Medical Chronicle recently hosted a CPD-accredited webinar on women and venous conditions. The webinar was sponsored by BSN Medical and presented by Sr Febe Bruwer, President of the Wound Healing Association of Southern Africa. The following article is based on her presentation.

To watch a replay of this webinar and still earn a CPD point, go to: https://event.webinarjam.com/go/replay/688/zk84khx0mizx3uyzzsv

The venous system​ includes valves​, muscle pumps​ and arteriovenous coupling​. Chronic venous insufficiency (CVI)​ refers to functional changes that may occur in the lower extremity due to persistent elevation of venous pressures. ​Pathophysiological hypertension and hypervolemia are observed in the venous system of the lower extremities​, because of reflux or obstruction (or both) in the superficial and deep veins.​

Venous reflux is due to faulty valve function developing as a long-term sequela of deep vein thrombosis (DVT) and recanalisation and may also develop due to primary valvular incompetence without previous episode(s) of DVT. ​The term CVI is usually reserved for more advanced disease involving oedema, skin changes, or ulceration.

Lymphoedema

Lymphoedema is caused by a deficiency of the lymphatic system, resulting in the accumulation of protein-rich fluid in the interstitial and predominantly effects women. Lymphoedema treatments include a combination of manual lymphatic drainage along with compression therapy, exercise and skin care which is known as complex decongestive therapy.

Deep vein thrombosis (DVT)​

Incidence of first occurrence is higher in women of childbearing age as well as up to three months post-partum​. Increased risk has also been shown during postmenopausal hormone therapy​.

Recurrence rate in woman is measured at 1,7% higher than men with a history of DVT​.

Venous thrombosis has been associated with altered levels of natural anticoagulant, procoagulant, and fibrinolytic factors. However, coagulation factors in women can be affected by female reproductive risk factors such as the oral contraceptive pill, pregnancy/ the postpartum period, and postmenopausal hormone therapy.

Risk factors

Age: The risk of developing venous disease increases with age, so older individuals are at a higher risk. ​

Mean age for developing venous complications is 62 years of age, but risk factors are often present from as early as 35​.

Gender: Women are more likely to suffer from venous diseases than men, due in part to weight distribution and in part to pregnancy. ​Women who have had multiple pregnancies are at increased risk. Pregnancy stimulates increased blood flow and pressure to the abdomen and causes leg veins to enlarge.​ In addition to hormonal changes, veins undergo changes during pregnancy that make women more susceptible to chronic venous hypertension. Venous leg ulcers are more frequent in women by 3.6% as opposed to men, 1.7%. ​

Pelvic congestion syndrome​: Venous ulcerations occur more frequently in women on the left lower leg. Pelvic congestion syndrome (PCS)​ offers a possible explanation for this. It is a disorder of the pelvic vein circulation with dilatation of the veins that leads to pelvic pain especially after pregnancy​. Radiological studies are required to confirm this​.

Obesity - the epidemic of phlebisity​: Lower limb venous disease affects up to one half, and obesity up to one quarter, of the adult population. Many people are therefore affected by, and present to health services for the treatment of both conditions.​ Roughly 31% of men and 68% of women in the country are obese. ​

Obesity causes:

• Increased IAP​
• Increased femoral vein pressure and diameter​
• Decreased femoral vein flow​
• Increased inflammation​.

Occupation​: Female-dominated occupations include nursing​, teachers​, social workers​, and administrative jobs​.

How can we reduce risk? ​

Use compression stockings to tighten the calf muscles. This allows the blood to flow back to the heart.​ If your job needs you to sit all day, stand up and walk for regular intervals to allow the blood to flow.​ Use stairs in your office rather than using the lift.​ Whenever you get a call, go for a walk to allow blood flow in your legs.​

Avoid wearing tight clothes and wear comfortable clothing to prevent the risk of developing varicose veins.​ Lose weight as it reduces the workload on the circulatory system and improves overall blood circulation.​ Practise regular exercise as it increases heart strength and pumps more blood to your body.​ After returning home from work, lie down with your legs elevated to prevent varicose veins.​ Wear low-heeled shoes to reduce pressure on your legs and prevent varicose veins.

Calf muscle pump

Calf muscle pump (CMP) is the motive force enhancing return of venous blood from the lower extremity to the heart. Impaired ​CMP function may reflect a measure of frailty or cumulative disease burden or may impede cardiac function.​

The aim of compression therapy is to:

• Reduce oedema​
• Counteract venous stasis and venous hypertension​:
• Increased blood flow velocity​
• Reduce pooling​
• Increase calf muscle pump function​
• Treatment of lymphoedema and lipoedema​
• Improve lymphatic drainage.

Compression stockings​

Compression stockings​ need to be graduated to produce sufficient pressure around the ankle. They are classified according to pressure applied. Pressure is dependent on:​

• Size of the limb​
• Calf muscle activity​
• Diameter of the compression hose​
• Static stiffness Index of the material.

How to choose​?

Exclude arterial disease through ABPI/ vascular assessment​.

Ensure you have the correct measurements for correct size​, and the correct class of stocking. Flat knit and circular knit​ have different uses.

Patient education​

Educate you patients by explaining the reason​ why they must wear compression garments. Show them how to apply the garments correctly, as well as explain the appropriate skin care. Explain how to take care of the stockings​ and ensure they replace them every three to six months​.

Physical activity, adopting a healthy way of life, and employing compression are the fundamental pillars in the management of venous conditions.

Compression stewardship could not only improve leg health but prevent leg complications.