Varicose veins affect a third of the western world. But what causes varicose veins? Are they dangerous or just unsightly? How can we prevent or reverse them? Are there natural remedies, or is it always just surgery? And what makes varicose veins a particularly personal subject for me?
25 years ago, I collapsed in a hospital corridor, with massive bleeding in my thyroid gland. Life-saving surgery removed the blood and one thyroid lobe (half of the gland.) When I bled into the surgical wound, I was rushed back to the theatre, and half of the remaining lobe was removed. I was left with only a quarter of my thyroid gland.
Following the second operation, I was unconscious in the intensive care unit for five days. I was the most serious patient in my own hospital! I decided that I needed to improve my health.
Then a friend of mine, a vascular surgeon at Kings College, observed that I had extensive varicose veins on my left leg. I reluctantly accepted my colleague’s recommendation for an operation, which he described as simple. He ligated a vein at the back of my knee. My leg looked better for a little but soon started to deteriorate.
Since childhood, I had had a small belly but normal weight. Later I realised that I had a sugar problem manifested as insulin resistance. My body is not efficient at processing sugar and carbs. I remember experiencing severe shaking and near fainting with hypoglycaemia (low blood sugar) almost every night before dinner.
Later, I realised that I had too much fat accumulated in my liver, a condition known as fatty liver, which gave me a pot belly. This condition is associated with high insulin, which I thought was the underlying cause of the thyroid cyst that bled and triggered the life-saving surgery.
In retrospect, the enlarged liver caused congestion of the portal vein that transports absorbed food nutrients from the gut to the liver. This can result in backflow and engorgement of the veins in the lower gullet, stomach, and rectum. It also raised pressure in the veins draining the lower half of the body, including the legs.
That is what had given me extensive leg varicosity.
Varicosity in the rectum – also known as haemorrhoids – is another form of varicose veins. I have a family history of varicose veins, and two brothers had haemorrhoid surgery. A study in Japan reported that 42% of patients with varicose veins had a family history, compared to 14% of those without.
The mechanism of varicosity
Two venous systems drain the lower limb. The superficial veins representing 10%, drain the skin and subcutaneous tissue, while the deep veins drain most of the leg (90%). Valves are present in both superficial and deep systems to ensure the blood flows in one direction, from the superficial to the deep veins, and against gravity, towards the heart. The deep veins are supported by fascia, making them less likely to dilate and give varicosity.
Valves open to let the blood through and then close to prevent it from flowing backwards. Valve dysfunction allows backflow, resulting in blood stasis and venous hypertension. Pressure build-up dilates veins, opening their valves and rendering them incompetent.
The problem usually happens due to thinning of vein walls due to loss of the supportive tissue (elastin) and deterioration in the valves’ structure. This results in dilated veins and incompetent valves, affecting primarily the superficial veins (Great Saphenous Vein and Small Saphenous Vein), which, unlike the deep veins, are not supported by facia. The dilatation and tortuousness give birth to varicose veins.
Blood clots (DVT) usually occur in the deep leg veins and are often big enough to obstruct blood flow in the deep veins and then in the superficial ones to cause varicose veins.
Without hesitation, I declined the proposal and left the operating theatre!
My marathon times unexpectedly increased by over 45 minutes within a short period – and I certainly took notice of this warning sign! I felt a lack of balance and had a few falls while running. A chiropractic assessment found my pelvis was tilted to the right. X-rays showed minor degenerative changes on a couple of spinal vertebrae.
I experienced further deterioration following my son’s wedding. The left leg varicosity became more extensive; the leg was swollen, and I developed an ulcer that did not want to heal. At the celebration, I no doubt consumed more sugar and carbs than normal, which likely worsened my sugar problem and negatively impacted my veins’ health.
Then, following a Thai massage, I developed severe pain in the lower leg, which worsened with movement. Even turning in bed at night woke me up, and I could not go back to sleep.
I applied an elastic stocking, raised my leg regularly and attended the vascular clinic. I was reassured that no DVT (blood clot) was seen on the scans, and all my blood tests, including D-dimer (a marker of a clot), were within normal range. I asked for a leg x-ray, and to my great amazement, there was a calcified segment 15cm above the median malleolus.
In retrospect, the vein calcification could have happened following infection of the vein (phlebitis). This has distorted my running mechanics and balance, resulting in falls. The tough Thai massage had broken the calcified venous segment into small pieces that acted like knives piercing the surrounding soft tissue every time I moved, giving me sharp pain.
The vascular surgeon decided to apply radiofrequency ablation to destroy the calcified segment of the vein. On arrival at the theatre, I was shocked to discover that the operation was to remove all of my great saphenous (GSV) to the groin and small (SSV) veins to the knee. Without hesitation, I declined the proposal and left the theatre.
What causes varicose veins?
Advancing age makes people more vulnerable to varicosity due to the weakening of the calf muscle, reduced mobility, and age-related thinning of the vein wall. This explains the high prevalence of senior varicosity – 55% in people 55 to 64, compared with 11% in those 18 to 24.
Research is not conclusive as to which gender is more susceptible. Indeed, ladies in the late stages of pregnancy are at risk. The pregnant uterus obstructs the main veins draining the lower limbs, which can dilate the superficial leg veins to give varicosity.
For the same reason, this can happen in women with uterine fibroid or ovarian mass. Oestrogen and progesterone in birth control pills also increase the risk. Progesterone has a more negative impact on vein health.
Men, particularly smokers, obese or overweight, or those with reduced mobility and sedentary lifestyles, are at risk of varicose veins. Trauma due to sitting, standing, or crossing legs for long periods can result in varicosity. Chronic health conditions like hypertension and diabetes can cause or aggravate varicose veins.
People with poor blood sugar control also have weight issues that increase their risk of varicose veins. Low-grade inflammation due to sustained venous hypertension, or high blood sugar damage to the venous wall causing incompetent valves, the hallmark of varicose veins.
High blood sugar at or below diabetes levels results in thick blood, slows blood flow, damages the vein lining by glycation (rusting), and tenses the vein wall by endothelial cell dysfunction and lack of nitric oxide.
Symptoms of varicose veins
Symptoms of varicose veins include achy, heavy, and uncomfortable legs, burning, sore, itchy skin over the affected area, and swollen ankles and feet.
There can be darkening of the skin around the varicose veins, due to leakage of red blood cells under the skin, releasing altered haemoglobin.
Complications of varicose veins are rare, happening more in advanced cases. These can include pain, swelling or ankle oedema, leg pain, leg ulcers, bleeding which is often difficult to stop, and blood clots – superficial thrombosis and DVT is more common in diabetics.
What can you do?
Simple tips include:
- Lose weight and keep your ideal body weight.
- Refrain from smoking, as this increases your risk 2.5 times.
- Stay hydrated, and reduce dehydrating caffeine in tea, coffee, and sports drinks.
- Wear knee compression socks during the day, and take them off at night.
- Minimise sitting, standing, or crossing legs for too long, and regularly move during the day.
- Keep your legs elevated, if possible, whilst sitting.
- Maintain a steady blood sugar and HbA1C within normal range.
- Foot and nail care like diabetes, including a podiatrist visit every six months.
- Exercise helps you reduce your symptoms and slow the progression of the disease.
- Women should avoid birth control pills, and choose another contraceptive method, if possible.
Your diet should be rich in the following:
- Fibre in fruits, vegetables, whole grains, beans, nuts, and seeds. Fibre prevents constipation and needs for straining that often precipitates or worsens varicose veins.
- Each colour of rainbow-coloured vegetables has a different antioxidant activity to stop veins’ rusting.
- Vitamin C in bell pepper, Kiwi, and citrus fruits. Vitamin C makes elastin and collagen to repair your veins.
- Anti-inflammatory omega 3 in small oily fish like salmon, mackerel, and herrings. Garlic is another anti-inflammatory agent with anti-microbial activity and helps to clear toxins.
- Brassica family vegetables like broccoli, cauliflower, cabbage, and kale. These are high in vitamin K1, which thins the blood and facilitates blood flow along veins.
- Healthy fat like avocados is packed with vitamin E and essential minerals; olive oil is rich in phytonutrients, both promote vein health.
- Cucumber, celery, and funnel prevent water retention and clear oedema if you have swollen legs.
- Vitamin A, B complex, C, E and K repair and promote vein health.
- Omega 3 and turmeric (containing curcumin), reduce inflammation.
- Horse chestnut extract, a natural anti-inflammatory herb, relaxes the vein wall.
- Probiotics populate your gut with beneficial bacteria, and pre-biotics feed them to promote vascular health.
Women tend to be keener on surgical treatment, because of varicose veins’ unsightly appearance. Ligation and stripping are options available for large veins. Less invasive procedures are popular for small and medium veins. These include laser and radio-frequency ablation; you can also destroy the veins by injecting an irritant agent (sclerotherapy) or removing varicose veins using a special hooked instrument (micro-phlebectomy).
Surgery can be complicated by bruising, bleeding, or infection. It can damage nerves and result in a foot drop – inability to lift the foot against gravity or clot blood in the deep veins (DVT) that can shoot an embolus (blood clot) to block a major Lung vein with serious consequences.
I have learned from this experience that surgery may often be a lifesaving procedure or the most effective treatment. But, when it is safe, please exhaust less invasive natural remedies before accepting any surgical treatment. You can’t return any part of your body once it’s removed!
One last example: I had a patient who worked hard to improve his diabetes through diet and other lifestyles. He had severe osteoarthritis and was not keen on knee replacement surgery. As a bonus, his severe knee pain settled, and he could take his name off the knee replacement waiting list.
So, my friends, I escaped the surgeon’s knife at the very last moment, and now I am working hard to stay away from it for the rest of my life! If you have varicose veins, I hope this blog will help you commit to a similar course of action. As always, please ask any questions in the Comment section below – and please subscribe to the newsletter so that you don’t miss further vital information. Thank you!
Pathophysiology and principles of management of varicose veins
Pathogenesis of primary varicose veins
A sluggish liver can cause varicose veins