Prevalence and Risk Factors of Varicose Veins in Japanese Women
Masafumi Hirai, M.D., F.I.C.A. Kenichi Naiki, M.D. and Ryu Nakayama, M.D., F.I.C.A.*
AICHI, JAPAN
Abstract The prevalence and risk factors of varicose veins in Japan were investigated in 541 Japanese women. Varicose veins were defined as any dilated, tortuous, and elongated veins of the lower extremity and classified into four types. The total prevalence rate was 45%. Saphenous type was observed in 22%, segment type in 35%, reticular type in 28%, and web type in 16%. Varicose veins in Japan seem to be less common than in the United States and Europe but more prevalent than in Africa. Concerning risk factors for varices, age, sex, heredity, and childbirth were related to the incidence of varicosities, as reported by others. However, these risk factors were shown to differ according to type of varicose veins.
Introduction
high incidence of varicose veins has been reported in both North America and Europe, in contrast to their rarity in Asia and Africa. Mekky et al’ reported that among European women the prevalence of varicose veins was 32 % , compared with 6% for Egyptians. Guberan et al2 found a prevalence of 33 % in women of Central European origin and 19 % in those of Mediterranean origin. However, little information concerning the prevalence of varicosities is available in Japan. We performed, therefore, an epidemiologic study of Japanese women. A
Subjects The present From the
study
Department
of
included 541 women, Surgery,
and the
and Methods
consisting
*Department
of
patients
without vascular diseases,
of Internal Medicine, Aichi Prefectural Owari
Japan
228
Hospital, Aichi,
229 TABLE I Prevalence of Varicose Veins
staff members, and residents in homes for the elderly. There was no deviation in the distribution of their occupations. They ranged in age from fifteen to ninety years, with a mean of forty-three ± twenty-three, including 180 subjects aged fifteen to twenty-four, 100 aged twenty-five to thirty-nine, 153 aged forty to fifty-nine, and 108 aged sixty years or more. All women were interviewed and then examined in the standing position by palpation of the lower extremities to detect enlargement or tortuosity of the veins. Data were obtained on age, sex, delivery, height, body weight, obesity, family history of varices, hypertension, diabetes mellitus, hyperlipidemia, and/or smoking. In all subjects with varicosities, color photographs of the lower extremities were taken to accurately evaluate the findings. Varicose veins were defined as any dilated, tortuous, and elongated veins of lower extremity,3 and they were morphologically classified into four
hospital
types&dquo;’: 1. saphenous type: varices of the saphenous vein and its major branches 2. segment type: venous dilatation of distal branches of the saphenous vein without varices of the saphenous main trunk 3. reticular type: reticularly arranged varices of small subcutaneous veins (mostly observed in the bend of the knee and appearing relatively clear blue) 4. web type: intradermal venectasia, usually colored red-purple, often located at the thigh or knee region As several types of varices sometimes overlapped, the priority in classification was in the order of: saphenous, segment, reticular, and web types. In addition, 105 men were also examined to study the difference in the prevalence between both sexes. The age of male subjects ranged from nineteen to ninety years, with a mean of forty-five ± fifteen.
Results As shown in Table I, 45 % of the women had varicose veins, and the prevalence increased with age: it was 14 % in subjects aged twenty and 69 % in those aged sixty. Varicose veins were usually bilateral (76%) and when unilateral they were detected with the same frequency on each side, 13 % on the right lower extremity and 11 % on the left. Table II shows the prevalence of each type of varices. Saphenous type was observed in 22 %
230 Types
of the
women
TABLE II Veins and the Prevalence Varicose of
with varicosities, segment type in
16%. The reticular and web types
35 % , reticular type in 28 % , and web type in
often seen combined with other types of varices. When they were counted independently from other types, the prevalence of the reticular type was 58 % and that of the web type 61 %. The incidence of saphenous and segment types increased with age, whereas the reticular and web types were independent of age. The prevalence of the reticular type was 61 % for women aged fifteen to twenty-four, 59 % for those twenty-five to thirty-nine, 60% for those forty to fifty-nine, and 58 % for those aged sixty or more; it was 48 % , 67 % , 65 % , and 54 % , respectively, for web type. The frequency of affliction in relatives was 42 % of the women with varicosity against 14 % of varicosity-free subjects. The value decreased in the high-age group: it was 59% in the age group twenty-five to thirty-nine, and 27 % at sixty years or more. There were no significant differences in the incidence of heredity among the four types of varicosities, accounting for 52 % in saphenous types, 46 % in segment type, 48 % in reticular type, and 42 % in web type. Women without experience of delivery had a lower incidence of varicose veins than multiparae (21 % vs 63 % ) . However, these computational results came mainly from findings in the fifteen to twenty-four and twenty-five to thirty-nine age groups and was not significant when these groups were excluded. No relationship was observed concerning the number of children borne, from 55 % among women with one child, 63 % among those two two children, and 66 % among those with three or more children. In 44 of 241 women with varicose veins, 18 % , the varicosities developed during pregnancy. The accompanying rate of the varicose veins with pregnancy decreased in the high-age group: it was 46 % in the age group twenty-five to thirtynine years, and 8.2 % at sixty years or more. In respect to each type of varicosis, the varices developed during pregnancy in 42 % of saphenous type, 13 % of segment type, 12 % of reticular type, and 7.9 % of web type, indicating that the saphenous type is most closely related to childbirth. Other factors such as height, weight, obesity, smoking, hypertension, diabetes mellitus, or hyperlipidemia were not associated with the prevalence of varicose veins. The prevalence of varicosities was higher in women than in men, who showed a prevalence of 34 % , in spite of the fact that both sexes were about the same average age. were
Discussion
The 45 %
prevalence of varicose veins in the present study might be thought to be too high,
231
with the prevalence reported by other institutions. This discrepancy is considered to be due to our criteria of varicose veins;9&dquo;O that is, we counted all dilated, tortuous, and elongated veins of the lower extremity.’ For these reasons, our figures were compared with those of the Basle study II from Switzerland,’ which included all types of varicosities from saphenous to dilated venule types. The prevalences were 25 % in the twenty to twenty-nine age group and 80% in the sixty to sixty-nine age group, whereas they were 14% and 69% in this study, respectively. These results indicate that the incidence of varicose veins in Japan is lower than that in Switzerland. However, Mekky et al’ reported that the prevalence among European women was five times greater than among Egyptians. Therefore, in Japan varicose veins seem to be less common than in Europe but more prevalent than in Africa. The geographic variation has been investigated by evaluating the risk factors of varices.I,2,7,1I-13 Our study showed that age, sex, heredity, and delivery were related to the incidence of varicosities. These risk factors have been reported by many authors from other countries. 1,1,14 Therefore, none of these factors explain the striking geographic variation in the occurrence of varicose veins. A racial factor may be important. However, Mekky et al’ concluded that in the United States varicose veins are equally common in Negroes and Caucasians, indicating that environmental rather than racial factors might be the cause of this difference among countries. Other risk factors such as climate, obesity, chest disease, constipation, diet, a life style with prolonged standing or sitting time, and garment worn have all been subjects of prolonged investigation and discussion.’’2’8’&dquo;-’3 However, these still remain
compared
controversial. In the present study, the risk factors were shown to differ among types of varices. Delivery was related most closely to the saphenous type. Reticular and web types did not increase with age, whereas saphenous and segment types did. These findings indicate that classification of varicose veins is very important in analyzing risk factors. Furthermore, the risk factors such as heredity and delivery were shown to differ among age groups, as reported by others.’ In future epidemiologic studies, the risk factors for varicose veins should be evaluated according to each
type and age group.
Masafumi Hirai, M.D., F.I. C.A. Department of Surgery Aichi Prefectural Owari Hospital 2135 Kariyasuga, Yamatocho, Ichinomiya-city, Aichi, Japan
References Walford J: Varicose veins in workers. An epidemiological study in England and Egypt. Br Med J 7:591-595, 1969. 2. Guberan E, Widmer LK, Glaus L, et al: Causative factors of varicose veins: Myths and facts. An epidemio1.
Mekky S, Schilling RSF, women cotton
logical study of 610 women. VASA 2:114-120, 1973. 3. Arnoldi CC: The aetiology of primary varicose veins. Dan Med Bull 4:102-107, 1957. 4. Leu HJ: The modern conception of therapy of varicose veins. Angiology 15:371-378, 1964.
232 5. Da Silva A, Widmer LK, Martin H, et al: Varicose veins and chronic venous insufficiency. Prevalence and risk factors in 4376 subjects of the Basle study II. VASA 3:118-125, 1974. 6. Stanhope JM: Varicose veins in a population of lowland New Guinea. Int J Epidemiol 4:221-225, 1975. 7. Malhotra SL: An epidemiological study of varicose veins in Indian railroad workers from the South and North of India, with special reference to the causation and prevention of varicose veins. Int J Epidemiol 1:177-183, 1972. 8. Abramson JH, Hopp C, Epstein LM: The epidemiology of varicose veins. A survey in western Jerusalem. J Epidemiol Community Health 35:213-217, 1981. 9. Beaglehole R: Epidemiology of varicose veins. World
J Surg 10:898-902, 1986. 10. Ludbrook J: Primary great saphenous varicose veins reviewed. World J Surg 10:954-958, 1986. 11. Burkitt DP: Varicose veins, deep vein thrombosis, and haemorrhoids: epidemiology and suggested aetiology. Br MedJ 2:556-561, 1972. 12. Alexander CJ: Chair-sitting and varicose veins. Lancet 15:822-823, 1972. 13. Beaglehole R, Prior IAM, Salmond CE, et al: Varicose veins in the South Pacific. Int J Epidemiol 4:295-299, 1975. 14. Maffei FHA, Magaldic C, Pinho SZ, et al: Varicose veins and chronic venous insufficiency in Brazil: Prevalence among 1755 inhibitants of a country town. Int J Epidemiol 15:210-217, 1986.
Masafumi Hirai, M.D., F.I.C.A. Kenichi Naiki, M.D. and Ryu Nakayama, M.D., F.I.C.A.*
AICHI, JAPAN
Abstract The prevalence and risk factors of varicose veins in Japan were investigated in 541 Japanese women. Varicose veins were defined as any dilated, tortuous, and elongated veins of the lower extremity and classified into four types. The total prevalence rate was 45%. Saphenous type was observed in 22%, segment type in 35%, reticular type in 28%, and web type in 16%. Varicose veins in Japan seem to be less common than in the United States and Europe but more prevalent than in Africa. Concerning risk factors for varices, age, sex, heredity, and childbirth were related to the incidence of varicosities, as reported by others. However, these risk factors were shown to differ according to type of varicose veins.
Introduction
high incidence of varicose veins has been reported in both North America and Europe, in contrast to their rarity in Asia and Africa. Mekky et al’ reported that among European women the prevalence of varicose veins was 32 % , compared with 6% for Egyptians. Guberan et al2 found a prevalence of 33 % in women of Central European origin and 19 % in those of Mediterranean origin. However, little information concerning the prevalence of varicosities is available in Japan. We performed, therefore, an epidemiologic study of Japanese women. A
Subjects The present From the
study
Department
of
included 541 women, Surgery,
and the
and Methods
consisting
*Department
of
patients
without vascular diseases,
of Internal Medicine, Aichi Prefectural Owari
Japan
228
Hospital, Aichi,
229 TABLE I Prevalence of Varicose Veins
staff members, and residents in homes for the elderly. There was no deviation in the distribution of their occupations. They ranged in age from fifteen to ninety years, with a mean of forty-three ± twenty-three, including 180 subjects aged fifteen to twenty-four, 100 aged twenty-five to thirty-nine, 153 aged forty to fifty-nine, and 108 aged sixty years or more. All women were interviewed and then examined in the standing position by palpation of the lower extremities to detect enlargement or tortuosity of the veins. Data were obtained on age, sex, delivery, height, body weight, obesity, family history of varices, hypertension, diabetes mellitus, hyperlipidemia, and/or smoking. In all subjects with varicosities, color photographs of the lower extremities were taken to accurately evaluate the findings. Varicose veins were defined as any dilated, tortuous, and elongated veins of lower extremity,3 and they were morphologically classified into four
hospital
types&dquo;’: 1. saphenous type: varices of the saphenous vein and its major branches 2. segment type: venous dilatation of distal branches of the saphenous vein without varices of the saphenous main trunk 3. reticular type: reticularly arranged varices of small subcutaneous veins (mostly observed in the bend of the knee and appearing relatively clear blue) 4. web type: intradermal venectasia, usually colored red-purple, often located at the thigh or knee region As several types of varices sometimes overlapped, the priority in classification was in the order of: saphenous, segment, reticular, and web types. In addition, 105 men were also examined to study the difference in the prevalence between both sexes. The age of male subjects ranged from nineteen to ninety years, with a mean of forty-five ± fifteen.
Results As shown in Table I, 45 % of the women had varicose veins, and the prevalence increased with age: it was 14 % in subjects aged twenty and 69 % in those aged sixty. Varicose veins were usually bilateral (76%) and when unilateral they were detected with the same frequency on each side, 13 % on the right lower extremity and 11 % on the left. Table II shows the prevalence of each type of varices. Saphenous type was observed in 22 %
230 Types
of the
women
TABLE II Veins and the Prevalence Varicose of
with varicosities, segment type in
16%. The reticular and web types
35 % , reticular type in 28 % , and web type in
often seen combined with other types of varices. When they were counted independently from other types, the prevalence of the reticular type was 58 % and that of the web type 61 %. The incidence of saphenous and segment types increased with age, whereas the reticular and web types were independent of age. The prevalence of the reticular type was 61 % for women aged fifteen to twenty-four, 59 % for those twenty-five to thirty-nine, 60% for those forty to fifty-nine, and 58 % for those aged sixty or more; it was 48 % , 67 % , 65 % , and 54 % , respectively, for web type. The frequency of affliction in relatives was 42 % of the women with varicosity against 14 % of varicosity-free subjects. The value decreased in the high-age group: it was 59% in the age group twenty-five to thirty-nine, and 27 % at sixty years or more. There were no significant differences in the incidence of heredity among the four types of varicosities, accounting for 52 % in saphenous types, 46 % in segment type, 48 % in reticular type, and 42 % in web type. Women without experience of delivery had a lower incidence of varicose veins than multiparae (21 % vs 63 % ) . However, these computational results came mainly from findings in the fifteen to twenty-four and twenty-five to thirty-nine age groups and was not significant when these groups were excluded. No relationship was observed concerning the number of children borne, from 55 % among women with one child, 63 % among those two two children, and 66 % among those with three or more children. In 44 of 241 women with varicose veins, 18 % , the varicosities developed during pregnancy. The accompanying rate of the varicose veins with pregnancy decreased in the high-age group: it was 46 % in the age group twenty-five to thirtynine years, and 8.2 % at sixty years or more. In respect to each type of varicosis, the varices developed during pregnancy in 42 % of saphenous type, 13 % of segment type, 12 % of reticular type, and 7.9 % of web type, indicating that the saphenous type is most closely related to childbirth. Other factors such as height, weight, obesity, smoking, hypertension, diabetes mellitus, or hyperlipidemia were not associated with the prevalence of varicose veins. The prevalence of varicosities was higher in women than in men, who showed a prevalence of 34 % , in spite of the fact that both sexes were about the same average age. were
Discussion
The 45 %
prevalence of varicose veins in the present study might be thought to be too high,
231
with the prevalence reported by other institutions. This discrepancy is considered to be due to our criteria of varicose veins;9&dquo;O that is, we counted all dilated, tortuous, and elongated veins of the lower extremity.’ For these reasons, our figures were compared with those of the Basle study II from Switzerland,’ which included all types of varicosities from saphenous to dilated venule types. The prevalences were 25 % in the twenty to twenty-nine age group and 80% in the sixty to sixty-nine age group, whereas they were 14% and 69% in this study, respectively. These results indicate that the incidence of varicose veins in Japan is lower than that in Switzerland. However, Mekky et al’ reported that the prevalence among European women was five times greater than among Egyptians. Therefore, in Japan varicose veins seem to be less common than in Europe but more prevalent than in Africa. The geographic variation has been investigated by evaluating the risk factors of varices.I,2,7,1I-13 Our study showed that age, sex, heredity, and delivery were related to the incidence of varicosities. These risk factors have been reported by many authors from other countries. 1,1,14 Therefore, none of these factors explain the striking geographic variation in the occurrence of varicose veins. A racial factor may be important. However, Mekky et al’ concluded that in the United States varicose veins are equally common in Negroes and Caucasians, indicating that environmental rather than racial factors might be the cause of this difference among countries. Other risk factors such as climate, obesity, chest disease, constipation, diet, a life style with prolonged standing or sitting time, and garment worn have all been subjects of prolonged investigation and discussion.’’2’8’&dquo;-’3 However, these still remain
compared
controversial. In the present study, the risk factors were shown to differ among types of varices. Delivery was related most closely to the saphenous type. Reticular and web types did not increase with age, whereas saphenous and segment types did. These findings indicate that classification of varicose veins is very important in analyzing risk factors. Furthermore, the risk factors such as heredity and delivery were shown to differ among age groups, as reported by others.’ In future epidemiologic studies, the risk factors for varicose veins should be evaluated according to each
type and age group.
Masafumi Hirai, M.D., F.I. C.A. Department of Surgery Aichi Prefectural Owari Hospital 2135 Kariyasuga, Yamatocho, Ichinomiya-city, Aichi, Japan
References Walford J: Varicose veins in workers. An epidemiological study in England and Egypt. Br Med J 7:591-595, 1969. 2. Guberan E, Widmer LK, Glaus L, et al: Causative factors of varicose veins: Myths and facts. An epidemio1.
Mekky S, Schilling RSF, women cotton
logical study of 610 women. VASA 2:114-120, 1973. 3. Arnoldi CC: The aetiology of primary varicose veins. Dan Med Bull 4:102-107, 1957. 4. Leu HJ: The modern conception of therapy of varicose veins. Angiology 15:371-378, 1964.
232 5. Da Silva A, Widmer LK, Martin H, et al: Varicose veins and chronic venous insufficiency. Prevalence and risk factors in 4376 subjects of the Basle study II. VASA 3:118-125, 1974. 6. Stanhope JM: Varicose veins in a population of lowland New Guinea. Int J Epidemiol 4:221-225, 1975. 7. Malhotra SL: An epidemiological study of varicose veins in Indian railroad workers from the South and North of India, with special reference to the causation and prevention of varicose veins. Int J Epidemiol 1:177-183, 1972. 8. Abramson JH, Hopp C, Epstein LM: The epidemiology of varicose veins. A survey in western Jerusalem. J Epidemiol Community Health 35:213-217, 1981. 9. Beaglehole R: Epidemiology of varicose veins. World
J Surg 10:898-902, 1986. 10. Ludbrook J: Primary great saphenous varicose veins reviewed. World J Surg 10:954-958, 1986. 11. Burkitt DP: Varicose veins, deep vein thrombosis, and haemorrhoids: epidemiology and suggested aetiology. Br MedJ 2:556-561, 1972. 12. Alexander CJ: Chair-sitting and varicose veins. Lancet 15:822-823, 1972. 13. Beaglehole R, Prior IAM, Salmond CE, et al: Varicose veins in the South Pacific. Int J Epidemiol 4:295-299, 1975. 14. Maffei FHA, Magaldic C, Pinho SZ, et al: Varicose veins and chronic venous insufficiency in Brazil: Prevalence among 1755 inhibitants of a country town. Int J Epidemiol 15:210-217, 1986.
