Varicose Veins: Psychological Impact and Quality of Life

Psychological impact and quality of life intends to review the psychosocial impact and quality of life (QoL) in patients with varicose veins (VV) up to very severe clinical classes and explore the impact of various treatment strategies on patient outcomes. This is an important subject as very little literature exists, with conclusions that contradict one another; in part due to the broad nature of the term QoL and the objective assessment of a predominantly subjective complaint. This is compounded by the heterogeneity of the disease and comparable prevalence in control populations. Although a negative impact has been generally accepted, little is known about the nature, severity, duration, and patient risk factors for developing significant psychosocial sequelae. Current C2-6 classes of VV have generally been accepted in most subjective literature as the cutoff for clinically significant disease, although this varies dependent on the disease-specific questionnaire utilized. These classes are characterized by subjective complaints, edema, skin changes, and in severe cases, ulceration. Because the CEAP classification system only involves the clinical profile, it is important to also explore its impact simply on patient-perceived disease severity.

Definition of Varicose Veins

Varicose vein can be classified as swollen and enlarged veins, usually a pale blue color or flesh colored, and are commonly found on the legs, back of the calves, or on the inside of the leg. The cause of this condition is due to malfunctioning vein valves and the impairment of blood flow in the legs. Normally, veins will bring blood from the other parts of the body back to the heart, but because of faulty vein valves, blood is stored in the vein. The vein then becomes swollen and twists, resulting in varicose veins. Though usually this condition is painless, some symptoms can surface. Some of the more severe symptoms include restless legs, swollen ankles, night cramps, and edema. The severity of these symptoms very much depends on the individual and lifestyle. This must be distinguished from a less severe condition called “spider veins”. These are smaller, red or blue vessels that are easily seen through the skin and are mainly a cosmetic problem.

Prevalence and Causes

Chronic venous diseases comprise a part of the spectrum of venous disease, affecting large numbers of people in the community. Up to half the population of the USA and Western Europe may be affected by varicose veins at some stage. Despite the large numbers of people suffering from this condition, it has been largely overlooked by healthcare providers. Patients with chronic venous disease may suffer symptoms and develop skin changes resulting in a normal lifestyle becoming abnormal and in many cases altering the role and functioning of the individual. This can lead to social and psychological drawbacks. Factors leading to the high prevalence of varicose veins in Western societies are the increasing average age of our community and a lifestyle that involves a standing or sitting occupation, increasing levels of high impact sport and increasing levels of obesity. The distribution of varicose veins varies throughout the world. In developing countries, it is less common due to factors such as the population being more mobile with fewer standing/sitting working occupations, it being hot which forces people to wear less clothing and walk barefoot, and higher levels of parasitic infections preventing the development of primary venous insufficiency. High-quality epidemiological studies of varicose veins are few and far between, and this should be an area of active research. With the increasing number of elderly people and the increasing levels of obesity in Western societies, it is likely that varicose veins will become an even more prevalent problem in the future.

Importance of Psychological Impact and Quality of Life

A study carried out in the USA revealed very poor scores in physical comfort and pain compared to the normal US population based on the SF-36 scoring system. This lack of physical comfort is a major issue considering the symptoms involved in varicose vein conditions such as heavy, aching, and uncomfortable legs. Currently, treatment for varicose veins will dramatically reduce the patients’ symptoms in the vast majority of cases, meaning the impact on quality of life will be improved. This could be expected to change the views of the importance of treatment to patients today, as similar results may not be obtained from studies on patients with more advanced conditions due to current methods of treatment being less effective than their risk-benefit ratios.

It is important to examine the psychological impact of varicose veins when figuring out its true significance. Early research on the topic suggested that varicose veins were mainly a cosmetic issue and did not require medical attention. However, in a study carried out by A J Palfreyman in 1992, patients with varicose veins were asked if they would prefer a successfully treated varicose vein condition that had a 90% chance of relief from presenting symptoms, although it would only last for 5 years, or a treatment that had only a 50% chance of relief but would last for 12 years. Astonishingly, only 25% of participants chose the shorter relief with the greater success rate, indicating that patients felt the longevity of their condition was the most influential factor regarding quality of life. This was particularly important because patients with a short terminal illness were asked the same question to act as a control, and there was no statistical difference in the answers between the two groups. This goes to show that patients with varicose vein conditions that were showing no signs of improvement, no matter at what rate, were feeling similarly to those with a terminal illness. Conversely, quality of life in regards to pain and how much it affects the individual’s physical capability has been easier to assess. Measures such as the pain visual analogue scale and SF-36 questionnaires are able to measure pain presence and intensity and show that the individual feels their health-related quality of life and health status.

Psychological Impact of Varicose Veins

It is remarkable that despite the frequency of varicose and spider veins, very little is known about their psychological impact. Tristen Brown and colleagues have acknowledged that there is a substantial gap in the research on how vein disorders can significantly affect a patient’s quality of life. They published a comprehensive paper identifying specific methodological limitations in research, including a proliferation of non-standardized psychometric measures, a lack of randomized controlled trials, and a lack of a unified conclusion on the overall psychological impact of chronic venous disease. This is an important issue to be addressed since a better understanding of the psychological morbidity can lead to improved medical and surgical treatment for patients.

Varicose veins, spider veins, and severe chronic venous disease are not just a physical affliction. The majority of patients experience some form of psychological impact. These impacts can significantly affect an individual’s quality of life. Whether the primary concern is the appearance of the leg veins or the more severe symptoms associated with venous disease, varicose vein patients are often affected on a psychological and emotional level. Studies have shown that the psychological impact suffered by vein patients can lead to feelings of unsightliness and a poor self-image, while also having a detrimental effect on their social activities and personal relationships. In some cases, it has been so profound as to lead to severe depression.

Body Image and Self-Esteem

Though there are no studies specifically discussing self-esteem in those with varicose veins, a recent study showed that women with chronic venous disease have significantly lower scores in the social, mental, and physical components of quality of life measures.

Those who are more appearance-focused might suffer lowered self-esteem from conditions such as varicose veins. Self-esteem is defined as a favorable or unfavorable attitude toward the self. Those with low self-esteem have a more unfavorable attitude towards themselves, and they often feel that they are unworthy or inferior to others. This can be detrimental to their quality of life, affecting their job prospects and putting a strain on their personal relationships, with depression often being a consequence.

In an American study of 112 women with varicose veins, it was found that 20% of the women felt severe or extreme shame and 40.2% felt moderate shame due to their veins, with 99% of them feeling that their veins had made their legs ugly. There are no studies evaluating the psychological impact of varicose veins in men; however, it is known that in general, those with perceived or actual appearance differences are more likely to suffer psychosocial and emotional difficulties and withdraw from social interactions because of the potential for negative social interactions and rejection from others.

Media glorification of a slim, perfect body and good looks in general has made people very conscious of their appearance and any deviation from the accepted norm and standard of beauty. By being visible at all times and those affected unable to hide them, varicose veins can be a cause of great distress and low self-esteem.

Emotional Distress and Anxiety

A chronic medical illness by definition is expected to impact long term functional health status and quality of life. Patients with varicose vein symptoms have been demonstrated to have minimal changes in their physical functional health status but larger negative impacts on their mental health status and quality of life. This has been shown in several US and European studies. The APG health status questionnaire has 2 subsets of questions applying to physical health and mental health. The validity of this questionnaire among patients with saphenous vein disease was supported by demonstration of changes in these subsets after treatment. Data supporting the above statement is seen by constuing… increasing symptom severity has less impact on the physical component of the SF36 but a more significant impact on the mental component. An Estonian SF36 study has shown that patients with skin changes or venous ulceration had significant impairments of their mental health status and quality of life. This is further supported by studies correlating the CIVIQ and AVVQ disease specific questionnaires with the SF 36 on the basis that worse disease should correlate with worse quality of life. These studies have been detailed reviewed with the grand summary statement that except for patients with minor symptoms, varicose veins permanently impair quality of life. Patients with superficial and those with more severe saphenous vein disease currently have equal impairments of their quality of life.

Human discomfort and suffering exist on a continuum of severity, and the decision to seek medical care is driven more by patient perceptions of the severity of their symptoms than by the objective physical findings. This concept has been demonstrated in several studies showing that the diverse signs and symptoms of varicose veins are not well correlated with the severity of these symptoms. Emotional distress is not directly measured by any of the scales used. The secondary AIM VI test of the SF 36 does tap into this by including questions about the amount of time the patient felt calm and peaceful and whether emotional problems interfered with social activities. Complete interpretations of scales are found in the original references but a few illustrative points are summarized in this text.

Since the pioneering work of Homans, Alligood, and Spencer about 45 years ago, all authors who have discussed the sign and symptom complex of varicose veins have mentioned the emotional distress connected with these signs and symptoms. Patients often restrict their activities and way of life because of their concern about exacerbating their varicose veins and because of the discomfort and fatigue that occurs with prolonged standing and walking. Although many patients with primary varicose veins have no serious physical impairment, some have severe lifestyle limitations. There are significant quality of life impairments in patients with venous ulceration and those with acute or chronic deep vein thrombosis, but those entities are considered separately. This discussion will be limited to patients with early to moderate varicose veins.

Impact on Daily Activities and Social Life

Repeatedly, there are significant findings to show changes in lifestyles and perspectives of patients living with varicose veins. Primary care research in Edinburgh reported 50% of patients having to raise their legs at intervals during the day, with this percentage rising to 80% in a study of United States veterans. This is an established method of reducing symptoms caused by venous insufficiency on the legs, but it is normally a practice to alleviate more severe symptoms such as leg ulcers. Raised legs aid circulation of blood because of gravity, and it helps to reduce the venous hypertension which is usually due to prolonged periods of standing or sitting. The increase in percentage mentions a much higher presence of severe chronic venous insufficiency in veterans compared to the normal population.

Patient testimony often indicates that the impact of chronic venous insufficiency and varicose veins on their quality of life is daunting. In a study using the SF-36 as a measure of quality of life, varicose vein patients showed a statistically significant impaired quality of life compared to national norms in the eight domains measured by the SF-36. The eight domains were physical functioning, role limitations due to physical health problems, bodily pain, general health perceptions, vitality, social functioning, and general mental health. Patient testimonies reported an inability to partake in physical and social activities, and additional findings from the study support this with 68% of patients reporting to have altered their recreational and leisure activities because of their varicose veins.

Quality of Life in Varicose Vein Patients

Physical Symptoms and Functional Limitations QOL is markedly reduced in venous disease patients with the worst perceived health in those with the highest CEAP classification when compared to those with lower CEAP classification. An increasing trend of worsening QOL with more advanced disease was seen in both physical and mental health factors. This is particularly relevant to the surgical treatment of varicose veins, in that improving patient symptoms and QOL is the primary directive of venous interventions. Measures of physical health, such as bodily pain and physical function, improved more with surgical treatment of superficial venous disease than those same measures in patients with angina pectoris or arthritic joint conditions. Measures of mental health were also seen to improve in patients with successful varicose vein treatment, particularly in patients with health preconceptions and those with reduction of embarrassing leg veins.

Quality of life (QOL) is an increasingly important concept in healthcare, which seeks to quantitate the functional capacities and well-being of patients in various disease states. General health perception and QOL are low in patients with chronic venous insufficiency (CVI) and/or varicose veins compared to the general population. When compared to population norm-based data, patients with superficial venous disorders fare worse in almost all physical and mental health domains. This has been shown to be worse than many common chronic diseases. Measures of physical health affected by venous disease include physical function, bodily pain, general health perception, as well as physical role limitations. Measures of mental health include vitality, social function, and mental health.

Physical Symptoms and Functional Limitations

The physical symptoms and cosmetic disfigurement from varicose veins can have a profound effect on patients’ lives. In a random sample of men and women from the community with an age range of 18-64 years, the disease was associated with the impairment of normal day-to-day activities in 27% of men and 44% of women, with numbers increasing to 49% of those reporting frequent or severe pain. This can be explained by the aching, discomfort, and throbbing often associated with varicose veins and skin changes, occurring at the end of the day and increasing in warm weather. This discomfort can restrict mobility and physical function in employment, recreation, and social activities.

Chronic venous diseases (CVD) affect a large percentage of the population, the most common of which is varicose veins. It has been documented that the prevalence of disease in the adult population can be as high as 68% in women and 43% in men. While there has been a greater understanding of the physiological changes in venous disease, there has been a dearth of well-designed studies on its psychosocial impact on quality of life.

Impact on Work and Productivity

From a health service research perspective, the primary outcome of interest is the impact of various health conditions and their treatment on patient health-related quality of life (HRQoL). This is also an important area from the patient’s perspective. Some of the most common health-related quality of life measures are physical functioning, mental health, vitality, pain, general health perceptions, and role limitations due to physical or emotional health problems. We have already noted the impact of varicose veins and, in particular, their recurrence, on patients’ physical functioning, particularly in relation to chronic venous ulceration. The association between venous disease and varicose veins and a detrimental impact on role functioning and HRQoL is done by a survey. It is a well-known fact that vein stripping can cause considerable postoperative pain and can take between 2-4 weeks from work depending on the type of job the patient performs. This can’t be a questionnaire was asked on 42 patients from a single clinical center. The patients underwent either long or short saphenous vein ligation, with or without stripping. Over the next 6 months, their HRQoL was documented using the SF-36, which is one of the most widely used instruments for measuring change in health status and HRQoL. This revealed that physical component summary scores decreased at 1 month after surgery and had only increased to high levels by 6 months post-surgery. The decline was greater for patients that underwent stripping compared to those that had non-invasive surgery. High levels of physical and social function had still not been reached after 6 months for all groups of patients. This only emphasizes the fact that varicose vein treatment is not only a cosmetic issue and the time to return to usual activities can be substantial.

Effect on Relationships and Sexual Functioning

A pilot study using the Aberdeen varicose vein questionnaire in patients with trunk varices and saphenous vein reflux has shown a high prevalence of symptoms and a lower QOL in comparison to patients with less severe forms of the disease. This study compared the QOL data of patients with different types of the disease to healthy controls, but a more useful comparison would have been to patients affected by other chronic diseases. This method has been used by to determine a somewhat poorer QOL for patients with lymphedema than for patients with various types of cancer.

The relevance of these findings has been questioned in a study by in which the researchers determined the minimal clinically important difference in the QOL scores recorded by patients following treatment. This will be useful for future studies wishing to assess patients’ opinions on treatment success.

Measures of treatment success have also incorporated the impact on social and psychological well-being. The Aberdeen varicose vein questionnaire and the VSQ have sections specifically aimed at measuring QOL. Using these measures, patients who undergo vein surgery display a significant improvement in their QOL in comparison to those treated conservatively or those who receive no treatment. This improvement matches that seen in clinical status.

Numerous studies have demonstrated that patients with varicose veins have lower social and psychological functioning scores in comparison to control groups. These results from a cross-sectional study using a generic QOL (SF-36) measure indicated that venous ulcer patients had worse functioning scales and worse bodily pain scores than COPD patients, and all other scores were significantly worse than those of healthy controls. Similar results were found by who concluded that patients with advanced chronic venous insufficiency had a worse QOL than patients with angina, except with regard to severe pain. This demonstrated the severe impact of venous disease on QOL.

This investigation aimed to establish the impact of varicose veins on patients’ lives and found repercussions to have a psychosocial, as well as a physical nature. Whilst the effects on QOL due to physical symptoms are well documented, the effect on social, emotional and sexual function have been much less well investigated. This chapter reveals the pervasiveness of these effects on patients’ lives. The most interesting finding was the pivotal role that the concealment of veins from others, due to feelings of embarrassment, played in patients’ social and personal lives.

Management and Treatment Options

There are a range of management and treatment options available. These range from conservative measures such as weight loss and exercise, to more invasive procedures such as surgery. The management strategy applied should consider both the patients’ symptomology and the disease severity. The patient’s co-morbid status, fitness levels and willingness to undergo intervention as well as the cosmetic implications of treatment will also be important factors influencing the choice of management strategy. It should be noted that with the exception of patients who present with acute leg ulceration, there has been no formal health economic assessment of the various management options for varicose veins. This is despite the fact that it is a very common condition that consumes a large amount of NHS resources.

Conservative Measures

This method is most effective for telangiectasia and reticular veins. It involves the wearing of support/compression stockings, above the level of the knee. Stockings are difficult to apply and are often uncomfortable to wear, with compliance rates being poor. They work by supporting the venous walls and help prevent edema. A 6-month trial is suggested as a first-line treatment for varicose veins. Herbal and diuretic treatments are potentially dangerous and so are not recommended. Weight loss and exercise are recommended if obesity is considered a leading factor, although these measures are unlikely to rid patients of their varicose veins, they can prevent aggravation of the disease. Bedtime leg elevation is beneficial with edema and should be continuous throughout the night, as there is rapid reflux of blood on cessation of elevation. High patient compliance is required for these measures to be effectively successful. High patient compliance rates can be problematic with conservative measures, and patients may become disheartened, as improvement can take a prolonged period of time. It is important to provide the patient with detailed information about their condition and education on the effectiveness and importance of conservative measures may help promote compliance.

Minimally Invasive Procedures

Foam Sclerotherapy There are two types of sclerotherapy (liquid and foam). Both forms introduce an irritant into the vein. The irritant causes the vein to become inflamed and eventually scar. The type of irritant and the concentration used can vary. Foam sclerotherapy is a newer technique in which, as the name suggests, foam is produced by mixing air with the irritant. High ligation and stripping then phlebectomy are techniques that have been around for many years. High ligation and stripping involves tying a knot in the vein at the point where it joins a deeper vein (high ligation) and then removing the vein through a series of small nicks in the skin. Phlebectomy involves the direct removal of a vein through a small nick in the skin. Both methods are considered surgical given that the veins are physically removed from the body.

Endovenous laser (radiofrequency) ablation (EVLA) EVLA is a technique that uses heat to seal the affected veins. This technique is carried out using ultrasound guidance. The greater saphenous vein is usually treated first. A small nick is made at the knee and a fine catheter is inserted into the vein. Local anesthetic is injected around the vein to numb it. The catheter is then slowly withdrawn while the vein is anesthetized. In doing so, EVLA is significantly less painful than the older laser technique known as stripping.

Surgical Interventions

A recent study has shown that conventional surgery is more effective than that of current endovenous techniques, but this may not be the case in the future, and the most important aspect is removal of the abnormal vein.

Stripping itself is the process by which a vein is tied off, and a wire passed through it, and then simply pulled out, removing the vein. This may sound brutal, but damage to the leg is no more than tying off the vein and leaving it in place, which can be a cause of much post-operative pain.

The traditional operation of varicose vein stripping has been much maligned, mostly due to patients’ fears of pain and a long recovery period. Modern techniques, using pinhole incisions under local anaesthetic, are virtually pain-free, and the recovery period is much shorter than in the past.

Pre-operatively, all cases should have a detailed duplex ultrasound scan. This not only maps all the abnormal veins, but establishes their underlying cause. If this is not done, and an abnormal vein missed, then this may become the cause of recurrence of varicose veins in the future. The importance of this cannot be overstressed.

There are different surgical methods which can relieve the burden of varicose veins, and are generally reserved for severe cases. Procedures are usually just a day case or one night in hospital and most are done under a local anaesthetic; patients can usually return to work after a few days.

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