• Glenn S. Rothfeld, MD

Varicose Veins : Not Just a Cosmetic Issue

In my practice, I tend to see all types and stages of disease and dysfunction. I’m kind of a last resort for a lot of patients, after conventional medicine has failed them (or frequently, not even paid proper attention to what was ailing them!). But it’s not always the patients with critical diseases that are the most desperate. In fact, I would say that one of the most common of complaints that bring patients (women, particularly) pleading for help is the appearance of varicose veins and their cousin, spider veins.

If you’re 65 or older, you have a greater than 75% chance of having varicose veins, those unsightly bluish, swollen lines and curls that can occur from the upper thigh to the lower leg and ankle. But even if you’re much younger, you can see the appearance of these swollen and poorly functioning vessels. In particular, many women start to develop varicose veins during or after childbirth. In fact, 40% of pregnant women report the appearance of varicose veins (also called varicosities).

They can occur when someone of any age has a job that involves standing all day long. And increased pressure from extra weight can be a causative factor. Other conditions that can lead to varicose veins and spider veins include problems with circulation, cigarette smoking, wearing high heels, chronic constipation, long-term bedrest, and weakening of muscles in the legs. And this is a problem that you can partially blame on your parents, as varicose veins definitely have a genetic component.

The fact that this problem can affect women of any age and lifestyle was brought to light several years ago by Summer Sanders, whose athletic prowess led her to be the most medaled US swimmer of the Barcelona Olympics in 1992, and whose beauty subsequently led to her career as a television sports correspondent. Summer was part of a campaign to raise awareness for the problem of varicose veins, which she says first appeared on her legs during her first pregnancy.

But varicosities are not only a cosmetic issue. They can be a sign of a much more serious, deeper problem of circulation. This problem is called “chronic venous insufficiency”, or CVI. Our venous system contains valves inside the veins at various intervals. These valves prevent the blood from flowing backwards. If the valves weren’t there, gravity would pull all the blood into our feet (and hands when our arms were dangling). In addition, the movement of our calf and leg muscles when we walk actually acts like a pump, to pump blood upwards into the body.

Spider veins (which are a smaller version of varicose veins) and varicosities occur when there is a breakdown of these valves, so that blood isn’t properly moved back into the body. Instead, blood pools in the small vessels of the body, eventually clotting and causing the bluish color as they’re seen through the layers of skin. The clotting blocks the vessels more, causing more pressure on the remaining valves and the venous walls, and leading to more damage.

So far we’ve just spoken about the aesthetic problems of varicosities, the swollen, bluish or corkscrewed appearance on the legs that is so hard on one’s vanity. This is because there are both superficial and deep veins in the legs, and varicosities are problems of the superficial veins. They are not dangerous by themselves, although they can become quite warm, painful and uncomfortable. In extreme cases the small clots in the vessels can become inflamed, causing something called superficial thrombophlebitis, which is treated by warm compresses, elevating the legs to lessen swelling, and using aspirin (or, as we prefer, white willow bark and clot-busting enzymes like bromelain).

But if the deep veins start to break down (the natural progression of venous insufficiency over time) then it’s called CVI and becomes a more ominous problem. The legs can become weak and heavy, and they can swell with fluid. Areas of skin, particularly at the ankles, can break down and form dangerous ulcers, which are difficult to heal due to the lack of proper circulation.

And an even worse danger can result from the chronic swelling and poor circulation of CVI. Blood can clot in the deep veins of the legs, leading to inflammation and spreading of that clot. This is called Deep Vein Thrombosis, or DVT. This can be a life-threatening situation, as a piece of clot can easily break off and travel into the heart (potentially obstructing flow of a heart valve) or through the pulmonary artery and into the lung, where the clot can lodge (called a Pulmonary Embolism or PE).

Although not all people with varicose and spider veins go on to develop CVI, it still is a significant warning signal. In the Edinburgh Vein Study (yes, someone did a large population study of people’s veins), 880 adults were followed for 13 years, and nearly half of those with CVI worsened, and around 1/3 of the people with only varicose veins at the start showed the skin changes and other signs of CVI by the end of the study!

So what can we do about these ugly and often painful reminders of aging? As with our approach to most health issues, the first step is prevention, and prevention starts with diet and lifestyle. Extra weight puts extra pressure on the blood trying to re-enter the body from the legs, and over time this causes venous breakdown. So, as with many other conditions that can be prevented, I try to lower the sugars, starches and carbohydrates in my patients’ diets, which in turn will lead to weight loss (a good idea for general health as well).

Fiber also becomes important in the prevention of varicosities and CVI. When I was in medical school in 1972, Dr. Denis Burkitt (who was famous for discovering the connection between Epstein-Barr Virus and the lymphoma that bears his name, Burkitt’s Lymphoma) was publishing controversial (at that time) papers blaming many medical conditions on the lack of dietary fiber and resulting poor bowel function. Among these conditions, Dr. Burkitt asserted that varicose veins (and hemorrhoids, which are actually varicose veins of the anal area) could be prevented by proper fiber intake. Of course, as happens with many mavericks in medicine, he was laughed at by his peers and, now forty some-odd years later, is recognized for the visionary that he was.

Another dietary aid in the prevention of venous breakdown is the addition of green, red and yellow fruits and vegetables, important for their antioxidant content. The damage to the venous walls, and to the skin above them, is actually caused by oxidative stress on the tissues, and antioxidants in the diet are critical in preventing that stress.

The next preventive measure after weight loss, fiber, and colorful produce, is proper exercise. As I’ve said, the movement of the leg muscles actually pumps the blood through those small vessels, preventing the pressure and venous pooling that can occur when you’re stationary. Patients on bedrest are actually given boards below their feet, so that they can put pressure on them, using their calf muscles to simulate walking and to help pump blood back into the body. If they can’t do this, there is an apparatus similar to blood pressure cuffs that are wrapped around the calves and rhythmically inflated and deflated, to perform the same function.

Several herbs are also highly useful in preventing varicosities, and in treating the symptoms that they result in. One herb that I always recommend is Ginkgo biloba. I recommend an extract of at least 24% in a dose of 40 mg, three times daily.

Another important antioxidant herb is called pycnogenol, extracted from a type of French pine bark. In one study published in the Italian journal Fitoterapia, a placebo-controlled randomized study demonstrated improvement of venous function both subjectively and by ultrasound evidence. The dose that they used was 100 mg daily, but I frequently have my patients take it twice daily for the first two months. Two other herbs that are also useful for varicose veins (and hemorrhoids) are Butcher’s Broom (40 mg) and Horse Chestnut (100 mg) twice daily. And finally, I recommend good old Vitamin C with bioflavonoids, 500-1000 mg twice daily.

As far as the various surgical procedures available, that’s an individual decision. You have to weigh the risks and discomfort of the procedure against the importance of looking good and feeling young (which I never discount). I have recently become aware of the use of ozone injections into the small spider veins, which is done in Europe and, less commonly, in the U.S. I’ll write about it as I learn more.

#varicoseveins #DVT #bloodclot #circulation #cosmetics