• Dilated, twisted veins in the legs
• May have no symptoms, or may be associated with fatigue, aching discomfort, a feeling of heaviness, or pain
• Possible swelling, darkening, and ulceration of the skin of the leg below the knee
• Women are affected four times as frequently as men
Veins are fairly frail structures. Defects in the wall of a vein and excessive pressure lead to dilation of the vein and damage to the valves. When the valves become damaged, the higher static pressure (which results when the valves no longer break up the gravitational pressure) results in the bulging veins known as varicose veins.
Varicose veins affect nearly 50% of middle-aged adults. The subcutaneous veins of the legs are the veins most commonly affected, owing to the gravitational pressure that standing exerts on them. When an individual stands for long periods, the pressure in the vein can increase by up to 10 times. Hence, individuals with occupations that require long periods of standing are at greatest risk for development of varicose veins.
Women are affected about four times as frequently as men; obese individuals have a much greater risk; and the risk rises with age owing to loss of tissue tone, loss of muscle mass, and weakening of the walls of the veins. Pregnancy, which increases venous pressure in the legs, may also lead to the development of varicose veins.
In general, varicose veins pose little harm if the involved vein is near the surface. These types of varicose veins are, however, cosmetically unappealing. Although significant symptoms are not common, the legs may feel heavy, tight, and tired. If the varicose veins are associated with significant chronic venous insufficiency, leg ulcers may form that are often difficult to resolve.
A more serious form of varicose vein involves obstruction and valve defects of the deeper veins of the leg. This type of varicose vein can lead to problems such as thrombophlebitis, pulmonary embolism, myocardial infarction, and stroke. Diagnosis is made by clinical signs and symptoms and diagnostic ultrasound.
The following are theories as to the causes of varicose veins:
• Genetic or functional weakness of the veins or venous valves.
• Excessive venous pressure due to a low dietary fiber–induced increase in straining during defecation.
• Long periods of standing and/or heavy lifting.
• Damage to the veins or venous valves secondary to thrombophlebitis.
The major cause of varicose veins is weakness of the vascular walls due to either abnormalities in the support structures of the vein or excessive expression, activity, or release of enzymes that degrade structural compounds. Damage to the lining of the vein also triggers infiltration of white blood cells, which can cause inflammation and lead to further vein wall damage, thus leading to chronic and progressive varicose vein formation.1,2
Healthy venous valves
Venous blood flows upward against gravity and any backflow is prevented by valves that shut against the flow.
The valves become damaged and do not function properly. Backflow of blood is not prevented and “pooling” of blood stretches and balloons the vein walls.
Vein Function in Normal and Varicose Veins
The treatment of varicose veins ranges from conservative measures to surgical interventions. Conservative therapy involves the following:
• Elevating the legs periodically
• Wearing graduated compression stockings with variable pressure gradients, especially if standing for long periods of time is unavoidable
• Exercise, especially walking, riding a bike, or jogging, as contraction of the leg muscles pushes pooled blood back into circulation
• Achieving or maintaining ideal body weight.
• Maintaining adequate intake of dietary fiber to avoid straining during a bowel movement, which increases venous pressure
• Using nutritional and botanical agents to assist in improving the function and structural integrity of the veins
For severely affected veins, more aggressive treatment may be necessary. The traditional surgical treatment has been vein stripping to remove the affected veins. Newer, less invasive treatments seal the main leaking vein on the highest point of valvular dysfunction on the thigh. Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10% of the total blood of the legs, can usually be removed or blocked off without serious harm.
A low-fiber diet that is high in refined foods contributes to the development of varicose veins.3,4 Individuals consuming a low-fiber diet tend to strain more during bowel movements, because their smaller and harder stools are more difficult to pass. This straining raises the pressure in the abdomen, obstructing the flow of blood up the legs. The increased pressure, over time, may significantly weaken the vein walls, leading to the formation of varicose veins or hemorrhoids, or may weaken the wall of the large intestine and produce diverticuli.5
A diet rich in vegetables, fruits, legumes, and grains promotes peristalsis, and many fiber components attract water and form a gelatinous mass, which keeps the feces soft, bulky, and easy to pass. The net effect of a high-fiber diet is significantly less straining during defecation. Natural bulking compounds can also be used. These substances, particularly psyllium seed, pectin, and guar gum, possess mild laxative action owing to their ability to attract water and form a gelatinous mass. Soluble fiber is generally less irritating than wheat bran and other cellulose fiber products.
Berries, such as hawthorn berries, cherries, blueberries, blackcurrants, and blackberries, appear to be beneficial in the prevention and treatment of varicose veins. These berries are very rich sources of proanthocyanidins and anthocyanidins.6–8 These flavonoids are noted for their ability to improve the function and integrity of the vascular system. Extracts of several of these berries are used widely in Europe for various circulatory conditions.
Another rich source of flavonoids is buckwheat (Fagopyrum esculentum), which is high in rutin. In one double-blind, placebo-controlled study, 77 patients with chronic venous insufficiency were given placebo tea or buckwheat tea for 12 weeks. The tea was standardized to contain 5% total flavonoids, yielding a daily dosage of 270 mg rutin. A statistically significant reduction in the total volume of fluid in the leg was seen in the treated group, along with statistically insignificant improvements in capillary permeability and symptoms. No adverse effects were noted.9
Consumption of these berries, their extracts, or other flavonoid-rich extracts such as grape seed or pine bark (Pycnogenol) is indicated for individuals with varicose veins as well as for those who wish to prevent them. These extracts’ efficacy is related to their ability to accomplish the following:
• Reduce capillary fragility
• Increase the integrity of the venous wall
• Improve the muscular tone of the vein.
Numerous double-blind studies with Pycnogenol have validated the effectiveness of procyanidolic oligomers in chronic venous insufficiency. Pycnogenol has an ability to decrease venous ulcer size,10,11reduce the swelling and blood clots associated with airline travel, reduce nighttime claudication (muscle pain), and reduce other signs and symptoms of chronic venous insufficiency.12–16
The most useful single flavonoid for varicose veins may be micronized diosmin. Micronization involves a high-technology grinding process with a jet of air at supersonic velocities, reducing the size of standard particles from more than 20 μm to less than 2 μm. As a result, there is better and faster absorption, and thus increased bioavailability, which lends greater clinical efficacy. Micronized diosmin has shown considerable benefits in promoting the healing of varicose veins, venous ulcers, and hemorrhoids.17–20
The horse chestnut (Aesculus hippocastanum) tree is native to western Asia but is now widely distributed all over the world. The seeds of the horse chestnut tree have been valued for centuries for their ability to improve hemorrhoids and varicose veins. This historical use ultimately has led to the development of topical and oral preparations with confirmed clinical benefits for these conditions.21,22
Horse chestnut compounds (escin, proanthocyanidin, and esculin) have shown a number of effects beneficial in the treatment of varicose veins. All three active components have been shown to exert significant protective and venotonic effects, such as antioxidant effects, combined with an ability to inhibit enzymes that destroy venous structures, such as collagenase, hyaluronidase, beta-glucuronidase, and elastase, thus improving the integrity and function of critical venous structures. In addition, horse chestnut seed extract prevents the accumulation of white blood cells in varicose veins. It appears that the ultimate effect of horse chestnut seed extract is the prevention of vascular leakage along with increase in the tone of the vein itself.23
The therapeutic benefits of horse chestnut seed extract have been confirmed in more than 16 double-blind clinical trials that demonstrate a positive effect in the treatment of varicose veins and thrombophlebitis.21 In fact, extracts of horse chestnut seed extract standardized for escin appear to be as effective as compression stockings without the nuisance. In one well-designed study, the effectiveness of horse chestnut seed extract vs. compression stockings was examined in 240 patients with varicose veins.24 Patients received either horse chestnut seed extract (50 mg escin per day), compression stockings, or a placebo for 12 weeks. Effectiveness was evaluated by a phlethysmograph, a machine that measures the volume of fluid in the leg. After the 12-week trial, fluid volume in the more severely affected leg decreased an average of 56.5 ml with compression therapy and 53.6 ml with horse chestnut seed extract, whereas it rose by 9.8 ml with the placebo.
In the treatment of varicose veins, escin can be given orally as well as topically. The topical formula is also of benefit in the treatment of bruises, owing to escin’s ability to reduce capillary fragility and swelling.
When given orally, an extract of gotu kola (Centella asiatica) containing 70% triterpenic acids (asiatic acid, madecassic acid, and asiatoside) has demonstrated impressive clinical results in the treatment of cellulite, venous insufficiency of the lower limbs, and varicose veins.25–28 The effect of centella in venous insufficiency and varicose veins appears to be related to its ability to enhance connective tissue structure, reduce hardening of the vein, and improve blood flow.
• A diet high in fiber helps prevent varicose veins.
• Veins can be strengthened with flavonoid-rich extracts.
• Several herbal extracts have been shown to act as venotonics—agents that enhance the structure, function, and tone of veins—and produce excellent clinical results.
The shrub butcher’s broom (Ruscus aculeatus) is a member of the lily family that grows in the Mediterranean region. The rhizome from butcher’s broom has a long history of use in treating venous disorders such as hemorrhoids and varicose veins. The active ingredients in butcher’s broom are ruscogenins. These compounds have demonstrated a wide range of pharmacological actions, including anti-inflammatory and tonic effects on blood vessels. In Europe, butcher’s broom extracts are used extensively, both internally and externally, in the treatment of varicose veins and hemorrhoids. Double-blind clinical studies have shown that these preparations offer benefits in both symptom relief and improved venous blood flow.29–31
Bromelain and Other Fibrinolytic Compounds
Individuals with varicose veins have a decreased ability to break down fibrin.32 This fact is extremely important because fibrin is deposited in the tissue near the varicose veins. The skin then becomes hard and “lumpy” owing to the presence of the fibrin and fat (lipodermatosclerosis). In addition, decreased fibrinolytic activity raises the risk of clot formation, which may result in thrombophlebitis, myocardial infarction, pulmonary embolism, or stroke.
Herbs and spices that increase the fibrinolytic activity of the blood are therefore indicated. Capsicum (cayenne),32 garlic,33 onion,34 and ginger35 all promote fibrin breakdown. Liberal consumption of these spices in foods is recommended for individuals with varicose veins and other disorders of the cardiovascular system.
The proteolytic enzymes from pineapple, bromelain, also appears to be indicated in the treatment of varicose veins. Vein walls are an important source of plasminogen activator, which promotes the breakdown of fibrin. Veins that have become varicose have decreased levels of plasminogen activator. Bromelain acts in a manner similar to plasminogen activator to cause fibrin breakdown.36
Another useful substance is nattokinase from natto, a traditional Japanese food prepared from fermented soybeans using Bacillus subtilis. Nattokinase is a protein-digesting enzyme that has potent fibrinolytic and thrombolytic (clot-busting) activity and has shown significant potential in improving cardiovascular conditions associated with clot formation and excessive fibrin deposits.37
Bromelain and nattokinase may help prevent the development of the hard and lumpy skin found around varicosed veins.
Conservative therapy, as described above, should be employed as early as possible for patients with varicose veins. It may halt the progression and prevent the need for more aggressive therapy. Note that patience is needed, as improving the structure and function of the veins takes time.
Follow the recommendations in the chapter “A Health-Promoting Diet.” A diet rich in dietary fiber is definitely indicated. The diet should also contain liberal amounts of proanthocyanidin- and anthocyanidin-rich foods, such as blackberries, cherries, and blueberries. Garlic, onions, ginger, and cayenne should also be consumed liberally.
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Vitamin D3: 2,000 to 4,000 IU per day (ideally, measure blood levels and adjust dosage accordingly)
• Fish oils: 1,000 mg EPA + DHA per day
• The following may be useful as an adjunct:
Bromelain (minimum 1,500 MCU): 500 to 750 mg three times per day between meals
Nattokinase: 100 mg (2,000 FU) per day
• One or more of the following:
Micronized diosmin: 500 to 1,000 mg per day
Grape seed extract (>95% procyanidolic oligomers): 150 to 300 mg per day
Pine bark extract (>95% procyanidolic oligomers): 150 to 300 mg per day
– Bark of root: 500 mg three times per day
– Escin: 50 mg two to three times per day (alternatively, escin preparations may be applied topically in a 1% concentration)
Gotu kola (Centella asiatica) extract (70% triterpenic acid content): 30 mg three times per day
Butcher’s broom extract (9% to 11% ruscogenin content): 100 mg three times per day