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Many people first notice green or purple veins appearing on their legs. For some, they may look like small veins just beneath the skin, while others may develop visibly enlarged, bulging, and twisted veins. Because of this, varicose veins are often considered merely a cosmetic issue—especially among people who can still walk normally and experience little or no pain.
However, varicose veins are part of a broader condition known as Chronic Venous Disease (CVD). Symptoms can range from aching and leg swelling to skin discoloration and, in more advanced cases, chronic wounds.
The good news is that the underlying cause can be evaluated and treated. Today, many treatment options are minimally invasive and no longer require major surgery as they often did in the past.
How Do Varicose Veins Develop?
Blood that travels down to the legs must return upward to the heart, working against gravity. To help this process, veins contain small structures called venous valves, which prevent blood from flowing backward.
When the walls of the veins or the venous valves become weakened or damaged, the valves may no longer function properly. This allows blood to flow backward, a condition known as venous reflux. As blood begins to pool in the legs, pressure inside the veins gradually increases.
Over time, veins located near the surface of the skin may become enlarged, swollen, and twisted, resulting in the varicose veins that can be seen externally.
Varicose Veins Are Not Just “Bulging Veins”
Many people seek medical attention even when their visible varicose veins are not particularly large because they experience symptoms such as aching, tiredness, heaviness, tightness, or fatigue in the legs—especially toward the end of the day.
Some people may experience throbbing pain, a burning sensation, itchy skin, or nighttime leg cramps. Symptoms often become more noticeable after standing for long periods and may improve after walking, elevating the legs, or resting.
As the condition progresses, swelling may develop around the ankles or lower legs, particularly in the evening. If elevated pressure within the venous system persists for a prolonged period, the skin around the ankles may become darker, thicker, itchy, or inflamed.
Therefore, people with varicose veins do not need to wait until the veins become “very large” before seeking medical evaluation. The size of visible veins alone does not indicate the full severity of the condition.
When Should You See a Doctor?
If you have varicose veins but no symptoms, treatment may not be necessary in every case. However, medical evaluation is recommended if you experience any of the following:
- Varicose veins that are increasing in number or becoming larger
- Leg pain, aching, heaviness, tightness, or symptoms that interfere with work or daily activities
- Swelling of the legs or ankles
- Itching, skin irritation, or skin around the ankles or lower legs becoming darker or hardened
- Wounds around the ankles or lower legs, particularly wounds that heal slowly
- Pain, redness, or a hard cord-like vein, which may indicate Superficial Vein Thrombosis (SVT)
- Bleeding from a varicose vein
Another symptom that should not be ignored is sudden swelling and significant pain in one leg. Medical evaluation is needed to rule out Deep Vein Thrombosis (DVT).
If sudden shortness of breath, chest pain, or difficulty breathing occurs at the same time, you should seek emergency medical attention immediately.
Are Varicose Veins Dangerous?
Varicose veins do not progress in the same way for everyone, and not every person with varicose veins will develop serious complications.
However, when high pressure within the veins continues for a long period, the condition may progress to leg swelling, skin inflammation, darkening of the skin, or hardening of the tissues around the ankle.
In more advanced cases, patients may develop a Venous Leg Ulcer, a chronic wound that typically occurs around the ankle and may take a long time to heal.
Another possible complication is Superficial Vein Thrombosis, which commonly causes pain, redness, and a firm, cord-like vein. Bleeding from varicose veins can also occur.
For this reason, evaluating varicose veins is not simply about appearance. Doctors also assess whether the condition has begun to affect symptoms, the skin, blood circulation, and the patient’s overall quality of life.
How Are Varicose Veins Diagnosed?
Evaluation begins with a medical history and physical examination. The doctor will assess the location of the varicose veins, the presence of swelling, and any skin changes, while also determining whether other vascular conditions may be present.
An important diagnostic test is Duplex Ultrasound, which allows doctors to examine the structure of the veins, identify possible obstruction, and evaluate abnormal backward blood flow or venous reflux.
According to the 2022 European Society for Vascular Surgery (ESVS) Clinical Practice Guidelines, Duplex ultrasound is the primary imaging method used to assess patients with chronic venous disease.
Importantly, the varicose veins visible on the surface may only represent the “end result” of an underlying problem. Duplex ultrasound can help determine which vein is responsible for the reflux and where the abnormal blood flow originates. This information directly influences the choice of treatment.
Treatment for Varicose Veins
One of the most common questions doctors hear is:
“If I have varicose veins, do I need surgery?”
The answer is not necessarily.
Treatment depends on the patient’s symptoms, the severity of the condition, the location of the affected veins, and the results of the ultrasound examination.
For some patients, conservative management may be appropriate. This may include regular exercise, maintaining a healthy weight, avoiding prolonged periods of standing or sitting, and using medical-grade compression stockings when appropriate.
However, if a patient has significant symptoms or clinically important reflux in the superficial veins, several minimally invasive endovenous treatments are now available.
These include:
- Endovenous Laser Ablation (EVLA)
- Radiofrequency Ablation (RFA)
- Other treatment techniques selected according to the patient’s individual vein anatomy and condition
The ESVS 2022 guidelines recommend endovenous treatment as a first-line treatment option for appropriately selected patients with indications for intervention.
These procedures are minimally invasive, involve only small access sites, and generally allow patients to return to normal daily activities relatively quickly.
Nevertheless, no single treatment is suitable for every patient. The most appropriate treatment plan should always begin with an accurate diagnosis.
What Should You Do If You Suspect Varicose Veins?
Another common question doctors hear is:
“If it doesn’t hurt very much yet, can I wait until it gets worse before having it checked?”
If you only have very small visible veins and no symptoms, monitoring the condition may be reasonable.
However, if you begin to notice bulging veins, aching, heaviness, swelling, or skin discoloration, seeking medical evaluation before complications develop can make assessment and treatment planning easier.
Having your veins examined does not necessarily mean that you will need a procedure. Evaluation can help determine:
- What is causing the visible bulging veins
- Whether your venous circulation is functioning normally
- Whether treatment is necessary
- How the condition should be monitored or managed going forward
Because the veins visible on the surface may represent only one part of the underlying problem, evaluation by a vascular specialist, together with Duplex ultrasound when clinically indicated, can help identify the actual cause and guide appropriate treatment—while avoiding both unnecessary treatment and undertreatment.
If symptoms begin to develop, do not wait until your legs become significantly swollen, the skin becomes darkened, or an ulcer develops before seeking medical attention.
Understanding the stage of the disease early is an important first step toward appropriate and effective management of varicose veins.
