Varicose veins are swollen, twisted veins that bulge just beneath the skin’s surface, most commonly in the legs. They affect roughly 10% to 30% of adults worldwide, though some populations show rates as high as 50%. Far from being purely cosmetic, varicose veins are a sign of underlying venous disease that can progress through several stages if left unmanaged.
Why Veins Become Varicose
Your leg veins contain tiny one-way valves that keep blood flowing upward toward the heart, working against gravity with every step. Varicose veins develop when these valves stop closing properly, allowing blood to flow backward and pool in the vein. This pooling raises pressure inside the vein, which stretches and weakens the vein wall, causing the bulging and twisting visible from the outside.
The process can start in two ways, and often both happen at once. The valves themselves may develop structural defects that make them leak. Or the vein wall near a valve junction can weaken and stretch first, pulling the valve leaflets apart so they no longer meet. Either way, the rising pressure triggers a cycle: the vein wall stretches further, which activates enzymes that break down the structural proteins holding the wall together, leading to even more stretching. Once this cycle starts, it tends to get worse over time without intervention.
Who Gets Them and Why
Genetics play a significant role. A large study of nearly 500,000 people identified 30 genetic regions associated with varicose veins, including genes involved in blood vessel development, vascular integrity, and how blood vessels sense mechanical pressure. Height is one of the clearest genetic links. Taller people face roughly 26% higher odds of developing varicose veins, likely because blood in longer leg veins exerts more downward pressure on those valves.
Beyond genetics, several factors raise your risk:
- Age: Vein walls and valves weaken naturally over time, making varicose veins increasingly common after middle age.
- Pregnancy: Blood volume increases, hormonal shifts soften vein walls, and the growing uterus compresses pelvic veins. Varicose veins from pregnancy sometimes resolve after delivery but often persist.
- Hormone replacement therapy: Supplemental estrogen increases vein wall flexibility, which sounds beneficial but actually makes veins more prone to stretching and pooling.
- Prolonged standing or sitting: Jobs that keep you in one position for hours put sustained pressure on leg veins without the muscle contractions that normally pump blood upward.
- Obesity: Extra weight increases pressure on leg veins.
Oral contraceptive use, despite common assumptions, has not shown a consistent link to varicose vein development in large-scale analyses.
What They Look and Feel Like
The most obvious sign is a rope-like, blue or purple vein visible through the skin, 3 millimeters or wider in diameter. Smaller spider veins (thin red or blue webs) are a related but milder condition. Many people with varicose veins experience no discomfort at all, while others notice aching, heaviness, or throbbing in the legs, especially after long periods of standing. Swelling around the ankles by the end of the day is common.
Some people feel burning or itching over the vein itself. Nighttime leg cramps and a sense of restlessness can also accompany varicose veins, though these symptoms overlap with many other conditions.
Stages of Venous Disease
Varicose veins exist on a spectrum. Clinicians use a seven-stage classification system to describe how far venous disease has progressed:
- Stage 0: No visible signs
- Stage 1: Spider veins or small reticular veins
- Stage 2: True varicose veins (3 mm or larger)
- Stage 3: Leg swelling from fluid buildup
- Stage 4: Skin changes, including darkening, eczema, or hardening of the skin near the ankles
- Stage 5: A healed venous ulcer
- Stage 6: An active, open venous ulcer
Not everyone progresses through all stages. Many people remain at stage 2 for years or even decades. But those who develop skin changes are at meaningful risk of ulceration, which is much harder to treat.
Potential Complications
Venous ulcers are the most serious complication of untreated varicose veins. These slow-healing open wounds typically appear near the inner ankle and affect about 1% of the Western population overall, rising to 3% in people over 65. They’re painful, prone to infection, and frequently recur.
A history of deep vein thrombosis (blood clots in the deep leg veins) significantly raises the risk of ulcers. In one study, 72.5% of ulcer patients with both deep and superficial vein problems had a history of deep vein clots. The combination of damaged deep veins and varicose surface veins creates especially poor circulation, making healing difficult.
Other complications include superficial blood clots (which cause a firm, tender cord along the vein), bleeding from a vein close to the skin surface, and chronic skin inflammation around the ankles.
How Varicose Veins Are Diagnosed
Diagnosis usually starts with a visual exam, but an ultrasound is the standard tool for confirming the problem and mapping its extent. During this test, you’ll typically stand with your weight on the opposite leg while the examiner checks blood flow with a handheld probe. You may be asked to bear down (a Valsalva maneuver) to increase abdominal pressure, which forces blood backward past any faulty valves.
The examiner watches for reverse blood flow using color imaging. Any backward flow lasting longer than half a second in surface veins, or longer than one second in deep veins, counts as clinically significant reflux. This mapping tells your provider exactly which veins are affected and helps determine the best treatment approach.
Treatment Options
Treatment depends on the severity of your symptoms and how far the disease has progressed. For mild cases, compression stockings and lifestyle changes may be enough. For more advanced disease, several procedures can close off or remove the damaged veins.
Compression Stockings
These graduated stockings apply the most pressure at the ankle and gradually less as they go up the leg, helping push blood back toward the heart. Stockings in the 15 to 20 mmHg range improve swelling and symptoms compared to no compression or very light compression. Interestingly, research shows little additional benefit from going above 20 mmHg for symptom relief alone. Higher-pressure stockings (30 to 40 mmHg) are reserved for more advanced disease, particularly for healing venous ulcers and preventing their return.
The catch with compression stockings is that they only work while you’re wearing them. They don’t fix the underlying valve problem, so symptoms return once you take them off.
Foam Sclerotherapy
A foam solution is injected directly into the vein, irritating the lining and causing it to collapse and seal shut. The procedure takes about 19 minutes on average and is the least painful option. Patients recall lower pain levels during both the procedure and recovery compared to surgery or laser treatment. The tradeoff is a lower success rate for completely closing the vein. Compared to laser ablation, foam sclerotherapy is significantly less likely to achieve full vein closure, particularly in larger veins.
Endovenous Laser Ablation
A thin fiber is inserted into the vein through a small puncture, and laser energy heats the vein from the inside, sealing it closed. The procedure takes about 46 minutes. It matches traditional surgery in closure rates and is significantly more effective than foam sclerotherapy. Pain during and after laser treatment tends to be higher than with foam, though recovery is faster and less invasive than open surgery.
Surgery
Traditional stripping surgery, where the damaged vein is physically removed through small incisions, takes about 52 minutes and involves the most painful recovery of the three options. It remains effective but has largely been replaced by less invasive alternatives for most patients. Surgery is still used for certain vein configurations that aren’t suited to catheter-based treatments.
Regardless of which procedure you have, blood naturally reroutes through healthy deeper veins. The treated veins were already functioning poorly, so removing them from circulation actually improves overall blood flow in the leg.
Managing Symptoms at Home
Several strategies help slow progression and reduce discomfort. Regular walking activates your calf muscles, which act as a pump to push blood upward. Elevating your legs above heart level for 15 to 20 minutes several times a day reduces pooling and swelling. Avoiding long stretches of standing or sitting without movement keeps blood circulating. If your job requires standing, shifting your weight and flexing your calves periodically makes a real difference.
Maintaining a healthy weight reduces the pressure on your leg veins, and regular exercise strengthens the muscle pump that supports venous return. These measures won’t reverse existing varicose veins, but they can meaningfully slow the progression from early stages to the skin changes and ulceration that make treatment more complex.