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Varicose Veins: More Than a Cosmetic Problem

  • Prof. Dr. Zahid Mahmood
  • August 3, 2026

Varicose Veins: More Than a Cosmetic Problem

By Prof. Dr. Zahid Mahmood — General, Laparoscopic & Laser Surgeon, Lahore

Varicose veins are so common that many people assume they are simply a normal part of getting older, or purely a cosmetic nuisance to be covered up rather than treated. In reality, they are a genuine medical condition — a sign that the valves inside your leg veins are no longer working properly — and while many cases stay mild, a significant number progress to real discomfort, skin damage, or complications that are far easier to prevent than to reverse. This article explains why varicose veins develop, how we assess them properly, and the full range of modern treatments available, well beyond the stripping surgery many patients still associate with this condition.

What varicose veins actually are

Veins in the legs carry blood back up toward the heart against gravity, a job made possible by one-way valves positioned along their length that stop blood from falling backward between heartbeats. When these valves fail — whether in the long veins running the length of the leg or in smaller connecting veins — blood pools and flows backward under gravity, a process called venous reflux. Over time, the affected veins stretch, thicken, and become the visible, twisted, bulging veins most people recognise as varicose veins. This is not simply a cosmetic change: the same faulty valves and rising venous pressure that cause the visible bulging are also what drive the symptoms and complications that can follow.

Just how common is this?

Visible varicose veins affect somewhere between 30% and 50% of adults, making this one of the most common conditions I see. Several factors clearly increase the risk: being female, increasing age (prevalence rises sharply decade by decade, from roughly 1 in 10 people in their twenties to well over half of people in their late fifties and sixties), pregnancy, a family history of varicose veins, and a higher body weight and height. Occupations involving prolonged standing are often blamed, though the evidence for this particular link is actually less conclusive than popular belief suggests. If your parents or siblings have varicose veins, you have a meaningfully higher chance of developing them yourself — this is a genuine inherited tendency, not just a shared environment or lifestyle. Smoking, constipation, and jobs involving long periods of standing are commonly blamed by patients, and while they may plausibly contribute in some individuals, the actual evidence linking them directly to varicose veins is genuinely mixed rather than firmly established — so I’m cautious about over-promising that changing any one of these alone will prevent or reverse the condition.

Clearing up a few common myths

A few misconceptions come up regularly in my clinic and are worth addressing directly. First, varicose veins are not purely a female problem — men develop them too, just somewhat less often, and male patients frequently delay seeking treatment longer because they assume it’s “a women’s issue.” Second, sitting with your legs crossed does not cause varicose veins — this is a persistent myth with no real evidence behind it, though it can worsen comfort temporarily in someone who already has them. Third, treating varicose veins is not simply a vanity procedure — for a patient with genuine symptoms or early skin changes, treatment is a legitimate medical intervention aimed squarely at preventing complications, not just improving appearance, even though the cosmetic improvement is naturally welcome too.

The symptoms patients describe

Beyond the visible, bulging veins themselves, patients commonly describe aching, heaviness, throbbing, burning, or a bursting sensation in the affected leg, sometimes spreading to the whole limb. These symptoms typically build up over the course of the day, are worse after prolonged standing, and improve with rest, leg elevation, or compression stockings. Itching over the affected veins is also common, and ankle swelling by the end of the day is frequent as venous pressure builds.

An important and often underappreciated point: how much a patient suffers does not reliably match how large or visible their varicose veins look. Someone with fairly modest visible veins can have significant, quality-of-life-affecting symptoms, while another person with quite prominent veins may have very few complaints. This mismatch is one reason I always take a patient’s symptoms seriously in their own right, rather than judging severity purely by appearance. It’s also worth knowing that fine thread veins (spider veins) without any true underlying reflux usually cause no physical symptoms at all — people seek treatment for these mainly for cosmetic reasons, and that is a legitimate reason to seek treatment, just a different one from treating true varicose veins.

When varicose veins become a complication, not just a nuisance

Left untreated over years, varicose veins can progress beyond simple bulging and aching into more serious territory. The vein can become acutely inflamed and clot-filled — a painful, hardened, red cord under the skin known as superficial thrombophlebitis. A thin-walled varicose vein sitting just under stretched skin can also bleed surprisingly heavily if knocked or scratched, sometimes needing urgent pressure and elevation to control. Over the longer term, chronically high venous pressure can cause the skin around the ankle to darken, thicken, and become fragile — changes that, if left to progress far enough, can eventually break down into a venous leg ulcer, a slow-healing wound that becomes far harder to treat than the varicose veins that caused it. This progression is exactly why I encourage patients with symptomatic varicose veins not to simply “live with it” indefinitely — treating the underlying reflux earlier, before skin changes set in, gives a much better long-term result than waiting until complications appear.

How we properly assess varicose veins

A visual examination tells us that varicose veins are present, but it does not reliably tell us which vein is actually failing, or how best to treat it — for that, a duplex ultrasound scan is essential before planning any treatment. This is a painless scan performed with the patient standing, since venous reflux is far easier to detect under gravity than lying flat. The scan maps exactly where the faulty valves are, which specific veins are involved, whether the deeper veins are open and working normally, and how large and tortuous the affected veins are — all of which shapes exactly which treatment will work best for that individual leg. Modern practice has moved away entirely from the older tourniquet tests and hand-held Doppler devices doctors once relied on; a proper duplex scan by someone experienced in reading them gives a far more reliable, individually tailored picture.

Treatment options: what’s actually available today

Not everyone with varicose veins needs a full intervention, and treatment is tailored to symptoms, the pattern of reflux found on the scan, and the patient’s own preferences.

Compression stockings work by applying graduated external pressure to the leg, helping push blood back toward the heart and reducing venous pressure. They genuinely improve symptoms for many patients and are a reasonable option for those who are not good candidates for a procedure, are pregnant, or simply prefer to avoid intervention for now. What they do not do is fix the underlying problem or reliably prevent the condition from progressing — and in practice, many patients find long-term daily stocking wear uncomfortable and difficult to sustain. For this reason, stockings are best thought of as a supportive option or a bridge to treatment, not a substitute for it when a patient has clear symptoms and wants a lasting solution.

Endothermal ablation — using either laser energy (endovenous laser ablation) or radiofrequency energy — has become the modern gold-standard treatment for the main trunk veins responsible for varicose veins, having replaced traditional open surgery in most cases. A thin fibre is passed into the faulty vein under ultrasound guidance through a single small needle puncture, and heat energy delivered through the fibre seals the vein shut from the inside, permanently closing off the reflux. Local anaesthetic fluid is infiltrated around the vein first, both numbing the area and protecting the surrounding tissue from the heat. This is done as an outpatient procedure, patients walk out the same day, and recovery is notably quicker and more comfortable than with traditional surgery, with excellent long-term success rates. Most patients wear a compression stocking for a short period afterward, are walking normally within a day, and are back to desk-based work within a couple of days and to full unrestricted activity, including exercise, within one to two weeks.

Foam sclerotherapy involves injecting a specially prepared foam solution directly into the vein, under ultrasound guidance, which irritates and seals the vein wall from within. It is particularly useful for smaller or more tortuous veins that aren’t well suited to a heat-based fibre, and is often used alongside ablation to treat visible surface varicosities in the same session.

Phlebectomy is a technique for removing the smaller, bulging surface veins themselves through a series of tiny nicks in the skin, each just a few millimetres long, leaving minimal scarring. This is frequently combined with ablation of the main trunk vein in the same session, treating both the underlying cause and the visible bulging veins together.

Traditional surgery — surgical ligation of the faulty junction combined with stripping (removing) the main vein — is still occasionally the right option, particularly where a vein’s anatomy isn’t suitable for the endovenous techniques above, but it has become a second-line option rather than the default, precisely because it involves a general anaesthetic, a longer recovery, and a higher rate of complications compared with modern ablation techniques.

Being honest about risks and recurrence

I believe patients deserve a realistic picture, not just the best-case outcome. Complications from traditional varicose vein surgery are reported in up to 1 in 5 patients, though most are minor — wound infection being the most common, and reduced by preventive antibiotics. Nerve irritation causing numbness or tingling, usually temporary, is the most common more troublesome complication, particularly with stripping of veins below the knee. Blood clot complications are uncommon, at around 1 in 200 patients, though individual risk factors are always assessed beforehand.

Recurrence is also worth discussing honestly: even after successful treatment, new visible veins can develop over subsequent years in a meaningful proportion of patients, most commonly through the formation of new, valve-less veins in the treated area, or reflux developing in a vein that wasn’t originally treated. This is not a sign that the original treatment failed — it reflects the fact that this is a chronic tendency of the venous system, not a single problem that is permanently cured in every vein for the rest of a patient’s life. The good news is that when recurrence does happen, it is usually managed just as effectively as the original presentation, often with a more limited, targeted procedure.

Special situations worth mentioning

Varicose veins that appear or worsen during pregnancy are extremely common, driven by hormonal changes and increased pressure from the growing uterus on the pelvic veins. In most cases, these genuinely improve on their own in the months after delivery, and it’s generally sensible to wait and reassess after pregnancy is complete before considering any intervention, unless symptoms are severe. A large, soft, painless lump appearing at the top of the thigh near the groin — especially one that appears on standing and disappears when lying down, and that gives a subtle impulse when coughing — can occasionally be mistaken for a hernia, but is actually a dilated varicose vein at the junction high in the thigh; distinguishing between the two is a straightforward part of a proper clinical assessment.

It’s also worth knowing that not every unusual varicosity pattern in a woman originates in the leg at all. Vulval varicose veins, or thigh varicosities in an atypical distribution, can sometimes be driven by incompetent veins deep in the pelvis — a condition called pelvic congestion syndrome, which typically causes a dull, non-cyclical pelvic ache in women of childbearing age, sometimes alongside period pain, heavy periods, or a feeling of pelvic heaviness. Because the leg varicosities in this situation are really a downstream sign of a pelvic problem, treating them locally without addressing the pelvic source rarely gives lasting relief — which is another reason a thorough assessment, rather than treating every visible vein as the same straightforward problem, matters.

Warning signs worth getting checked

  • Aching, heaviness, throbbing, or burning in the leg, especially worsening through the day
  • Visible bulging, twisted veins, with or without discomfort
  • Itching or ankle swelling associated with visible veins
  • A hot, red, tender, hardened cord along a vein — possible superficial thrombophlebitis
  • Bleeding from a varicose vein after a minor knock
  • Darkening, thickening, or fragile skin around the ankle
  • Any wound near the ankle that isn’t healing as expected

What you should do

If you have symptomatic varicose veins, don’t assume nothing can be done beyond compression stockings, and don’t wait until skin changes or an ulcer develop before seeking assessment. A proper duplex ultrasound scan and an individualised discussion of the modern options available — most of which are outpatient procedures with a quick recovery — will give you a much clearer picture of what’s actually driving your symptoms and the most effective way to treat it.

To book a consultation with Prof. Dr. Zahid Mahmood, call 0300 413 0159 or visit professorzahid.com.

This article is for general awareness and does not replace a personal medical consultation.

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