What is Pelvic Congestion Syndrome?
Pelvic congestion syndrome (PCS) is a condition that often gets incorrectly diagnosed. It’s a typical reason for long-term pelvic pain in women who are still able to have children. Chronic pelvic pain, which is pain in the pelvic or abdominal area that comes and goes or sticks around for 3 to 6 months, is not related to pregnancy and can happen at any time during the menstrual cycle. The pain can be so severe that it affects the normal functioning of the individual and requires treatment. Almost 10% to 20% of the visits to the gynecologist are due to these chronic pelvic pain concerns, though only about 40% of those individuals get sent to a specialist for further examination.
What Causes Pelvic Congestion Syndrome?
Pelvic venous insufficiency occurs when there are problems with the internal iliac vein, which is in the pelvis, the ovarian vein, or both. This issue can often lead to something called pelvic congestion syndrome. Almost 10% of women have ovarian varices, a condition where the veins in the ovaries become enlarged and twisted. Out of that group, around 60% experience pelvic congestion syndrome.
The exact causes of pelvic congestion syndrome aren’t completely understood, but it’s thought to involve a mix of factors. These might include hormones, problems with the valves in the veins, and obstructions in the veins. It seems likely that the pain associated with pelvic congestion syndrome is caused by substances that induce pain being released due to the veins becoming enlarged and blood flow slowing down.
Risk Factors and Frequency for Pelvic Congestion Syndrome
Pelvic congestion syndrome mainly impacts women who are premenopausal and have had more than one pregnancy. This condition is not reported in women who have gone through menopause. Among patients who visit doctors because of chronic pelvic pain, about 30% are found to have pelvic congestion syndrome.
Signs and Symptoms of Pelvic Congestion Syndrome
Pelvic congestion syndrome (PCS) is a condition associated with persistent pelvic pain in women. However, discovering if this syndrome is causing the pain can be tricky, since the swelling and failure of pelvic veins, which are common in PCS, can also occur in women without any pain. Meaning, the mere presence of these varicose veins does not always imply that the pain a woman is experiencing is because of PCS.
The pain from PCS often feels like a constant dull ache or heaviness in the pelvic area, and can persist for three to six months. This pain can affect one or both sides of the pelvis, and may switch from side to side. Activities like walking, changing posture, lifting heavy objects, or standing for a long time can make the pain more intense. The pain often gets worse just before or during a woman’s menstrual cycle, and it may increase with each new pregnancy, or during or after sexual intercourse. Interestingly, the pain has also been observed to be worse at the end of the day.
If symptoms such as these are present, doctors can often diagnose PCS through a physical examination. If pain is felt when touching the uterus, ovaries, or cervix during a pelvic exam, this could point to PCS being the cause of chronic pelvic pain.
In fact, one study found that if a woman experienced pain after sex and tenderness in the area next to her uterus and ovaries during a physical checkup, there is a 77% chance that those symptoms suggest PCS rather than other pelvic conditions. This method was also found to be 94% effective at correctly identifying PCS when it is present.
Testing for Pelvic Congestion Syndrome
If you are diagnosed with Pelvic Congestion Syndrome (PCS), a condition that causes pain in the lower abdomen, you might see some changes in the veins of your pelvis when your doctor performs certain imaging tests. However, sometimes, women who don’t have symptoms can also show changes, such as dilated or widened ovarian veins.
For patients with PCS who need treatment, more specific imaging tests are necessary. These may include ultrasound tests to check for blood flow in the pelvis, retrograde internal iliac or ovarian venography to look at the blood flow in veins, computed tomography (known as CT scans) which use X-rays to reveal images of the inside of the body, or magnetic resonance (MR) imaging, which uses magnetic fields and radio waves to create detailed images.
Ultrasound, which uses sound waves to create images, is often the first imaging test used if your doctor suspects PCS. It can help the doctor check for other problems like lumps in the pelvis or issues with the uterus that might be causing pain. Color-Doppler ultrasound can show changes in the ovaries, enlargement of the uterus, and widening of certain veins in the uterus and ovaries.
In some cases, the ultrasound can see blood flow moving backwards in enlarged veins of the left ovary, and slower blood flow. The ultrasound may also show varicose veins in the pelvis and changes in the ovaries.
Computed tomography (CT) and magnetic resonance (MR) imaging can provide a detailed view of the veins and tissues in the pelvis. However, because CT scans use X-rays, they are not often recommended for women who are still having periods.
Magnetic Resonance Venography is another useful technique for tracking changes in the veins of the pelvis. This is a safe and noninvasive procedure, but it may not be as helpful because the patient has to lie down during the test.
An MRI-based technique known as phase-contrast velocity mapping can also measure the speed and direction of blood flow in your veins.
Venography is considered the standard test for diagnosing PCS. In this procedure, a dye is injected into your veins, helping to create a clearer picture on X-rays. A venogram can indicate if the veins are not working properly, if there is slow blood flow in certain veins, or if there is backward flow of blood in the ovarian veins.
Finally, a procedure called laparoscopy could be performed. This is where a surgeon makes a small incision and uses a camera to look inside your pelvis. Studies have shown that PCS is sometimes detected in women undergoing laparoscopy due to chronic pelvic pain.
Treatment Options for Pelvic Congestion Syndrome
For Pelvic Congestion Syndrome (PCS), a condition that causes chronic pain in the lower abdomen, the preferred initial treatment is medications. These treatments are preferred because they tend to have fewer complications compared to more invasive procedures. Among the medications that have been effective in managing the pain associated with PCS are certain hormone therapies, birth control pills, progestins, drugs for improving blood flow (phlebotonics), and anti-inflammatory drugs like ibuprofen.
Medications like the etonogestrel implant, goserelin and medroxyprogesterone acetate – all types of hormone therapies – have shown success in reducing PCS-related pain. It’s particularly noted that pain relief improves when medroxyprogesterone is combined with mental health therapy. While goserelin, a type of hormone regulator, shows even better results in controlling pain than medroxyprogesterone acetate, it isn’t recommended to be used for longer than a year.
In cases where medication doesn’t fully address the symptoms of PCS, doctors may consider a procedure to tie off the veins causing the pain (ligation). Doing this can lead to favorable results in nearly 75% of women by relieving symptoms. However, removing the ovaries and fallopian tubes (bilateral salpingo-oophorectomy), or removing the uterus (hysterectomy), has not shown to be beneficial for treating PCS.
If necessary, doctors may choose to treat PCS by damaging the problem-causing veins. This can be done by a minimally invasive procedure called endovascular ablation. This procedure is done on an outpatient basis which tends to lead to quicker recovery and fewer complications than more invasive procedures. During the procedure, doctors can use various agents, like platinum coils, glue, foam, or liquid sclerosants, to cause damage to the vein lining and stop blood flow to the troublesome veins.
What else can Pelvic Congestion Syndrome be?
Finding the exact cause for Pelvic Congestion Syndrome can be challenging because there are many medical conditions that could cause similar symptoms. Such conditions include:
- Diseases of the urinary tract
- Problems with the digestive system
- Muscle and bone conditions
- Neurological diseases (conditions affecting the nerves)
- Gynecological issues (problems with the female reproductive system)
- Mental health disorders
More specifically, common conditions that can cause chronic pelvic pain similar to Pelvic Congestion Syndrome include:
- Painful bladder syndrome
- Inflammatory disease of the pelvis
- Interstitial cystitis (a type of bladder inflammation)
- Endometriosis (a condition where cells similar to those in the womb lining grow outside the womb)
- Pelvic neuralgia (chronic pelvis pain)
- Irritable bowel syndrome
- Myofascial pain (a generalized pain condition)
- Pelvic floor myalgia (pain in the pelvic floor muscles)
Even with advanced technology like laparoscopy and X-rays, it’s not always easy to pinpoint the exact cause of chronic pelvic pain.
What to expect with Pelvic Congestion Syndrome
For women suffering from pelvic congestion syndrome, successfully treating the condition can resolve the symptoms in most cases – nearly 68.2% to 100%. But, it’s important to note that pelvic embolization, a common treatment for this condition, doesn’t always lead to significant pain relief. A percentage ranging from 6% to 31.8% of women have reported no significant reduction in pain following the procedure.
Possible Complications When Diagnosed with Pelvic Congestion Syndrome
When treating pelvic congestion syndrome with surgery, the chances of experiencing repeating pelvic pain increases by 20%, while 33% of patients may continue feeling residual or lingering pain. Additionally, surgical treatments can lead to physical changes that might affect the patient’s appearance and require longer hospital stays.
Possible side effects:
- Repetitive pelvic pain
- Lasting, or residual, pain
- Physical changes or aesthetic damage
- Longer periods spent in hospital
- Loss of reproductive functionality leading to the need for hormone replacement therapy. This can happen particularly due to procedures like ovarian vein ligation and oophorectomy.
Preventing Pelvic Congestion Syndrome
Pelvic congestion syndrome is a condition that affects about 2.1% to 24% of women aged between 18 and 50 years. This signals the need to inform these patients about their condition, particularly pelvic congestion syndrome (PCS). It’s important they understand the need to stick to their prescribed treatment and observe if their symptoms change during their menstrual cycle. If both ovaries are removed, which is a procedure called bilateral oophorectomy, they may need to take hormone replacements. Patients should be aware of these potential complications. [29]
