Pelvic Congestion Syndrome Diagnosis and Treatment

What is pelvic congestion syndrome?

Pelvic congestion syndrome, also referred to as pelvic venous insufficiency, is a chronic pain disorder involving blood flow abnormalities in the pelvic veins. The term "chronic" denotes pain persisting for over six months and unrelated to menstrual cycles or pregnancy.

This pain often arises due to defective veins in the ovaries and pelvis. These veins may dilate (expand), twist, and become overfilled with blood. Consequently, blood can accumulate in the pelvis, leading to discomfort and pain.

Who does pelvic congestion syndrome affect?

PCS predominantly affects individuals aged between 20 and 45 years who have given birth more than once. Additional risk factors include:

• The presence of varicose veins.
• A family history of varicose veins.
• Polycystic ovarian syndrome (PCOS).

It is unusual for those who have undergone menopause to develop pelvic congestion syndrome.

How common is pelvic congestion syndrome?

Chronic pelvic pain accounts for approximately 40% of gynaecological consultations. Among these, it is estimated that up to 30% of cases may be linked to pelvic congestion syndrome.

What are the symptoms of pelvic congestion syndrome?

The pelvic pain associated with PCS can range from dull, achy, or heavy sensations to sharp, intense pain (though the latter is less common). This pain often occurs on the left side of the pelvis but can also present on the right or both sides. Pain frequently begins during or shortly after pregnancy and tends to worsen with subsequent pregnancies.

Pain related to PCS is typically exacerbated under the following circumstances:

• Towards the end of the day.
• Before and during menstruation.
• During and following intercourse (dyspareunia).
• When standing or sitting for extended periods (improves when lying down).

Other symptoms may include:

• Varicose veins around the buttocks, thighs, pelvis, thighs, vagina and vulva.
• Alternating diarrhoea and constipation (linked to irritable bowel syndrome).
• Stress incontinence (accidental urination triggered by laughing, coughing, or similar actions that strain the bladder).
• Painful urination (dysuria).

What causes pelvic congestion syndrome?

The precise cause of PCS is unknown, but it is associated with impaired blood flow in the veins of the ovaries and pelvis.

Normally, blood travels upwards from the pelvic veins to the heart through the ovarian veins. Valves within the veins prevent the backflow of blood, a process referred to as reflux. In cases of PCS, excessively dilated veins cannot effectively stop reflux. The blood flows backwards, overfills the veins, and twists them. Blood accumulation in the pelvic veins results in pain, potentially due to the strain imposed on overstretched veins as they accommodate excess blood. Additionally, these misshapen veins may press against nearby pelvic nerves, triggering further pain.

The structural abnormalities in pelvic veins seen with PCS might result from several factors, including:

Pregnancy

One prevailing theory links PCS to changes in blood vessels during pregnancy. During this time, blood vessels expand to 50% of their normal size to accommodate increased blood flow for foetal development. These adaptations may cause lasting damage to vein walls, leaving them permanently dilated even after childbirth.

Oestrogen

The rarity of PCS among postmenopausal individuals suggests that oestrogen plays a role. Following menopause, oestrogen levels drop significantly. This hormone may influence vein walls, making them more prone to defects that contribute to PCS.

It is likely that PCS arises from a combination of these interconnected factors.

Diagnosis and Tests

How is pelvic congestion syndrome diagnosed?

Your doctor or healthcare provider will gather information about your medical history and symptoms. A physical examination, including a pelvic exam, will likely be conducted. During this time, your doctor will check for tenderness in your uterus, cervix and ovaries to find the origin of the pain.

Imaging techniques are used to rule out other conditions causing chronic pelvic pain and identify possible vein irregularities associated with pelvic congestion syndrome (PCS). Common imaging procedures include:

• Ultrasound: This is typically the first imaging test ordered. It can reveal vein dilation and help identify abnormalities causing pain. If the Doppler feature is used, it can also detect backward blood flow.
• MRI or CT scan: These scans offer more detailed visuals of vein dilation and twisted veins in the ovaries and pelvis, which an ultrasound might miss. Additionally, they can identify other possible causes of chronic pain, such as irregular growths related to endometriosis.
• Pelvic venography: This is considered the most reliable imaging method for PCS but is more invasive, so it is typically reserved for cases where other tests provide insufficient information. It's also used in preparation for vein-related procedures. During this test, a catheter is inserted into a vein (usually in the neck or groin), guided by X-rays into the ovarian veins, and a safe dye is injected. This process makes twisted and dilated veins visible on X-rays, along with blood flow patterns and pooling.
• Laparoscopy: While laparoscopy can reveal dilated veins, it is generally less effective for identifying PCS-related blood flow issues. It may be used to exclude other conditions, such as endometriosis, that could be causing pelvic pain. The procedure involves making small incisions in the abdomen and inserting a specialised device to examine reproductive organs.

Diagnosing Pelvic Congestion Syndrome can be difficult because people without pelvic pain may also have vein irregularities. Imaging may reveal dilated veins, but treatment is not required unless chronic pain is present. It is usually diagnosed after other potential causes of pelvic pain have been ruled out.

Is there a cure for pelvic congestion syndrome?

While there is no definitive cure for pelvic congestion syndrome, a combination of medications and medical procedures can effectively alleviate symptoms.

Are there treatment options for pelvic congestion syndrome?

You may work with multiple specialists, such as a gynaecologist, gastroenterologist, pain management expert, or physical therapist. Your care plan usually begins with medication to control symptoms before exploring surgical options.

Medications

Medications to suppress oestrogen production can reduce PCS-related pain. These may include:

• Medroxyprogesterone acetate (Depo-Provera®)
• Etonogestrel implants (Implanon®)
• GnRH agonists
• Goserelin

Procedures

When medications fail to provide sufficient relief, medical procedures may be recommended:

• Ovarian vein sclerotherapy or embolisation: This minimally invasive procedure blocks problematic veins. A catheter is inserted into the faulty ovarian and pelvic veins, and chemicals, tiny metal coils, glue, or foam are introduced to block backward blood flow and prevent pooling.
• Laparoscopy: This surgical option involves tying off veins to stop blood reflux and pooling.
• Bilateral salpingo-oophorectomy: In rare cases, when other treatments fail, the doctor may remove reproductive organs such as the uterus, fallopian tubes, and ovaries. This option is usually considered only when the individual no longer wishes to conceive.

How can pelvic congestion syndrome be prevented?

Currently, there are no known methods to prevent pelvic congestion syndrome.

Is pelvic congestion syndrome life-threatening?

Pelvic congestion syndrome is not life-threatening but can significantly impact your quality of life by limiting your ability to enjoy daily activities. It is essential to consult your doctor if chronic pelvic pain is disrupting your life.

What is to be expected with pelvic congestion syndrome?

While there is no single standard treatment for PCS, outcomes for pain-relief interventions are generally positive. For example, approximately 75% of individuals experience relief after ovarian vein embolisation, with recurrence in only 5% of cases.

What questions should I ask my doctor?

When discussing PCS with your doctor, consider asking:

• Will I need to see multiple specialists for diagnosis or treatment?
• Which medications would you recommend to manage my symptoms?
• At what point would you suggest a medical procedure?
• Which specific procedure is most suitable for my case?
• What risks are associated with the recommended procedures?

In Conclusion

Diagnosing the cause of pelvic pain can take time because many conditions may contribute to pain in this region. You may need several diagnostic tests and input from various specialists to confirm PCS. Medications often provide significant symptom relief, but medical procedures are available to help if these do not work. Promptly seek care to reduce discomfort and enhance your quality of life.

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