Varicose veins are swollen and enlarged veins that usually occur on the legs and are usually blue or dark purple in appearance. They may also be lumpy, bulging or appear twisted.
Symptoms
Causes
Diagnosis
Treatment
Complications
Overview
Apart from the symptoms above, other symptoms include:
- aching, heavy and uncomfortable legs
- swollen feet and ankles
- muscle cramp in your legs
- dry skin and colour changes in the lower leg
Your GP can diagnose varicose veins based on these symptoms, although further tests may be carried out.
Some History
Varicose veins have troubled mankind for thousands of years. Varicose veins are mentioned as early as 1550 B.C. in the Ebers papyrus, where it was recommended not to treat them. Varicose veins were also mentioned in ancient Greece. The role of varicose veins and venous hypertension in creating venous ulcers was recognized as early as the days of Hippocrates. Compression therapy, still in use today for the treatment of varicose veins and venous ulcers, was also recommended by Hippocrates. Also, the name ‘varicose veins’ is derived from the Latin word ‘varix’ which means twisted.
Some of the first true-to-life diagrams of varicose vein anatomy were created by Leonardo da Vinci during the 15th century. He also delineated normal venous anatomy, with much accuracy, despite lack of the posterior arch vein. Valves were not described until later when the Padova school of medicine anatomy professor Jeronimus Fabricius d’Aquapendente described them in 1603. Interestingly, the term ‘varicose’ was first coined to correlate between varicose veins and venous ulcers only in the mid sixteen hundreds. (source: https://www.angiologist.com/)
Why do varicose veins happen?
Varicose veins develop when the small valves inside the veins stop working properly.
In a healthy vein, blood flows smoothly to the heart. The blood is prevented from flowing backwards by a series of tiny valves that open and close to let blood through.
If the valves weaken or are damaged, the blood can flow backwards and collect in the vein, eventually causing it to be swollen and enlarged (varicose).
Certain things can increase your chances of developing varicose veins, such as:
- pregnancy
- being overweight
- old age
Who is affected?
Varicose veins are a common condition, affecting up to 3 in 10 adults. Women are more likely to develop them than men.
Any vein in the body can become varicose, but they most commonly develop in the legs and feet, particularly in the calves. This is because standing and walking puts extra pressure on the veins in the lower body.
Symptoms of varicose veins
Varicose veins are dark purple or blue in colour and usually twisted and bulging in appearance. Some people with varicose veins may experience pain or discomfort.
As well as their distinctive appearance, symptoms of varicose veins can include:
- aching, heavy and uncomfortable legs
- swollen feet and ankles
- burning or throbbing in your legs
- muscle cramp in your legs, particularly at night
- dry, itchy and thin skin over the affected vein
These symptoms are usually worse during warm weather or if you’ve been standing up for long periods of time. They may improve when you walk around or if you rest and raise your legs. Pillows are a good way to raise your legs comfortably.
Varicose veins usually develop on the legs, either on the back of your calf or on the inside of your leg. However, they can also sometimes occur in other parts of your body, such as your:
- gullet (oesophagus)
- womb (uterus)
- vagina
- pelvis
- rectum (back passage)
If you are worried about the appearance of your veins, see your GP.
Causes of varicose veins
Varicose veins are usually caused by weak vein walls and valves.
Weakened valves
Inside your veins are tiny one-way valves that open to let the blood through and then close to prevent it flowing backwards.
Sometimes the walls of the veins become stretched and lose their elasticity, causing the valves to weaken.
If the valves don’t function properly, this can cause the blood to leak and flow backwards. If this happens, the blood will collect in your veins, which will become swollen and enlarged.
The reasons why the walls of the veins stretch and the valves in your veins weaken are not fully understood. Some people develop the condition for no obvious or apparent reason.
Increased risk
A number of things can increase your likelihood of developing varicose veins, including:
- gender
- genetics
- age
- being overweight
- occupation
- being pregnant
- other conditions
Gender
Women are more likely to be affected by varicose veins than men. Research suggests this may be because female hormones tend to relax the walls of veins, making the valves more prone to leaking.
Hormones are chemicals produced by the body, and changes may be caused by pregnancy, premenstrual syndrome or the menopause.
Genetics
Your risk of developing varicose veins is increased if a close family member has the condition. This suggests varicose veins may be partly caused by your genes (the units of genetic material you inherit from your parents).
See genetics for more information about how you inherit your physical and behavioural characteristics.
Age
As you get older, your veins start to lose their elasticity and the valves inside them stop working as well.
Being overweight
Being overweight puts extra pressure on your veins, which means they have to work harder to send the blood back to your heart. This can put increased pressure on the valves, making them more prone to leaking.
The impact of body weight on the development of varicose veins appears to be more significant in women.
Use the healthy weight calculator to check whether you are overweight.
Occupation
Some research suggests jobs that require long periods of standing may increase your risk of getting varicose veins. This is because your blood does not flow as easily when you are standing for long periods of time.
Pregnancy
During pregnancy, the amount of blood increases to help support the developing baby. This puts extra strain on your veins.
Increased hormone levels during pregnancy also cause the muscular walls of the blood vessels to relax, which also increases your risk.
Varicose veins may also develop as the womb (uterus) begins to grow. As the womb expands it puts pressure on veins in your pelvic area, which can sometimes cause them to become varicose.
Although being pregnant can increase your risk of developing varicose veins, most women find their veins significantly improve after the baby is born.
See the pregnancy guide for more information about preventing varicose veins during pregnancy.
Other conditions
In rare cases, varicose veins are caused by other conditions. These include:
- a previous blood clot
- a swelling or tumour in the pelvis
- abnormal blood vessels
Diagnosing varicose veins
If you have varicose veins and they don’t cause you any discomfort, you may not need to visit your GP. Varicose veins are rarely a serious condition and they don’t usually require treatment.
However, speak to your GP if:
- your varicose veins are causing you pain or discomfort
- the skin over your veins is sore and irritated
- the aching in your legs is causing irritation at night and disturbing your sleep
Varicose veins are diagnosed by their appearance. Your GP will examine your legs while you’re standing to check for signs of swelling.
You may also be asked to describe any pain you have and whether there are situations that make your varicose veins worse. For example, some women find their menstrual cycle (periods) affects their varicose veins.
Your GP will also want to know if you’re at an increased risk of developing varicose veins, such as:
- having a family history of varicose veins
- being pregnant
- whether you have a healthy body mass index (BMI)
- having deep vein thrombosis (a blood clot in one of the deep veins of the body)
- a history of leg injury (for example, having previously broken a bone in your leg)
Further investigation
Your GP may refer you to a vascular specialist (a doctor who specialises in veins) if you have any of the following:
- varicose veins that are causing pain, aching, discomfort, swelling, heaviness or itching
(whether or not you have had varicose veins before) - changes in the colour of the skin on your leg that may be caused by problems with the blood flow in the leg
- skin conditions affecting your leg, such as eczema, that may be caused by problems with the blood flow in the leg
- varicose veins that are hard and painful that may be caused by problems with the blood flow in the leg
- a healed or unhealed leg ulcer (a break in the skin that has not healed within two weeks) below the knee
In most cases, a test called a duplex ultrasound scan will be carried out. This is a type of scan that uses high-frequency sound waves to produce a picture of the veins in your legs.
The picture shows the blood flow and helps the vascular specialist locate any damaged valves that might be causing your varicose veins.
Treating varicose veins
Varicose veins don’t always need treatment. If your varicose veins are not causing you discomfort, you may not need to have treatment.
Treatment of varicose veins is usually necessary:
- to ease symptoms – if your varicose veins are causing you pain or discomfort
- to treat complications – such as leg ulcers, swelling or skin discolouration
- for cosmetic reasons – but this kind of treatment is rarely available on the NHS, so you’ll usually have to pay for it to be done privately
If treatment is necessary, your doctor may first recommend up to six months of self care at home, including:
- using compression stockings
- taking regular exercise
- avoiding standing up for long periods
- elevating the affected area when resting
The various treatments for varicose veins are outlined below. You can also read a summary of the pros and cons of the treatments for varicose veins, allowing you to compare your treatment options.
Compression stockings
Compression stockings are specially designed to steadily squeeze your legs to improve circulation. They are often tightest at the ankle and get gradually looser as they go further up your leg. This encourages blood to flow upwards towards your heart.
Compression stockings may help relieve the pain, discomfort and swelling in your legs caused by your varicose veins. However, it’s not known whether the stockings help prevent your varicose veins getting worse, or if they prevent new varicose veins appearing.
The National Institute for Health and Care Excellence (NICE) only recommends using compression stockings as a long-term treatment for varicose veins if all other treatments are not suitable for you.
If you are pregnant and you have varicose veins, NICE says you may be offered compression stockings for the duration of your pregnancy.
Compression stockings are available in a variety of different sizes and pressures. Most people with varicose veins will be prescribed a class 1 (light compression) or class 2 (medium compression) stocking. They are also available in:
- different colours
- different lengths – some come up to your knee, while others also cover your thigh
- different foot styles – some cover your whole foot and some stop before your toes
Compression tights are also available, but not on the NHS. They can be bought from pharmacies or directly from the manufacturers.
You may need to wear compression stockings for the rest of your life if you have deep venous incompetence. Deep venous incompetence is where you have problems with the valves, or blockages, in the deep veins in your legs.
In these circumstances, you will need to wear compression stockings even if you have had surgery to treat some varicose veins.
Wearing compression stockings
You usually need to put your compression stockings on as soon as you get up in the morning and take them off when you go to bed.
They can be uncomfortable, particularly during hot weather, but it’s important to wear your stockings correctly to get the most benefit from them.
Pull them all the way up so the correct level of compression is applied to each part of your leg. Don’t let the stocking roll down, or it may dig into your skin in a tight band around your leg.
Speak to your GP if the stockings are uncomfortable or don’t seem to fit. It may be possible to get custom-made stockings that will fit you exactly.
If custom-made compression stockings are recommended, your legs will need to be measured in several places to ensure they are the correct size. If your legs are often swollen, they should be measured in the morning, when any swelling is likely to be minimal.
If compression stockings are causing the skin on your legs to become dry, try applying a moisturising cream (emollient) before you go to bed to keep your skin moist.
You should also keep an eye out for sore marks on your legs, as well as blisters and discolouration.
Caring for compression stockings
Compression stockings usually have to be replaced every three to six months. If your stockings become damaged, speak to your GP because they may no longer be effective.
You should be prescribed two stockings (or two sets of stockings if you are wearing one on each leg) so that one stocking can be worn while the other is being washed and dried. Compression stockings should be hand washed in warm water and dried away from direct heat.
Further treatment
If your varicose veins need further treatment, or if they are causing complications, the type of treatment will depend on your general health and the size, position and severity of your veins.
A vascular specialist (a doctor who specialises in veins) will be able to advise you about the most suitable form of treatment for you.
Endothermal ablation
One of the first treatments offered will usually be endothermal ablation. This involves using energy either from high-frequency radio waves (radiofrequency ablation) or lasers (endovenous laser treatment) to seal the affected veins.
These treatments are described in more detail below.
Radiofrequency ablation
Radiofrequency ablation involves heating the wall of your varicose vein using radiofrequency energy. The vein is accessed through a small cut made just above or below the knee.
A narrow tube called a catheter is guided into the vein using an ultrasound scan. A probe is inserted into the catheter that sends out radiofrequency energy.
This heats the vein until its walls collapse, closing it and sealing it shut. Once the vein has been sealed shut, your blood will naturally be redirected to one of your healthy veins.
Radiofrequency ablation is carried out under local anaesthetic (you are awake). The procedure may cause some short-term side effects, such as pins and needles (paraesthesia).
You may need to wear compression stockings for up to a week after having radiofrequency ablation.
Endovenous laser treatment
As with radiofrequency ablation, endovenous laser treatment involves having a catheter inserted into your vein and using an ultrasound scan to guide it into the correct position. A tiny laser is passed through the catheter and positioned at the top of your varicose vein.
The laser delivers short bursts of energy that heat up the vein and seal it closed. The laser is slowly pulled along the vein using the ultrasound scan to guide it, allowing the entire length of the vein to be closed.
Endovenous laser treatment is carried out under local anaesthetic. After the procedure you may feel some tightness in your legs, and the affected areas may be bruised and painful. Nerve injury is also possible, but it’s usually only temporary.
Ultrasound-guided foam sclerotherapy
If endothermal ablation treatment is unsuitable for you, you’ll usually be offered a treatment called sclerotherapy instead.
This treatment involves injecting special foam into your veins. The foam scars the veins, which seals them closed. This type of treatment may not be suitable if you have previously had deep vein thrombosis.
The injection is guided to the vein using an ultrasound scan. It’s possible to treat more than one vein in the same session. Both standard sclerotherapy and foam sclerotherapy are usually carried out under local anaesthetic, where a painkilling medication will be used to numb the area being treated.
After sclerotherapy, your varicose veins should begin to fade after a few weeks as stronger veins take over the role of the damaged vein, which is no longer filled with blood. You may require treatment more than once before the vein fades, and there is a chance the vein may reappear.
Although sclerotherapy has proven to be effective, it’s not yet known how effective foam sclerotherapy is in the long term. NICE found, on average, the treatment was effective in 84 out of 100 cases. However, in one study, the varicose veins returned in more than half of those treated.
Sclerotherapy can also cause side effects, including:
- blood clots in other leg veins
- headaches
- lower back pain
- changes to skin colour – for example, brown patches over where the treated veins were
- fainting
- temporary vision problems
You should be able to walk and return to work immediately after having sclerotherapy. You will need to wear compression stockings or bandages for up to a week.
In rare cases, sclerotherapy has been known to have serious potential complications, such as strokes or transient ischaemic attacks.
Surgery
If endothermal ablation treatments and sclerotherapy are unsuitable for you, you’ll usually be offered a surgical procedure called ligation and stripping to remove the affected veins.
Varicose vein surgery is usually carried out under general anaesthetic, which means you will be unconscious during the procedure.
You can usually go home the same day, but an overnight stay in hospital is sometimes necessary, particularly if you are having surgery on both legs.
Ligation and stripping
Most surgeons use a technique called ligation and stripping, which involves tying off the vein in the affected leg and then removing it.
Two small incisions are made, approximately 5cm (2in) in diameter. The first cut is made near your groin at the top of the varicose vein. The second cut is made further down your leg, usually around your knee or ankle. The top of the vein (near your groin) is tied up and sealed.
A thin, flexible wire is passed through the bottom of the vein and then carefully pulled out and removed through the lower cut in your leg.
The blood flow in your legs will not be affected by the surgery. This is because the veins situated deep within your legs will take over the role of the damaged veins.
Ligation and stripping can cause pain, bruising and bleeding. More serious complications are rare, but could include nerve damage or deep vein thrombosis, which is where a blood clot forms in one of the deep veins of the body.
After the procedure, you may need up to three weeks to recover before returning to work, although this depends on your general health and the type of work you do. You may need to wear compression stockings for up to a week after surgery.
Transilluminated powered phlebectomy
Transilluminated powered phlebectomy is a relatively new treatment, and there is some uncertainty about its effectiveness and safety.
NICE does not recommend it as part of the normal treatment plan for varicose veins. However, NICE says the treatment may be offered if your doctor thinks it will help and the benefits and risks are explained.
During transilluminated powered phlebectomy, one or two small incisions are made in your leg. Your surgeon will place a special light called an endoscopic transilluminator underneath your skin so they are able to see which veins need to be removed. The affected veins are cut before being removed through the incisions using a suction device.
Transilluminated powered phlebectomy can either be carried out under general anaesthetic or local anaesthetic. You may experience some bruising or bleeding afterwards.
Questions about your treatment
If you are referred for surgery, you may want to ask your GP or surgeon some questions. For example, you may want to ask:
- Who will do my operation?
- How long will I have to wait for treatment?
- Will I have to stay in hospital overnight?
- How many treatment sessions will I need
Complications of varicose veins
Varicose veins can cause complications because they stop your blood flowing properly.
Most people who have varicose veins won’t develop complications, but, if you do, it will usually be several years after your varicose veins first appear.
Some possible complications of varicose veins are explained below.
Bleeding
Varicose veins near the surface of your skin can sometimes bleed if you cut or bump your leg. The bleeding may be difficult to stop.
You should lie down, raise your leg and apply direct pressure to the wound. Seek immediate medical advice if this doesn’t stop the bleeding.
Blood clots
If blood clots form in superficial veins (veins located just under the surface of your skin), it could lead to conditions such as thrombophlebitis or deep vein thrombosis.
Thrombophlebitis
Thrombophlebitis is swelling (inflammation) of the veins in your leg caused by blood clots forming in the vein. This can occur within your varicose veins and can:
- be painful
- look red
- feel warm
When thrombophlebitis occurs in one of the superficial veins in your leg it’s known as superficial thrombophlebitis.
Like varicose veins, thrombophlebitis can be treated with compression stockings. In some cases, non-steroidal anti-inflammatories (NSAIDs), such as ibuprofen, may be prescribed.
Deep vein thrombosis
Deep vein thrombosis may develop in up to 20% of people who develop a blood clot in superficial veins.
It can cause pain and swelling in the leg, and may lead to serious complications such as pulmonary embolism.
Chronic venous insufficiency
If the blood in your veins doesn’t flow properly, it can interfere with the way your skin exchanges oxygen, nutrients and waste products with your blood.
If the exchange is disrupted over a long period of time, it’s known as chronic venous insufficiency.
Chronic venous insufficiency can sometimes cause other conditions to develop, including those described below.
Varicose eczema
Varicose eczema is a condition that causes your skin to become red, scaly and flaky. You may also develop blisters and crusting of your skin.
This condition is often permanent, but does not lead to any major problems.
Lipodermatosclerosis
Lipodermatosclerosis causes your skin to become hardened and tight, and you may find it turns a red or brown colour. The condition usually affects the calf area.
Venous ulcers
A venous ulcer develops when there is increased pressure in the veins of your lower leg. This causes fluid to seep from your vein and collect under the skin.
The fluid can cause the skin to thicken, swell and eventually break down to form an ulcer. Venous ulcers most commonly form in the ankle area.
You should see your GP immediately if you notice any unusual changes in your skin, such as those mentioned above. These conditions can usually be easily treated, but it’s important you receive treatment as soon as possible.