“Varicose Veins!” – with Dr. Tikva Jacobs

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Dr. Tikva Jacobs, welcome to the podcast. This is awesome. I’m so happy we’re doing this.

Dr. Jacobs: Thank you so much for having me. I’m very excited to be here.

Dr. Fox: Oh, that’s sweet. And you are a general surgeon and vascular surgeon at the NewYork-Presbyterian/Weill Cornell in New York City. How’s that going in that part of town?

Dr. Jacobs: It’s great. It’s really going well. Yes, I’m really just a vascular surgeon. I did do my training in general surgery, but I don’t do general anymore.

Dr. Fox: Yeah, well, you know, but you are. It’s like being a Marine. You’re never a former Marine. It’s like you’re never a former general surgeon. You may not do it, but you are. You’re trained. You’re…

Dr. Jacobs: That’s true. I’m trained. I’m board-certified. I took all those tests. Yes, exactly, but I don’t practice that anymore.

Dr. Fox: And we go way back because we are the cause of our respective spouses having a lot of time alone with our respective children over many years of training at Mount Sinai.

Dr. Jacobs: Yes, correct. You make that sound a little sketchy there, but yes.

Dr. Fox: Yeah, I guess so, no, but yeah, Michal Zalmi always talks about, like, yeah, they were, like, raising the kids while, you know, you’re on call for seven straight years and I’m on call for four straight years.

Dr. Jacobs: Exactly.

Dr. Fox: But that’s crazy. You’ve known each other a long, long time. That’s all good.

Dr. Jacobs: Yeah, it is. It’s been great. Exactly.

Dr. Fox: Good stuff. So how did you get into vascular surgery?

Dr. Jacobs: That’s a very good question. So I guess in medical school, I wasn’t sure what I wanted to do, and I eventually decided on general surgery. At that time, you couldn’t just match directly into vascular surgery. There are some programs now that you can go directly into vascular. And during my general surgery residency, I guess I had a mentor in vascular surgery. And I did my general surgery residency at Mount Sinai and it had a very strong vascular surgery division.

And I did some research and really enjoyed I guess the technical aspect of vascular surgery. You know, you have to have a lot of attention to detail. There’s small anastomosis. You’re suturing arteries to veins, arteries to arteries. And also, I think what I liked about vascular surgery was that you were operating on different parts of the body. So one day you could be at the neck working on a carotid and you could be in the abdomen and the aorta or the leg. So it was diverse. And I guess I liked that part of vascular surgery.

Dr. Fox: Just so our listeners understand, from the start of your first day of residency of general surgery till you finish your vascular surgery fellowship, how many years we talking here to train to do what you do?

Dr. Jacobs: Right. So general surgery was a five-year clinical residency. I did one year of research in the middle of that. So in between my third and fourth clinical year, I took a year off and did research in vascular surgery. And then my fellowship for vascular surgery was one year. And then next year it became a two-year fellowship. So I did a total of seven years, right, seven, yeah, so five, six, seven years after medical school to be a vascular surgeon.

Dr. Fox: Wow.

Dr. Jacobs: But yeah, I guess if you didn’t do research, you’d have five years and then two years would be seven also.

Dr. Fox: Yeah. And just again so our listeners understand, I mean, vascular surgeries is considered pretty badass in the hospital. I mean, this is not like a poofy she/she type of thing. You guys are knee-deep and very complicated operations. And so people have a lot of respect for the vascular surgeons. Not so much for us, you know, the GYNs.

Dr. Jacobs: Thank you.

Dr. Fox: No, and I remember…

Dr. Jacobs: No, that’s all right.

Dr. Fox: No, it’s crazy stuff. I mean, you know, you’re talking about, you know, aortas and carotids, and these are important parts of the body, I’m told.

Dr. Jacobs: Yeah. I guess you sort of need those. You need those vessels, right?

Dr. Fox: And so we’re talking, you know, carotids and aortas. How did you switch or not switch, or how did you start to focus a lot on veins?

Dr. Jacobs: So when I finished my fellowship, I was I guess the most junior person at Mount Sinai. Mount Sinai had quite a few vascular surgeons and no one was really doing any venous work. And I felt like it was an area that really was needed at Mount Sinai. And I enjoyed doing the venous work because unlike some of the arterial work, which tended to be in older, sicker patients, the venous work really was more healthy young men and women. So I sort of liked that part of the venous work.

I started to just, you know, be the one at Mount Sinai to do the vein work. I actually went for, like, a week. I went to the West Coast and sort of just shadowed someone who only did venous work and really, like, you know, her set up there and tried to bring that back as an outpatient vein work at Mount Sinai. I was at Mount Sinai for, like, three years where I did arterial and venous work. And then I guess slowly I moved to just do venous work and not do arterial work.

I was at Elmhurst for three years also. It is a Level 1 trauma center. So I did a lot of arterial work there, but I did do some vein work there also and then started a private practice where I only did vein work while I was still working at Elmhurst Hospital doing, you know, arterial work and trauma there. And then eventually decided just to focus on the vein work state of my private practice. And seven years ago I moved to Cornell.

Dr. Fox: Wow. Amazing. I think most of our listeners probably think of vein work as varicose veins, right? That’s it. But from your end, on the doctor end, like, what are the types of things you are seeing day to day for vein work? Is it all varicose veins? Is it predominantly that? Are there other things you’re seeing? Just so they get a flavor, like, the kinds of things that you would do or you would take care of.

Dr. Jacobs: Yeah, sure. So I do see a spectrum of, you know, I guess venous disease, for lack of a better word. You know, I will see patients that just have swollen legs, I’ll see a few wounds, and then I’ll see spider veins, reticular veins, which are veins that are slightly larger than spider veins but still sort of flat on the leg. And then varicose veins are typically the veins that sort of bulge out that most commonly I guess, like, see. I’ll see them for medical reasons as well as cosmetic reasons. Because some patients come in and have, you know, no symptoms at all. Their legs feel fine and they just don’t like the way the veins on their legs look. They never had them when they were younger and now they’re starting to get more. And then sometimes patients will be referred to me from their OB-GYN or their primary care doctor for pain, heaviness, or other complications that can happen from varicose veins or the veins not working.

Dr. Fox: And are all of these things that you’re referring to, like, the same condition just along a spectrum, or are they really sort of different from one another in other ways?

Dr. Jacobs: So I’d say that they’re probably slightly different. You know, I guess I could start with that. We have arteries and veins in our body from a vascular standpoint. The arteries have to pump all the blood from our heart everywhere, to our head, to our hands, to our feet. The veins have to bring the blood back up to our heart. So in your legs, the veins have to work against gravity to get the blood back up to your heart. So they have valves in them so that when the blood moves a certain portion up the leg, the valve closes to prevent gravity from pulling the blood back down to the foot.

Over time, for hereditary reasons, those valves can get a little leaky or insufficient, and some of the blood can go back down to the foot. You know, the valves are supposed to close in about half a second. So anything longer than half a second, one second, two seconds, staying open a little bit longer allows more blood to go back down to the foot, which can cause more pressure in the veins. Sometimes people don’t notice it or feel any heaviness, but then sometimes people can feel some heaviness, a tired sensation in their legs. Sometimes that pressure in those veins can cause other veins that are closer to the surface of the skin to sort of become enlarged and bulge and become more varicose veins.

Sometimes those veins that aren’t working are responsible for some of those smaller veins, like the reticular veins or the spider veins, just because there’s more pressure in those veins. And as it gets closer to the skin, other veins become enlarged. But sometimes you can end up with spider veins or those reticular veins just purely from hereditary reasons, sometimes from trauma. So they could sort of all be related, but sometimes they could just be two separate entities, like spider veins or varicose veins.

Dr. Fox: Got it. And then just some things that people may have heard of. How are all of these things that we’re referring to different from a DVT, which is like a thrombosis or a blood clot?

Dr. Jacobs: Right. So we have deep veins and superficial veins in our body. The deep veins are responsible for 90% of blood getting back up to your heart, and the superficial veins are responsible for the remaining 10%. When you talk about someone who has a deep vein thrombosis, usually it’s a clot or a thrombosis in one of those deep veins. The veins that I really am talking about, I do treat patients with DVTs or deep vein thrombosis, but this talk I think is more about the superficial system. So yeah, the veins that we’re talking about, spider veins, reticular veins, varicose veins, those are all in the superficial system. So even if someone can get a clot in a superficial vein, it’s still treated differently and it’s not considered dangerous the way a deep vein thrombosis or a DVT would be.

Dr. Fox: Right. So people with DVTs, this is something where it can then propagate and travel to your lungs and to your heart. And these are the ones you take blood thinners for. But for the superficial veins, I would say it’s unusual. I mean, some people end up on them, but it’s unusual to need a blood thinner for medical reasons because of that, maybe, you know, make them feel better potentially. But basically, it’s not used in the same way. Correct?

Dr. Jacobs: Right. The only time we really treat patients with superficial clots with a blood thinner is, one, like you said, for symptomatic relief. So if someone’s having a lot of pain because there’s just a large clot burden, meaning the vein is very large, it’s putting a lot of pressure, it could be just a lot of inflammation in the area. So we could put them on a blood thinner for symptomatic relief. Or if the superficial vein that has the…if the clot in a superficial vein is close to a deep vein, we might put you on a blood thinner for a couple of weeks just to prevent the propagation into a deep vein.

Dr. Fox: Right, because they’re all connected.

Dr. Jacobs: Because the superficial veins… Yeah, exactly. So the superficial veins do empty into deep veins in certain parts of your leg. So we’d get an ultrasound and assess how close the clot was to a deep vein and decide whether or not someone needed a blood thinner or just to monitor it with a repeated ultrasound.

Dr. Fox: Why do some people get this issue a lot more than others? Right? Because certainly, you know, these things become more common as we get older, for example. But why would one person have, like, horrible, you know, bothersome, painful, you know, severe form and others get nothing? Is it just, like, luck of the draw, genetic, or are there other factors?

Dr. Jacobs: Right. So I like to tell my patients the number one reason for developing these veins is heredity. So you can blame your parents.

Dr. Fox: Well, that’s definitely the answer to most problems in life. Yeah.

Dr. Jacobs: Right, exactly. And then there are other factors that play a role. So hormonal issues. So being a woman increases the risk of developing, you know, spider veins or varicose veins as well, although I definitely see and treat plenty of men. And then pregnancy, the hormones of pregnancy, could increase the risk of developing any kind of varicose veins or spider veins. I like to call something occupational hazards. So if you stand a lot or sit a lot, that also increases the risk. But the number one reason really is heredity.

Dr. Fox: And are these things where there’s, like, known genetic conditions or just one of these things where, hey, my mother or father has it, so I’m more likely to have it?

Dr. Jacobs: Yeah, it’s more if your mother or father or grandmother has it, you know, then you’re at… It’s not like you are going to search for it and decide, you know, am I at an increased risk? But when you have it, they’re like, “Oh, yeah, my grandmother had it. My mother had it.” Like you said earlier, you know, as you get older, that also increases the risk. And 70% of the population has some sort of venous disease or, you know, varicose veins or spider veins. So it is very, very common. I keep calling it a disease. Like I said, I hate calling it that. But 70% of the population has some sort of issues with their veins.

Dr. Fox: Right. And it’s interesting because, I mean, there are some unusual genetic conditions where people get very abnormal veins or arteries as well, but that’s not what we’re talking about here.

Dr. Jacobs: I mean, I do see those patients, but that’s not what we’re talking about when we say 70% of the population or, you know, if your mother has it and you’ve had, you know, 4 or 5 pregnancies, you’re going to get it. That’s something totally different. Yeah.

Dr. Fox: Right. And then the interesting thing also…

Dr. Jacobs: That could be a whole other podcast.

Dr. Fox: Yeah, I mean, those are pretty severe. And the other interesting thing about pregnancy, as you said, it’s sort of a double whammy, because if you have more babies, you’re more likely to get them in life. But also when you’re pregnant, whatever you have tends to get worse.

Dr. Jacobs: Correct. Correct. Yeah, it does. So, you know, I usually tell my patients who has or who have had varicose veins and they’re getting pregnant again or they’re thinking about getting pregnant, I usually tell them that they should start wearing compression stockings right away, you know, as soon as they find out they’re pregnant because again, it’s the hormones in pregnancy that causes the veins to dilate and allow more blood to pool and put more pressure on the veins. As well as you progress during your pregnancy, the weight of the uterus putting pressure on the veins in your pelvis and lower legs also, you know, can cause for the veins to get worse.

The nice thing about, you know, your veins when they do get worse during pregnancy, they do improve after delivery, but they’ll never go back to the way they were before you were pregnant. But you should get some either symptomatic relief or some of the veins should go away after pregnancy as well.

Dr. Fox: Now, in your practice, what would you say is the percentage of people who are coming to see you because of cosmetic reasons for the veins versus symptoms related to the veins? And my second question is the percentage you see you think that’s typical for people who do what you do.

Dr. Jacobs: So I knew you were going to ask me this. I was trying to come up with, like, what would I say? So I feel like sometimes it changes depending on the month. So, like, definitely in the spring, my practice becomes more cosmetic.

Dr. Fox: That makes sense.

Dr. Jacobs: You know, I probably say it’s about 50/50 or maybe 60/40 cosmetic medical. But I definitely see a lot of medical also. And then sometimes people don’t realize they’re having necessarily pain from their veins. Like, someone will come in and say, “I don’t know, I feel like I have restless leg syndrome,” you know, or their legs sort of hurt at night. And then I’ll tell them I can’t guarantee them if we treat their veins that that will go away since, you know, I can’t say for sure the veins are causing it. But then if we treat their veins, those symptoms do get better. Or if I’ll treat one leg and then the patient will be like, “Oh, my gosh, this leg feels so much better now and then they realize that they were having symptoms.

Dr. Fox: Interesting. And so someone comes to see you, you know, first time they’re coming to see you. How do you evaluate them? Like, what is the process that you do? Is it just, like, I take a look at your legs and here we go? I mean, how much of it is, like, related to their story and their symptoms? I’m just trying to get a sense like what people should expect if they saw you or someone like you for this.

Dr. Jacobs: Yeah. Sure. So, you know, I feel like it’s back to medical school where you’re learning, you know, how to take your whole history and physical. So we start with the history and physical. You know, I get their medical history, how long they’ve had varicose veins, who else in their family had varicose veins, if they’ve ever had any treatment. And when I say varicose veins, I’ll just say spider veins, you know, whatever vein you’re presenting. Exactly.

And then once I, you know, talk to them about if they have any symptoms or, you know, how long it’s been going on, then I do a physical exam and see where the veins are on the leg. And then I usually get an ultrasound, a duplex ultrasound where we look at the veins. So at that point, we look at the deep veins as well as the superficial veins just to make sure that the deep veins have no blood clots in them and that they’re working properly.

And then I like to see which of the superficial veins aren’t working, because sometimes, you know, based on which veins aren’t working, that will help me decide what the best treatment would be for that particular patient. So sometimes people could just come to me and say, “I have this one little vein right here that I don’t like the way it looks,” but when we get the ultrasound, we see that there is, like, a whole bunch of veins, you know, slightly deeper than what the eye can see but still considered superficial vein that we can only see on ultrasound that’s actually causing that vein. And if we were to just, you know, remove that one vein that we see with our eye, you know, that patient would be back like maybe a year later with new veins because we didn’t treat the problem. Most of my patients, unless they just have a few spider veins in certain areas, like, always get an ultrasound just to sort of figure out, you know, what veins are causing the problems.

Dr. Fox: And when you say causing the problem, what would they see on ultrasound? Is it just that they’re dilated, or do they look at that valve and measure it or the time you were talking about? Is that something that could be done, or is it just visual, this vein’s more dilated than it should be?

Dr. Jacobs: Right. So we look at the size of the vein as well as the valves, whether the valves are working or not. So typically, you know, what we do is, well, the ultrasonographer will be looking at the superficial veins. There are usually two veins that cause most of the varicose veins that we see. One is called the great saphenous vein and it runs from the inside of the ankle to the inside of the groin, and the other is the small saphenous, which runs from behind the ankle to behind the knee.

And then some people have some extra veins that if we see them on ultrasound, we map those out also and we check the size as well as we check the valves. And the way we check the valves is we press on the lower calf and sort of push the blood up the leg and we can see if the blood comes back down to the ultrasound probe and we can see that on ultrasound. We can also hear it. And we document how long it takes for the valve to close. So it’s how big the vein is and how long it takes for that valve to close. And like I said earlier, anything greater than half a second is considered refluxing or insufficient or the valve isn’t working.

But sometimes, you know, the valve will close in one second and they’re really not that symptomatic, so I don’t think it’s as big a deal compared to someone whose valve is open for five seconds. You know, those patients have a lot more blood going back down to their foot. You know, eventually, it always goes back up to the heart. But, you know, when you’re standing for long periods of time, you can just imagine if your valve is staying open for five seconds, there’s a lot more blood sort of hanging out in your calf and not going back up to your heart as efficiently.

Dr. Fox: Great. And then do you ever find situations where the valve sort of looks like it’s functioning normal, but despite that, there’s a ton of dilation in the vein? Does that ever happen?

Dr. Jacobs: Usually not. Usually when the valve’s not working, the veins…

Dr. Fox: They go together.

Dr. Jacobs: Yeah, it usually goes together. I mean, there was always a question of, you know, which came first? Like, was it the valve isn’t working and then that causes the dilation, or does the vein dilate and the valves can’t close as well as they used to? Sort of like the chicken and the egg. But so they usually go together though.

Dr. Fox: Got it. Okay. So you’ve done the evaluation, and then how do you decide? I guess I should ask you, what are the possible treatments? Like, what’s the list? Like, what’s the menu of treatments that sometimes you do, and then how would you pick one for a specific patient? So I guess let’s first go through the menu. Like, what are the options? I guess let’s start from least aggressive to most aggressive. That’s how we usually do to medicine.

Dr. Jacobs: Right. So it really does depend on which vein isn’t working properly. But what I would like to start off by saying is that all the treatments that I do are office-based under local anesthesia or no anesthesia. And like I said, all outpatient office space, you know, usually about an hour, maybe an hour and a half. So, you know, gone are the days where people used to need general anesthesia or spinal anesthesia to do an invasive vein stripping. We don’t do that anymore.

So I guess the spectrum, we could start with the small spider veins. We treat with something called sclerotherapy, which is an injection of medication into the vein, done with no anesthesia because it’s just a very small needle injecting medicine in the vein. I guess I could sort of say that all the treatments we do are either some sort of destruction of the vein or removing the vein. So sclerotherapy is something where we’re destroying the vein. So the medication we inject into the vein destroys the interlining of the vein, causing the vein to get sticking close on itself. And when it closes on itself, it’s no longer part of the circulation, and your body over time will say, “Hey, this vein’s not doing anything. Let’s get rid of it.” And over the next couple of weeks, the veins will get smaller and smaller.

There is a little bit of blood that gets trapped in the vein after we do sclerotherapy, so the veins do look darker before they look lighter, but then over time, you know, your body breaks the blood down as well as the vein. So I usually tell my patients it looks darker before it looks lighter. So it does take a couple of weeks, usually four to six weeks to see the full result. So that’s usually used for smaller veins.

Then if we have to treat the great saphenous vein or the small saphenous vein, those veins that I said are usually the ones that we need the ultrasound to see but sometimes they’re the cause of the varicose veins, those are the veins that in the olden days, you know, people used to do vein strippings for. What we do now is some sort of procedure called an ablation, which is also just a destruction of the vein. There are a lot of different ways to destroy those veins, the great saphenous or the small saphenous. There’s laser ablation. There’s radiofrequency ablation. Sometimes we use something called chemical ablation, which is really just, like, another kind of medication similar to the medication that we use for the small spider veins. Some people will use blue. So all of those techniques do the same thing. They’re just destroying the inner lining of the vein, causing a superficial clot to form so that your body says, “This vein’s not working. Let’s get rid of it.” If I were to ultrasound you, like, four or five months after that ablation, I wouldn’t even see the vein anymore. So it’s a way of getting rid of the vein without having to surgically remove it.

Dr. Fox: And since these veins are only 10% of the blood returns to your heart, it doesn’t affect people sort of in any other way.

Dr. Jacobs: Exactly. So these are all veins that are not working. And once we close them down or destroy them, your body finds more efficient ways of getting the blood back up to your heart. And we never touch the deep veins, which, like you stated, 90% of the blood goes back that way.

Dr. Fox: When you say that people used to have stripping, what was stripping? Like, how did that… They just, like, opened your leg and pulled it out? What was this surgery that was being done?

Dr. Jacobs: So you would need general anesthesia or spinal. And we actually would make an incision at the ankle and at the groin and find, you know, the great saphenous vein at those two points. And we’d pass a stripper, which was, like, this metal, and then later on it became plastic, but instrument into the vein from the ankle all the way up to the groin and then sort of tie the top of the vein after we would divide it at the groin where it met the deeper vein, and then tie it to that stripper and then just pull the whole vein out through that incision down at the ankle. So yeah, it was painful. People used to have to stay in bed for a couple of days. Like I said, you definitely need a general or a spinal. And then, I mean, like I said, I have not done a stripping since my training, and not that I like to admit how long ago that was, you know, at least 20 years ago, really. You very rarely need to do that.

Dr. Fox: Wow. Wow. Okay. When people say vein stripping, you don’t do that anymore because it’s not necessary.

Dr. Jacobs: Right. So what we do sometimes is something called a phlebectomy, but I do find that sometimes patients will come in and say that they had a stripping but it’s really more of phlebectomy, which for those big, large varicose veins, they’re sort of bulging. I usually like to remove them because you get a better cosmetic result faster. You know, you could inject them and, you know, wait for your body to break down the vein and all the blood that’s trapped in the vein, but it takes more time because they’re large veins.

I would do under local anesthesia something called the phlebectomy, where, you know, the patient would come in, we mark the veins, all the veins that we see or feel, and then under local anesthesia, I make very small incisions the size of a pen tip and then just sort of remove the veins. And people ask, “How do you do that?” I use something, it almost looks like a crocheting hook and you just sort of fish the vein out and then just slowly pull it out. I try to…

Dr. Fox: And then you just would tie it off at each end or something?

Dr. Jacobs: Yeah. You try to tie them off as many as possible just to decrease the amounts of bleeding, but all venous bleeding stops with compression and elevation. So if there are a few veins that you don’t get to tie off, as long as, you know, you hold pressure and keep the leg elevated for a little bit, the bleeding stops. But all my patients have to use a compression stocking after the procedures either for a week or two weeks, depending on the procedure as well.

Dr. Fox: Yeah. I was going to ask you just in general, does compression stockings or keeping your legs elevated more, does that ever work as a primary treatment for these things?

Dr. Jacobs: So it works very well for symptomatic relief of, you know, what you want to call venous insufficiency. So that heaviness, tired sensation at the end of the day after standing for long periods of time. So if you go home and elevate your legs, you know, you’re working with gravity to get the blood out of your lower leg and back up to your heart. So if you put on compression stockings first thing in the morning after you’ve been laying in bed, you know, horizontal all night, your veins are nice and small. So you put the stocking on right away and then you go about your day, the compression stockings will prevent the veins from sort of dilating and filling with that blood. But as soon as you take them off, you know, your veins are going to fill again. So it doesn’t do anything to fix the veins or fix the valves, but it does help with symptoms.

So I do have a few patients that don’t want procedures and they love wearing their compression stockings and are happy to continue to wear their compression stockings for the rest of their lives. Most patients prefer not to have to wear compression, especially, you know, like a week like this week where it’s heat wave, 90 degrees. But I do have, well, like, you know, a handful of patients that love their compression stockings and don’t want any procedures done. And that’s fine also. I tell my patients, “There’s really no emergency to treat your veins.”

Dr. Fox: Right. Do people ever get this, I know the answer to this, you know, not in their legs, but, like, in their groin? And if so, how do you treat those? Similarly?

Dr. Jacobs: Are you talking about like…

Dr. Fox: Like vulvar veins, for example.

Dr. Jacobs: Right. So for sure. So much more common in pregnancy. And for those, I usually like to do sclerotherapy, which is the injection of the medication into those veins because it’s just a very sensitive area and I feel like trying to, like, phlebectomize them or remove them doesn’t work well. But I do. I see a lot of patients. You cannot treat patients while they’re pregnant with sclerotherapy. I mean, I guess if someone came in with, like, a bleeding vein that would be different, but we prefer not to treat patients while they’re pregnant, just because the medications we use have never been tested in pregnant women. It’s actually a detergent. It’s like a soap. So it’s not something that’s like… Not really toxic medication, but still, we prefer not to treat patients while they’re pregnant. So pregnancy is just compression.

Dr. Fox: Yeah. And also, I mean, typically, again, it’s going to improve after pregnancy. It’s probably easier to treat afterwards I would imagine.

Dr. Jacobs: Exactly. Right. They do get smaller.

Dr. Fox: Do people get these in other parts of their body, like their arms or their back or their chest? I mean, does that happen there? And if so, is it just a cosmetic thing, or is there sometimes a vascular problem that’s not in the legs?

Dr. Jacobs: Right. So if someone’s… Sometimes, I mean, there are people that have prominent veins in their arms and hands and they’ll come for cosmetic reasons because they don’t like the way they look. But if you have real tortuous varicose veins like on your chest wall or in your arm, it usually means that, or it could mean that there’s something wrong with one of the deeper veins. It’s very uncommon to have varicose veins on your chest or in your upper arms unless there’s, like, a blockage in one of the deep veins in your arm or chest.

Dr. Fox: Okay.

Dr. Jacobs: But people could have prominent veins. As you see the bodybuilders, you know, they have very prominent veins on their arms, but they’re usually just normal veins that are more prominent.

Dr. Fox: Yeah. And so getting back to the legs, between those treatments, is the recommendation for which one to do, you know, the sclerotherapy versus, you know, the procedure and to…you know, bigger ablation or to sort of remove them, is that just based on the severity, or is there other factors that go into that?

Dr. Jacobs: So you always want to treat, you know, the largest vein first. So if one of those veins, like the great saphenous vein or small saphenous veins aren’t working, you always want to treat that first with an ablation where you destroy that vein first. Then you go to the next size. Like, so if they have large varicose veins, then I would probably remove those. Then if there were spider veins in the area of those larger veins, then we would inject the spider veins.

So sometimes it can take, you know, a couple of months to get, you know, the full treatment. But most people after the ablation of that great saphenous vein usually have symptomatic relief right away if they have symptoms. If there is no insufficiency or reflux in those great saphenous veins or small saphenous veins and you’re really just treating the veins that people see, you know, with your naked eye and you don’t have to treat anything deeper than that, then part of it has to do with the size of the vein. I often, I think, choose phlebectomy over the sclerotherapy, just because, like I said, you get a better cosmetic result faster.

If I happen to be injecting other veins at the same time and the patient’s like, “Oh, you know, I don’t want to have a…no anesthesia no procedure,” then sometimes I will inject those veins at the same time, but it can take, like, two or more sessions if it’s a larger vein to get rid of it with the sclerotherapy.

Dr. Fox: Cool. How would someone listening know if they should be seeing a vascular surgeon? Is it really just if something bothers them they should go, and if they don’t leave it be?

Dr. Jacobs: You mean for their veins or their [crosstalk 00:31:40]?

Dr. Fox: Yeah. I mean, in general for this. Yeah. Good point. Yeah. For this specifically.

Dr. Jacobs: So I tell my patients there are two reasons to treat your veins and they’re both valid reasons. One is a cosmetic reason. If you don’t like the way your veins look and it’s a perfectly valid reason to get them treated, the treatments we do today are very safe, effective, low risk. Like I said, all outpatient are under local or no anesthesia sometimes. And the second reason is if you’re having complications. So, you know, what are the complications of varicose veins? So there is a spectrum and, you know, it usually starts with maybe some heaviness, a tired sensation, maybe some leg cramping, and then you can have some swelling. Then some people will progress, and again, not a large group of people will progress to the other side of complications or the worst complications. Those would be maybe developing clots in your varicose veins, maybe some of the veins start to bleed. Sometimes people can get skin changes or skin thickening and eventually ulcer formation in their legs. So it’s a spectrum of, I guess I call them complications or really symptoms of venous disease.

And when my patients come to me, like, you know, I really work with them. If they just have some tired legs, heaviness, I never sort of push them to have a procedure done. It has to be something they want done. But if they’re starting to have more severe complications, I’m a little bit, I don’t want to say aggressive, but I try to convince them that, you know, treating their veins is the right thing to do at that point, because you don’t want them to develop another clot. Or if they had an ulcer, you want to help them heal the ulcer and not develop another ulcer. So really, if you don’t like the way your veins look, your legs hurt a little bit, I’m happy to see you, or you can see another vascular surgeon that specializes in venous disease.

Dr. Fox: Amazing. Wow. Good stuff, Dr. Tikva Jacobs.

Dr. Jacobs: Thanks.

Dr. Fox: Thank you so much for… This has been a long time coming to get you on the podcast.

Dr. Jacobs: I know. Thank you. Thank you for sticking with me.

Dr. Fox: You’re busy. You’re a surgeon.

Dr. Jacobs: I know. I apologize.

Dr. Fox: You’re doing stuff. No, listen…

Dr. Jacobs: I really appreciate it.

Dr. Fox: Yeah, you know, those of us who take care of women and certainly pregnant women see a lot of this. And it’s basically just that, like, hey, you know, there’s really one good option if you want to treat these. And you have to see somebody who does this, and, you know, you’re, as you know, my go-to person.

Dr. Jacobs: Oh, thank you.

Dr. Fox: And people, you know, it tends to work for them, which is great. But it’s…yeah.

Dr. Jacobs: It does. It really does. The one other thing I could just say, I do have patients sometimes that come to me between pregnancies. You know, back in the I guess olden days, people used to wait until they were done having all their children to have their veins treated. And, you know, I do have people that have come to me that said, “My veins hurt so much. I do not want to have another child.” Like, you know, “I just can’t go through that again.” And I try to explain to them that’s not a reason not to have another kid and that, you know, we can treat you in between pregnancies, you know, as long as they’re aware that they will develop new veins and we’ll just treat them again. People are usually very happy with the treatment.

Dr. Fox: A hundred percent. Excellent. Well, thank you for coming on the podcast and taking the time. I really appreciate it. Hope to see you around.

Dr. Jacobs: Okay. Thanks so much.

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.

The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.