Pelvic Congestion Syndrome – Causes, Symptoms, Treatment

Pelvic congestion syndrome (PCS) is one of the pelvic venous syndromes that is frequently misdiagnosed. It is a common cause of chronic pelvic pain in women of reproductive age. Pain that is intermittent or constant lasting for 3-6 months, present in the pelvic or abdominal region, occurring throughout the menstrual cycle, and without any association with pregnancy is chronic pelvic pain. Often chronic pelvic pain is severe enough to result in functional disability and warrant treatment. Nearly 10-20% of the gynecologic consultations are due to chronic pelvic pain complaints, and only 40% of them are referred for evaluation by a specialist.[rx]

Pelvic congestion syndrome, also known as pelvic vein incompetence, is a long term condition in women believed to be due to enlarged veins in the lower abdomen.^[rx][rx] The condition may cause chronic pain, such as a constant dull ache, which can be worsened by standing or sex.^[rx] Pain in the legs or lower back may also occur.^[rx]

Causes of Pelvic Congestion Syndrome

• The exact etiology of pelvic congestion syndrome is unclear. It is most likely dependent on multiple factors. The congestion of the pelvic veins can be due to hormones, insufficiency of the valve, and venous obstruction. The release of pain-inducing substances due to increased dilatation of the veins along with stasis is a likely cause of the pain in PCS.[rx]
• Pelvic venous insufficiency is due to the incompetency of the internal iliac vein, the ovarian vein, or both. It is often the underlying cause of pelvic congestion syndrome. Nearly 10% of women are suffering from ovarian varices. Of this 10%, about 60% have pelvic congestion syndrome.[rx]
• One theory is that hormonal changes and weight gain along with anatomic changes in the pelvic structure during pregnancy can cause an increase of pressure within the ovarian veins. This may weaken the vein wall leading to dilatation. Estrogen also can weaken the vein walls, predisposing women to PCS.
• What we do know is that in normal veins, blood flows from the pelvis up toward the heart in the ovarian vein and is prevented from flowing backward by valves within the vein. When the ovarian vein dilates, the valves do not close properly. This results in a backward flow of blood, also known as “reflux.” When this occurs, there is the pooling of blood within the pelvis. This, in turn, leads to pelvic varicose veins and clinical symptoms of heaviness and pain.

Symptoms of Pelvic Congestion Syndrome

Women with this condition experience a constant pain that may be dull and aching but is occasionally more acute. The pain is worse at the end of the day and after long periods of standing, and sufferers get relief when they lie down. The pain is worse during or after sexual intercourse and can be worse just before the onset of the menstrual period.^[rx]

Women with pelvic congestion syndrome have a larger uterus and a thicker endometrium. 56% of women manifest cystic changes to the ovaries,^[rx] and many report other symptoms, such as dysmenorrhea, back pain, vaginal discharge, abdominal bloating, mood swings or depression, and fatigue.

• Dull, aching or “dragging” pain in the pelvis or lower back, particularly on standing and worse around the time of your menstrual period
• An irritable bladder that sometimes leads to stress incontinence
• Irritable bowel (recurrent abdominal pain and diarrhea alternating with periods of constipation)
• Deep dyspareunia (discomfort during or after sexual intercourse)
• Vaginal or vulvar varicose veins (bulging veins around the front passage)
• Varicose veins of the top of the inner thighs or the back of the thighs

Diagnosis of Pelvic Congestion Syndrome

The pain associated with PCS presents as a dull ache or a sensation of heaviness in the pelvis. It can last 3 to 6 months and can be unilateral or bilateral. However, pain can switch from one side to the other. Any factor increasing the abdominal pressure (walking, postural changes, lifting, and longtime standing position) can increase the intensity of pain. It is often exacerbated before or during the menstrual periods. The intensity of pain worsens with each subsequent pregnancy, and during or after sexual intercourse the time of the day also affects the intensity with pain being worse at the end of the day.[rx]

If the findings of characteristic pelvic pain are present, physical examination can help in formulating the final diagnosis. The uterine tenderness, ovarian tenderness, and cervical motion tenderness on direct palpation during bimanual examination in a patient presenting with a complaint of chronic pelvic pain support the diagnosis of PCS.

Evaluation

The presence of characteristic pelvic venous changes on imaging supports the diagnosis but is not necessary for forming the final diagnosis. Dilated ovarian veins with incompetency of the valves is also a common finding in asymptomatic women.[rx]

For patients with PCS, in whom an intervention is being planned, require evaluation for pelvic venous reflux with ultrasound, retrograde internal iliac or ovarian venography, computed tomography (CT), or magnetic resonance (MR) imaging.[rx]

• Ultrasound – The first-line imaging study for pelvic congestion syndrome is pelvic ultrasound. Ultrasound helps rule out the presence of pelvic masses or uterine problems as the underlying cause for pelvic pain. Using color-Doppler and conventional B-mode ultrasound, the pelvic anatomy, ovarian changes, uterine enlargement, and dilated uterine and ovarian veins can be evaluated.[rx]  Retrograde flow of blood with an increase in the size of the left ovarian vein and a decrease in velocity of the blood flow can be observed using ultrasonography. Enlarged, tortuous pelvic venous channels can be noted. The incompetency of valves in the pelvic varicose veins can be noted using Valsalva’s maneuver. These varicoceles will show variable duplex waveforms on such maneuvers. Polycystic changes of the ovary are also seen in patients with pelvic congestion syndrome.[rx][rx]
• Computed tomography and magnetic resonance – The anatomical details of the pelvic vasculature along with the tissue of the pelvic cavity can be easily visualized with computed tomography and magnetic resonance imaging. Since CT utilizes radiation, it is not recommended in premenopausal women.[rx] The direction and velocity of flow in different vascular channels can be assessed with phase-contrast velocity mapping, which is an MRI based technique. This technique can be used to evaluate pelvic veins.[rx]
• Venography – The gold standard for diagnosing pelvic congestion of the vasculature is ovarian and iliac catheter venography. Ovarian veins are catheterized by approaching via percutaneous jugular and femoral pathway. The distension of the venous channels is better assessed when a venogram is done during Valsalva. Venographic diagnostic findings of PCS that can be seen include incompetent pelvic veins (with diameter more than 5-10mm), and congestion of flow in venous channels of ovarian, pelvic, vulvovaginal, and thigh veins. Venous reflux in ovarian veins can also be noted.[rx]
• Laparoscopy – Chronic pelvic pain is a major cause of gynecologic diagnostic laparoscopies. According to certain reports, more than 40 percent of such laparoscopic procedures are due to chronic pelvic pain.[rx] The rate for the occurrence of pathological findings identified on laparoscopies on women with chronic pelvic pain range between 35% and 83%. In 20% of these cases, pelvic congestion is also identified.[rx]

Treatment of Pelvic congestion syndrome

Medical management should be the first-line treatment for PCS. This is due to decreased complications of medical management as compared to invasive procedures. Gonadotropin-releasing hormone agonists, danazol, combined oral contraceptives, progestins, phlebotomists, and non-steroidal anti-inflammatory drugs are a few treatment options that have shown effective management for the pain in PCS.[rx] Etonogestrel implant, goserelin, and medroxyprogesterone acetate have also been successful in alleviating the pain associated with PCS.[rx] Improved pain relief is observed when medroxyprogesterone is given along with psychotherapy.[rx] Goserelin, a GnRH agonist, has better results in controlling the pain as compared to medroxyprogesterone acetate, but it cannot be continued beyond 1 year due to it being a GnRH agonist.[rx]

Medical treatment of PCS includes psychotherapy, progestins, danazol, phlebotomists, gonadotropins receptor agonists (GnRH) with hormone replacement therapy (HRT), dihydroergotamine, and nonsteroidal anti-inflammatory drugs (NSAIDS). Specifically, the literature supports the use of medroxyprogesterone acetate (MPA), or the GnRH analog goserelin in an effort to suppress ovarian function and/or increase venous contraction. MPA may be given orally 30 mg/day for 6 months. Goserelin acetate is dosed as an injection of 3.6 mg monthly over a 6-month period. As chemical ovarian ligation has numerous side effects, estrogen replacement or “add-back” therapy is frequently required as well.¹²

Ligation of incompetent ovarian veins can lead to favorable results. In nearly 75% of women, ligation of the incompetent ovarian or pelvic vessels leads to the resolution of the symptoms. Gynecologists have used bilateral salpingo-oophorectomy and hysterectomy as a treatment for pelvic congestion syndrome, but the results were not favorable.[rx]

The ablation of incompetent veins can also be achieved by endovascular procedures using a minimally invasive approach. These procedures can be performed in an outpatient setting leading to comparatively quick recovery and fewer complications.[rx] Different agents like platinum embolization coils, glue, foam, or liquid sclerosants can be used for causing endothelial damage in the incompetent vessels.[rx]

Embolotherapy for PCS is an exciting therapy that has proven to be safer over the past 2 decades. A more recent article by Chung et al examined the effect of patient stress level on treatment efficacy, directly comparing hysterectomy with oophorectomy versus venous embolization for the treatment of PCS. Using both the social readjustment rating scale and visual analog pain scale, patients were divided into subsets. Following a directed comparison of the subgroups after treatment, analysis of pain scores showed that venous embolization was more effective than hysterectomy, especially for patients who are “typically or moderately highly stressed. Kim et al has demonstrated that PCS patients who underwent ovarian and pelvic venous embolization have a more durable result in a reduction of their pelvic pain.^[rx]

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.
• Before your visit, write down the questions you want to be answered.
• Bring someone with you to help you ask questions and remember what your healthcare provider tells you.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also, write down any new instructions your provider gives you.
• Know why a new medicine or treatment is prescribed, and how it will help you. Also, know what the side effects are.
• Ask if your condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you do not take the medicine or have the test or procedure.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your healthcare provider if you have questions.

• https://www.ncbi.nlm.nih.gov/books/NBK560790/
• https://www.ncbi.nlm.nih.gov/books/NBK338514/
• https://www.ncbi.nlm.nih.gov/books/NBK79386/
• https://www.ncbi.nlm.nih.gov/books/NBK338506/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036528/