Pelvic Congestion Syndrome

Pelvic congestion syndrome (PCS) is a common cause of chronic pelvic pain due to blood flow issues in the veins in your pelvis. It can involve other symptoms, like swelling in your vulva and legs. PCS most often affects females who are 20 to 45 years old and have given birth more than once.

The pelvic pain associated with PCS typically involves faulty veins in your ovaries and pelvis. The veins widen (dilate) and may twist and overfill with blood. As a result, blood may pool in your pelvis and cause pain.

Pelvic congestion syndrome isn’t life-threatening. But it can disrupt your quality of life and keep you from activities you enjoy. See a healthcare provider if you have long-term pelvic pain. Medications or vein procedures may help lessen your symptoms.

Symptoms of pelvic congestion syndrome

Pelvic pain that lasts longer than six months is the most common symptom of pelvic congestion syndrome. But it can cause other symptoms, too.

The pain typically feels dull, achy or heavy. You feel it throughout your menstrual cycle, not just during your period. You may have it on one or both sides of your pelvis. The pain may get worse:

• At the end of the day
• Before and during your period
• During and after sex
• When you stand, walk or sit for long periods (but feels better when you lie down)
• When you do heavy lifting
• With each pregnancy you have

Other symptoms of PCS may include:

• Varicose veins in your genital region and/or upper thighs
• Leg pain, swelling or heaviness
• Painful periods
• Swollen vulva
• Vaginal discharge
• Persistent genital arousal
• Urgency to pee or pain while peeing
• Pain in your butthole
• Bloating and nausea

Chronic pelvic pain and other symptoms of PCS can take a toll on your quality of life. You may be at increased risk of depression, anxiety and general fatigue. Reach out to a mental health provider if this condition causes distress.

Pelvic congestion syndrome causes

Researchers don’t know the exact cause of pelvic congestion syndrome. Many factors likely contribute to it. Problems with blood flow in your ovarian and pelvic veins play a big role. This happens due to issues with the valves that help keep blood moving in the right direction. It’s called pelvic venous insufficiency.

Normally, blood flows upward from your pelvic veins and toward your heart via the veins in your ovaries. Valves in your veins prevent blood from flowing backward. Backflow of blood is called reflux.

With PCS, veins are so widened that the valves don’t prevent reflux. Blood flows backward through the veins. They become overly filled and twisted. Blood pools in your pelvic veins and causes pain. The pain may result from vein stretching. Or the misshapen veins may touch nearby nerves in your pelvis, triggering pain.

Two main theories of how these vein issues happen include:

• Pregnancy: Blood vessels expand 50% of their normal size during pregnancy. These changes may cause long-term damage to your blood vessel walls.
• Estrogen: PCS is uncommon among women who’ve been through menopause, when there’s a big drop in estrogen. This means estrogen may be involved. Estrogen’s effects on your blood vessel walls may make you more prone to PCS.

Risk factors

Risk factors for PCS include:

• High number of pregnancies
• Biological family history of pelvic pain
• Polyendocrine metabolic ovarian syndrome (PMOS) (formerly, polycystic ovary syndrome, PCOS)
• Estrogen therapy
• Varicose veins in your lower limbs
• Vein inflammation (phlebitis)
• Prolapsed uterus
• Previous pelvic surgery
• Anatomical compression syndromes

How doctors diagnose this condition

Your healthcare provider will ask about your medical history and symptoms. You’ll likely have a physical and pelvic exam. They’ll check for tenderness in your ovaries, cervix and uterus.

Imaging can help your provider rule out other conditions that also cause chronic pelvic pain. It can also identify structural issues with your veins related to PCS. Imaging procedures include:

• Ultrasound: Your provider will likely start with an ultrasound. It checks for other causes of pelvic pain. It can also show vein dilation and whether your blood flows backward.
• MRI or CT scan: These scans can show details in your veins that an ultrasound may miss. They can show twisted and widened veins in greater detail.
• Pelvic venogram: This is the gold standard for PCS imaging. It’s an X-ray procedure that uses contrast dye to show blood flow in your veins. It shows where dilated and twisted veins are and how blood flows and pools.
• Laparoscopy: This procedure can show if your veins are dilated. But it may not be as helpful as other procedures. Your provider makes tiny cuts in your abdomen that allow them to view your reproductive organs.

Diagnosing pelvic congestion syndrome can be challenging. This is because vein issues don’t guarantee that PCS is the cause of your pelvic pain. Some people have vein abnormalities without symptoms. It’s also possible to have more than one condition that causes pelvic pain.

Because of this, providers usually aim to rule out all other possible causes of pelvic pain before diagnosing PCS. You may need to see more than one medical specialist throughout the process.

How is it treated?

Treatment for pelvic congestion syndrome involves a range of options. There isn’t a go-to treatment. At first, your healthcare provider may recommend one or more of the following:

• Medications
• Compression therapy, like compression stockings
• Pelvic floor physical therapy
• Talk therapy for pain management

These treatments may not provide long-term relief. Because of this, your provider may recommend a procedure to directly treat abnormal veins.

Medications

Medications that limit estrogen production may help relieve pain due to PCS. They include:

• GnRH agonists, like goserelin (Zoladex®)
• Combined birth control pills
• Medroxyprogesterone acetate (Depo-Provera® and Provera®)
• Etonogestrel implant (Nexplanon®)

Another medication that your provider may suggest is micronized purified flavonoid fraction (MPFF). It triggers your veins to contract so they’re not as wide.

Each of these medications has potential side effects. Your provider will go over them with you.

Procedures

Your healthcare provider may suggest a medical procedure to treat abnormal veins directly. These include:

• Ovarian vein embolization or sclerotherapy: Your provider places a catheter into the faulty veins. They send chemicals through the catheter to irritate or inflame the veins. They also insert tiny metal coils, glue or foam to prevent reflux.
• Laparoscopy: Your provider ties off the veins, preventing reflux.
• Bilateral salpingo-oophorectomy: Your provider may remove your pelvic organs (uterus, fallopian tubes and ovaries) if you don’t have plans for a future pregnancy. This surgery is rare for PCS.

Each of these procedures has risks and possible complications. Your provider will walk you through them.

What can I expect if I have this condition?

Most people who get treatment for pelvic congestion syndrome experience pain relief. But there isn’t much research on how long these benefits last.

Your symptoms may return. Each case is different. Stay in contact with your healthcare provider. There may be other treatment options you can try.

After menopause, you may have significant symptom improvement.

Can men have pelvic congestion syndrome?

Yes, but it’s much rarer. Enlarged scrotal veins (varicocele) are a common issue in males. PCS affects other veins in your pelvic area.

PCS pain usually feels like a dull ache in your scrotum, lower abdomen or perineum. The pain may spread to your thighs or buttocks. It may worsen with standing or physical activity.