Post-menopausal leg swelling

Abstract

Background: Leg swelling after menopause is common. The prevailing concept in primary care is that it is polycentric and a treatable cause may not be found. Traditional systemic causes may be investigated, but venous etiology is rarely considered. Patients are prescribed empiric diuretics, often without benefit. Our clinical experience indicates that iliac venous vein obstruction is frequently the core cause. A variety of secondary factors that are common in the postmenopausal life stage (eg, joint surgery, onset of venous reflux, venosclerosis, seated orthostasis) disturb the precarious regional fluid balance and precipitate swelling. Postulated but undefined hormonal and metabolic imbalances may be contributory. Methods: Intravascular ultrasound (IVUS)-guided vein stenting imaging was done in 310 limbs of 256 postmenopausal women (aged ±55 years) with leg swelling unresponsive to conservative therapy (49 with concurrent endovenous laser therapy) during an 11-year period. The group constituted 18% of the 1760 limbs with chronic venous disease stented during the same period and 34% of those stented for swelling. Median age was 66 years (range, 55-92 years) and the left/right ratio was 3:1. Results: Obstruction was primary in 65% and post-thrombotic in 35% of limbs. Thirty-one percent of limbs had obstruction only and 69% combined obstruction and reflux: 32% had superficial reflux, 10% deep reflux, and 24% had both. Axial reflux was present in 8%. Lymphatic dysfunction was present in 13% of the limbs. Mean IVUS area stenosis was 70% ± 20% (SD). The 30-day mortality was nil. Deep venous thrombosis occurred in seven limbs <30 days and in five others later (overall, 4%). Mean follow-up was 19 ± 22 months (range, 1-120 months). Secondary stent patency at 6 years was 100% in primary and 78% in post-thrombotic limbs (91% overall). Five of 14 stents that occluded were reopened. Swelling improved significantly (P < .0001) from preoperative grade 2 ± 1 to postoperative grade 1 ± 1.2. Associated pain also improved significantly (P < .0001) from preoperative VAS 4 ± 3 to postoperative 0.6 ± 1.7. Scores on the Chronic Venous Insufficiency Quality of Life Questionnaire improved significantly (P < .0001) in every category (pain, work, sleep, social, morale) and overall (from 66 ± 20 preoperative to 49 ± 22 postoperative; P < .0001). Conclusions: Patients with post-menopausal leg swelling frequently have obstructive venous pathology and two-thirds have associated reflux. Morbidity arises from painful swelling that retards mobility and compromises ability of self-care at a frail stage of life. Characteristic clinical features and pathology should qualify this large subset as a distinct clinical entity. Outpatient percutaneous iliac vein stenting alone or with concurrent saphenous ablation affords substantial symptom relief and improvement in quality of life measures. Greater clinical awareness among primary care physicians is essential to serve this otherwise neglected patient population.