Varicose veins (VVs) are swollen or gnarled veins that occur most commonly in the legs, resulting from a weakening of the vessel wall or malfunction of the vein valves. It is estimated that 10-15% of adult men and 20-25% of adult women have VVs. Age and sex significantly affect the prevalence of the condition, and it is widely recognized that VVs are a condition primarily afflicting the elderly and women, particularly those who have had more than one pregnancy. The condition is not only unsightly but can lead to the development of chronic wounds on the lower leg that are difficult to treat and can have serious implications. Furthermore, the societal stigma regarding varicose veins can cause emotional stress and reduce the quality of life of those afflicted. The impact of VVs on the quality of life, particularly with regard to mental health, has only recently become a focus for those researching the condition. While the Grove Scale, which measures the severity of chronic venous disorders, is heavily based on the physical manifestations of VVs, a trailblazing piece of research has led to a shift in focus towards investigating the impacts on the emotional well-being of sufferers.
Overview of Varicose Veins
Varicose vein in the legs refer to enlarged and sometimes twisted veins, very close to the surface of the skin. The veins look unsightly and are often removed, even though they are usually harmless. They are common and affect up to 3 in 10 adults. Women are more likely than men to be affected. The underlying cause of varicose veins is that the small valves in the veins stop working properly, which causes the vein to become enlarged or twisted. This stops the blood flow up the legs, which can cause the legs to ache or feel heavy. This can also lead to the person having swollen ankles due to a buildup of fluid. Other possible symptoms include dry or itchy skin over the veins and some numbness in the legs. In severe cases, varicose veins can lead to more serious health problems. It is important to note that not all varicose veins are visible (i.e. close to the skin) and sometimes smaller, deeper veins are affected. These are often only detected by using an ultrasound. Deep veins are more important than superficial veins because they carry up to 90% of the blood back to the heart. Deep veins are surrounded by a layer of muscle, which pumps the blood in the veins back to the heart. If the deep veins become varicosed then there is an increased likelihood of long-term swelling, skin discoloration, and leg ulcers.
Understanding Mental Health Impacts
Finally, changes in the workforce can cause significant functional and mental struggle. Older age varicose vein patients have been affected by changes to occupational health and safety guidelines. Static standing occupations have been associated with a high risk of severe varicose vein disease. Many patients with symptoms of chronic venous disease have transitioned to light or modified duties believing that they may achieve improvement in symptoms. Recent job employment changes may result in income loss if the patient cannot continue work, and ultimately there is a large impact on self-worth associated with earlier than planned retirement.
Another common cause for impaired mental wellbeing is body image embarrassment due to visible varicose veins. The association with varicose veins and below-knee ulcers with past historical treatments is a strong negative predictor of quality of life in patients aged 65 or older. Unsightly scarring can cause further cosmetic concerns in older varicose vein patients. These symptoms trigger social embarrassment and ultimately result in patients avoiding social situations, as well as intimate relationships.
High-quality vein care services need to offer more forms of treatment that result in improvement for any given pattern of vein disease and extend treatment availability to those with early disease.
Another significant factor in determining the mental health impact of varicose veins is the severity of the disease. In particular, there is a significant psychological impact in women who possess visible and uncomfortable varicose veins during pregnancy but who are then advised that invasive treatment is inappropriate until after childbirth. This is due to the fact that they cannot gain expected relief of symptoms and cosmetic improvement with the available treatments, and the knowledge of the potential for disease progression.
In both Western society and Japan, the psychosocial burden of varicose veins on the patient is now well-documented. In 1999, a study showed that varicose vein patients have a significant reduction in their quality of life. The physical symptoms that are associated with chronic venous disease, such as leg swelling, pain, fatigue, and heaviness, have been known to reduce the quality of life in vein patients. This, in turn, has a detrimental effect on mental health and has been shown to cause a higher likelihood of depression.
Varicose veins can have a significant impact on an individual’s mental wellbeing, as well as physical health. The fact that varicose vein symptoms can limit an individual’s daily living activities such as standing and walking can result in decreased self-confidence and further cause depression. These symptoms can cause limitations at work and the inability to participate in family or social activities.
The Relationship Between Varicose Veins and Mental Health
And on a related note to the emotional consequences, varicose veins can also have a large impact on a sufferer’s work and daily activities. Changes in skin and ulceration can cause considerable pain and discomfort, resulting in days off work and decreased mobility. Patients can find that even the act of prolonged standing exacerbates symptoms. This can often conflict with the common belief that standing worsens veins. When in fact, many medical professionals suggest that the development of varicose veins is not due to the time spent on one’s feet, but rather the reason for this, i.e. work involving prolonged standing is likely to aggravate symptoms that are already present.
One study looked at the symptoms experienced by varicose vein patients before and after treatment, comparing their quality of life with normative data. It was found that patients experienced more severe pain, swelling, leg fatigue, and skin changes compared to the normal population, and attributed a large proportion of this to their veins. Psychological and social scoring was significantly lower than the norm, reflecting the negative impact of vein symptoms on the overall quality of life. In another study, 64 patients with untreated varicose veins were evaluated using various questionnaires to compare their symptoms with a control group of 64 patients with mild or moderate peripheral neuropathy. The varicose vein patients scored significantly worse in 7 out of 8 domains of the SF-36 quality of life measure.
Research suggests that individuals with varicose veins may experience a decreased quality of life due to the physical and psychological implications of this condition. Throughout many years, varicose veins have generated a stereotype of being a cosmetic issue, to be expected with aging or increasing weight. In response, a number of people attempt to cope with feelings of embarrassment, either by covering up or physically concealing the veins in any way possible. This can often exacerbate the psychological and emotional impact of varicose veins.
Psychological Effects of Varicose Veins
When an individual experiences a physical issue, there is often an emotional and psychological response that accompanies it. Varicose veins can have the detriment of affecting an individual’s psychological state, and this is unfortunately often an area of the condition that is overlooked. A study found that the quality of life in relation to the physical and emotional state was worse in those with venous problems than in those who suffered from cardiovascular disease or hypertension. Compared to those with healthy legs, the quality of life in both men and women with the most severe form of varicose veins is the same as patients who suffer from heart failure. Psychological state is also an area that, if affected, can have a bearing on the physical condition of varicose veins. For example, an individual with reduced mobility due to a venous leg ulcer may become depressed because of the loss of activity, which can, in turn, have an effect on the ulcer healing.
Emotional Impact on Individuals
Varicose veins were compared to non-painful conditions (eczema and psoriasis) to identify if the emotional domain is unique to varicose veins. It was concluded that individuals with varicose veins have a higher emotional impact compared to other chronic skin diseases. This helps to highlight the emotional impact patients may experience with their varicose veins and shows that there is a necessity for seeking out these emotional effects and the best means of treating them.
Emotional impact on individuals can be affected by having varicose veins. It is a condition experienced differently by patients. Establishing good and effective communication with the patient will allow you to gain a better understanding of how they feel about their varicose veins and how it affects them. This will influence the strength of the clinician-patient relationship and will allow you to monitor progress or deterioration more effectively. This, in turn, will improve patient compliance and satisfaction with their care.
Social Consequences and Stigma
The influence of varicose veins on mental health also has wider societal implications. The social and leisure activities of individuals with varicose veins are significantly impaired compared to those without. It is well recognised that depression reduces productivity and this impact may be particularly marked in individuals with varicose veins. Finally, as the population ages and the proportion of people with varicose veins increases, the direct and indirect cost of varicose veins on society can be expected to grow. An increased understanding of the full extent of the burden of varicose veins can help guide decisions about allocation of healthcare resources and focus attention on developing effective preventative and treatment strategies.
Varicose veins are typically viewed as a benign and somewhat inevitable consequence of aging. Nevertheless, they have far-reaching consequences that can be hugely debilitating. While often regarded as a merely cosmetic problem, varicose veins are associated with significant physical symptoms that have a substantial impact on daily life. Varicose veins are a cause of chronic leg edema, which can lead to skin changes and skin ulcers. Not only are such skin changes and ulcers painful and inconvenient, they are also associated with significant individual and societal cost. People with a leg ulcer have a greatly reduced quality of life and impaired functional status compared to those without ulcers. They are also more likely to be depressed and experience greater restriction of social and leisure activities. In addition, chronic leg ulcers are costly to manage and are a significant drain on healthcare resources.
Coping Strategies and Support for Mental Health
High ligation and vein stripping is a surgical technique used under general anesthesia. Small incisions are made below the groin, and a device is threaded through the vein to pull it out. This is a particularly invasive technique and often requires several weeks off work for recovery.
Over-the-counter pain relievers such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can be used for pain relief, although they will not have any effect on the veins themselves. Topically applied creams can be used to provide relief by improving the skin condition in the lower leg and decreasing the itchiness associated with more severe varicose veins. Weight loss and exercise can also help to improve the symptoms of varicose veins, however this will not make the veins go away and it is still important to consider future treatment for the veins.
Self-care and non-surgical interventions can provide symptom relief for patients with mild symptoms. In mild cases, patients can be advised to elevate their legs and avoid prolonged standing. The use of compression stockings at 25-30 mmHg provides the least expensive and most non-invasive form of treatment for varicose veins. Support hose squeeze the leg tissues and help the veins to work better. Generally, they are well-tolerated by most patients. Stockings must be put on first thing in the morning before getting out of bed and before the veins become more swollen. The idea is to prevent blood from pooling in the superficial leg veins.
Since varicose veins are often considered by patients to be a cosmetic problem and not a medical one, consumers must be educated about the medical implications of varicose veins. They must be made aware that by treating their varicose veins, they may be able to prevent more serious problems later on in life.
There are a number of strategies that may be used to alleviate some of the mental health symptoms associated with varicose veins. The most important one is to treat the varicose veins themselves. With modern minimally invasive surgical techniques, most patients with varicose veins can be treated on an outpatient basis.
Self-Care Techniques for Varicose Veins
The phrase “if it’s too uncomfortable, don’t do it” should be kept in mind as a general rule for those with varicose veins. Excessive standing, prolonged sitting, and tight restrictive clothing are to be avoided whenever possible as they all contribute to increased venous pressure. The same can be said for high-impact activities such as running, which are likely to exacerbate symptoms. Instead, low-intensity exercise is recommended to improve overall leg strength and circulation. Walking is a prime example of this and has the added benefit of being simple, cheap, and easily incorporated into daily routine. For those with access to a pool, swimming is an extremely beneficial form of exercise, although walking in water and leg exercises can also be effective. In all situations, it is important not to overdo it and to rest if tired or experiencing significant discomfort. As a final note, leg elevation is an excellent means of reducing both swelling and the feeling of heaviness in the legs. If possible, 10-15 minutes of rest with the legs raised should be taken several times throughout the day.
Skin care is that vital combination of both prevention and treatment for those already suffering from varicose veins. Preventative measures such as sunscreen and insect repellent help to avoid skin damage and thus lessen the risk of ulcer formation. Daily moisturizing coupled with regular massage using a moderate strength cream or ointment can do much to improve skin texture. This process serves to cool and soothe the legs as well as helping to avoid the dry, itchy skin which is all too common in those with venous problems. Caution should be exercised when selecting skin care products as some can cause a flare-up of rash or worsen the appearance of varicose veins. A patch test for sensitivity is always advisable in this situation.
While the impact of varicose veins on self-image is undeniable, there is some relief to be found in minimizing the discomfort and appearance of these troublesome veins. Simple lifestyle changes and meticulous skin care can often improve the situation dramatically.
Seeking Professional Help
There are numerous treatment options to consider when seeking professional help. Due to the wide range of severity of varicose veins, there is no one-size-fits-all approach and new procedures are constantly being developed and improved. Surgery is often the most effective treatment for long-term alleviation of severe varicose vein conditions. High ligation and vein stripping was the traditional surgical treatment, but more recent methods such as ambulatory phlebectomy or endoscopic vein surgery are considered to be comparable or better in overall results with less pain and shorter periods of incapacity.
General practitioners are a good first port-of-call and often refer patients to specialist medical practitioners such as phlebologists who specialize in vein care. Post-procedural recovery duration and limitations of any treatments should also be made clear to patients before treatments commence. Patients will be able to determine the necessity of consulting a specialist through economic factors and associated rebates.
For vigorous, more severe forms of varicose veins where the patient is experiencing substantial discomfort or is self-conscious about the veins’ visible appearance, seeing a professional may be the best solution. Expectations should be carefully managed in terms of what to expect for treatment-induced changes to the veins’ appearances and potential recurrence of the veins after treatment.
Support Groups and Peer Networks
For individuals with varicose veins, the internet has made it possible to form a global community of individuals searching for others who are looking for information and support in dealing with this chronic condition. People have a range of feelings about participating in support groups. Some value connecting with others who are dealing with similar health issues and may remain members of a support group for an extended period of time. Others are not interested in groups but may find it helpful to talk with an individual who has experienced similar health problems. This is also possible using internet resources. Support groups for individuals with chronic health problems can be an outstanding source of practical information about coping and health-related matters. At their best, support groups serve as bridges that link individuals with health issues, allowing them to share personal experiences, explore ways of addressing common problems, and offer each other encouragement and understanding. Support groups can develop a sense of community that helps individuals feel less isolated in dealing with their health issues. Unfortunately, not all support groups are successful in fulfilling these goals. Some may degenerate into gripe sessions or devote most of their time to discussions of medical treatments. Some are poorly facilitated. For a new member who is hopeful about finding support and useful information, finding a group that is unsatisfactory can be discouraging. People considering joining a support group may find it helpful to visit several different groups to find out which one best suits their needs. Because of the wide variability in the nature and quality of support groups, the success of a particular group for a given individual is often difficult to predict.
A vicious cycle exists between the symptoms caused by varicose veins and the sufferer’s mental state. This is unless cognitive therapy can break the cycle. Widespread apprehension about venous injections and surgical treatments may yet prove unfounded, and the possibility exists that endovenous treatments aimed at curing reflux without destroying the vein could reduce the impact on self-esteem. With increasing knowledge about the effect of varicose veins on quality of life, venous surgeons should remember that their first duty is to do no harm. Fearing that might no longer be the case, an important first step in helping varicose vein patients with psychological issues is through a coordinated approach between the vascular surgeon and the psychologist or psychiatrist. By understanding the psychological aspects of varicose veins, vascular surgeons and their teams may be better equipped to help their patients. This could result in a greater demand for psychiatric help related to varicose veins and ultimately improved quality of life for the sufferers.
