The differing patients’ perceptions of varicose veins and its severity can lead to differences in the management of the condition. The traditional management of varicose vein was by ligation and stripping of the long or short saphenous veins. This procedure is invasive and often requires a lengthy hospital stay and recovery time. In more recent years, newer techniques such as Endovenous Laser Ablation have been developed for treatment of varicose veins. This is a much less invasive technique than ligation and stripping and is often performed as a day case. The key difference with this technique is that it is able to burn and close the varicose vein, thereby treating the cause of the varicose vein and not just the varicose vein itself. This technique has been proven to be very effective and has been said to have a 90-95% success rate in treating varicose veins.
The management and presentation of varicose veins is often a result of the perception that varicose veins are a cosmetic issue, rather than a serious medical condition. Because of this, many patients suffer with varicose veins for years before seeking medical advice. Women are often more concerned with the cosmetic appearance of varicose veins and are much more likely to seek medical treatment. This is supported by the fact that varicose veins are twice as prevalent in women than in men. It has also been reported that “severe disease is three to four times as common in women as men”. This indicates that perception of the severity of varicose veins may also differ depending on the gender of the patient.
Varicose veins are defined as “veins that are tortuous, dilated, and elongated” and are commonly found in the legs. They are typically caused by valve incompetence in the veins of the lower extremity. They can often lead to chronic venous insufficiency. The process of developing varicose veins is a result of various risk factors. There are many different presentations and severities of varicose veins, and this can often depend on the gender of the patient. The way that varicose veins are managed can also differ depending on the gender of the patient, with women often seeking treatment as a result of the cosmetic appearance of varicose veins. This essay aims to explore the gender differences in presentation and management of varicose veins.
Definition of Varicose Veins
Varicose veins can be simply defined as elongated, dilated, tortuous, and superficial veins usually greater than 3mm in diameter. Usually, the saphenous vein or the deep leg veins are the site for primary valvular incompetence. This occurs in the superficial veins when, in the standing position, intraluminal venous pressure is transmitted to the perforating veins because the vein is incompetent due to faulty or damaged valves, which leads to the vein becoming distended with blood and tortuous in course. The damaged valves can be due to a number of reasons. The primary cause is due to genetics, and there is evidence to support that varicose veins are an autosomal dominant condition. An increase in age also increases the chances of having varicose veins. Hormonal factors such as pregnancy and the use of the contraceptive pill also have an effect due to the vein’s walls being softened, and this occurs more often in pregnancy. Women also have higher chances of varicose veins, and due to menopausal changes, the prevalence of varicose veins in women increases. Obesity and occupations causing prolonged standing increase intraluminal venous pressure and are also significant causes of varicose veins. High intraluminal pressure, then using the upright position to predispose a person, and phlebectasia also have a great effect on varicose veins. Varicose veins can also be classified as primary and secondary. Primary being simply due to prolonged increase in intraluminal pressure, and they are more commonly displayed in women. Secondary varicose veins are those stemming from a thrombotic or inflammatory condition in the deep veins.
Prevalence of Varicose Veins
The prevalence of varicose veins is very high in the western world, with the Framingham study finding a 2-year incidence rate of 2.6% in men and 3.3% in women. The San Diego population study found that 16% of men and 26% of women had visible varicose veins. The Edinburgh Vein Study found that 60% of men and 41% of women had trunk varicose veins. This shows that in all studies, the prevalence of varicose veins has a higher percentage in women. These findings have been supported by a meta-analysis. This pooled analysis of 57 studies with a total report of over 400,000 patients found that the odds ratio of developing varicose veins for women compared to men was 1.72. Both African American ethnic origin and Asian ethnic origin were associated with a significantly lower prevalence as opposed to white ethnic origin. Educating has also been shown to have an effect; men who only educated up to elementary schooling had a prevalence eight percent higher than those who were educated up to high school level. This was reversed in women, with those who were educated up to high school level having a lower prevalence than those who had only educated up to the elementary level.
Gender Differences in Varicose Vein Presentation
Symptoms experienced by males and females, although similar, often vary. Skin changes, edema, night cramps, and leg ulcers are symptoms more likely to be experienced by males. Skin changes and ulceration are the most definitive symptoms of severe chronic venous insufficiency. These symptoms are of greater significance to males due to increased morbidity and are thought to be associated with occupational causes of varicose veins. Due to the nature of varicose veins, the cosmetic appearance is often the overriding concern, and it is widely documented that females are more likely to seek medical treatment. This decision to seek treatment is often influenced by the aforementioned symptoms experienced by females, and earlier research identified that the decision to seek treatment is often a complex decision in which considerations of quality of life play a significant role. Nowadays, the advent of less invasive endovenous techniques has allowed greater optimization of symptoms, and earlier intervention may prevent disease progression.
Varicose veins are a debilitating condition that can manifest in varying degrees of severity. It is widely accepted that there is a prevalence of varicose veins within the female population. Exploring the reasons that cause this difference are somewhat unknown, however it is evident that the role of women in childbearing has a substantial impact. Case control studies have suggested that both pregnancy and the number of children are highly associated with varicose veins, and more specifically, prolonged standing and lifting habits during pregnancy are strongly correlated with the presence of varicose veins.
Symptoms experienced by males
In the early clinical stages of varicose veins, females often say that the symptom of leg tiredness is a particular problem when they are standing. However, in both the Edinburgh vein study and the Framingham Study, when asked to choose from a list of symptoms associated with venous disease, it was older men who were most likely to report both leg tiredness and leg pain although they had neither visible varicose veins nor skin changes at the gaiter level. This suggests that the presence of more subtle symptoms is more bothering to the male than female patient, or that older men with leg symptoms are more likely to assume that this is due to their occupation and possibility of retirement is what draws the information from this research. Simulation is required to decide which gets closer to the truth. Proponents of the latter theory would argue that leg symptoms associated with venous disease or any other cause is less acceptable to men than women and has implications for their lifestyle and employability.
Males who suffer from varicose veins often present with a different spectrum of signs and symptoms than females. In general, their symptoms are less severe and occur at an older age than females. As with females, a detailed history and physical examination will allow appropriate categorization of the patient’s clinical state and determine an appropriate course of treatment. However, it is more likely for men with clinical manifestations of venous disease to have a secondary cause for their varicose veins, such as previous trauma or surgery to the lower extremities. This may reflect the fact that men are less likely to seek medical treatment for venous disease until they have developed potentially serious complications.
Symptoms experienced by females
The symptoms experienced by women have been postulated to account for the gender difference in varicose vein prevalence and presentation. The most obvious factor accounting for this difference is pregnancy. Prevalence can increase with successive pregnancies and the veins tend to improve to a degree after the pregnancy is finished. This varies, however, and it is not uncommon for the veins and any associated symptoms to worsen with each subsequent pregnancy. In a study looking at the epidemiology of varicose veins in the Western Australian population, it was found by self-reporting that 64% of pregnant women develop varicose veins during pregnancy, with 39% having a previous history of varicose veins. These women are also affected earlier in life compared to men, with women seeking treatment at a mean age of 42.92 and men waiting until the seventh decade before seeking treatment. Pain and aching in the symptomatic and asymptomatic reflux populations was the most common complaint in women, with men only displaying varicose veins as their most common complaint. Women were also predisposed to more severe symptoms, with skin changes and ulceration affecting a significantly higher number of women compared to men. Deep vein thrombosis is also slightly higher in women, which is important when considering the usage of compression stockings.
Gender Differences in Varicose Vein Management
For the minority of men who do get offered a surgical treatment, the pattern of referral to a vascular surgeon among GPs is unlikely to vary from that of a woman. This suggests equal access at this level, however, in going to the consultant, there may be a difference. This stems from the fact that with both activity and occupation having an influence on the type of surgery offered, it may not be in the best interest of a man with a physically demanding job to undergo a surgical treatment option if a recurrence is undesirable. This could mean that some men are discouraged from surgery due to their special circumstances and kept on a waiting list for a more conservative option.
A man having varicose veins may be asymptomatic and not bothered by his appearance, so a case may be made for no treatment to be undertaken. Additionally, men who have physically demanding jobs may be advised against surgery for fear of aggravating the veins and causing a recurrence. This is due to the fact that surgery has a higher recurrence in those who do heavy manual work compared to those who have their veins treated and continue to work a less physically demanding job.
Given that varicose veins are more common in women, this is reflected in the lack of treatment options available to men. This is not to say that a man cannot have a surgical treatment that is offered to women, but instead means that they are more likely to be offered a conservative management option.
Treatment options for males
Given the above male-specific issues related to varicose veins, it would be expected that men might benefit more from medical, minimally invasive, or surgical treatments and not respond as well to conservative therapy as women with similar disease severity. However, studies investigating gender differences in treatment options and response to treatment for varicose veins are quite limited. It is difficult to generalize findings across studies due to considerable differences in methods and patient populations. Nonetheless, a 2016 systematic review and network meta-analysis is the most recent comprehensive analysis comparing modern treatments for varicose veins in different populations and includes a subgroup analysis on male vs female treatment outcomes. This will be discussed in greater detail in the next section.
The primary reason for male gender being a risk factor for getting varicose veins is related to occupational factors. Men are more likely to work in physically strenuous jobs, putting more pressure on their veins. Also, certain occupations require prolonged standing, and people working in these jobs have a significantly higher prevalence of varicose veins. Male varicose vein sufferers may also have less social and emotional support in dealing with their condition. This may be an added stress in situations where symptoms are severe or there is a complicated underlying health issue.
Treatment options for females
In the past, many phlebologists reported that women complain more about their varicose vein symptoms, but there have been no studies on gender differences in vein-related quality of life. More women report leg edema, swollen ankles, and night cramps, but there is no evidence to suggest that these symptoms are more severe in women than men. Similarly, it appears that women have a higher incidence of venous skin changes and leg ulceration, but this may simply reflect the longer life expectancy of women than men.
There is a general agreement among experts that women seek advice and treatment for their varicose veins far more readily than men. This is probably due to the fact that varicose veins are often seen as unsightly and an indicator of age in women, more so than in men. In addition, women of childbearing age are more aware of their bodily health and more used to seeking medical advice and treatment than younger men. The likelihood of seeking medical intervention increases with the severity of varicose veins for both sexes.
Effectiveness of different treatments
High ligation and vein stripping is also effective. However, a randomized control trial in the UK has shown no significant difference between high ligation and stripping and sclerotherapy in an assessment of disease-specific quality of life and generic quality of life. Patching up the saphenofemoral junction during high ligation is an effective way to stop the reflux at this point and avoids long saphenous vein stripping, reducing morbidity. Although, again, there are no gender-specific trials comparing this to other treatments.
Endovenous surgery, both for radiofrequency ablation and endovenous laser ablation, is currently considered the best treatment for varicose veins, providing the best results for stopping reflux. After this treatment, an improvement in quality of life and reduction in disease severity is noticed more than any other treatment. It is effective both symptomatically and aesthetically in both men and women. However, it has a high start-up cost and may not be provided by local NHS trusts.
