Pelvic Congestion Syndrome

What is pelvic congestion syndrome?

Pelvic congestion syndrome — also called pelvic venous insufficiency — is a chronic pain condition associated with blood flow problems in your pelvic veins. “Chronic” means pain lasting longer than 6 months that isn’t associated with either your menstrual cycle or pregnancy.

The pelvic pain associated with PCS often involves faulty veins in your ovaries and pelvis. The veins dilate (widen) and may become twisted and overfilled with blood. As a result, blood may pool in your pelvis and feel painful.

Who does it affect?

You’re more likely to have PCS if you’re between ages 20 to 45 and have given birth more than once. Other risk factors include:

• Varicose veins.
• A family history of varicose veins.
• Polycystic ovarian syndrome (PCOS).

It’s rare for people who’ve gone through menopause to have pelvic congestion syndrome.

How common is pelvic congestion syndrome?

Approximately 40% of gynecological visits involve chronic pelvic pain complaints. It’s estimated that up to 30% of these are likely related to pelvic congestion syndrome.

What are the symptoms of pelvic congestion syndrome?

The pelvic pain you experience with PCS may feel dull, achy or heavy. Less commonly, the pain may feel sharp and intense. You may notice the pain on the left side only (most common), on the right side of your body or both sides. Often, pain starts during or soon after pregnancy. It may worsen with future pregnancies.

The pain associated with PCS may feel worse:

• At the end of the day.
• Before and during your period.
• During intercourse and afterward (dyspareunia).
• When you stand or sit for long periods (but it feels better when you lie down).

Other symptoms include:

• Varicose veins in your pelvis, butt, thighs, vulva and vagina.
• Frequent bouts of diarrhea and constipation (irritable bowel).
• Peeing accidentally from laughing, coughing or other movements that stress your bladder (stress incontinence).
• Pain when you pee (dysuria).

What causes pelvic congestion syndrome?

Researchers don’t know what causes pelvic congestion syndrome. Still, problems with blood flow in your ovarian veins and the veins in your pelvis play a role.

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

With PCS, veins are so dilated (widened) that the valves don’t prevent reflux. Blood flows backward through the veins, causing them to become overly filled and twisted. Blood pools in your pelvic veins and causes pain. The pain may result from the stretching your stressed veins must do to contain the extra blood. It’s also possible that the misshapen veins touch nearby nerves in your pelvis, triggering pain.

There are a few possible reasons that veins become structurally unsound with PCS:

• Pregnancy: One theory is that PCS is related to blood vessel changes during pregnancy. Blood vessels expand 50% of their normal size during pregnancy to manage the extra blood flow needed to support a developing fetus. These changes may cause long-term damage to your blood vessel walls, causing veins to remain dilated even after you’ve had your baby.
• Estrogen: Pelvic congestion syndrome is uncommon among people who’ve experienced menopause, suggesting that estrogen may be involved. Estrogen levels decrease after menopause. Estrogen’s effects on your blood vessel walls may make you more susceptible to defects that lead to PCS.

PCS likely results from various interrelated factors.

How is pelvic congestion syndrome diagnosed?

Your healthcare provider will ask about your medical history and symptoms. You’ll likely have a physical exam that includes a pelvic exam. Your provider will check for tenderness in your ovaries, cervix and uterus to try and pinpoint where the pain originates.

Imaging can help your provider rule out other conditions that cause chronic pelvic pain and identify any irregularities in your veins potentially related to PCS. Imaging procedures include:

• Ultrasound: Your provider will likely order an ultrasound first. An ultrasound can show vein dilation. It can help your provider spot other abnormalities that may be causing your pain. The Doppler feature on the ultrasound can show whether your blood is flowing backward.
• MRI or CT scan: An MRI and a CT scan can show details in your veins that an ultrasound may miss. They can show twisted veins and vein dilation in your ovaries and pelvis in greater detail than an ultrasound. They can also show irregular growths in your pelvis that may indicate other causes of chronic pain, like endometriosis.
• Pelvic venography: Pelvic venography is the gold standard for PCS imaging. It’s more invasive, though, so it’s generally used when other imaging doesn’t provide enough evidence for a diagnosis. Your provider may also use pelvic venography to prepare for a procedure to operate on your veins. During pelvic venography, your provider inserts a small tube called a catheter into a vein in either your neck or your groin. They use an X-ray to guide the positioning of the catheter so that it goes into your ovarian veins on the right and left sides of your body. A safe dye is injected into the vein, making your veins more visible on the X-ray. Venography shows where the dilated and twisted veins are, how the blood is flowing and where the blood is pooling.
• Laparoscopy: Laparoscopy can show if your veins are dilated. Still, it may not be as helpful as other procedures for understanding problems with blood flow related to PCS. Your provider may perform a laparoscopy to rule out conditions other than PCS that may be causing your pelvic pain. During a laparoscopy, your provider performs surgery through tiny cuts in your abdomen that allow them to view your reproductive organs.

Diagnosing pelvic congestion syndrome can be challenging because many people without pelvic pain have stressed veins similar to those who do experience pain. Imaging studies have shown that people with chronic pelvic pain and those without it may have distorted blood vessels and backflow of blood.

Even if imaging shows that your veins are dilated, you don’t need treatment unless you’re experiencing chronic pain.

Pelvic congestion as a cause of pelvic pain is a diagnosis that’s generally given after all other causes of pelvic pain have been excluded.

Can pelvic congestion syndrome be cured?

There isn’t a cure for pelvic congestion syndrome, but medications and medical procedures can help ease your symptoms.

What are the treatments for pelvic congestion syndrome?

You may see different healthcare providers for treatment, including a gynecologist, gastroenterology (GI) specialist, pain specialist and physical therapist. Your provider or care team will likely recommend medications to manage your symptoms before recommending surgery.

Medications

Medications that suppress estrogen production can lessen the pain associated with pelvic congestion syndrome. They include:

• Medroxyprogesterone acetate (Depo-Provera®)
• Etonogestrel implant (Implanon®).
• GnRH agonists.
• Goserelin.

Procedures

Your provider may perform a medical procedure if medications don’t ease your symptoms. These include:

• Ovarian vein embolization or sclerotherapy: During this procedure, your provider blocks the blood vessels causing the blood to flow backward so that blood doesn’t pool. First, they place a catheter into the faulty ovarian vein and pelvic veins. Then, they send chemicals through the catheter to irritate or inflame the veins. Tiny metal coils, glue or foam are also inserted into these veins to prevent reflux.
• Laparoscopy: Your provider may perform a laparoscopy to tie off the veins, preventing the backflow of blood.
• Bilateral salpingo-oophorectomy: Your provider may remove your pelvic organs (uterus, fallopian tubes and ovaries) if you’ve finished birthing children or don’t wish to give birth. This surgery is rare for PCS.

How can I prevent pelvic congestion syndrome?

Pelvic congestion syndrome isn’t preventable.

Is pelvic congestion syndrome life-threatening?

Pelvic congestion syndrome isn’t life-threatening. Depending on the severity of your pain, it can disrupt your life and keep you from activities you enjoy. See your healthcare provider if your pelvic pain is compromising your quality of life.

What can I expect if I have pelvic congestion syndrome?

Although there isn’t a standard treatment for pelvic congestion syndrome, the outcomes associated with interventions to provide pain relief are excellent. For instance, 75% of people who receive ovarian vein embolization experience pain relief. Recurrence happens in only 5% of these cases.

What questions should I ask my doctor?

• Will I need to see multiple specialists to receive a diagnosis or treatment?
• What medications would you recommend to relieve symptoms?
• At what point would you recommend a procedure to improve my symptoms?
• Which procedure would you recommend?
• What are the potential risks associated with this procedure?

A note from Cleveland Clinic

It may take some patience to pinpoint what’s causing your pelvic pain. Indeed, many conditions can cause pain in your pelvis. It may take a few tests and maybe even a few specialists working collaboratively to diagnose your PCS. The good news is that medications often relieve symptoms. If medicine doesn’t work, your healthcare provider can recommend procedures that can help. Don’t delay when it comes to seeking care and experiencing relief.