DEAR DR. ROACH: Forty-five years ago, I had ovarian cancer. I had surgery, followed by 30 radiation treatments. Twenty years later, I was diagnosed at first with venous insufficiency, then with lymphedema in my lower extremities. I was on spironolactone for 15 years before I was told that a diuretic does nothing for either condition, so I stopped taking it. I wear compression stockings and get manual lymphatic drainage treatments as needed.

What is the difference between venous insufficiency and lymphedema? What is the role of sodium intake in both? Is there a cure for venous insufficiency? — O.M.L.

ANSWER: The systemic arteries take oxygen-rich blood from the heart’s left ventricle to the body, and the veins carry the oxygen-depleted blood back to the heart. However, veins leak a little bit. They don’t leak blood cells, but they do leak fluid. This fluid (called lymph) tends to collect in places where it is pulled by gravity. Most adults have had the experience of having some swelling in the feet or fingers, especially after a hot and humid day, with a lot of standing or after taking in high amounts of salt and water. The body uses the lymphatic system to return this fluid to the heart. Thin-walled lymphatic vessels — which, roughly speaking, parallel the veins — return excess fluid leaked out by blood vessels back to the heart.

In venous insufficiency, the veins leak more than they ought to. This is often because the valves in the veins, which should prevent blood from going the wrong way, become damaged and “insufficient.” By contrast, in lymphedema, the lymphatic vessels are damaged. Radiation and cancer are common causes, but it sometimes happens for no known reason.

Diuretics, like spironolactone, furosemide (Lasix) and HCTZ are not an effective long-term treatment for either condition. Support stockings, keeping the affected area elevated above the heart (a half-hour three times daily is usual), and avoiding excess sodium are appropriate for both conditions. Manual lymphatic drainage is the most effective treatment for lymphedema, but it is labor-intensive, often not covered by insurance and can be hard to find.

The booklet on edema and lymphedema provides information on the causes of swelling. Readers can order a copy by writing:

Dr. Roach

Book No. 106

628 Virginia Dr.

Orlando, FL 32803

Enclose a check or money order (no cash) for $4.75 U.S./$6 Can. with the recipient’s printed name and address. Please allow four weeks for delivery.

DEAR DR. ROACH: Every time a doctor takes my blood pressure, he tucks my arm under his to keep it at heart level, unless I am sitting down and can stretch out my arm at a desk or table to keep it at heart level.

But the doctor rarely takes my blood pressure anymore. And every medical technician who takes it lets the arm dangle down my side (usually while I am sitting on the exam table).

How would the position of the arm affect the reading? And what is the correct position? — E.S.H.

ANSWER: The doctor is using the correct position, since we are interested in the pressure inside the heart. If the cuff is lower than the heart (such as when the arm is dangling), the reading will be artificially high, whereas if it is above the heart (which I have never seen anyone do, but I suppose it’s possible), the reading would be artificially low. It’s just an effect of gravity, and the magnitude is small — roughly 0.7 mm Hg (the units of blood pressure) for every cm above or below the heart. For most people, that might translate to plus or minus 3-4 mm Hg, which may not affect treatment of blood pressure. On the other hand, that might be the difference between needing medicine or not, so it’s best to perform the technique correctly.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters at 628 Virginia Dr., Orlando, FL 32803. Health newsletters may be ordered from www.rbmamall.com.

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