Varicose Veins: A Nutrition and Natural-Health Reference
Definition and Clinical Presentation
Varicose veins (VV) are dilated, tortuous subcutaneous veins that permit reverse flow. They are the externally visible manifestation of superficial lower extremity venous insufficiency. Varicose veins are characterized by subcutaneous dilated, tortuous veins greater than or equal to three millimeters, involving the saphenous veins, saphenous tributaries, or non-saphenous superficial leg veins, with age and family history considered important risk factors.
Varicose veins and telangiectasia (spider veins) are the visible surface manifestations of an underlying problem with reverse venous flow, also termed venous insufficiency syndrome. Mild forms of venous insufficiency are merely uncomfortable, annoying, or cosmetically disfiguring, but severe venous disease can produce serious systemic consequences and can lead to loss of life or limb.
The signs of chronic venous insufficiency (CVI) include swelling of the leg, feelings of tired and painful legs, dry scaly skin, varicose veins, hardening of the skin, and leg ulcers. CVI severity is often graded into three categories: stage I, swelling (edema); stage II, swelling (edema) plus skin changes; stage III, the presence of open or healed leg ulcers — considered the most severe stage.
Chronic venous insufficiency eventually produces chronic skin and soft tissue changes that begin with mild swelling and then progress to include discoloration, inflammatory dermatitis, recurrent or chronic cellulitis, cutaneous infarction, ulceration, and even malignant degeneration. Varicose veins may thrombose or rupture and bleed, especially when large, traumatized, or located over bony prominences. In a large observational cohort study, varicose veins were associated with a seven-fold increased risk of deep vein thrombosis (DVT).
Anatomy and Body Systems Involved
Varicose veins in the lower extremities involve the great and small saphenous veins and their tributaries between the fascia and the skin. Any vein may be involved, including the great/small saphenous, perforators or small venules.
In healthy veins, one-way valves direct the flow of venous blood upward and inward. Patients with muscle pump and/or venous valve failure and/or venous outflow obstruction demonstrate raised ambulatory venous pressure (AVP). It is this raised AVP that underlies all the symptoms and signs of chronic venous insufficiency.
The molecular pathology is multi-step. The generally accepted molecular pathology of varicose veins involves five major processes: (1) disrupted vascular endothelium homeostasis due to altered shear stress from increases in venous pressure and/or valve failure, resulting in (2) immune cell activation, adhesion, and infiltration of the blood vessel wall, causing (3) local inflammatory processes and cytokine production, followed by (4) remodeling of the extracellular matrix, and (5) angiogenesis.
Deficiency in structural contents of the veins, including smooth muscles, collagen, and elastin, also appears to be involved in varicose vein disease development.
Two broad hemodynamic theories have been described. The descending theory, initially described by Trendelenburg, has been the dominant hemodynamic theory for many years, and from it derive the practices of ligation of the saphenofemoral junction and radiofrequency and laser ablation of the saphenous vein. The ascending theory of varicose vein development suggests that caudal venous shunts and reflux entry points allow filling of varicosities and the creation of an ascending column of hydrostatic pressure with consequent inability to drain the superficial system.
Primary and secondary forms are distinguished. Primary varicose veins are the result of primary incompetence of the venous valves separating the superficial venous system from the deep venous system; secondary varicose veins occur as the result of deep venous hypertension which has damaged the valves of the perforating veins.
Epidemiology
Lower extremity venous insufficiency and varicose veins are common conditions, affecting up to 25% of women. About 10% to 15% of adult men and 20% to 25% of adult women present signs and symptoms consistent with a diagnosis of CVI, and the prevalence increases with age.
The Venous Insufficiency Epidemiological and Economical Study (VEINS) showed that 65.2% of subjects with varicose veins had concomitant venous disease, and that physical and mental quality-of-life scores decreased as the severity of venous disease increased. Chronic venous ulcerations result in the loss of 2 million workdays and cost an estimated $3 billion per year to treat in the United States.
Contributing and Associated Factors
A myriad of intrinsic and extrinsic factors contribute to the formation of varicose veins, including age, gender, pregnancy, obesity, height, race, diet, occupation, history of deep vein thrombosis (DVT), and genetics.
Age
Age is a significant predictor of the prevalence of varicose veins, as confirmed by a multitude of reports. With advancing age, the weakening of calf muscles and the reduced flexibility of venous valves can lead to an increased prevalence of varicose veins. People in their 70s are twice as likely to have venous disease as those in their 40s. The risk of varicose veins and spider veins increases linearly with age, while the risk of chronic venous insufficiency and ulcers increases exponentially with age.
Sex and Hormonal Factors
Varicose veins are more common among women because estrogen affects venous structure, pregnancy increases pelvic and leg venous pressures, or both. The effect of estrogen on the risk of varicose veins may explain, in part, the increased prevalence among women. Factors that contribute to the increased frequency in women are hormonal fluctuations (especially progesterone) and pregnancy. Although varicose veins are twice as common in women, more advanced chronic venous disease is seen more often in men.
Genetics and Family History
Varicose veins are common within families, suggesting a genetic component. In varicose veins, some contributory elements play an important role in disease development, incorporating constant venous wall aggravation, hereditary variation, and persistent venous hypertension.
Obesity and Body Weight
Obesity is a major risk factor for varicose veins. Excessive weight increases the pressure on the veins of the legs and aggravates the condition.
Occupation and Physical Inactivity
Prolonged standing or sitting increases pressure in the veins. Healthcare workers and others in occupations requiring prolonged standing have been identified as higher-risk groups in systematic reviews. The predisposing factors for CVI include female gender, long periods of standing, decreased physical activity, obesity, poor nutrition, metabolic syndrome, tight and restrictive clothing, as well as advanced age, constipation, pregnancy, and ascites.
Pregnancy
In addition to powerful hormonal changes that occur during pregnancy, the increased blood volume to support the growing fetus puts added pressure on the veins, particularly in the lower body, where the weight of the uterus compresses the pelvic veins.
Smoking
Smoking is an important modifiable risk factor for varicose veins and more severe forms of chronic venous disease, including venous ulceration.
Circulating Minerals
It has been demonstrated that height, body mass index, smoking, and circulating iron levels were positively associated with the risk of varicose veins. However, circulating minerals including calcium and zinc levels showed an inverse association with varicose vein development.
Deep Vein Thrombosis (Post-Thrombotic Syndrome)
Post-thrombotic syndrome after deep vein thrombosis may result in varicose veins in the absence of primary venous disease.
Dietary and Lifestyle Factors
Dietary Fiber
Denis Burkitt hypothesized that varicose veins result from a fiber-poor diet that leads to constipation-induced straining during defecation. This straining may raise intra-abdominal pressure, causing transmission of pressure to the major venous trunks draining the leg veins, resulting in retrograde blood flow and dilation of the proximal segment of the veins and failure of the valves in a sequential manner. Dr. Burkitt hypothesized a similar mechanism for the pathogenesis of hemorrhoids.
The presence of varicose veins in some developing regions is associated both with increases in refined (fiber-poor) carbohydrate and decreases in stool weight. Straining during defecation resulted in an almost three-fold higher risk for the prevalence of both mild and severe trunk varices, though this was observed in men only.
However, the evidence is not unanimous. The hypothesis that a diet without fiber-rich plant foods is a major risk factor for varicose veins was proposed in 1959, but results from the Edinburgh Vein Study did not support the association between dietary fiber content and the presence or severity of varicose veins. Similarly, diet was not reported to be a factor of influence for varicose veins in a Polish follow-up study. Current data on the effects of diet on chronic venous disease are limited and inconsistent.
Obesity, Weight, and Physical Activity
Chronic venous insufficiency and varicose veins appear to be related to an obesity-promoting Western lifestyle poor in dietary fiber and low in physical activity. Physical activity encourages return of venous blood from the legs back to the heart by activating the pumping action of the muscles. Weight loss reduces pressure on leg veins and improves blood circulation.
Sodium Intake
High sodium intake is discussed in the dietary literature on venous disease in relation to fluid retention and increased venous pressure. Salty foods can cause water retention, which consequently hinders blood flow. Cutting back on sodium can help reduce this problem. However, the direct evidence specifically linking sodium restriction to improvement in varicose vein outcomes in controlled trials remains limited.
Nutrients, Herbs, and Natural Ingredients
In addition to synthetic drugs, naturally derived coumarins, flavonoids, rutin derivatives, pycnogenol, micronized purified flavonoid fraction, and saponosides are used in the treatment of chronic venous disease. Medicinal plants and natural compounds are highly preferred for treating CVI and varicose veins due to their biological activities, such as anti-inflammatory, antioxidant, and vascular tone improvement.
Horse Chestnut Seed Extract (Aesculus hippocastanum)
Traditional Use
The extract of horse chestnut seeds has been used in Europe since the 1800s as an oral remedy for various venous diseases. Published reports from France starting in 1896 discuss its use in varicose veins with insufficiency, hemorrhoids, and phlebitis. Extracts from the seed of the horse chestnut (Aesculus hippocastanum L.) have traditionally been used to treat patients with chronic venous insufficiency and to alleviate its associated symptoms, including lower leg swelling.
Active Constituents and Proposed Mechanisms
The medicinal portion comes from the dried seeds. Most commonly, the dried seeds are pulverized and mixed with water and alcohol to yield a solution that contains triterpene saponins, hydroxycoumarins, flavonoids, and tannins. The most active ingredients are thought to be in the saponin mixture and are called escins (α- and β-escin). The active component of HCSE is called escin (also spelled aescin). Escin appears to promote blood circulation through the veins and thereby reduce swelling and inflammation of the legs, possibly by "sealing" leaking capillaries. The efficacy of preparations that contain horse chestnut seed extract (HCSE) is believed to be due largely to an inhibitory effect on the catalytic breakdown of capillary wall proteoglycans.
Scientific Evidence
Seventeen randomised controlled trials were included in the Cochrane review. In all trials the extract was standardised to escin, which is the main active constituent. Overall, the trials suggested an improvement in the symptoms of leg pain, oedema and pruritus with horse chestnut seed extract.
A meta-analysis identified 13 RCTs of CVI (1,051 patients) and 3 observational studies (10,725 patients). Safe and effective oral therapies for CVI would provide an important alternative to mechanical compression treatment.
The use of HCSE is associated with a decrease of the lower-leg volume and a reduction in leg circumference at the calf and ankle. Symptoms such as leg pain, pruritus, and a feeling of fatigue and tenseness are reduced. The superiority of HCSE is suggested by all placebo-controlled studies. Five comparative trials against the reference medication indicate that HCSE and O-(beta-hydroxyethyl)-rutosides are equally effective. One trial suggests therapeutic equivalence of HCSE and compression therapy.
The evidence implies that HCSE is an efficacious and safe short-term treatment for CVI. However, several caveats exist and more rigorous RCTs are required to assess the efficacy of this treatment option. Unprocessed horse chestnut seeds contain a toxin called esculin (also spelled aesculin), which may increase the risk of bleeding due to its ability to prevent blood clot formation — thus only standardized extracts with esculin removed are used medicinally.
Evidence strength: Moderate to good. Multiple RCTs and a Cochrane systematic review support short-term symptomatic benefit in CVI; longer-term evidence is limited.
Diosmin, Hesperidin, and Micronized Purified Flavonoid Fraction (MPFF)
Traditional and Botanical Context
Flavonoids are oral venoactive drugs frequently prescribed to relieve the symptoms of chronic venous disorders. Among venoactive drugs, diosmin is a naturally occurring flavonoid glycoside that can be isolated from various plant sources; it can also be obtained after conversion of hesperidin extracted from citrus rinds. Diosmin is a naturally occurring flavonoid glycoside that can be isolated from various plant sources or derived from hesperidin, another flavonoid which is chemically and structurally very similar. Various specialties containing diosmin are available, including micronized purified flavonoid fraction (MPFF) which contains 90% diosmin and 10% hesperidin.
Scientific Evidence
Based on systematic reviews or meta-analyses of clinical studies looking at the effects of individual venoactive drugs on symptoms of chronic venous disease, MPFF was shown to be effective on improving leg symptoms, oedema, and quality of life in patients with CVD. Successive international guidelines for CVD management have presented MPFF as the flavonoid preparation that achieved the highest level of recommendation.
Three clinical studies meeting the review criteria showed a significant decrease of chronic venous disease symptom intensity (up to approximately 50%) and global patient satisfaction after one-to-six-month treatment with diosmin or MPFF, without statistical differences between the preparations.
In a meta-analysis, hydroxyethylrutoside and Pycnogenol showed significant benefits in pain reduction and resting flux improvement when compared to diosmin/hesperidin combination standard therapy.
Evidence strength: Good. Diosmin and MPFF are among the most-studied venoactive compounds, supported by multiple RCTs and systematic reviews.
Rutin and Hydroxyethylrutosides (Oxerutin)
Traditional and Botanical Context
Rutin is a bioflavonoid glycoside found naturally in buckwheat, citrus fruits, and many other plants. Hydroxyethylrutosides (HR) are semisynthetic derivatives of rutin used widely in Europe as venoactive agents.
Scientific Evidence
Most trials of flavonoids in patients with CVI have used a type of flavonoid called hydroxyethylrutosides (HR), derived from rutin. These double-blind and other controlled trials have consistently shown a beneficial effect of HR in clearing leg swelling and other signs of CVI. O-β-hydroxyethyl rutosides are reported to have beneficial short-term effects by reducing oedema and relieving symptoms of CVI; however, their efficacy during long-term use has yet to be established.
Oxerutin, a mixture of semisynthetic flavonoids derived from rutin, is commonly used in Europe in the treatment of venous disorders. Multiple clinical trials have demonstrated that oxerutin reduces edema and pain associated with venous disease.
Evidence strength: Moderate. Multiple controlled trials support short-term benefit; long-term evidence is less established.
Pycnogenol (French Maritime Pine Bark Extract)
Traditional and Botanical Context
Pycnogenol is used in the treatment of chronic venous insufficiency and related venous disorders such as deep vein thrombosis, post-thrombotic syndrome, long-haul air-travel-related leg oedema, and venous ulcers. It is a French maritime pine bark extract produced from the outer bark of Pinus pinaster Ait. Pycnogenol is a branded extract promoted for various uses due to its antioxidant and anti-inflammatory properties, which are thought to derive in part from oligomeric proanthocyanidin complexes (OPCs) found in pine bark.
Scientific Evidence
Studies have demonstrated that pycnogenol may improve symptoms of chronic venous insufficiency, promote healing of venous ulcers, and reduce leg edema and the risk of blood clots, especially during long flights, due to its anti-inflammatory compound called procyanidins. Supplemental therapy with pycnogenol has been shown to reduce oxidative stress and may slow progression of varicose veins to chronic venous insufficiency.
Pycnogenol has been reported to significantly reduce ankle swelling by 35% in severe CVI compared to a 19% reduction seen with the comparator drug Daflon.
A meta-analysis found that Pycnogenol showed significant benefits in pain reduction, with a mean difference in resting flux improvement of 25.30 (95% CI: 18.73–31.87).
Evidence strength: Preliminary to moderate. Clinical trials show encouraging findings for CVI symptoms and edema, but study quality and size vary. Most evidence is from smaller or industry-supported trials.
Grape Seed Extract / Vitis vinifera Seed Proanthocyanidins
Traditional and Botanical Context
Grape seed extract (GSE) is rich in oligomeric proanthocyanidins (OPCs), compounds also found in pine bark, red wine, and many berries. Red vine leaf extract (standardized as AS 195) is derived from the leaves of Vitis vinifera and is distinct from seed extract.
Scientific Evidence
Proanthocyanidins exhibit capillary-stabilizing effects, reduce vascular permeability, and may strengthen venous walls by preserving endothelial integrity and inhibiting collagen and elastin-degrading enzymes. These water-soluble compounds are naturally found in various fruits and have demonstrated a favorable safety profile with minimal side effects. Due to these vascular-specific mechanisms, grape seed proanthocyanidins represent a hopeful noninvasive option for patients with venous and lymphatic insufficiency.
The blood flow velocity on 4D flow MRI was significantly increased in participants who underwent grape seed proanthocyanidin extract supplementation, highlighting its potential for CVI treatment. Recent comparative studies have shown grape seed extract to be noninferior to micronized purified flavonoid fraction for symptomatic relief in chronic venous disease. However, although symptomatic benefits have been established, direct evidence demonstrating its effects on objective hemodynamic parameters such as venous reflux time remains limited.
For red vine leaf extract specifically: Clinical trials in patients with chronic venous insufficiency have found that red vine leaf extract (AS 195) reduces leg edema, enhances blood flow, and improves symptoms such as pain and sensation of heaviness and swelling. A 2020 systematic review concluded that red vine leaf extract had a beneficial therapeutic role in patients with CVI, but that further high-quality trials are required to provide strong evidence.
Evidence strength for grape seed and red vine leaf: Preliminary to moderate. Mechanistic rationale is well-supported; clinical RCT evidence is growing but still limited in scale and methodological rigor.
Butcher's Broom (Ruscus aculeatus)
Traditional Use
Butcher's broom (Ruscus aculeatus L.) is a perennial shrub native to the Mediterranean and Black Sea regions. Traditionally, the rhizome and root have been employed in folk medicine for the treatment of venous insufficiency, hemorrhoids, edema, and various dermatological and urinary ailments. These therapeutic applications are attributed primarily to the presence of steroidal saponins such as ruscogenin and neoruscogenin, as well as flavonoids and other bioactive compounds.
Active Constituents and Proposed Mechanisms
The primary active constituents of butcher's broom are compounds called ruscogenins. Ruscogenins from extracts of butcher's broom inhibit elastase enzymes, which degrade the elastin protein that imparts flexibility to veins. Butcher's broom also reduces vascular permeability, which contributes to edema.
Scientific Evidence
Several controlled clinical trials have found that butcher's broom improved venous function and reduced symptoms of chronic venous insufficiency including itching, cramping, and swelling. Ruscus extract decreases capillary filtration rate in healthy volunteers and in people with CVI.
An important caveat regarding attribution of effects: Most research articles focus on Cyclo 3 Fort, which is actually a mixture of dry extract of butcher's broom, hesperidin methylchalcone (HMC), and ascorbic acid (vitamin C). Therefore, the observed effects are difficult to attribute specifically to the activity of Ruscus aculeatus itself.
Butcher's broom is particularly effective when combined with another flavonoid (hesperidin) and vitamin C. Benefits include improved venous emptying; decreased capillary filtration rate; reduction of pain severity, cramps, heaviness, paresthesia, venous capacity, and severity of edema; and decreases in calf and ankle circumference.
Evidence strength: Preliminary to moderate. Most positive evidence comes from combination-product trials; evidence for butcher's broom as a solo agent is more limited, and most studies are small.
Centella asiatica (Gotu Kola)
Traditional Use
Centella asiatica, also called Gotu kola, is a tropical plant with a long history of use as a traditional medicine in Southeast Asia. It has been used traditionally for wound healing, skin conditions, and to support venous circulation.
Active Constituents and Proposed Mechanisms
The leaves of Centella asiatica contain triterpenes which have been shown in animal studies to have anti-inflammatory properties and to promote wound healing by stimulating collagen and glycosaminoglycan synthesis as well as angiogenesis. Compounds in Centella asiatica have been shown to stimulate collagen I, Fibroblast Growth Factor (FGF), and Vascular Endothelial Growth Factor (VEGF) production. In preclinical studies, Centella asiatica inhibits enzymes that break down collagen while increasing collagen synthesis.
Scientific Evidence
The pooling of data from similar studies showed that Centella asiatica significantly improved microcirculatory parameters such as transcutaneous partial pressure of CO₂ and O₂, rate of ankle swelling, and venoarteriolar response. Three of the eight included studies reported that patients treated with Centella asiatica showed significant improvement in CVI signs such as leg heaviness, pain, and oedema. The results show that Centella asiatica may be beneficial for improving signs and symptoms of CVI, but this conclusion needs to be interpreted with caution as most of the studies were characterised by inadequate reporting and unclear risks of bias.
A review of eight clinical trials (seven of which were placebo-controlled) lasting from one to three months concluded that 60 to 120 mg of gotu kola per day (taken in divided doses, two to three times daily) reduced leg pain, heaviness, and swelling in people with chronic venous insufficiency, venous hypertension, and related conditions, compared to placebo.
Evidence strength: Preliminary. The 2013 systematic review (eight RCTs) shows positive signals but notes methodological limitations in the primary trials. Higher-quality trials are needed.
Oligomeric Proanthocyanidins (OPCs) from Multiple Sources
Flavonoids found in pine bark, grape pip, grape skin, bilberry, cranberry, black currant, green tea, black tea, and other plants have been shown to strengthen capillaries in double-blind research using as little as two 50 mg tablets per day. In a double-blind trial using a total of 150 mg OPCs per day, French researchers reported reduced symptoms for women with CVI.
Evidence strength: Preliminary. Individual OPC-rich extracts have supporting data but are heterogeneous in composition; results cannot be assumed to generalize across all sources.
Vitamin C (Ascorbic Acid)
Nutritional and Traditional Context
Vitamin C is an essential micronutrient required for collagen biosynthesis. It appears in many traditional venous formulations (e.g., combined with butcher's broom and hesperidin in commercial preparations). Centella asiatica is rich in carotenoids and vitamins C and B complex.
Scientific Evidence in Relation to Venous Disease
Vitamin C's role in venous health is mechanistically plausible given its essential function in collagen cross-linking and its antioxidant capacity, both relevant to the extracellular matrix changes seen in varicose veins. Deficiency in structural contents of the veins, including smooth muscles, collagen, and elastin, appears to be involved in varicose vein disease development. However, direct clinical evidence from standalone vitamin C supplementation trials focused specifically on varicose veins is limited; its best-evidenced role in this area is as a component of combination formulations such as the butcher's broom/hesperidin/vitamin C triad.
Evidence strength: Indirect and mechanistic. No high-quality, standalone RCTs exist for vitamin C supplementation as a treatment for varicose veins; the mechanistic rationale is sound based on collagen biology.
Summary Table of Natural Agents and Evidence
- Horse chestnut seed extract (aescin/escin): Seventeen RCTs included in the Cochrane review; all trials standardized to escin, the main active constituent. Moderate–good evidence for short-term symptomatic relief of CVI.
- Diosmin/MPFF: Systematic reviews and meta-analyses confirm efficacy on leg symptoms, oedema, and quality of life; presented as the reference flavonoid treatment in international CVD guidelines. Good evidence.
- Hydroxyethylrutosides (HR/oxerutin): Demonstrated significant benefits in pain reduction in meta-analysis. Moderate evidence, short-term well studied.
- Pycnogenol: Studied in CVI, DVT, long-haul travel edema, venous ulcers, and related conditions. Preliminary–moderate evidence; variable study quality.
- Grape seed / red vine leaf proanthocyanidins: Red vine leaf extract (AS 195) has shown efficacy in improving signs and symptoms of CVI. Preliminary–moderate evidence; growing body of RCT data.
- Butcher's broom (Ruscus aculeatus): Extracts have been incorporated into numerous pharmaceutical preparations intended to improve venous tone, reduce swelling, and alleviate symptoms of chronic venous disorders. Preliminary evidence; most data from combination trials.
- Centella asiatica (gotu kola): There is preliminary evidence that gotu kola can help reduce symptoms of venous insufficiency, but higher-quality research is needed to prove a benefit.
References
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