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Photo by Everton Vila on Unsplash

Should I be Worried About Varicose Veins?

What are all those bluish blackish lines on people’s legs, anyway?

When I was a teenager Kids Say the Darndest Things* was one of my favourite bathroom reading books. So I wasn’t the least bit surprised when I heard about this incident at a local elementary school. (names are changed to protect the innocent)

One of the teachers, Ms Jones, asked if anyone had any more questions?

Billy, an 8 year old, put up his hand and when called upon, he asked,

“Ms Jones, what are all those black lines on your legs?”

As you can imagine, there was lots of giggling and looks of surprise from all the other children. And the teacher, too!

No, it wasn’t halloween and part of her costume. And it wasn’t a tattoo pattern, either. He was asking about her varicose and spider veins.

It was definitely a “teachable moment”!

That shouldn’t be too surprising because most kids that age may not have seen or noticed them before. Their parents are probably young adults (although younger people can get them) and their parent’s friends and siblings are all pretty young, too. They seem to occur more commonly in middle to later aged people.

I have to admit, I had seen them lots over my lifetime, too, but I had no idea how they formed, why they formed, if they were dangerous or harmful in any way. I just figured they were blue veins that stuck out on people’s legs, lots of people had them and don’t worry about it.

And the bluish blackish colour didn’t surprise me either because in all the lab dissections I did when I was a biology student, i.e., the fetal pig, the arteries were red and the veins were blue.

So it seemed quite natural to have blue veins in our legs, too! Do they only show up blue when you get older? Nope, I knew that all my life I could see what I thought were veins in my forearms and hands and they were blue. So what’s going on here?! Should I care about varicose veins?

In this article, I’ll try to answer all those questions and more. I’ll talk about how varicose veins form, what, if any risks are associated with them, how to treat and “cure” them and what the current state is of varicose vein research.

So let’s get started, there’s lots of interesting biology to discover here!

Quick review of our circulatory system

Before we can really delve into and understand this topic we need a quick review about the blood circulatory system in our bodies to get back up to speed.

Our blood circulatory system is made up of the arteries, veins and the heart and smaller vessels like the capillaries. The heart pumps the blood through the arteries and veins. Ok, you knew that but we had to start somewhere.

The arteries move blood out and away from the heart and bring it to all parts of the body to supply oxygen and other nutrients to our tissues.

Interestingly, normal human blood is always red. It’s bright red when it is carrying oxygen to the various tissues and once it delivers the oxygen, it turns a dark red when it is in the veins and returning to the heart.

Arteries have thick layers of muscles and elastic tissue to help push the blood through them.

An interesting factoid: you probably remember that the arteries also branch out to the smaller capillaries. Well, there are lots of capillaries carrying blood into your lips and that’s why they are naturally reddish in colour.

As we mentioned above, your veins return oxygen depleted blood to your heart. To do this, they employ the surrounding muscle tissue and a system of one-way cup-shaped valves embedded in them.

The valves open to allow the blood to flow through and then close to prevent it from flowing back the way it just came. There are lots of these valves in a vein and they function to create manageable pools of blood along the vessel.

In the legs and feet, there are two types of veins, deep veins and superficial or shallow veins. Deep veins return the blood directly to the heart.

The superficial veins run under the skin and in the layer of fat directly under the skin (called subcutaneous fat). They collect less than 1% of the blood and return it to the deep veins.

These are the veins that most often become varicose or spidery.

You can see normal superficial veins in the hands and arms because there is less fat under the skin there. So that’s why I could see them. Cool.

Interesting factoid #2: why are they blue if the blood is still red? I found that answer here.

“Veins look blue because light has to penetrate the skin to illuminate them, blue and red light (being of different wavelengths) penetrate with different degrees of success. What makes it back to your eye is the blue light.”

Voila, that’s why the veins look blue 👍

And that finishes our quick review of our blood circulatory system. Now on to the topic at hand, varicose veins.

Everything you wanted to know about varicose veins and then some

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Photo taken from this page on WebMD showing both varicose and spider veins

Varicose veins are veins that are permanently swollen or enlarged. In most cases they affect the legs and feet and they appear as bluish or blackish cords bulging just below the skin, as Billy noticed.

I also mentioned spider veins above. Are they the same as varicose veins? The answer is no but I’ll talk more about them and their differences a little later on.

Varicose is a medical term and not a word we normally use. The quote about its derivation was taken from here).

It is derived from 15th century latin varicosus “with dilated veins,” from varix (genitive varicis) “dilated vein,” from varus “bent outward, bow-legged,” which is of uncertain origin.

Merriam-Webster defines varicose as “abnormally swollen or dilated.

Veins become varicose from excessive pressure exerted on the legs or abdomen. This causes the veins to become stretched or dilated. This in turn causes the valves in the veins to leak.

The pressure causing the leakage is what we call hydrostatic pressure. This is the pressure that arises simply from the height of the blood column above the vein and the volume of blood in that column.

When the valves are functioning normally, they prevent a backflow in the blood column by separating it into many partitions within the vein. Those are the normal blood pools we talked about earlier.

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Figure taken from a Mayo Clinic article.

In varicose veins, because the leaky valves aren’t working properly, blood forms larger pools in the vein. This can increase the pressure in the vein and can cause it to bulge and twist. When it bulges, that’s when we notice it. The figure above shows this quite nicely.

You might be wondering if your veins are likely to varicose.

About 1 in 4 of all Americans are affected. 20 to 30 million Americans currently have varicose veins, and as many as 45% of men and 55% of women will suffer from them at some point in their lives.

There are lots of ways that they arise. In no particular order here are the most common:

  • Standing for long periods of time without a break in a job like teachers or chefs
  • People who are sedentary
  • People who are obese
  • People with chronic constipation
  • Tumours can cause them
  • Women are more likely to get them than men but both sexes get them.
  • Genetic family traits
  • More likely as age increases
  • Pregnant women

Varicose veins in pregnant women are a bit of a special case so let’s talk about them for a bit.

It’s quite common to get varicose veins during a pregnancy. Your mother may have gotten them, too. They’re usually hereditary.

A woman in pregnancy has a 50% increase in total body water — most of it in the legs, causing dilation of leg veins and leg swelling. After delivery, the extra fluid is lost and the veins shrink, but they don’t go back to their former size.

With each pregnancy, they get a little bit larger, and if you inherited a “weakness” of the vein wall or your job involves lengthy standing or sitting, there is a continuous stretch.

Another contributing factor is pregnancy hormones; they may cause the walls of your veins to weaken and swell.

Pressure on the veins behind your uterus also slows the circulation of blood to your heart, making the smaller veins in your pelvis and legs swell.

In late pregnancy, they may also appear in your vulva, the area outside your vagina. Varicose veins in your rectum, called hemorrhoids, are also common. Unlike the varicose veins other people get, a pregnant women’s will probably recede and disappear after the baby is born, when pressure on the veins is eliminated.

To avoid or reduce them and their discomfort during pregnancy, if possible, sleep or rest on your left side to ease pressure on the vein that carries blood from your feet to your heart. It’s on your right side.

Here’s some additional health tips for pregnant women from the Varicose Vein Clinic of BC:

“Try to keep weight gain to approximately 20–30 pounds, wear compression garments, take every opportunity to elevate the legs….Get in a swimming pool to relieve some of the pressure on your legs”.

What can you do to prevent getting varicose veins?

By now you’re wondering if there’s anything you can do to prevent getting them or lessen the frequency if you already have them.

Unfortunately, there’s nothing you can do to completely prevent getting them if you’re genetically programmed to have them but you can do things to increase your circulation so they will not occur as often or be as severe.

Here are the 7 most common recommendations.

Exercise more often. Swimming, walking, cycling and yoga are all excellent low impact physical activities that get your calf muscles working and help lower blood pressure in the legs and feet.

Alter your diet. Foods that are salty or high in sodium lead to water retention and that leads to greater hydrostatic pressure in your circulatory system. Foods that are high in potassium help reduce water retention and lessen the pressure. These include:

  • almonds and pistachio nuts
  • lentils and white beans
  • potatoes
  • leafy vegetables
  • some fish, such as salmon and tuna

Also ensure that you are getting enough fibre in your diet. That will help bowel movement to prevent constipation, which can be a contributing factor. Straining can also aggravate and make the varicose veins worse.

High fibre foods include seeds, nuts and legumes; whole grains; oats, whole wheat and flax seeds.

Include more flavonoids in your diet. They help increase your circulation, keep the blood moving, relax the blood vessels and prevent unnecessary pooling. Here’s some foods that are high in flavonoids:

  • vegetables, including onions, bell peppers, spinach, and broccoli
  • citrus fruits and grapes, cherries, apples, and blueberries
  • cocoa
  • garlic

Elevating your legs can help relieve the hydrostatic pressure. Keeping them at the same level as your heart or above it reduces the pressure and the gravity will help the blood flow more smoothly back to the heart without pooling.

Avoid high heels and tight hosiery. These both put strain on the veins and arteries. Wear flat soled shoes and if you have to wear high heels, minimize the time you keep them on. Wear looser fitting clothing whenever possible. Only wear high heels socially, not at work, while traveling, or when there will be extended standing. Avoid tight-fitting clothes like spanks and corsets when sitting for long periods of time.

Maintain a healthy weight. Overweight is a strong contributing factor as it puts a lot of strain on the vessels which leads to swelling and discomfort. The physical activity and diet recommendations above can help you shed pounds but don’t lose them too fast as that can also cause problems.

Changing your sitting or standing position at regular intervals. Too long in either position is detrimental. And avoid sitting with crossed legs as this can restrict blood flow and can cause additional pressure on the vessels.

Incorporate daily compression into your habits. Compression stockings are the single best way to control swelling and leg symptoms and help push the blood upward. Put them on before you get out of bed in the morning.

The best stockings for the job have 20–30mm Hg graduated compression, but if you don’t have a history of swelling, compression socks with 15–20mmHg are sufficient for some. The lesser grade leggings are great for social settings and short trips.

Can I cure or treat varicose veins or do anything to make them go away?

Yes, you can. There are several different kinds of treatments for different conditions.

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Photo taken from this page showing before and after treatment

As you can see from the photo above, the results of treatment can be quite dramatic!

Here’s everything you need to know about the various treatments.

You may need several treatment sessions to make them go away.

Endoveinous Laser treatment- multiple treatments to treat the smaller veins. Pulses of laser light are delivered inside the vein, which causes the vein to collapse.

Lasers and intense pulsed light- Surface laser or intense pulsed light treatments, such as Vasculight and PhotoDerm, are other options. These devices use heat energy to selectively damage or destroy abnormal veins. An advantage of these treatments is that no needles or sclerosing solutions (see below) are required; however, there may be some minor discomfort. Side effects do occur, including discoloration or staining and blister formation. The results can be disappointing.

Radiofrequency occlusion- A small catheter is inserted into the vein. The catheter delivers radiofrequency energy to the vein wall, causing it to heat, collapse, and seal shut. The procedure is generally done in an outpatient or office setting, sometimes under local anesthesia.

Sclerotherapy- a chemical (highly concentrated saline solution or special detergent) is injected into the veins that collapses its walls so it can no longer transport blood. It is eventually reabsorbed into the surrounding tissue.

Microsclerotherapy uses a smaller needle to treat smaller veins.

Surgery — removal or stripping.

Surgery is called for if your veins are painful, have developed blood clots or you have skin problems. If your vein is surgically closed off, it will fade away and the blood flow will shift to other veins.

Endoscopic Ablation Therapy- a small camera attached to a tiny tube is inserted into the vein which also has a surgical device at the end of the tube. This is used to close the vein. This is only done in cases where the vein has caused a severe ulcer.

Ambulatory phlebectomy- less complicated. The area is numbed and the surgeon/doctor removes the veins through small cuts in the skin. You are awake the whole time.

Vein stripping and ligation- this is for more serious cases and usually requires anesthesia. The surgeon makes cuts in the skin, ties off the vein and removes it. You might go home the same day. Recovery is 1 to 4 weeks and you may experience various side effects such as swelling, bruising, change in skin colour, and pain.

Complications from this procedure can include blood clots, severe pain, infection, and scarring.

Legs may be wrapped in elastic bandages after surgery and you may need to wear compression stockings.

You mentioned Spider Veins? How are they different?

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Photo taken from this page on WebMD

Although caused by the same underlying venous disorder, spider veins differ in several ways.

Varicose veins are larger, usually exceeding three millimeters in diameter. They typically appear as blue- or purple-colored bulging ropes along the legs, feet, or ankles. They can be swollen and visible on the legs, but sometimes are not close enough to the surface of the skin to be seen. Other symptoms of varicose veins include aching, throbbing, heavy feeling in the extremities.

In contrast, spider veins are typically one millimeter in diameter. They appear as web-like clusters of blue or red veins on the surface of the skin. Unlike varicose veins, spider veins do not bulge out from under the skin. Though they crop up most often on the legs, spider veins develop on the face, too. Spider veins rarely cause symptoms, so when patients seek treatment, it’s usually for cosmetic reasons.

This article from the archives of WebMD also talks about spider veins. They mention that though they are generally harmless, they can cause some people to want to cover up even in the heat.

They also reaffirm that no one knows why some people develop spider veins and others don’t, but genetics, the hormone estrogen and possibly the hormone progesterone are thought to play a role. Spider veins appear more frequently in women than in men, and are particularly common in pregnant women and those taking oral contraceptives or hormone-replacement therapy.

Getting rid of spider veins is safe and easy. Doctors who treat them often use a combination of sclerotherapy and lasers: sclerotherapy for the major part of the treatment and a laser to get rid of the tip of the vein. Laser techniques for removing spider veins are expected to improve greatly during the next decade. At the present time, sclerotherapy is still the gold-standard treatment for spider veins.

OK, now you know a whole lot more about both varicose and spider veins.

But there’s still one important area that we mentioned that I’d like to present in greater depth. Varicose vein genetics. Just how might our genes be causing or affecting these conditions?

That’s our next and final topic of this article.

Research into possible genetic causes of varicose vein formation

The journal “Frontiers in Physiology”, published an article online in May 2019, “Weighted Gene Co-expression Network Analysis for RNA-Sequencing Data of the Varicose Veins Transcriptome” by Jianbin Zhang and others.

Ok, that title is a mouthful. Let’s do a bit of unpacking and translating into plain English kinda like we did in the Lichens and How Do We Die articles so we can understand just what they are looking at and what their results might indicate.

We’ll start with the title. There’s 4 distinct pieces in that title:

  1. Weighted gene co-expression,
  2. network analysis,
  3. RNA sequencing data and
  4. varicose veins transcriptome.

To best understand it, we need to work backwards.

Remember that our genes are found in our DNA as long molecular codes that tell the cell how to make proteins and other stuff we need. There is a whole molecular system with many components in our cells that do the production work and we can’t go into all of that here, now.

The first step is to make a copy of the gene’s DNA sequence — that’s called transcribing the DNA to make a molecule made up of what we call RNA. The process of transcribing DNA to make RNA is called transcription.

Every different kind of cell in our body needs to make a unique set proteins or they would all look and be the same and we’d be just a big amebic blob! The unique set of transcribed RNAs in a given cell of interest is called its transcriptome.

The suffix -ome indicates that we are looking at the totality of the components. So if we were to look at all of a cells proteins, we’d be looking at its proteome and so on for other components.

And just like DNA, RNA can also be sequenced so we can isolate the cell’s various RNAs and sequence them to find out its transcriptome. Then we have a catalog of all the RNAs in the cell’s transcriptome. In this study, they determined the varicose veins’ transcriptome.

That takes care of pieces 3 and 4! Just 1 and 2 to go.

When a piece of DNA is transcribed into RNA we say the gene has been expressed.

As you will see below, the blood vessel and surrounding tissue is made up of many different kinds of cells and subcellular components. What the researchers wanted to find was the sets of similar genes that were expressed in all the different cells. This is what they mean by co-expression.

Those co-expressed genes might be parts of different networks. For instance, all the genes that are expressed that help to make up a cell’s membrane would be one network, genes that make the “machines” that transcribe RNA would be another network and so forth.

So they were looking to find out which networks were co-expressed by the various different cells that make up veinous vessels and they could do that by collecting and comparing the data from sequencing the RNA and seeing what was in their transcriptomes.

That wasn’t that difficult, was it!

Lastly, they used a statistical method called Weighted gene co-expression to tell them what genes their catalogued RNA sequencing data told them were expressed differently in the non-varicose versus varicose veins.

In order to separate out these kind of differences, you need to compare apples to apples, not apples to oranges. In this case their apples were a vein in the legs called the Great Saphenous Vein. They took them from cardiac patients that did not display any varicosity and compared them to varicose Great Saphenous Veins taken from affected patients.

What were they hoping to find?

Symptoms in varicose vein patients span the gamut from non threatening cosmetic worries to severe ulcerous conditions that are resistant to treatment.

Although many studies have looked at the possible causes of how varicose veins arise, the etiology, or causation, origination, and pathogenesis of varicose veins are still not well defined.

Zhang compared Great Saphenous Veins taken from Coronary Artery Bypass Grafting patients and varicose Great Saphenous Veins taken from conventional stripping surgery patients.

RNA was taken from both sets of samples and sequenced to compare which genes were being expressed differentially between the varicose and non varicose vein samples.

They identified 333 genes that were expressed differently between the 2 samples; 87 were upregulated and 246 were down regulated. Upregulated means that a given gene has transcribed that RNA more than it usually would and down regulated means that is has transcribed that RNA less than it usually would.

Many of the differentially expressed genes were in signalling pathways (these are the pathways that direct how the cell responds to molecules like hormones). Another important cluster was in skeletal muscle myofibril genes which contribute to forming and maintaining the structure of the veins.

Myofibrils are the long filaments or threads that make up muscle tissue and you can see them in the picture below. Remember we mentioned above that veins and arteries use muscles to help them move the blood through them.

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Image for post staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2).

Previous work by other labs had shown roles for several genes in varicose vein pathogenesis using limited RNA expression techniques. (For these references, please see the original article.)

Zhang’s study used comprehensive state-of-the-art RNA expression profiling by sequencing. Their weighted gene co-expression network analysis showed a critical role in varicose vein pathogenesis was indicated for the skeletal myofibril assembly pathway.

Previous work looked at the structural components of varicose veins

Due to initial observations by scientists back in the early 1970s, a fair amount of work started to concentrate on varicose vein structure and the components that make up the vein.

Zhang noted that this “…indicated that the primary variation of venous wall components and structure may be vital in the pathogenesis of varicose veins… Therefore, an increasing number of studies began to focus on the primary changes of venous wall components and structure in patients with varicose veins.

So Zhang and colleagues stained tissue sections from their samples for components thought to be involved in pathogenesis. Three of the genes they stained for were found to be expressed at lower levels in the varicose vein samples.

“Histopathological analysis showed that in the varicose veins group, the thickness of vascular wall, tunica intima, tunica media and collagen/smooth muscle ratio were significantly increased, and that the elastic fiber/internal elastic lamina ratio was decreased.”

Translation for us regular folks: when varicose vein and non-varicose vein tissue was sliced into thin sections and made into microscopic slides the researchers could see that all the parts of the varicose vein walls were thicker than non-varicose vein walls and the components that make up the walls were more abundant.

But the ratio of expression of genes that specify the components like the myofibrils, and other skeletal components that contribute to the elasticity or stretchiness of the varicose veins, were decreased.

In summary the varicose vein walls were thicker but less able to stretch along the direction the vein was running. So you get bulging which pulls apart the overlapping valve pieces and results in blood pool leakage instead stretching and valve maintenance of the pools.

They also found that some inflammatory genes were expressed in lower amounts in the varicose vein samples.

And to give Zhang and colleagues full credit, they emphasized that this study was not definitive. Rather, they suggest that it was a successful pilot study that gives a future direction for the kind of study that is needed in the future to really answer these questions.

Why would we want to do that? Very simply, if we can find out the genes that are responsible, they could be the source of new treatments that specifically target them and either enhance or shut down their expression, as required, using gene therapy or pharmacological interventions.

And now you know the rest of the story.

As you can see, there’s still a lot we don’t know about varicose vein formation and as it can sometimes lead to serious illness and consequences, more research is definitely called for.

Oh, I never told you how Ms Jones responded to Billy. She noticed that he looked quite concerned so she said, “Those are called varicose veins. Not to worry, Billy, they don’t hurt.”

Billy was satisfied with her answer and you should be, too!

For now, that’s all I have to say about those black lines on Ms Jones’ legs.

Until next time,


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