exercise for the healing of venous leg ulcers — a more severe chronic venous disorder than varicose veins — when compared to usual care.[30]
A systematic review on the use of therapeutic exercise (i.e., flexibility, strength, resistance, and breathing exercises) for chronic venous disease concluded that there was insufficient evidence to support or refute the efficacy of any exercise in improving patients’ quality of life, pain, or physical functional performance. However, only four randomized controlled trials were included in this review, and while only one study found a benefit of exercise, the other three were rated as having a very low methodological quality.[20] Balneotherapy may result in an improvement in disease symptoms and severity, pain, and quality of life in patients with chronic venous disease.[31]
Varicose veins are caused by a combination of genetic and environmental factors that ultimately lead to venous dysfunction. Normally, healthy veins return blood to the heart with the help of skeletal muscle pumps (which are activated during muscle contraction) and one-way valves (which prevent blood from flowing backward).[25]
In people with varicose veins, these mechanisms do not work properly, often due to high blood pressure, insufficient one-way valve function, or structural/functional changes to the walls of the veins. Consequently, blood begins to flow backwards (venous reflux), increasing venous blood pressure. Over time, this leads to weaker blood vessel walls, dilated (stretched) blood vessels, and dysfunctional one-way valves. The result is the appearance of large, discolored, and twisting veins in the lower extremities.
High blood pressure and altered blood flow patterns in the veins also elevate levels of inflammatory cytokines, lymphocytes, neutrophils, monocytes, macrophages, and other growth factors, which further contribute to venous remodeling and structural damage.[26] All of these processes are enhanced in the presence of risk factors, such as obesity, pregnancy, tall height, a family history of varicose veins, age, smoking, and occupations that require prolonged standing or sitting.[26]
The risk for varicose veins increases with age due to “wear and tear” on the veins and an increase in cardiovascular disease risk factors. Less than 1% of men and 10% of women under the age of 30 are estimated to have varicose veins, but the prevalence increases to 57% of men and 77% of women over the age of 70.
A family history of varicose veins, female sex, overweight/obesity, pregnancy (multiple pregnancies further elevates risk), and being in an occupation that requires standing or sitting for extended periods of time or lifting heavy objects are risk factors for developing varicose veins.[2] A few studies have also indicated that varicose veins are associated with smoking, reduced physical activity, oral contraceptive use and hormone replacement therapy, and a history of diabetes, hypertension (high blood pressure), and injury to the extremities.[12]
Epidemiological studies suggest that a family history of varicose veins is a risk factor for developing the condition, but the specific genes that are responsible for the disease have yet to be identified. Genome-wide association studies indicate that heritability may account for around 28% of the variance in a person’s susceptibility to varicose veins; genes that are involved in height, vascular development and integrity, blood pressure, limb development, and skeletal abnormalities are associated with the condition.[24]
Some studies find that the presence of varicose veins is higher in women than men. A possible explanation for the increased risk in women is pregnancy: the frequency of varicose veins is higher in women who have had a child than in those who have never been pregnant.[27] In fact, each additional pregnancy further increases a woman’s risk of developing varicose veins. Other pregnancy-related risk factors for varicose veins include excessive weight gain, post-term pregnancy, and preeclampsia.[28]
Some women appear to develop varicose veins during pregnancy, indicating a causal relationship.[29] During pregnancy, there is an increase in intra-abdominal pressure which, along with weight gain, increases direct pressure on the veins of the lower extremities. Elevated pressure can rupture venous valves, leading to the development of venous reflux and the appearance of varicose veins. The hormones estrogen and progesterone — which increase during pregnancy — may also contribute to lower-extremity vein dilation and valve rupture.
In most women, even without treatment, varicose veins can resolve following pregnancy.[29]
References
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- ^Heller JA, Evans NSVaricose veins.Vasc Med.(2015-Feb)
- ^Allen HamdanManagement of varicose veins and venous insufficiencyJAMA.(2012 Dec 26)
- ^Knight Nee Shingler SL, Robertson L, Stewart MGraduated compression stockings for the initial treatment of varicose veins in people without venous ulceration.Cochrane Database Syst Rev.(2021-Jul-16)
- ^Raetz J, Wilson M, Collins KVaricose Veins: Diagnosis and Treatment.Am Fam Physician.(2019-Jun-01)
- ^Martinez-Zapata MJ, Vernooij RW, Simancas-Racines D, Uriona Tuma SM, Stein AT, Moreno Carriles RMM, Vargas E, Bonfill Cosp XPhlebotonics for venous insufficiency.Cochrane Database Syst Rev.(2020-Nov-03)
- ^Pittler MH, Ernst EHorse chestnut seed extract for chronic venous insufficiency.Cochrane Database Syst Rev.(2012-Nov-14)
- ^Belcaro G, Dugall M, Luzzi R, Ippolito E, Cesarone MRPostpartum Varicose Veins: Supplementation with Pycnogenol or Elastic Compression-A 12-Month Follow-Up.Int J Angiol.(2017-Mar)
- ^Yuan S, Bruzelius M, Damrauer SM, Larsson SCCardiometabolic, Lifestyle, and Nutritional Factors in Relation to Varicose Veins: A Mendelian Randomization Study.J Am Heart Assoc.(2021-Nov-02)
- ^Barber GA, Weller CD, Gibson SJEffects and associations of nutrition in patients with venous leg ulcers: A systematic review.J Adv Nurs.(2018-Apr)
- ^García-Rodríguez MT, Rodríguez-Parrado M, Seijo-Bestilleiro R, González-Martín CInfluence of Nutrition Status and Compression Therapy on Venous Ulcer Healing: A Systematic Review.Adv Skin Wound Care.(2023-Jan-01)
- ^Jennifer L Beebe-Dimmer, John R Pfeifer, Jennifer S Engle, David SchottenfeldThe epidemiology of chronic venous insufficiency and varicose veinsAnn Epidemiol.(2005 Mar)
- ^Elamrawy S, Darwish I, Moustafa S, Elshaer N, Ahmed NEpidemiological, life style, and occupational factors associated with lower limb varicose veins: a case control study.J Egypt Public Health Assoc.(2021-Jul-06)
- ^Erdal ES, Demirgüç A, Kabalcı M, Demirtaş HEvaluation of physical activity level and exercise capacity in patients with varicose veins and chronic venous insufficiency.Phlebology.(2021-Sep)
- ^Lyndsay Orr, Kathleen A Klement, Laura McCrossin, Deirdre O'Sullivan Drombolis, Pamela E Houghton, Sandi Spaulding, Shauna BurkeA Systematic Review and Meta-analysis of Exercise Intervention for the Treatment of Calf Muscle Pump Impairment in Individuals with Chronic Venous InsufficiencyOstomy Wound Manage.(2017 Aug)
- ^Mancini S, Piccinetti A, Nappi G, Mancini S, Caniato A, Coccheri SClinical, functional and quality of life changes after balneokinesis with sulphurous water in patients with varicose veins.Vasa.(2003-Feb)
- ^Bissacco D, Mosti G, D'Oria M, Lomazzi C, Casana R, Morrison N, Caggiati ARationale and current evidence of aquatic exercise therapy in venous disease: A narrative review.Vascular.(2022-May-19)
- ^Klonizakis M, Tew G, Michaels J, Saxton JImpaired microvascular endothelial function is restored by acute lower-limb exercise in post-surgical varicose vein patients.Microvasc Res.(2009-Mar)
- ^M Klonizakis, G Tew, J Michaels, J SaxtonExercise training improves cutaneous microvascular endothelial function in post-surgical varicose vein patientsMicrovasc Res.(2009 Jun)
- ^da Silva JL, Lima AG, Diniz NR, Leite JCEffectiveness of therapeutic exercises for improving the quality of life of patients with chronic venous insufficiency: a systematic review.J Vasc Bras.(2021-Jun-16)
- ^Sisto T, Reunanen A, Laurikka J, Impivaara O, Heliövaara M, Knekt P, Aromaa APrevalence and risk factors of varicose veins in lower extremities: mini-Finland health survey.Eur J Surg.(1995-Jun)
- ^Brand FN, Dannenberg AL, Abbott RD, Kannel WBThe epidemiology of varicose veins: the Framingham Study.Am J Prev Med.(1988)
- ^Iannuzzi A, Panico S, Ciardullo AV, Bellati C, Cioffi V, Iannuzzo G, Celentano E, Berrino F, Rubba PVaricose veins of the lower limbs and venous capacitance in postmenopausal women: relationship with obesity.J Vasc Surg.(2002-Nov)
- ^Eri Fukaya, Alyssa M Flores, Daniel Lindholm, Stefan Gustafsson, Daniela Zanetti, Erik Ingelsson, Nicholas J LeeperClinical and Genetic Determinants of Varicose VeinsCirculation.(2018 Dec 18)
- ^Chwała M, Szczeklik W, Szczeklik M, Aleksiejew-Kleszczyński T, Jagielska-Chwała MVaricose veins of lower extremities, hemodynamics and treatment methods.Adv Clin Exp Med.(2015)
- ^Gregory PiazzaVaricose veinsCirculation.(2014 Aug 12)
- ^Ismail L, Normahani P, Standfield NJ, Jaffer UA systematic review and meta-analysis of the risk for development of varicose veins in women with a history of pregnancy.J Vasc Surg Venous Lymphat Disord.(2016-Oct)
- ^Charles DeCarlo, Laura T Boitano, Harold D Waller, Anna A Pendleton, Christopher A Latz, Adam Tanious, Young Kim, Abhisekh Mohapatra, Anahita DuaPregnancy conditions and complications associated with the development of varicose veinsJ Vasc Surg Venous Lymphat Disord.(2022 Jul)
- ^Stansby GWomen, pregnancy, and varicose veins.Lancet.(2000-Apr-01)
- ^Benedict R H Turner, Sara Jasionowska, Matthew Machin, Azfar Javed, Adam M Gwozdz, Joseph Shalhoub, Sarah Onida, Alun H DaviesSystematic review and meta-analysis of exercise therapy for venous leg ulcer healing and recurrenceJ Vasc Surg Venous Lymphat Disord.(2023 Jan)
- ^Melissa Andreia de Moraes Silva, Luis Cu Nakano, Lígia L Cisneros, Fausto Miranda JrBalneotherapy for chronic venous insufficiencyCochrane Database Syst Rev.(2023 Jan 9)
Examine Database References
- Chronic Venous Insufficiency Signs - Allegra C, Pollari G, Criscuolo A, Bonifacio M, Tabassi DCentella asiatica extract in venous disorders of the lower limbs. Comparative clinico-instrumental studies with a placeboClin Ter.(1981 Dec 15)
- Chronic Venous Insufficiency Signs - Marastoni F, Baldo A, Redaelli G, Ghiringhelli LCentella asiatica extract in venous pathology of the lower limbs and its evaluation as compared with tribenosideMinerva Cardioangiol.(1982 Apr)