Pelvic Congestion Syndrome – Chronic Pelvic Pain in Women

It is estimated that 39% of all women will experience chronic pelvic pain in their lifetimes. Chronic pelvic pain is the reason for 15% of all outpatient gynecological visits. Studies indicate that 30% of the patients who consult their gynecologists for this pain are actually suffering from pelvic congestion syndrome. Often difficult to detect, this is a real medical condition that can be treated when properly diagnosed. The causes of chronic pelvic pain are varied, but are often associated with the presence of ovarian and pelvic varicose veins. Pelvic congestion syndrome is similar to varicose veins in the legs. In both cases, the valves in the veins that help return blood to the heart against gravity become weakened and don’t close properly, this allows blood to flow backward and pool in the vein causing pressure and bulging veins. In the pelvis, varicose veins can cause pain and affect the uterus, ovaries and vulva. Up to 15 percent of women, generally between the ages of 20 and 50, have varicose veins in the pelvis, although not all experience symptoms.

Pelvic congestion syndrome can be a difficult diagnosis because its symptoms often mimic other conditions which must be ruled out first. There are several minimally invasive techniques for diagnosis, including MRI and ultrasound. Many women with pelvic congestion syndrome spend many years trying to get find out why they have chronic pelvic pain. Living with chronic pelvic pain is difficult and affects not only the woman directly, but also her interactions with her family, friends, and her general outlook on life. Because the cause of the pelvic pain is not diagnosed, no therapy is provided even though there is therapy available.

If you have pelvic pain that worsens throughout the day when standing, or any of the other symptoms mentioned below, you may want to seek a second opinion from the clinicians from MakrisMD.  He will work with your gynecologist to determine the best treatment option for your pain.

A Common Condition

• Women with pelvic congestion syndrome are typically less than 45 years old and in their childbearing years.
• Ovarian veins increase in size related to previous pregnancies. Pelvic congestion syndrome is unusual in women who have not been pregnant.
• Studies show 30% of patients with chronic pelvic pain have pelvic congestion syndrome (PCS) as a sole cause of their pain and an additional 15% have PCS along with another pelvic pathology.

Risk Factors

• Two or more pregnancies
• Hormonal dysfunction
• The presence of small ovarian cysts

Symptoms

The chronic pain that is associated with this disease is usually dull and aching. The pain is usually felt in the lower abdomen and lower back. The pain often increases during the following times:

• Following intercourse
• Menstrual periods
• When tired or when standing (worse at end of day)
• Pregnancy

Other symptoms include:

• Irritable bladder
• Abnormal menstrual bleeding
• Vaginal discharge
• Varicose veins on vulva, buttocks or thigh.

Diagnosis and Assessment

Once other abnormalities or inflammation have been ruled out by a thorough pelvic exam, pelvic congestion syndrome can be diagnosed through several minimally invasive methods. An interventional radiologist, using imaging for guidance, will use the following techniques to confirm pelvic varicose veins that could be causing chronic pain.

Pelvic Venography: Thought to be the most accurate method for diagnosis, a venogram is performed by injecting contrast in the veins of the pelvic organs to make them visible during an X-ray. To help accuracy of diagnosis, interventional radiologists examine patients on an incline, because the veins decrease in size when a woman is lying flat.

MRI: May be the best non-invasive way of diagnosing pelvic congestion syndrome. The exam needs to be done in a way that is specifically adapted for looking at the pelvic blood vessels. A standard MRI may not show the abnormality.

Pelvic Ultrasound: Usually not very helpful in diagnosing pelvic congestion syndrome unless done in a very specific manner with the patient standing while the study is being done. Ultrasound may be used to exclude other problems that might be causing pelvic pain.

Transvaginal Ultrasound: This technique is used to better see inside the pelvic cavity. As with a pelvic ultrasound it is not very good at visualizing the pelvic veins unless the woman is standing. However it may be used to exclude other problems.

Treatment Options

Once a diagnosis is made, if the patient is symptomatic, an embolization should be performed. Embolization is a minimally invasive procedure performed by interventional radiologists using imaging for guidance. During the outpatient procedure, the interventional radiologist inserts a thin catheter, about the size of a strand of spaghetti, into the femoral vein in the groin and guides it to the affected vein using X-ray guidance. The physician inserts tiny coils through the catheter to seal the faulty, enlarged vein, closing the vein and relieving pressure. Embolization is performed on an outpatient basis and the procedure is usually completed within an hour. Additional treatments are available depending on the severity of the woman’s symptoms. Analgesics may be prescribed to reduce the pain. Hormones such as birth control pills which decrease a woman’s hormone levels, causing menstruation to stop, may be helpful in controlling her symptoms. Surgical options include a hysterectomy with removal of ovaries, and tying off or removing the veins.

Efficacy

In addition to being less expensive than and much less invasive than surgery, embolization offers a safe, effective, minimally invasive treatment option.The procedure is successfully performed in 95-100 percent of cases. A large percentage of women experience improvement in their symptoms, between 85-95 percent of women are improved after the procedure. Although women are usually improved, the veins are never normal and in some cases other pelvic veins are also affected which may require further treatment.