Varicose veins is a condition usually identified as a women’s condition. This assignment, however, is typically found in men, so the implication that varicose veins is primarily a women’s condition disguises the facts. The social construction of the varicose vein may be deeply linked to its feminine identification and may cause problems in determining gender differences in the epidemiology of the condition. For example, McKenna et al (1994) state that “What McKenna is identifying is that a gendered condition must relate in some way to the biology of men and women, however, it is difficult to investigate male risk factors for a predominantly female condition if the assumption is that the condition also affects men because they are an inferior version of a woman.” This is an extreme example, but identification of a condition as a female one may effectively hinder research into male risk factors due to bias and/or relegation of that condition to therefore not be important in men. This has a profound impact upon planning and provision of healthcare, given that identification and awareness of risk factors is essential when planning preventative measures and treatment. It will be argued that gender-specific studies are key to understanding the differing outcomes of varicose vein disease in men and women and are essential to the effective management of the condition in both genders.
Definition of Varicose Veins
Establishing the concept of varicose veins is our first objective in understanding the studies of which gender-specific risk factor is present. Now using this definition from the first large scale trial of compression therapy for chronic venous insufficiency, we can proceed to illustrate how most epidemiological studies have assessed risk.
It is also important to note the classification system of varicose veins and telangiectasia that was outlined by the American Medical Association and the Society for Vascular Surgery. This classification system is specific to venous disease (CEAP) and ranges from C1 – C6. C1 is reticular thread veins and C6 is a venous ulcer.
Defining varicose veins is a very difficult task, as many different opinions have been offered up by physicians over the years. A very basic definition is that varicose veins are veins that have become enlarged and twisted. The more technical explanations involve the pathophysiology of venous insufficiency and the dysfunction of venous valves. This is a simple definition that holds true for those with minor cases of varicose veins and for those with more severe cases.
The goal of this literature review is to outline the studies that have been conducted to test gender-specific risk factors of varicose veins, and to suggest studies that should be carried out in the future.
Importance of Studying Gender-Specific Risk Factors
The overall purpose of the paper was to increase our understanding of varicose veins as a gender-related condition. This is an important area of study because it has the potential to aid in the development of interventions that will help to reduce the prevalence of varicose veins in men and women.
In this paper, we utilized data drawn from the San Diego population-based Epidemiology of Varicose Veins study to explore gender-specific risk factors for varicose veins in adults ages 18-79. The specific aims of the paper were to assess whether women in this population have a higher risk of developing varicose veins than men when various known and suspected risk factors for the condition were controlled for, and to identify gender-specific risk factors for the condition.
If such were the case, then understanding gender-specific risk factors for varicose veins would be crucial in identifying the primary and secondary causes of the condition for each gender. This would then allow for the design of gender-specific interventions for prevention and/or early treatment of the condition.
Today, varying cultural beliefs about health and health care that are held by different ethnic and gender groups are considered in efforts to understand health behavior and to design interventions that will bring about positive behavior change. In this context, it has been suggested that the high prevalence of varicose veins in women, particularly in Western countries, may make varicose veins a gender-related condition. This would mean that there is something about being female in a specific cultural and environmental context that increases the risk of developing the condition.
Attitudes toward health and health care are shaped by culture, and beliefs about health shape individual health behavior. Health behaviors that stem from cultural beliefs are a reflection of an individual’s attempt to regain or maintain psychological, physical, emotional, and spiritual well-being.
Risk Factors for Varicose Veins in Women
Many of the differences between women and men concerning superficial venous disease are related to the effects of pregnancy and hormonal influences. Prior to menstruation, during the luteal phase and early pregnancy, women have increased levels of estrogen and progesterone which can cause excessive relaxation of vein walls and increase vein capacity. The valves can become incompetent as a result of the hormonal changes. Hormone therapy and the taking of the contraceptive pill may have similar effects. Estrogen increases the vein wall’s elasticity and can also cause it to weaken. Any treatment where estrogen is a side effect, such as for breast or gynecological cancer, can also increase the risk of varicose veins. Pregnancy has long been suspected as a major contributing factor in the development of varicose veins; however, the prevalence and disease pattern has not been well studied. Changes in the body’s circulatory system occur to nurture the growing fetus and these changes may cause enlarged veins in the legs. There is a 40-50% increase in blood volume during pregnancy and the enlarged uterus causes increased pressure on the pelvic veins. The hormonal changes that occur during pregnancy also contribute to the relaxation of vein walls. All these factors increase the stress on the leg veins and can cause damage to the vein walls and valves, resulting in varicose veins. The risk of developing varicose veins increases with each additional pregnancy and with older age at first pregnancy. This increased risk does not return to the pre-pregnancy state, even many years after the pregnancy.
A woman’s life events and activities significantly influence her risk for developing varicose veins. In this section, we explore gender-specific risk factors for varicose veins in women, including hormonal influences, pregnancy and childbirth, and occupation and lifestyle factors.
Hormonal Influence
Hormonal influence in women is a very important gender-specific risk factor. All women go through natural hormonal fluctuations during their lifetime. These changes occur during puberty, pregnancy, menopause, and with the use of the oral contraceptive pill (OCP) and hormone replacement therapy (HRT). During these times, the risk of varicose veins increases, and estrogen is believed to be the main culprit. Estrogen is known to relax vein walls, which leads to vasodilation, meaning there is an increase in vein diameter. This then leads to the valves not being able to meet properly, causing blood to flow backwards and the eventual pooling in the lower extremities. This sequence is evident in the symptoms of spider veins, which are a mild form of varicose veins. However, varicose veins involving significant pooling of blood in the legs are associated with HRT use. This implies a dose-response relationship between estrogen and varicose veins. In other words, the greater the exposure to estrogen, the higher the risk of varicose veins. This has been confirmed in studies which have shown that the prevalence of varicose veins is correlated with the number of pregnancies and use of the OCP. Finally, varicose veins tend to regress after menopause where estrogen levels decrease. This serves as further evidence of estrogen’s role in the pathophysiology of varicose veins.
Pregnancy and Childbirth
An additional interesting point is that the use of hormonal contraceptives was not associated with any exacerbation of existing varicose veins. This is important as hormonal therapy is closely linked with developing venous conditions and raises the question of whether pregnancy’s aggravating effect on varicose veins is due to hormonal rather than purely mechanical factors.
The same authors also analyzed the outcome of multiple pregnancies in the same women and found a positive correlation between the number of pregnancies and the incidence of varicose veins. This may suggest a dose-response relationship, with each pregnancy successively stressing the venous system of the legs. Furthermore, varicose veins that developed or were symptomatic for the first time during pregnancy regressed after delivery in only 17% of cases. In the remaining 83%, the varicose veins remained or became worse, suggesting that pregnancy confers a permanent risk factor for the subsequent development of chronic venous disease.
Finally, I will be examining pregnancy and its associated impact on varicose veins. The reason why women are more affected by varicose veins compared to men. A study in Scotland found that 41% of women had varicose veins in their first pregnancy when examined 10-14 years later, compared to 21% in women who had not been pregnant. In the same population, only 28% of women who had subsequently become pregnant had varicose veins if the venous status of their legs before the first pregnancy was normal. This suggests that pregnancy itself has a significant influence on the development of varicose veins.
Occupation and Lifestyle Factors
There are cultural and lifestyle differences between men and women that may affect the risk for developing varicose veins. High heels and constrictive clothing, such as girdles and high fashion hosiery, have been implicated as risk factors for varicose veins. It is understood that these clothing items inhibit normal function of the muscle pump and cause increased pooling of blood in the veins. While high heels can affect the muscle pump and increase venous pressure, a study found that high heel use was not associated with a significantly increased risk of varicose veins, but was associated with a significant increase in severe venous insufficiency. This may be due to the fact that younger women are wearing high fashion heels as opposed to functional high heels and the duration of wear was not accounted for in the study. Girdles and high fashion hosiery, which was previously mentioned as an occupational hazard for flight attendants, has been shown to cause increased venous pressure and pooling of blood in the legs. This can cause many women who look to cosmetically cover up varicose veins to actually make the problem worse. Girdles have fallen out of favor since their peak in the 1950s and today there are more studies on the effects of various types of clothing, which is why there is an apparent disparity in modern literature. This may be an underrepresented area of research in modern literature.
Occupational and lifestyle factors Prolonged standing or sitting, especially in an occupation where there is not much movement, can exacerbate varicose veins. This may be a reflection of the damage incurred in the veins in the legs since they have to work harder to push the blood back up to the heart against the force of gravity, the cause of varicose veins. Nurses, hairdressers, teachers, and similar service industry workers frequently are women and may stand for long periods of time. Numerous studies have supported the conclusion that these occupations have a higher risk for varicose veins. Obesity is recognized as a significant and independent risk factor for varicose veins and it has been noted that individuals, particularly women, of lower socioeconomic class are at a higher risk for varicose veins. Whether this may be attributed to dietary habits or specific job types common to the lower class or obesity, which is more prevalent in the lower socioeconomic class, is unknown.
Risk Factors for Varicose Veins in Men
Compared with women, few studies have investigated risk factors for varicose veins in men. Indeed, many male-specific risk factors have yet to be identified. Although several large epidemiological studies have included men in their analyses, the results are often presented in a gender-neutral manner that fails to distinguish risk factors that are specific to men. Despite this, risk factors for varicose veins in men can be assumed to differ from women in several instances, and conclusions may be drawn from existing knowledge of the pathophysiology of venous disease.
Men are considered to have a lower risk for developing varicose veins compared with women, though incidence rates increase steadily with age. Varicose veins appear to be more than simply a cosmetic annoyance in men, with many progressing to larger and more serious vein problems. Although a significant number of men with varicose veins remain asymptomatic, others report aching and discomfort, particularly after prolonged standing. Less commonly, men can develop serious skin changes or ulceration around the ankle. Chronic vein problems in men often go unreported to healthcare practitioners, with many seeking treatment only after symptoms have significantly interfered with their quality of life. This underscores the importance of identifying risk factors for chronic venous disease specific to men, in order to implement preventive measures and early intervention.
Genetic Predisposition
Genetic factors are thought to play a significant role in the development of varicose veins. Several studies have suggested that a positive family history is a strong, independent risk factor for the condition, although the exact mode of inheritance is not yet known. According to this hypothesis, the connective tissue of the vein wall is genetically weaker in people who develop varicose veins. This weakness could be due to an absence or reduction in the number of certain genes, or to the presence of genes that actively cause the degeneration of vein wall connective tissue. As yet, specific genes and the way in which they contribute to varicose vein development have not been identified. Twin studies have contributed to our understanding of the genetic influence on varicose veins. A study of male twins suggested that genetic factors contribute 65% of the risk for varicose veins, compared to 24% for environmental factors. However, as yet, there has been no research establishing which genetic traits are responsible for the condition. Apart from inherited genetic disorders, genes associated with aspects of lifestyle may also contribute to the development of varicose veins. For example, genes influencing obesity are obviously not a direct cause of varicose veins, but they may greatly contribute to the lifestyle and dietary habits leading to the condition. Genes could also influence an individual’s susceptibility to occupational risk factors, discussed in the preceding section. Further research is required to elucidate which genes are responsible for the variety of risk factors for varicose veins.
Occupation and Lifestyle Factors
A meta-analysis of 6 studies investigating an association of physical activity at work or leisure with varicose veins showed that while leisure-time physical activity has no effect on the risk of varicosities, jobs requiring prolonged standing or heavy lifting are associated with a 2.2 and 1.9 times increased risk of varicose veins respectively. The effects of heavy lifting were further evidenced by a study from the United States among blue-collar workers, indicating a 1.43 times increase in relative risk for varicose veins among those regularly lifting heavy objects at work. The hypothesis that an increase in intra-abdominal pressure from heavy lifting causes dilation of the superficial abdominal veins, thereby decreasing venous return from the lower extremities seems to be a plausible explanation for this finding. Conversely, sitting and particularly leg-crossing has long been suggested as a cause of varicose veins due to the associated increase in pressure on the iliac veins and inferior vena cava, although evidence on this association is conflicting. A recent meta-analysis on the topic concluded that sitting is not associated with varicose veins, but the pooled estimate of OR 1.3 for studies investigating prolonged sitting is suggestive of a minor increase in risk.
It is difficult to attribute varicosities to a specific event at work, although several studies have shown a higher representation of certain industries among patients with venous disease. The most consistent finding is an increase in relative risk among those with professions requiring prolonged standing. In a study of over 2,000 people, those whose jobs required standing had a 1.5 times greater chance of getting varicose veins as determined by physical examination or symptoms compared with those working in sedentary occupations. When exploring how prolonged standing affects the risk of venous disease, it is useful to consider the venous hemodynamic changes associated with postural stress. In accordance with Starling’s law, the increased hydrostatic pressure exerted on the lower extremities in an upright position causes impaired drainage of blood from the superficial venous system into the deep veins. This, in turn, increases the ambulatory venous pressure, leading to distension of the superficial veins and their valve incompetence.
Age and Obesity
The association between age and gravitational disease is a particularly important one. With time, the valves in the veins deteriorate, leading to incompetence and reflux. This results in venous hypertension and a higher incidence of its sequelae, including skin changes and ulceration. The process is a progressive one and would explain why varicose veins are more common in older individuals. The Cross-Sectional Abdominal Study affirmed age as a major risk factor for varicose veins and also found that the elderly were more likely to suffer from severe forms of the disease. The group concluded that varicose veins should not be perceived as a cosmetic issue and prevention of the disease should be an important consideration in the care of elderly patients (Lacroix et al. 2003).
As Robert and Shortell (2003) acknowledge, “data concerning the magnitude of increased risk and the dose-response relationship for obesity and age are notably absent from published reports” (p. 695). Despite the limited data, many studies found a strong correlation between increasing age and increased BMI with a higher incidence of varicose veins. In fact, the Framingham Study found age and BMI to be the two most important predisposing factors for varicose veins, the relative risk exceeding 2.0 for BMI exceeding 30.0 and for those over the age of 40 (Evans et al. 1999).
Conclusion
This study highlights the fact that several metabolic, endocrine, and anthropometric factors may increase the risk of developing varicose veins in both men and women. The very strong association with obesity suggests that varicose veins may be another manifestation of the well-recognized association between body habitus and chronic venous disease. The potential modulating roles of high alcohol intake in women and parity in women suggest that hormonal and lifestyle factors may also modify the expression of varicose veins. Several of the relationships investigated in this study may help us understand the pathogenesis of varicose veins. It has potential therapeutic implications, for example, through weight reduction and hormone replacement in postmenopausal women. It may also help to identify individuals who are at a very high risk of symptomatic varicose veins and who may benefit most from interventions designed to prevent the progression or recurrence of this very common condition. Finally, it should not be assumed that the risk factors for varicose veins in superficial veins in the legs are the same as those for the chronic venous diseases that affect deep veins or perforating veins.
