Varicose veins

Varicose veins are swollen and enlarged veins, usually blue or dark purple in colour.

Introduction

Varicose veins are swollen and enlarged veins, usually blue or dark purple in colour. They may also be lumpy, bulging or twisted in appearance. They mostly occur in the legs.

Other symptoms include:

  • aching, heavy and uncomfortable legs
  • swollen feet and ankles
  • muscle cramp in your legs

Read more about the symptoms of varicose veins.

Your doctor can diagnose varicose veins based on these symptoms, although further tests may be carried out.

Read more about diagnosing varicose veins.

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 can 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

Read more about the causes of varicose veins.

Who is affected?

Varicose veins are a common condition, affecting up to three in 10 adults. Women tend to be more affected 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.

Treating varicose veins

For most people, varicose veins do not present a serious health problem. They may have an unpleasant appearance, but should not affect circulation or cause long-term health problems. Most varicose veins do not require any treatment.

If your varicose veins are causing you pain or discomfort or they cause complications, they can be treated in several ways, the most common being:

  • endothermal ablation - treatment where heat is used to seal affected veins
  • sclerotherapy, which uses special foam to close the veins
  • a phlebectomy, involving surgery to remove the affected veins
  • compression stockings - specially designed to improve circulation in the legs

If you do require treatment it might help you to print treatment options for varicose veins to discuss with your

Read more about treating varicose veins and complications of varicose veins.

Preventing varicose veins

There is little evidence to suggest you can stop varicose veins getting worse, or completely prevent new ones developing.

However, there are ways to ease symptoms of existing varicose veins, such as:

  • avoiding standing or sitting still for long periods, trying to move around every 30 minutes
  • taking regular breaks throughout the day, raising the legs on pillows while resting to ease discomfort
  • exercising regularly, this can improve circulation and help maintain a healthy weight.

Symptoms

Varicose veins are dark purple or blue in colour and are 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 up. Pillows are a good way to raise your legs up 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 doctor.

Causes

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 can become stretched and lose their elasticity, causing the valves to weaken. If the valves do not 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 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.

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.

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 significant improve after the baby is born.

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

Diagnosis

If you have varicose veins and they do not cause you any discomfort, you may not need to visit your doctor. Varicose veins are rarely a serious condition and they do not usually require treatment.

However, you should seek advice from your doctor 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 doctor will examine your legs while you are 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 doctor will also want to know if you are at an increased risk of developing varicose veins, such as:

  • having a family history of varicose veins
  • being pregnant
  • having 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

If your doctor feels it is necessary to investigate your varicose veins further, they may refer you to a vascular specialist (a doctor who specialises in veins), who will decide if further tests are necessary.

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.

Treatment

Varicose veins do not 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

If your varicose veins need to be treated, 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.

In some cases, varicose veins can be treated at home. Simple methods for easing the symptoms include:

  • exercising
  • avoiding standing up for long periods
  • elevating your legs

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. 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 and 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.

Sclerotherapy

If endothermal ablation treatment is unsuitable for you, you will 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 is 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.

Following 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 that the vein may reappear.

Although sclerotherapy has proven to be effective, it is not yet known how effective foam sclerotherapy is in the long term. The National Institute for Health and Care Excellence (NICE) found that, on average, the treatment was effective in 84 out of 100 cases. However, in one study, the varicose veins returned in over 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

Following sclerotherapy you should be able to walk and return to work immediately afterwards. 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 (TIAs).

Surgery

If endothermal ablation treatments and sclerotherapy are unsuitable for you, you will usually be offered a surgical procedure called a phlebectomy to remove the affect veins.

Varicose vein surgery is usually carried out under general anaesthetic, which means you will be unconscious during the procedure. You will usually be able to go home the same day. However, in some cases an overnight stay in hospital may be 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 that are 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.

Following the procedure, you may need between one and three weeks to recover before returning to work, although this will depend 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.

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 is not known whether the stockings help prevent your varicose veins getting worse, or prevent new varicose veins appearing.

NICE only recommends using compression stockings as a long-term treatment for varicose veins if all the treatments described above 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 instead of the treatments above.

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 and some 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 will 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 is important to wear your stockings correctly for you 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 doctor if the stockings are uncomfortable or do not 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 that your stockings 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 doctor 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.

Transilluminated powered phlebectomy

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.

As this treatment is relatively new, there is some uncertainty about its effectiveness and safety and 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.

Complications

Varicose veins can cause complications because they stop your blood from flowing properly. Most people who have varicose veins will not 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 does not stop the bleeding.

Thrombophlebitis

Thrombophlebitis is inflammation (swelling) of the veins in your leg caused by blood clots forming in the vein. This can occur within your varicose veins and it can:

  • be painful
  • look red
  • feel warm

When thrombophlebitis occurs in one of the superficial veins in your leg it is known as superficial thrombophlebitis. A superficial vein is a vein located just under the surface of your skin.

Like varicose veins, thrombophlebitis can be treated with compression stockings. In some cases, non-steroidal anti-inflammatories (NSAIDs), such as ibuprofen, may be prescribed.

Chronic venous insufficiency

If the blood in your veins does not 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 is 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.

Lipodermatosclerosis

Lipodermatosclerosis causes your skin to become hardened and tight, and you may find that 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 doctor immediately if you notice any unusual changes in your skin, such as those mentioned above. These conditions can usually be easily treated, but it is important you receive treatment as soon as possible.

Read more about venous leg ulcers.

Real stories

Marilyn Adams, 62, a receptionist, had her varicose veins ligated and stripped.

“I first noticed my varicose veins after my son was born in 1978. They must run in the family as my mother and sisters also suffered from them.

"I had always been quite proud of my legs. I taught line dancing for 10 years and often wore fairly short skirts, but as I got older, my varicose veins got worse. As they got lumpier I became very self-conscious of them and wore support tights to conceal them.

“My evening job involves a lot of standing. I serve drinks from behind the bar in a hotel and my veins were uncomfortable when I was doing this, as well as unsightly. When I discussed it with my doctor, I was referred to a specialist who said I would feel and look much better if they were tied and stripped.

“I went into hospital early on a Wednesday morning and the surgeon marked up my veins. I had a general anaesthetic so I don’t really remember much about the surgery.

"When I came round I had a cup of tea and a piece of toast and then a friend drove me home. I had the rest of the week off and was back at work the following Monday.

“It didn’t take long for me to be back to normal, thank goodness. I do a lot of walking with my dog and I love rock and roll, so I wouldn’t have enjoyed a long recovery period. But I wasn’t stuck at home as I was able to drive within just a few days.

“For me, the operation was really successful. My legs don’t ache any more and best of all, I’ve got rid of the horrible lumpiness. In fact, two years ago I was a Dawlish Calendar Girl and my legs were used on the cover of the calendar. We raised more than £2,000 for charity.”

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