Leg pain caused by venous reflux disease often presents as leg pain, heaviness, fatigue, that tends to get worse throughout the day and with standing. It may be worse in hot weather. Women may experience worsening symptoms during menstruation from hormonal influence. Night-time symptoms of leg cramping and restlessness is common. There may or may not be visible signs of venous disease, as venous reflux usually starts in veins that are not visible to the naked eye before becoming visibly apparent. Signs of vein disease include varicose veins (bulging, twisted, enlarged veins and the surface of the skin), spider veins, ankle swelling, and long term venous reflux, called chronic venous insufficiency can cause the skin to darken around the ankles and ulcerate.