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Varicose Veins: The Role of Hormonal Changes and Menopause

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Upon first sight of the swollen and knotted veins, a treatment of let blood from the ankle or groin is to be applied. Then, the use of wool soaked in wine and a bandage is used to compress the vein. A sponge soaked in cold water is to be applied above the bandage, then the patient should move around and continue this process each day. After a few days the swelling should reduce and then the vein is to be massaged with the fingers, coated in oil or butter, in an upward motion towards the heart, then repeat the first process. This method was later put into practice by ‘Ambroise ParĂ©’ the barber surgeon in the service of the French kings. This sixteenth century surgeon was the first to notice the healing process of veins left open after amputations, and after hearing the story of a Spanish soldier whose gangrenous veins were tied found a decrease in the swelling of his varicose veins, he developed a method of tying off the long saphenous vein, giving him a reduction in the treatments time and a much quicker recovery for the patient. This method is still the basis for varicose vein surgery today, even though the ‘stripping’ of veins was not popularised until the turn of the century. ParĂ© was the first to publish his method of vein ligation and this was cited by John Homans in his use of catgut ligatures to tie off saphenous veins. The incidence of varicose vein development is the same as it has been for history although the great diversity in experience and treatment is due to mankind’s development in health sciences. Today surgical methods and technology are improving and with greater understanding of vein physiology methods have become less invasive and more effective.

Hormonal Changes and Varicose Veins

There doesn’t seem to be much evidence supporting the theory that progesterone plays a significant role in the development of varicose veins. However, an indirect link can be made with it being the precursor of many other steroid hormones, hence a hormonal imbalance. Testosterone has also shown to have little effect on the development of varicose vein. This is no surprise considering it is a predominantly male hormone, and varicose veins are a condition affecting the majority of women.

Elevated levels of estrogen have been widely linked to the occurrence of varicose veins in women. Studies have shown that vein walls contain proteins that can bind to estrogen. In high levels, this can cause relaxation of the vein walls. There is evidence to suggest that when these levels drop, such as at childbirth or menopause, the veins revert back to their normal size. Currently, hormone replacement therapy (HRT) is the only recognized way to elevate hormone levels, although it has been highlighted for its capability to cause blood clots. Blood clots are, in most cases, a far more serious condition than varicose veins, and if this were the outcome, it would be a case of robbing Peter to pay Paul.

Impact of Estrogen Levels

Analysis suggests that hormones have a large influence on vein health, particularly estrogen and progesterone. Hormones are essential chemicals in the body that help control and coordinate cell activity. They essentially act as messengers between cells because they are synthesized in one location and affect the metabolism of another cell either adjacent or a distance away. Estrogen and progesterone are no exception to this, and the way in which they affect vein health makes them particularly significant.

To prevent such forms of venous diseases from occurring, a strong understanding of what causes weakened veins is necessary. Effectively treating the causes will help prevent the onset of venous diseases. One of the most influential discoveries that help identify a cause for venous disease is the relationship between hormonal changes and weakened veins.

Varicose veins are a very common condition, especially in the United States. Characterized by their bulging appearance on the skin, they are a result of weakened veins in the body. Often caused by an excess of pressure in the veins, the blood flow becomes restricted and pools inside them. Varicose veins are the unfortunate consequence of this. While the symptoms are mainly cosmetic, with some cases they can lead to much more serious conditions.

Influence of Progesterone

Like estrogen, the main effects of progesterone are vasodilation and an increase in vein distensibility. However, progesterone is also associated with water retention and an increase in overall intravascular volume. Increased vein distensibility in combination with the increased volume and stretching of the vein wall may lead to valve damage and vein wall dilation. This is also supported by the clinical observation that women will often develop varicose vein symptoms shortly after starting oral contraceptive therapy, which is high in progesterone content. A high prevalence of vein disease has been found in women with a long history of oral contraceptive use.

High levels of progesterone and estrogen are known to be the main hormonal changes of pregnancy. Estrogen is known to cause relaxation and an increase in vein distensibility. However, estrogen has also been shown to have anti-inflammatory and anti-thrombotic effects, which would suggest an overall protective effect against vein disease. This is contradicted by the fact that many women develop vein problems during pregnancy and the disappearance or improvement of symptoms after cessation of oral hormone therapy previously described (progesterone and vein change).

The same study above also indicates that a significant number of women develop varicose veins during their first pregnancy. Consequently, the incidence of varicose veins has been observed to be higher in parous women than in nulliparous women. An epidemiological study carried out to investigate the relationship between vein disease and parity showed that parous women had an approximately 3-fold increased risk of developing vein problems than nulliparous women, suggesting that hormonal changes during pregnancy may play a role.

Role of Testosterone

The overall conclusion from the current data available is that testosterone has a bad protective effect against the development of varicose veins. From this, we can infer that men have a decreased chance of developing varicose veins as they age when compared to women; this is due to the consistent level of testosterone in their bodies when compared to the fluctuating hormone levels in women. This also means that the development of a testosterone treatment for both men and women in later life could help to prevent varicose vein development. This is a contrast to gender-specific hormone treatments for males and females which aim to increase hormone levels for various reasons, e.g. postmenopausal hormone treatments in women aim to reduce symptoms from a decrease in estrogen levels.

Investigation into the impact of testosterone has been conducted in recent years; this research has shown that testosterone actually has a protective effect against varicose veins. This is proven by the fact that women rarely suffer from varicose veins before the age of 30 and from the knowledge that testosterone levels decrease with age. Testosterone causes an increase in muscle strength and tone, along with an increase in overall body strength and a decrease in body fat levels. The action in the muscles results in an increased venous tone. This has been proven during pregnancy when increased hormonal levels cause an increase in vascular distensibility in the veins. This increased venous distensibility leads to reflux in the veins and then to varicose veins. During the postmenopausal period when hormone levels have reduced, there is a noted decrease in physical performance, muscular strength, and the ability to carry out non-exhausting energy-related tasks. Studies have also shown that a certain testosterone treatment can reverse many of those effects. This is relevant because the decrease in physical performance coincides with an increase in the development of varicose veins. state in 2016 that a sedentary lifestyle or a low level of various physical activities has been proven to be risk factors for an increase in varicose vein prevalence.

Menopause and Varicose Veins

This concept is important to our understanding of hormone-related varicose veins because it is possible that estrogen treatments to prevent menopausal symptoms could help prevent varicose veins. This has not been proven though, and such treatment involves an increased risk of other health issues.

During menopause, most women experience symptoms due to the decreasing levels of estrogen and progesterone. While estrogen levels accumulate in hip and thigh fat to prepare the body for pregnancy, it has been linked with increased occurrence of varicose veins in these areas. Women who have had multiple pregnancies (and therefore have accumulated more hip and thigh fat) and reach menopause may notice worsening of their varicose veins at this time. This is because the decrease in estrogen means that the body is no longer trying to regulate hormone levels up to prepare for pregnancy, so hormone-related varicose veins will not improve.

Estrogen, a hormone produced by the ovaries, helps keep the vein valves from weakening. It also aids in preventing narrowing of the blood vessels. Therefore, as a woman approaches menopause and her estrogen levels decrease, it is more likely that the vein valves and walls will weaken, leading to varicose veins.

Effects of Declining Estrogen

Declining estrogen is not a direct cause of varicose veins in menopausal women, but studies show a rise in vein problems in women ages 40-50. This surely has to do with the ceasing of menstruation and the decrease in estrogen levels. In menopause, as the ovaries stop secreting eggs, estrogen and progesterone levels decrease significantly. This sharp decrease in these hormone levels may cause elastin and collagen in the vein walls to lose some of their strength and the veins to lose some of their tone. When this happens, it is easier for the veins to become distended. These hormones also have an effect on a blood substance called fibrinogen. Fibrinogen levels rise with high estrogen and/or birth control pill use. High levels of fibrinogen can be related to dilution of blood and increased viscosity. If inflammation is present, fibrinogen can also lead to the formation of a blood clot. Studies have also shown in menopausal women a decrease in HDL (good cholesterol) and an increase in LDL (bad cholesterol). High levels of LDL and low levels of HDL can lead to atherosclerosis. All of these factors mentioned above can also lead to a buildup of blood and increased pressure in the veins, ultimately affecting their performance and possibly causing varicose veins.

Changes in Progesterone Levels

An increase in the level of progesterone in the body can reduce the feminizing effect of estrogens on the vessel wall. It achieves this by altering the estrogen receptors on the vein in such a way as to reduce the effect of estrogen when it is also present. This can result in a relative dominance of progesterone over estrogen where a decrease in the ratio of estrogen to progesterone appears to exacerbate symptoms of varicose veins. This imbalance of hormones is also thought to cause a decrease in the vein wall’s strength because of a reduction in collagen production. One study showed decreased collagen synthesis in rats given progesterone. This effect was magnified when progesterone was given in combination with estrogen, mimicking the effects of the hormones in pregnancy and increasing the likelihood of varicose veins during this time. Although this study was not done on humans, increased collagen production and strength of the vein wall have also been linked to a decreased occurrence of varicose veins. Another possible effect of hormones on the vasculature is through the presence of estrogen and progesterone receptors. One study demonstrated that the higher the grade of varicosities in the long saphenous vein of women, the more estrogen and progesterone receptors were present. This could mean that there is a direct effect of hormones on the development of varicose veins.

Testosterone and Menopause

At first glance, testosterone might seem irrelevant to a menopausal woman, but in reality, women have long been known to be exposed to more than we once believed. There are proven testosterone increases post-menopause, and the question is whether the testosterone increase is an attempt to create estrogen and if that has any effect on the risk for varicose veins. Should the increase in testosterone be linked to the hormone therapy for estrogen given to menopausal women, there may be yet another variance to consider when discussing the increased risk in varicose vein development.

A longitudinal study from 2000 to 2008 explored the relationship between hormone therapy, which includes estrogen, and the occurrence of varicose veins. The Women’s Health Initiative was the study used, and it established a baseline age of 50 to 79. It concluded that women in correlation with hormone therapy have an increased risk of developing varicose veins. The cause of varicose veins was unable to be directly linked to estrogen, but aging and estrogen did prove to be risk factors. This study was the first of its kind to explore age and the development of varicose veins, and it was found that the increase in risk accelerates to its highest rate when reaching ages 60-69. With this conclusion, it was explored that estrogen or the lack thereof due to menopause could be a risk factor for the development of varicose veins.

Other Factors Contributing to Varicose Veins during Menopause

Apart from hormonal changes during menopause, a combination of factors may influence the development of varicose veins in many women. Women who are pregnant may notice that their varicose veins persist after delivery. This may be due to weakened vein walls from the increased pressure of the uterus on the veins. The use of hormone replacement therapy (HRT) to alleviate menopausal symptoms is another factor believed to contribute to the high incidence of varicose veins in menopausal women. Studies have shown a higher incidence of varicose veins in women taking HRT than those not taking HRT. HRT usually consists of giving estrogen to women whose estrogen levels have declined. This can thicken the blood and increase the likelihood of developing blood clots. Additionally, high estrogen levels are a known cause of making the blood more likely to clot. While blood clots themselves are not varicose veins, the tendency for increased blood clotting may lead to a future development of varicose veins. Since HRT is often used for symptom relief only, the risks of HRT should be weighed against the benefits. Another factor that may contribute to varicose veins in menopausal women is obesity. Obesity is a major risk factor as it increases the pressure in the abdomen and legs, causing veins to enlarge. Obesity also increases the likelihood of blood clot formation. Diet is an associated factor with obesity. Consuming excessive salt can cause the body to retain more water. This in turn may increase the pressure on the veins. High-fat, low-fiber diets are also considered a contributing factor, as constipation caused by such a diet can lead to varicose veins. Lastly, higher age is associated with a higher prevalence of varicose veins. This is due to wear and tear on the veins over the years. While children and young adults can and do develop varicose veins, the veins above 50 years of age are likely to be more severe and may warrant treatment.

Conclusion

The effects of hormones on the vein wall can be summarized during puberty, pregnancy, and HRT. High levels of estrogen weaken the vein wall and valves by affecting the synthesis of collagen and various factors. It is uncertain exactly how this occurs, but there are likely to be changes in gene transcription. Estrogen also increases the tendency for blood clotting, which will further weaken vein wall and valve function. During pregnancy, blood volume and vein flow rates are greatly increased, and this places a high burden on the vein wall, causing stretching and a slowing of blood flow to allow the effective transfer of nutrients to the baby. Although very necessary for a healthy pregnancy, these changes are harmful to vein function. Estrogen levels return to pre-menopausal levels with combined HRT, and this has, by and large, the same effects as during pregnancy. Estrogen levels determine the number of fatigue failure cycles that the vein can withstand, and changes in these levels in a relatively short space of time are most damaging to the vein wall. Thus, it may be said that increased estrogen at various stages in life acts as a mechanical stressor to the vein wall. High progesterone levels are also harmful, but its effects are less well known. During the menses or taking progestin medicine, women actually experience PMS-like symptoms similar to what occurs when men get varicose veins from high physical stress. This is due to increased aldosterone, which causes sodium and water retention, thereby increasing blood volume and pressure. This results in further mechanical stress to the vein wall. Aldosterone also directly acts on the vein wall, but it is uncertain how this occurs.

The explanation lies partly in understanding the effects of hormones on the vein wall. The vein wall is made up of collagen and elastin fibers in a matrix formation, with cells and connective tissue in between. This provides a structure that allows veins to be stretched. Elastin is a very important component; it allows the vein to resume its normal shape after stretching. Loss of this capability, as we shall see, is an important factor in varicose vein development.

Hormonal changes are a key factor in varicose veins, and gender is vital, with women developing the condition more frequently than men. This itself indicates, importantly, that it is hormonal changes in women that are a key factor in varicose vein development.

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