Everything You Need to Know About Pelvic Congestion Syndrome

Pelvic congestion syndrome is an underappreciated and often misdiagnosed cause of chronic pelvic pain that mostly occurs in women who are premenopausal.  On average, about 30 – 40 percent of premenopausal women with chronic pelvic pain suffer from this condition. Pelvic congestion syndrome is not a life-threatening disorder; however, this condition can significantly impair the quality of life of women suffering from it.

What is Pelvic Congestion Syndrome?

Pelvic congestion syndrome, also known by some as ovarian vein reflux, is a cause of chronic pelvic pain secondary to the pooling of the blood in veins of the ovaries and pelvis, similar to varicose veins in the legs. Normally, blood flows from the ovarian and pelvic veins into the inferior vena cava which then returns deoxygenated blood back to the heart. In pelvic congestion syndrome, however, there is an obstruction that prevents blood from flowing from the pelvic and ovarian veins back to the heart; alternatively, these veins may be abnormally dilated such that blood flow back to the heart is poor and sluggish. In either of these circumstances, blood pools up in the ovarian as well as pelvic veins; as such, affected women may have a feeling of heaviness and pain in their pelvic area. This pooling of blood can also further worsen the dilation of the ovarian and pelvic veins which results in more blood pooling, thereby worsening this condition.

Causes of Pelvic Congestion Syndrome

There are no known, definite causes of pelvic congestion syndrome. However, there are several predisposing factors that increase a premenopausal woman’s risk of developing this condition:

  • Previous pregnancies: Women who have had 2 or more previous pregnancies have a higher risk of developing this condition.
  • Previous pelvic surgery: Having pelvic surgery can increase a woman’s risk of developing pelvic congestion syndrome
  • Anatomic abnormalities: There are several anatomic anomalies which could result in an increased risk of a woman developing pelvic congestion syndrome. In the Nutcracker phenomenon, the left ovarian and left renal veins are obstructed by the superior mesenteric artery, thereby impeding the flow of blood back to the heart. In May-Thurner syndrome, the left iliac vein is compressed by the right iliac artery, preventing return blood flow to the heart.

Signs and Symptoms of Pelvic Congestion Syndrome

Part of the reason that pelvic congestion syndrome is underdiagnosed is because it has non-specific signs and symptoms. Some of the presenting features that would make a provider suspect this condition are:

  • Pain: The pain is typically greater than 6 months and is localized to the lower abdomen or pelvic area. This pain worsens when standing, lifting, during pregnancy, during or after intercourse. The pain symptoms are relieved by either resting or lying down.
  • Stress incontinence: The pooled blood in the dilated ovarian and pelvic veins can increase the pressure placed on the bladder. As such, affected women may have a decreased ability to control their bladder and may, therefore, become stress incontinent.
  • Irritable bowel syndrome: Similar to stress incontinence, the dilated pelvic and ovarian veins can increase the pressure placed on the large intestines. For women already suffering from irritable bowel syndrome, this increased pressure may worsen their symptoms.

Differential Diagnosis of Pelvic Congestion Syndrome

Due to the sometimes vague and non-specific symptoms of pelvic congestion syndrome, the provider often has to rule out other disease conditions that may cause chronic pelvic pain. Some of these conditions include:

  • Endometriosis
  • Metastatic cancer
  • Irritable bowel syndrome
  • Ovarian cysts
  • Fibromyalgia
  • Fibroid tumors
  • Pelvic Inflammatory Disease (PID)
  • Pregnancy

Diagnosis of Pelvic Congestion Syndrome

Before a definitive diagnosis of pelvic congestion syndrome can be made, tests have to be done to rule out all the other possible causes of chronic pelvic pain in premenopausal women listed above. Once these tests have been performed to exclude other causes of chronic pelvic pain, definite tests that can be done to establish a diagnosis of pelvic congestion syndrome include:

  •  Ultrasound: This non-invasive procedure is typically the first diagnostic test done to prove that a woman is suffering from pelvic congestion syndrome. The ultrasound can either be abdominal or transvaginal and may reveal the presence of dilated pelvic or ovarian veins suggestive of pelvic congestion syndrome.
  • CT venogram: The CT venogram is a non-invasive diagnostic test, just like the ultrasound. This procedure involves the use of a CT scan machine to scan the pelvic and ovarian veins. It is better than the ultrasound in visualizing abnormally dilated pelvic or ovarian veins.
  • MRI venogram: This is similar to the CT venogram, the only difference being that an MRI machine is used to perform the testing rather than a CT machine.
  • Pelvic venography: This is the gold standard in the diagnosis of pelvic congestion syndrome. With pelvic venography, a contrast dye is placed using local anesthetic into the common femoral or internal jugular vein. An x-ray machine is then used to take several images as the dye spreads throughout the venous system. Abnormal vessels can then be easily located and visualized. Any areas of obstruction are also highlighted by the contrast as well.

Treatment of Pelvic Congestion Syndrome

Once a diagnosis has been established, there are several treatment modalities available to treat pelvic congestion syndrome and provide relief:

  • Non-steroidal anti-inflammatory drugs (NSAIDs): NSAIDs can be taken to provide symptomatic relief from the chronic pain that is associated with pelvic congestion syndrome. However, these medications do not address the underlying cause of the pelvic pain, which is the insufficiency of the pelvic or ovarian veins.
  • Medroxyprogesterone acetate (MPA): This suppresses ovarian function and increases venous contraction, thereby enhancing the flow of blood back to the heart.
  • Goserelin: This is a Gonadotropin-releasing hormone (GnRH) analogue which functions similar to Medroxyprogesterone acetate in increasing venous contraction as well as suppressing ovarian function.
  • Foam sclerotherapy: With this procedure, the provider inserts a catheter close to the dilated pelvic or ovarian veins. When this is done, a substance known as a sclerosant is injected into these veins which then seals up the veins. The pain symptoms are improved once all the dilated veins are completely sealed up.
  • Pelvic vein embolization: Female pelvic vein embolization is the gold standard in the treatment of pelvic congestion syndrome. Typically, a catheter is placed through the internal jugular, femoral, subclavian, or brachial veins and directed to the site of the dilated pelvic or ovarian veins. Tiny coils are then inserted into the dilated veins which then results in the development of clots. These clots then seal off the dilated veins and provide relief from pelvic congestion syndrome.

At the Ultimate Vein Guide, we have the knowledge and expertise necessary to address any vein issues that you might be having. Consult us today so that we can perform an assessment and suggest the treatment modality best suited to take care of your condition.

Sources

https://www.amjmed.com/article/S1561-8811(15)00191-1/pdf

https://www.bsir.org/patients/pelvic-venous-congestion-syndrome/

https://www.merckmanuals.com/home/women-s-health-issues/menstrual-disorders-and-abnormal-vaginal-bleeding/pelvic-congestion-syndrome

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036528/

https://www.atlantichealth.org/content/dam/atlantichealth-v2/vascular-lab-symposium/Primary%20Pelvic%20Congestion%20Syndrome.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500858/

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