This study was carried out as an offshoot of an American-French epidemiologic survey of Raynaud phenomenon conducted from 1988 to 1992, the sampling procedure of which has been detailed^{8, 9, 10} and can be briefly summarized as follows. Random samples from households of 4 geographic areas of France, that is, Tarentaise (Savoie), Grenoble (Grésivaudan), Nyons (Baronnies), and Toulon (Côte d'Azur), were obtained from telephone lists. Every subject aged 18 years or older and living in the selected households was included in the survey until the planned sample size of 2000 subjects per geographic area was attained. The subjects were interviewed by telephone (phase I) about demographic and socioeconomic data and the occurrence of cold-related symptoms in the hands, suggestive of Raynaud phenomenon, the primary focus of the original study. No questions were asked about chronic venous disorders in this stage. All cold-sensitive subjects and a random sample of non-cold-sensitive subjects in equivalent number were invited to be interviewed and undergo medical examination (phase II). Venous data were recorded during this phase.

Data regarding venous symptoms, history of venous diseases and treatments, and presence of varicose veins, edema, and skin trophic changes in the legs were systematically evaluated clinically by a trained vascular medicine physician as part of a standardized medical interview and examination. No ultrasound examination was performed.

Varicose veins were defined as enlarged, tortuous, subcutaneous veins, either visible or palpable clinically with the patient standing.¹¹ They were classified as follows. Saphenous varicose veins were those that involved the saphenous trunks (great and small saphenous veins) or the first-order tributaries of the great saphenous vein (accessory anterior and posterior great saphenous veins). Other subcutaneous varicose veins were classified as non-saphenous varicose veins.

Intradermal visible veins and venules (telangiectasia, “hyphen webs,”reticular veins, CEAP C1) were not considered in this study, because of difficulties in setting up operational criteria to clearly differentiate normal from abnormal.

Subjects were classified as having saphenous varicose veins if they had at least 1 such vein in 1 lower limb; they usually had smaller varicose veins as well. Subjects classified as having non-saphenous varicose veins had only non-saphenous varicose veins in either 1 or both lower limbs.

The venous symptoms inquired about were sensations of heaviness, swelling, or restlessness in the legs, abnormally felt in usual daily living; these are the symptoms most frequently quoted by French patients with venous disorders of the legs.¹² They were recorded before medical examination in a standardized interview that asked whether they had “sensations of heaviness in the legs, swollen legs, or restless legs, abnormally felt in usual daily living.” No mention of a venous origin was made in the questionnaire about these symptoms. In the analysis, subjects were considered to have venous symptoms if they complained of any of these 3 symptoms.

Skin trophic changes of the gaiter area and lower leg, such as pigmentation (pigmented dermatitis), dermatitis (venous eczema), induration (lipodermatosclerosis), white atrophy, ulcer scars, and active leg ulcers were carefully evaluated.¹³ The presence of pitting edema in the pre-tibial or malleolar areas was also noted.

History of thromboembolic disease was based on the word of the subject that a medical diagnosis of deep vein thrombosis or pulmonary embolism was made after specific imaging studies and followed by anticoagulation therapy. Special efforts were made to rule out superficial thrombophlebitis and undocumented suspicion of deep vein thrombosis or pulmonary embolism.

Family history of varicose veins was restricted to first-degree relatives, and was evaluated according to information obtained from the subjects.

Subjects were placed in 1 of 3 categories: prolonged sitting, prolonged standing, or actively moving, according to their usual daily activity. The first 2 categories were merged for logistic regression analysis.

Exercise activities were evaluated in 4 categories, and subsequently were combined into 2 groups for logistic regression analysis: less than 1 session or at least 1 session of exercise per week, routinely.

Education level was recorded on a 10-grade scale, but a 2-grade classification (primary school only, more than primary school) was used in the logistic regression.

Occupations were recorded and classified into 30 categories, and subsequently were combined into 2 classes (skilled, unskilled) for logistic regression. Pensioned subjects were classified according to their last active occupation before retiring.

Early abortions and fetal losses were taken into account in the number of pregnancies.

Cigarette smoking and use of alcoholic beverages were quantitatively evaluated in a standardized questionnaire.¹¹ For logistic regression, they were further categorized as follows: never smoked (<100 cigarettes), current smoker (during the past year), no alcohol ever (<10 g of alcohol per week any time), and current alcohol consumption (>10 g of alcohol per week during the last year).

Prevalence estimates of varicose veins, skin trophic changes, venous symptoms, and of history of venous thromboembolism in the 4 investigated geographic areas are shown in Table I. Large sex-related differences contrast with the absence of conspicuous geographic variations.

Risk factors for varicose veins are summarized in Table II, A and B. Age (Fig 1), and a history of varicose veins in first-degree relatives were the most important risk factors in both sexes. In women, height and number of pregnancies were positively associated with the presence of varicose veins. In men, lack of sufficient routine exercise (P = .028) and unskilled work (P = .053) were associated with higher risk (Table II, B).

The distribution pattern of varicose veins found in the lower limbs of women and men is shown in Table III. No difference was found between left and right legs. The prevalence of saphenous varicose veins was similar in women and men. By contrast, a 3-fold higher prevalence of non-saphenous varicose veins was found in women compared with men (P < .001). No difference in other risk factors was found between saphenous or non-saphenous varicose veins. Both types were equally associated with venous symptoms (70.1% in women with saphenous varicose veins vs 63.7% with non-saphenous varicose veins [P = NS], vs 36.4% and 34.0%, respectively, in men [P = NS]), but skin trophic changes were mostly associated with the saphenous type (13.4% vs 4.2%, combined data for women and men; P = .003).

Skin trophic changes were found only in subjects with varicose veins. Therefore subsequent analyses for risk factors were performed in the subgroup of subjects with varicose veins, combining data from men and women to alleviate the problem of small numbers (Table IV). Age (Fig 2) and presence of pitting ankle edema were the best associated variables after adjustment. Family history of varicose veins and personal history of venous thromboembolism were of borderline significance (P = .044 and P = .052, respectively).

Limb-by-limb analysis of the data showed no difference between left and right sides. Association pattern of the different types of skin trophic changes found in the same limb showed that major trophic changes, such as induration of lipodermatosclerosis, white atrophy, and ulcer scars, seldom occur in limbs without pigmentation (7.5%).

Only one of the 33 subjects with pitting ankle edema did not have venous symptoms (P < .001), which made it impractical to enter in the logistic regression analysis. Female sex also was a risk factor, as shown by a much larger prevalence in women compared with men.

Other main risk factors for these symptoms were prolonged sitting or standing during daily activity, presence of varicose veins in both sexes, and history of venous thromboembolic disease (Table V, A and B). A negative relationship with age was unexpectedly found in women, in contrast to the direct relation to age shown for varicose veins and skin trophic changes (Fig 3).

Fig 3

Prevalence of venous symptoms as a function of age. Negative relationship in women remained significant (P < .001) after adjusting for presence of varicose veins. By contrast, in men an apparently significant increase with age is removed by adjusting for varicose veins.

The 3 symptoms assessed in the interview were highly associated with each other. The sensation of heaviness in the legs was the most typical symptom in the French population, with only 6.7% of women and 19.7% of men with symptomatic disease not mentioning it.

This study is the first to analyze the prevalence of chronic venous disorders of the lower limbs in a general population-based sample in France. The prevalence of varicose veins appears to be high, with approximately half of women and a third of men affected. High figures have also been found in industrialized countries such as Switzerland,¹⁴ Wales,¹⁵ the United States,¹⁶ Israel,¹⁷ Brazil,¹⁸ Italy,¹⁹ England,²⁰ Japan,²¹ and Scotland,²² with some variations probably explained by the criteria used to define varicose veins, and the age limits of the investigated populations. Regarding the sex-related difference in prevalence, most other studies found a higher female-male ratio than we did, with the exception of the Basle Study III and the Edinburgh Vein Study,²² in which a male preponderance was found. Several factors could explain this discrepancy. Reporting or selection biases can occur in studies based on subject self-evaluation or with sampling drawn from clinical practice or industry. As pointed out by Evans et al,²² most studies were carried out several decades ago; in the meantime, changes in lifestyle have occurred, leading to smaller differences in environmental factors that affect men and women. Differences in lifestyle may also account for some geographic variations, as shown by Beaglehole et al²³ and discussed by De Backer.²⁴ We could not, however, show any significant differences between our 4 geographic areas of France, ranging from an Alpine valley to the shore of the Mediterranean Sea, and including 2 rural and 2 urban areas. Differences in lifestyle between these geographic areas are certainly small in comparison with what could be found between different countries. The use of different operational criteria could also be an important factor. Indeed, trunk saphenous varicose veins seem to be at least as prevalent in men as in women, according to Widmer,¹⁴ Evans et al,²² and our study, whereas varices of smaller veins, although defined differently, were found more frequently in women than in men in all 3 studies mentioned. Some other studies did not looked at subtypes of varicose veins, and some have included telangiectases, which are much more prevalent in women, as shown by Evans et al²² and Guberan et al.²⁵ The corona phlebectatica is also treated differently in the clinical classification of dilated veins by various authors. It is therefore difficult to compare results of different studies. A distinction between saphenous and non-saphenous varicose veins is of great practical interest, because saphenous varicose veins are more strongly linked with cutaneous trophic changes than are non-saphenous varicose veins. The prognostic significance of this distinction remains to be confirmed in longitudinal studies. We think that a clear-cut topologic classification used by an experienced physician trained in the field of vascular medicine is an important methodologic tool for further epidemiologic studies. Additional use of duplex ultrasound scanning could aid in mapping the entire venous system, but this examination is time-consuming, and its use in epidemiologic surveys has been restricted to evaluation of the main trunks.^{26, 27} It was not possible in this study, which was originally designed to examine the Raynaud phenomenon. However, inasmuch as the definition of varicose veins remains clinical, this could not alter prevalence estimates.

The results obtained are, however, not biased by using the same random sample from the general population, because we could not find any association between Raynaud phenomenon (or cold sensitivity) and chronic venous disorders. The recruitment of phase II, in which clinical examinations were performed, was not related to any venous disease, and subjects in the study were not aware of our main research interest.

Age was the most important risk factor in both men and women, in this study and in all others.²⁸ A family history of varicose veins in first-degree relatives also proved to be a strong risk factor. This evidence was based on information reported by the subjects (no family members were examined), but it corroborates previous family studies based on clinical examination of relatives.^{29, 30} Pregnancy was also a significant risk factor, as reported in several studies,^{17, 18, 23, 31, 32} and remained significant after adjusting for age, which is also consistent with the fact that the differences in prevalence were mainly related to first and second pregnancies.

We find it interesting that in men lack of exercise was an independent factor linked with varicose veins, which is consistent with our knowledge of the positive influence of the muscle pump function on the venous system, which, we may hypothesize, somehow prevents development of varicose veins. The borderline significance of unskilled work as a predictor of varicose veins, although a rough categorization, corroborates some descriptions in working populations³³ and underlines the need for further studies in the workplace.

We could not find any significant relationship with overweight. In contrast, we found a significant relation with height in women (P = .007), and a similar, but non-significant trend (P = .127) in men. Other authors have found significant relationships with height in both sexes.^{17, 23} Inasmuch as the height measurement is related to venous pressure in the standing position, this association has some physiologic significance. This makes it more difficult to assess the influence of overweight, because any index of body mass is based on the relation of weight to height. Furthermore, only the present weight was measured, which could well minimize the power to detect the influence of overweight on development of varicose veins, because of potentially large variations in weight over time. Therefore it is not surprising that conflicting results were found in cross-sectional studies.³⁴ It should be noted, however, that two longitudinal studies confirmed a positive relationship in women.^{35, 36}

The prevalence of skin trophic changes was found in the same range as previously published by others, in particular for leg ulcers and their strong relation with age.^{34, 37, 38} In our sample we included pigmentation, dermatitis, induration, ulcers, and white atrophy. Our prevalence estimates are somehow lower that the estimation of “chronic venous insufficiency” in the Basle¹⁴ and Edinburgh²² studies, but this may be explained by inclusion of the corona phlebectatica in these studies.

Prevalence of venous symptoms was also high in this study, with an important disproportion between women and men. Few data can be found on this subject in the literature.^{22, 27, 39} In addition, comparison between studies is difficult because the words used to express the feeling of discomfort by patients with venous disorders vary between countries. It is possible that the link we found between venous symptoms and varicose veins, stronger than seen in the Edinburgh Vein Study, is related to a smaller number of more specific words we used and to the restriction to symptoms “abnormally felt in usual daily living,” which enabled us to rule out subjects who experience such feelings in exceptional conditions. The almost constant complaint of such symptoms in subjects with pitting ankle edema is in accordance with the popular notion that these symptoms are probably related to the perception of increased interstitial fluid volume, whether clinical or sub-clinical. But the unexpected and striking decrease in prevalence of venous symptoms with age in women shows that varicose veins are not the only etiologic factor and that the presence of venous symptoms without varicose veins should not be considered a preclinical phase of varicose disease, as feared by many young women. Our results suggest that lifestyle, that is, prolonged sitting or standing, has an important role, in addition to varicose veins, in the pathogenesis of venous symptoms in both sexes, that also refers to the physiology of the venous system.With this in mind, other environmental factors related to clothes and shoes that could account for some part of the unexplained and important difference found between women and men should be explored in future studies. A history of venous thromboembolism was also significantly related to venous symptoms, which further emphasizes the importance of venous physiologic features in the genesis of these symptoms. We were unable to find any link between such symptoms and a history of osteoarthritis (n = 144; 20.2% vs 15.0%; P = NS) or of peripheral arterial disease (n = 11; 0.8% vs 1.7%; P = NS), as previously suggested.³⁹ Therefore, we think they deserve their usual denomination as venous symptoms, although we agree with Bradbury et al² that they should not be considered strictly as symptoms of varicose veins.

We thank Sophie Bouton, Corine Trolliet, and Christiane Féchoz for organizing field studies.