Pelvic Congestion Syndrome

What is pelvic congestion syndrome (PCS)?

Pelvic congestion syndrome is a cause of pelvic pain in 13-14% of women. It can also be known as ovarian vein reflux. It is like having varicose veins, but inside the pelvis – the veins around the pelvic organs become swollen. 

This pressure from the swollen veins is what is thought to cause the pelvic pain. The swelling may also involve the vulva, vagina, inner thigh, sometimes the buttocks and down the legs.

What are the symptoms of pelvic congestion syndrome?

Chronic pelvic pain is pain in the lower abdomen which has been present for more than 6 months. It can be one sided, but both sides can be affected. It’s worse when doing anything that increases the pressure in the abdomen, such as standing, lifting and pregnancy. Lying down can help the symptoms feel better.

Symptoms include:

• Pain or aching around the pelvis and lower abdomen;
• A dragging or fullness sensation in the pelvis, vagina, pelvis and legs;
• Passing urine accidentally when coughing/sneezing/jumping;
• Deep pain during sex and/or aching in the pelvis after sex;
• Worsening irritable bowel syndrome symptoms such as bloating, constipation or diarrhoea;
• Vaginal discharge without a known cause;
• Difficulty getting pregnant.

The veins are also affected by hormones and the menstrual cycle so there may be a pattern to when the pain is worse  (e.g. during a period or around ovulation).

What is the cause of pelvic congestion syndrome

The cause of pelvic congestion syndrome is not fully understood. It tends to occur in younger women, especially those who have had at least one child. The average age when someone first has the condition is around 33.

Increased Vein Pressure

During pregnancy the ovarian veins are either squashed as the womb gets bigger, or they enlarge because of increased blood flow to the womb. Veins have little one-way valves in them that keep blood flowing back towards the heart. However, if there is a lot  of pressure applied to the vein (such as when the womb is pressing on it), it can damage the valves and blood can leak back through them causing swelling. 

Birth defects and family history

Being born without valves can lead to pelvic vein congestion syndrome and varciose veins are usually pretty obvious from an early age. Pelvic congestion syndrome can also run in families.

Hormones

Oestrogen causes blood vessels to dilate, so high levels are thought to contribute to the development of pelvic congestion syndrome (another reason why pregnancy makes this worse, and why it tends not to happen in women who are post-menopausal).

Obstruction of the ovarian and pelvic veins

If the veins become blocked for whatever reason, this can cause pelvic congestion syndrome (e.g. a tumour), although this is much less common.

Polycystic Ovaries

It can be associated with polycystic ovaries, probably due to the hormonal fluctuations this condition can cause. PCOS can also cause weight gain, and this is another risk factor for developing PCS. 

How is pelvic congestion syndrome diagnosed?

Examination

The first way to diagnose pelvic congestion syndrome is through examination. It may be possible to see varicose veins on the vulva and they may extend down the inner thighs. Abdominal tenderness can be both sides or one side on examination.

Scans

The next step is to have an ultrasound scan of the pelvis. It can help to detect the abnormal veins by showing how blood flows through them. 

If this doesn’t help to identify the abnormal veins, then other scans like magnetic resonance imaging (MRI) and computed tomography (CT) may be needed, especially if treatment needs to be planned.

Pelvic Venogram

Pelvic venography is then used to plan the correct course of treatment. This is a more invasive test, but it is a simple and safe procedure. It is done by injecting dye (contrast) that can be seen on the x-ray machine through a small tube placed in the vein at the groin or neck using local anaesthetic. The contrast is then injected and the images seen on the x-ray machine give a picture of the veins. 

How is pelvic congestion syndrome treated?

Medication

Hormonal contraception can help by stopping ovulation and the surge in oestrogen during a cycle. Progesterone only contraceptives are particularly helpful. Provera is another hormonal treatment that is not used for contraception, but is progesterone only and can help reduce pain (at a dose of 30mg per day). Unfortunately it may not help long term once stopped.

An alternative is to bring on a chemical menopause, such as goserelin. This can be used for 6 months and is helpful to reduce the pain, but unfortunately comes with menopausal side effects including a risk of bone thinning. 

Hormonal treatments impact fertility, so they aren’t always the best to start with.

Pelvic vein embolisation

The usual treatment is a procedure called pelvic vein embolisation. This is a minimally invasive treatment that can be done as a day-case (not needing to stay in hospital overnight). During this procedure (similar to the venogram described above), metallic coils are placed in the abnormal veins to block them. Sometimes this is in combination with a foam that helps to block it further. 

Following the procedure, recurrence rates are reported to be less than 8%. Improvement of symptoms occurs within the first 2 weeks in 70 – 85 % of treated patients, and 83% of patients continue to show symptom improvements for many years afterwards.

Surgery

Other treatment options are open or laparoscopic surgery to tie the affected veins, or a hysterectomy (removal of the womb and cervix). These are of course more invasive, carry risks and need careful consideration before being done.

Final thoughts

There are many people with pelvic congestion syndrome and they don’t even know it. If you’re struggling with abdominal pain that doesn’t seem to “fit” a condition like endometriosis, then it’s worth speaking to a doctor and asking if you could be investigated for pelvic congestion syndrome.

Sources

1. Dr Shaheen Dixon, Dr Charles Ross Tapping, Dr Wei Chuen Liong and Dr Dinuke Warakaulle: Departments of Radiology, John Radcliffe Hospital, Oxford and Stoke Mandeville Hospital, Aylesbury; Pelvic Venous Congestion Syndrome: https://www.bsir.org/patients/pelvic-venous-congestion-syndrome/#what-is-pelvic-venous-congestion-syndrome 
2. Pelvic Congestion Syndrome: https://www.cedars-sinai.org/health-library/diseases-and-conditions/p/pelvic-congestion-syndrome.html 
3. GP Notebook: Pelvic Congestion Syndrome: https://gpnotebook.com/simplepage.cfm?ID=1093992460 
4. Andrew Prentice BSc, MA, MD, MRCOG (2000); Medical management of chronic pelvic pain: https://www.sciencedirect.com/science/article/abs/pii/S1521693499900871?via%3Dihub 
5. Mark A Bittles, Eric K Hoffer (2008): Gonadal vein embolization: treatment of varicocele and pelvic congestion syndrome; https://pubmed.ncbi.nlm.nih.gov/21326516/ 
6. Boston Scientific Patient  Leaflet: https://www.bostonscientific.com/content/dam/bostonscientific/pi/portfolio-group/pelvic/patient_leaflet/FV_BVS171718_Patient_Leaflet_PCS_210x210_72dpi.pdf 
7. Arul Ganeshan, Sara Upponi, Lye-Quen Hon, M C Uthappa, Dinuke R Warakaulle, Raman Uberoi (2007): Chronic pelvic pain due to pelvic congestion syndrome: the role of diagnostic and interventional radiology; https://pubmed.ncbi.nlm.nih.gov/17805925/ 
8. Boleslaw Bendek, Nicole Afuape, Elizabeth Banks, Nita A Desai (2020): Comprehensive review of pelvic congestion syndrome: causes, symptoms, treatment options; https://pubmed.ncbi.nlm.nih.gov/32487799/
9. Darci Phillips, MD, PhD, Amy R. Deipolyi, MD, PhD, Richard L. Hesketh, MB, BCh, MPhil (2014); Pelvic Congestion Syndrome: Etiology of Pain, Diagnosis, and Clinical Management: https://www.jvir.org/article/S1051-0443(14)00103-1/fulltext