Most people assume that varicose veins are a problem affecting the legs, due to faulty valves in the leg veins themselves – for the majority of patients, that indeed proves to be the case once the veins have been mapped with ultrasound.
But ultrasound scanning has now shown us that up to 20% of women coming to see a doctor with varicose veins in the legs, do not have a problem with the leg valves at all – rather that the bulging leg veins are in fact filled by faulty valves from within the pelvis.
To a certain extent that is not surprising – the female pelvis has a lot more organs in it than the male one and pregnancy causes significant anatomical and physiological changes in the female pelvis which have long lasting effects. Women with pelvic vein problems causing veins in the legs have often had trouble with veins during pregnancy – either in the legs or in the vulva. Under normal circumstances, when the pregnancy is over, the vulval veins recede and often completely disappear. The leg veins often persist.
The question is how best to treat these leg veins to get the best result with the lowest chance of the problem recurring. For ‘standard’ leg veins arising from leaking valves in the groin, treatment has improved substantially in recent years. The use of endovenous laser procedures, where the vein is sealed and destroyed using a tiny laser fibre, put in under local anaesthetic, has radically improved the results and decreased the chances of the veins coming back again.
Currently available treatment options
Pelvic vein treatment is a lot more complex. For a start the veins are usually quite tortuous and twisted – this means that the surgeon can’t thread a laser fibre up them as with the more standard pattern of leg veins. Then there is the problem of where the faulty valves are located. In the leg, this is usually in the groin crease – that’s easy to access for the surgeon and quite easy to seal off. In the pelvis the faulty valve is deep within the body – that’s difficult to access, so treatment is a lot trickier to achieve.
The currently available treatment options include injecting the leg veins from below with a chemical called foam sclerotherapy. This acts by irritating the lining of the veins and makes them seal up. For smaller veins it can work very well. It also has the advantage of being quite cheap to do. On the other hand, it also makes the veins feel quite lumpy and sore for a few weeks and the veins come back quite frequently.
The big problem with foam sclerotherapy is that it does not get right to the point of the problem in the pelvis itself, so even if the leg veins can be made to seal up, the faulty valve in the middle of the pelvis is still leaking. That is thought to be the root cause of why the veins sometimes come back again.
The other option is to use a technique called ‘pelvic vein embolisation’. Using this technique, a doctor inserts a catheter (a tiny tube) into a main vein in the top of the leg or neck and steers the tube into the pelvic vein using an x-ray picture as a guide. When the catheter is wiggled into the correct place in the pelvis (where the faulty valve is leaking) the doctor passes tiny coils of metal or sponges of material through the catheter into the faulty vein. When put into the correct place, this will cause the vein to seal up and stop the leaking into the leg veins.
It does not take a medical degree to work out that pelvic embolization is a tricky thing to do! Wiggling a tiny tube into the middle of the female pelvis is technically demanding and it sometimes doesn’t work. Having said that, in good hands it can work extremely well to ‘turn off the tap’ in the pelvis and make the leg veins go down – a bit like a slow puncture. It will come as no surprise to readers that this is a complicated problem to fix. Like most complicated problems, there is no easy answer and there is plenty of disagreement among expert doctors as to what the best options are for patients.
My own views on this matter are that relatively simple and smaller pelvic veins can be treated successfully by foam sclerotherapy, while larger ones do better with pelvic vein embolization first, followed by sclerotherapy later. I think this gives the best balance between treating the easy cases with a simple technique that usually works well, and reserving the more technically challenging embolization for the 20% of severe cases.