Varicose Veins: Symptoms, Causes & Treatment Options

What Are Varicose Veins?

Varicose veins are enlarged, twisted veins that appear bluish and bulging beneath the skin, most commonly in the legs. They develop when one-way valves in the veins become weak or damaged, allowing blood to flow backward and pool, causing the veins to stretch and become visible. Approximately 30% of adults have varicose veins.

Varicose veins are a form of chronic venous disease that affects the superficial veins in the legs. The word "varicose" comes from the Latin "varix," meaning twisted or dilated. These enlarged veins typically appear as rope-like, bluish-purple cords that bulge above the skin surface, most commonly on the calves, inner thighs, and behind the knees.

The venous system in your legs works against gravity to return blood to the heart. Inside the veins are one-way valves that prevent blood from flowing backward. When these valves become weakened or damaged, blood can pool in the veins, causing them to stretch, dilate, and become tortuous (twisted). This process is called venous reflux or venous insufficiency.

While varicose veins are often considered a cosmetic concern, they can indicate underlying venous disease that may progress to cause significant symptoms and complications. Understanding the difference between varicose veins and their smaller counterparts, spider veins (telangiectasias), is important. Spider veins are tiny, web-like vessels visible just under the skin that rarely cause symptoms, while varicose veins are larger, more prominent, and more likely to cause discomfort.

Types of Varicose Veins

Varicose veins are classified according to the CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification system used by vascular specialists worldwide. This system ranges from C0 (no visible signs) to C6 (active venous ulcer). The most common types include:

• Trunk varicose veins: The largest type, affecting the main superficial veins (great saphenous vein or small saphenous vein)
• Reticular varicose veins: Medium-sized blue-green veins, typically 1-3mm in diameter
• Spider veins (telangiectasias): Small, fine veins less than 1mm, often red or purple

The distinction between these types is clinically important because treatment approaches may differ. Trunk varicosities often require endovenous ablation, while smaller veins may respond well to sclerotherapy or surface laser treatment.

What Are the Symptoms of Varicose Veins?

Common symptoms of varicose veins include visible bulging veins, leg heaviness and fatigue, aching or throbbing pain, swelling (especially after standing), itching around affected veins, skin discoloration, and muscle cramps. Symptoms typically worsen with prolonged standing or sitting and improve with leg elevation.

Varicose veins don't always cause symptoms beyond their visible appearance. However, when symptoms do occur, they can significantly impact quality of life and daily activities. The symptoms of varicose veins result from increased venous pressure in the legs and the resulting poor circulation. Understanding these symptoms helps in recognizing when medical evaluation is needed.

The severity of symptoms doesn't always correlate with the size or extent of visible varicose veins. Some people with prominent varicosities have minimal discomfort, while others with seemingly minor veins experience significant symptoms. This variability relates to factors including the degree of underlying valve dysfunction, individual pain perception, and the specific veins affected.

Most people with varicose veins notice that their symptoms follow a predictable pattern throughout the day and across different situations. Morning symptoms are typically minimal because overnight leg elevation allows fluid to drain from the legs. As the day progresses and time spent upright increases, symptoms gradually worsen. Hot weather, menstrual periods, and hormonal changes can also exacerbate symptoms.

Primary Symptoms

The most common symptoms reported by people with varicose veins include:

• Visible, bulging veins: Bluish-purple, twisted veins that you can see and often feel beneath the skin
• Heaviness and fatigue: A tired, heavy feeling in the legs, particularly after standing
• Aching and throbbing: Dull, aching discomfort that may become throbbing pain
• Swelling (edema): Ankle and lower leg swelling, especially later in the day
• Skin itching: Itchiness around the varicose veins, often a sign of early skin changes
• Burning sensation: A burning or warm feeling in the affected areas
• Muscle cramps: Night cramps, particularly in the calf muscles

When Symptoms Indicate Complications

While most varicose vein symptoms are uncomfortable rather than dangerous, certain symptoms may indicate developing complications that require medical attention. Skin changes such as darkening (hyperpigmentation), thickening, or a leathery texture around the ankles suggest chronic venous insufficiency is progressing. Red, inflamed, tender areas along a varicose vein may indicate superficial thrombophlebitis (blood clot in a surface vein). Any open wound or ulcer near the ankle requires prompt evaluation.

What Causes Varicose Veins to Develop?

Varicose veins develop when one-way valves in leg veins become weak or damaged, allowing blood to flow backward and pool. Key risk factors include family history (genetics account for up to 80% of cases), pregnancy, prolonged standing or sitting, obesity, age, and previous blood clots. Hormonal factors explain why women are affected more often than men.

The development of varicose veins involves a complex interplay of genetic predisposition, structural changes in vein walls, and environmental factors that increase venous pressure. Understanding these causes helps identify who is at risk and what preventive measures may be effective.

The primary mechanism involves failure of the venous valves. Leg veins contain bicuspid (two-leaflet) valves positioned every few centimeters that normally allow blood to flow only toward the heart. When these valves fail to close properly, blood flows backward (reflux) and pools in the veins below, creating a cascade of increasing pressure. This elevated pressure causes vein walls to stretch and dilate, which in turn damages more valves, perpetuating the cycle of venous insufficiency.

Research has shown that vein wall weakness often precedes valve failure, suggesting that changes in the connective tissue of vein walls may be the initiating event. These walls contain collagen and elastin fibers that can become weakened by genetic factors, hormonal influences, and inflammatory processes. When the vein wall loses its structural integrity, it cannot support the delicate valve leaflets, leading to reflux.

Genetic and Family Factors

Genetics play a dominant role in varicose vein development, with family history being the strongest predictor of risk. Studies of twins have shown heritability estimates of 70-80%, meaning genetic factors account for most of the variation in who develops varicose veins. If both parents have varicose veins, a child has approximately a 90% chance of developing them. If one parent is affected, the risk is around 60% for daughters and 25% for sons.

Multiple genes appear to be involved, affecting vein wall structure, valve formation, and inflammatory responses. Researchers have identified variations in genes encoding collagen, matrix metalloproteinases (enzymes that break down connective tissue), and inflammatory mediators that may increase susceptibility.

Hormonal and Pregnancy Factors

Women are significantly more likely to develop varicose veins than men, with hormonal factors playing a key role. Estrogen and progesterone affect vein wall elasticity, making veins more prone to dilation. These hormonal effects explain why varicose veins often first appear or worsen during:

• Pregnancy: Increased blood volume (up to 50% more), hormonal changes, and uterine pressure on pelvic veins all contribute
• Menstrual cycles: Many women notice symptom fluctuation with their cycle
• Menopause: Hormonal shifts can trigger new varicose veins or worsen existing ones
• Hormone therapy: Birth control pills and hormone replacement therapy may increase risk

During pregnancy, varicose veins develop in approximately 40% of women. While pregnancy-related varicose veins often improve within 3-12 months after delivery, they may persist or recur with subsequent pregnancies. The risk increases with each pregnancy.

Lifestyle and Occupational Factors

Prolonged standing or sitting impairs the calf muscle pump that normally assists venous return. Occupations requiring extended standing (healthcare workers, teachers, retail workers, factory workers) carry increased risk. Similarly, sedentary jobs involving prolonged sitting can also contribute to venous stasis and increased leg vein pressure.

Obesity increases intra-abdominal pressure, which impedes venous return from the legs. Body mass index (BMI) above 30 is associated with significantly increased varicose vein risk. The inflammatory state associated with obesity may also directly damage vein walls.

When Should You See a Doctor for Varicose Veins?

Seek medical care if you have leg swelling, skin changes (discoloration, eczema, thickening), leg ulcers, inflammation along a vein (redness, tenderness, warmth), or symptoms significantly affecting daily activities. Most routine varicose veins can be evaluated by a primary care physician who may refer to a vascular specialist.

While many people with varicose veins never require medical treatment, certain situations warrant professional evaluation. Understanding when to seek care helps ensure timely intervention when needed while avoiding unnecessary worry for benign cases.

The decision to seek medical attention depends on several factors: the severity of symptoms, the presence of complications or warning signs, and the impact on quality of life. Even varicose veins that don't currently cause symptoms may benefit from evaluation if you have risk factors for progression, such as family history of venous ulcers or previous blood clots.

Primary care physicians can evaluate varicose veins and provide initial management with compression therapy and lifestyle recommendations. Referral to a vascular surgeon or phlebologist (vein specialist) is appropriate when symptoms persist despite conservative measures, complications develop, or interventional treatment is being considered.

Warning Signs Requiring Prompt Evaluation

Contact a healthcare provider promptly if you experience:

• Significant leg swelling: Especially if it persists overnight or is accompanied by pain
• Skin changes: Brown or reddish discoloration, thickening, or scaling near the ankles
• Venous eczema: Itchy, red, flaky skin over varicose veins
• Leg ulcers: Any open wound or sore that doesn't heal, particularly near the ankle
• Thrombophlebitis: Hard, tender, red, warm area along a vein
• Bleeding: Bleeding from a varicose vein after minor injury

What Can You Do Yourself to Manage Varicose Veins?

Self-care for varicose veins includes regular walking and exercise, avoiding prolonged standing or sitting, elevating legs when resting, maintaining healthy weight, wearing compression stockings, and avoiding tight clothing that restricts circulation. These measures can significantly reduce symptoms and slow progression.

Conservative management with lifestyle modifications and compression therapy forms the foundation of varicose vein treatment. For many people, these measures provide adequate symptom control without requiring interventional procedures. Even when interventional treatment is planned, lifestyle modifications remain important for long-term management and preventing recurrence.

The goal of self-care is to reduce venous pressure in the legs, promote blood flow back to the heart, and maintain skin health. Consistent application of these strategies often produces noticeable improvement within a few weeks.

Physical Activity and Movement

Regular physical activity is one of the most effective ways to manage varicose veins. The calf muscle pump—activated by walking and other leg movements—helps push blood up through the leg veins against gravity. Without this pump action during prolonged sitting or standing, blood pools and venous pressure increases.

• Walk regularly: Aim for at least 30 minutes of walking daily; even short walks help
• Avoid prolonged immobility: If you must stand or sit for long periods, take breaks to walk around every 30-60 minutes
• Exercise your calves: Simple exercises like heel raises, ankle circles, and calf stretches improve circulation
• Consider low-impact activities: Swimming, cycling, and yoga are excellent for leg circulation

Leg Elevation

Elevating your legs above heart level allows gravity to assist venous drainage. This simple measure can dramatically reduce swelling and discomfort. For best results:

• Elevate legs for 15-20 minutes several times daily
• Sleep with legs slightly elevated using pillows under the foot of the mattress
• At work, use a footrest or elevate legs during breaks
• Avoid crossing legs when sitting, which can restrict circulation

Compression Stockings

Compression stockings apply graduated pressure to the legs—strongest at the ankle and decreasing up the leg—which helps squeeze blood up through the veins. They are a cornerstone of conservative varicose vein management.

How Are Varicose Veins Treated?

Modern varicose vein treatment includes minimally invasive options like endovenous laser ablation (EVLA), radiofrequency ablation (RFA), and foam sclerotherapy, all with success rates of 90-95%. These outpatient procedures have largely replaced traditional vein stripping surgery. Treatment choice depends on vein size, location, and patient factors.

Treatment for varicose veins has evolved dramatically over the past two decades. Traditional surgical stripping—which required general anesthesia, hospitalization, and significant recovery time—has been largely replaced by minimally invasive endovenous techniques. These newer procedures are performed as outpatient treatments under local anesthesia with minimal downtime.

The goals of varicose vein treatment include eliminating symptoms, preventing complications, improving cosmetic appearance, and enhancing quality of life. Treatment decisions are individualized based on the severity of disease, specific veins affected, patient preferences, and overall health status.

Endovenous Thermal Ablation

Endovenous ablation techniques use heat energy delivered through a thin catheter inserted into the vein to seal it closed. The two main methods are:

Endovenous Laser Ablation (EVLA): A laser fiber is inserted into the varicose vein under ultrasound guidance. Laser energy heats and seals the vein from the inside. The procedure takes 30-60 minutes, uses only local anesthesia, and has success rates of 93-97%. Most people return to normal activities within 1-2 days.

Radiofrequency Ablation (RFA): Similar to laser ablation, but uses radiofrequency energy instead of laser. A catheter delivers controlled thermal energy that causes the vein to collapse and seal. RFA may cause less post-procedure discomfort than laser. Success rates are comparable at 92-97%.

Both techniques work by destroying the vein lining, causing the vein to close and eventually be absorbed by the body. Blood is naturally rerouted through healthy veins. The procedures are performed in outpatient settings, and patients walk immediately afterward wearing compression stockings.

Sclerotherapy

Sclerotherapy involves injecting a chemical solution directly into the varicose vein, causing it to scar and close. It's particularly effective for smaller varicose veins and spider veins:

• Liquid sclerotherapy: Direct injection of sclerosant solution; best for small veins
• Foam sclerotherapy: The sclerosant is mixed with air to create foam, which displaces blood and has better contact with vein walls; effective for larger veins
• Ultrasound-guided foam sclerotherapy (UGFS): Uses ultrasound to precisely guide foam injection into deeper veins; can treat larger varicosities

Sclerotherapy is less invasive than thermal ablation but may have slightly lower long-term success rates and higher recurrence rates for large veins. Multiple sessions are often needed. It's an excellent option for treating remaining varicose veins after ablation of the main trunk vein.

Surgical Treatment

Traditional surgery (vein stripping and ligation) involves removing the affected vein through small incisions. While largely replaced by endovenous techniques, surgery remains appropriate in certain situations:

• Very tortuous veins that cannot accommodate ablation catheters
• Recurrent varicose veins after failed endovenous treatment
• Patient preference or when minimally invasive options are unavailable

Modern surgical techniques use smaller incisions and ambulatory procedures. Phlebectomy (removal of varicose vein tributaries through tiny punctures) is often combined with endovenous ablation to treat visible varicosities. Recovery typically takes 1-2 weeks with bruising that resolves over several weeks.

Comparing Treatment Options

What Complications Can Varicose Veins Cause?

Untreated varicose veins can lead to venous eczema (itchy skin changes), hyperpigmentation (brown discoloration), lipodermatosclerosis (hardened skin), superficial thrombophlebitis (vein inflammation with clots), bleeding from minor trauma, and venous leg ulcers. Early treatment helps prevent these complications.

While many people with varicose veins never experience complications, chronic venous insufficiency can progress over years to cause significant problems. Understanding potential complications helps motivate preventive measures and early treatment when appropriate.

The progression from uncomplicated varicose veins to more serious manifestations typically occurs gradually over many years. However, not all complications follow this timeline—thrombophlebitis or bleeding can occur suddenly. Regular monitoring and awareness of warning signs enable early intervention.

Skin Changes and Venous Eczema

Chronic venous hypertension causes inflammatory changes in the skin and subcutaneous tissues. This manifests as:

• Venous eczema (stasis dermatitis): Itchy, red, scaly skin typically affecting the lower leg and ankle
• Hyperpigmentation: Brown discoloration from iron deposits left by leaked red blood cells
• Lipodermatosclerosis: Hardening and scarring of skin and underlying fat, giving the leg a "champagne bottle" appearance
• Atrophie blanche: White, scarred skin patches often preceding or following ulcers

Superficial Thrombophlebitis

Blood clots can form within varicose veins, causing inflammation. Symptoms include a hard, tender, red, warm cord along the course of the vein. While superficial thrombophlebitis is painful, it's generally not dangerous unless the clot extends toward the deep venous system. Treatment typically involves anti-inflammatory medications, compression, and walking; anticoagulation may be needed if clots are extensive.

Venous Leg Ulcers

The most serious complication of chronic venous disease is venous leg ulceration, affecting approximately 1% of the adult population at some point in their lives. Venous ulcers typically occur near the inner ankle (medial malleolus) and result from prolonged elevated venous pressure damaging the skin and underlying tissues.

Venous ulcers are often chronic and difficult to heal, significantly impacting quality of life. They require specialized wound care, compression therapy, and often treatment of the underlying venous disease to achieve lasting healing. Prevention through early management of varicose veins is far preferable to treating established ulcers.

Can Varicose Veins Be Prevented?

While you cannot completely prevent varicose veins (especially with genetic predisposition), you can reduce risk and slow progression through regular exercise, maintaining healthy weight, avoiding prolonged standing or sitting, wearing compression stockings for high-risk occupations, and elevating legs when resting.

Complete prevention of varicose veins is not possible, particularly for those with strong family history. However, lifestyle modifications can significantly reduce risk, delay onset, and slow progression for those who do develop them. These preventive measures become especially important for people with known risk factors.

Primary prevention focuses on maintaining healthy vein function before problems develop. Secondary prevention aims to prevent existing varicose veins from progressing to complications. Both approaches rely on similar lifestyle strategies.

Lifestyle Strategies for Prevention

• Stay active: Regular walking, swimming, or cycling strengthens the calf muscle pump and promotes healthy circulation
• Maintain healthy weight: Reducing excess weight decreases pressure on leg veins
• Avoid prolonged standing or sitting: Take regular breaks to walk and move; flex calf muscles when stationary
• Elevate legs: Raise legs above heart level for 15-20 minutes several times daily
• Wear compression stockings: Especially important for high-risk occupations or long flights/drives
• Avoid tight clothing: Waistbands and leg garments that restrict circulation can worsen venous pressure
• Wear low-heeled shoes: High heels limit calf muscle pump effectiveness