When 15-20% of women between the ages of 18 and 50 years of age experience some type of long-standing (chronic) pelvic pain, there is a problem. There are various causes of chronic pelvic pain in women, but a common cause that is an often over-looked is pelvic congestion syndrome.
What is pelvic congestion syndrome?
Pelvic congestion syndrome is characterized by veins in the pelvis and ovaries that have become enlarged from weakened valves that do not close properly. This is very similar to varicose veins in the legs. When the veins and valves are too weak to close properly this allows blood to flow backwards and collect in the veins. This creates an increase in pressure and causes the veins to bulge. This often results in pain and can affect the uterus, ovaries and vulva. More than half of the women with pelvic congestion syndrome will have cystic changes to the ovaries and tend have a larger uterus and a thicker endometrium. Although pelvic congestion syndrome is present in about 15% of women, not all women experience symptoms. For those that do however, they can be very uncomfortable and sometimes excruciating symptoms.
Signs and symptoms of pelvic congestion syndrome
Pain is long-standing and located in the lower abdomen and sometimes lower back. The pain is experienced as a dull and aching sensation.
Factors that may increase the symptoms:
- Following Intercourse
- During or just before the onset of a menstrual period
- During Pregnancy
- After a long day of standing
Other reported symptoms include:
- Overactive bladder
- Abdominal bloating
- Abnormal menstrual bleeding
- Vaginal discharge
- Swollen vulva/vagina
- Varicose veins on the groin, buttocks or thigh
- Mood swings
Risk factors for pelvic congestion
- It is most commonly seen between the ages of 20 and 45 years
- It is more common in women with multiple pregnancies eg twins and triplets etc
- Hormonal changes: Estrogen in the body causes vasodilation and can weaken the vein walls. This can result in the accumulation of blood in the veins in the pelvic area.
- It is often seen in pregnant women and those who have just delivered due to the high estrogen levels that are found in a woman’s body during pregnancy
Diagnosis of pelvic congestion syndrome
Pelvic congestion syndrome is often missed during routine exams because when the woman lies down for her pelvic exam , this relieves pressure from the ovarian veins, causing the veins to no longer bulge and stops them from being painful.
So many women will spend years trying to find out what the cause of their chronic pelvic pain is and not ever receive a correct diagnosis. These unanswered questions can eventually cause feelings of helplessness and depression. The woman having to live with this chronic pain is not the only one affected. Her family and personal relationships can also become strained. Not having an answer to why you have pain can be exhausting and decrease your outlook on life.
If you have chronic pelvic pain, with or without the associated symptoms above, you may want to seek the opinion of your physician to rule out other conditions. Once other pathologies or inflammation have been ruled out by a thorough pelvic exam, you may be referred to a specialist for imaging. Patients are often referred to an interventional radiologist. These specialists can diagnose Pelvic congestion syndrome through several minimally invasive imaging tests.
Receiving a pelvic ultrasound is most likely to be the first step to help in diagnosing pelvic congestion syndrome. This ultrasound test can also show if there is another cause to the pain besides pelvic congestion syndrome. The ultrasound can be performed either transabdominally or transvaginally. Transabdominal ultrasound is performed with the device on top of the abdomen and transvaginal is performed with the device inside of the vaginal cavity, allowing for a more direct look at the affected area.
This procedure is commonly performed with the patient lying down. Health care professionals need to be aware that this will lower the pressure in the veins and cause a decrease in the once abnormal vein size. Thus, they may mistakenly rule out pelvic congestion syndrome with the use of this test. Health care professionals need to have the patient standing in order to clearly make the diagnosis of pelvic congestion syndrome.
CT or MRI:
Both a CT and MRI can detect the enlarged veins, but they will not be able to detect whether or not there is reversal of flow within the ovarian vein. Performance of the CT exam has a risk for radiation exposure and it is not recommended for use in pregnant women.
This is considered the most accurate method for the diagnosis of pelvic congestion syndrome. It can clearly recognize the abnormal veins and the reversal of flow within the affected veins through the use of a contract dye that is injected into the veins and then visualized through the use of an X-ray. It is performed on an examination table that is placed on an incline so the veins remain bulging and visible.
Luckily there are several treatment options that are minimally invasive.
Often it is the interventional radiologist who performs the treatment procedure of embolization. A thin catheter is inserted into the femoral vein and then guided, by using x-ray technology, directly to the abnormal ovarian vein. The affected vein is then sealed shut. This inhibits the reversal of blood flow and will reduce the pressure within the pelvic veins.
This process may be performed as an outpatient procedure, with most patients discharged from the hospital after a few hours of observation. Nearly all patients will be able to return to normal activity within 24 hours.
Depending on the severity of the woman’s symptoms embolization may not be the best treatment option.
Additional treatments may include:
- Prescribing analgesics to reduce the pain.
- Hormone treatment in order to decrease a woman’s hormone level and cause. menstruation to stop, in order to relieve the painful symptoms
- If the symptoms are severe and embolization is not an option, surgical options include a hysterectomy with removal of ovaries, and removal of the veins.
In the rare case that recovery is not seen with embolization the additional treatment options listed above are very effective at managing the symptoms. As well as embolization being less expensive than surgery and much less invasive. There is a very low complication rate associated with ovarian vein embolization and 85- 95% of patients report improvement in their symptoms. After the initial embolization, other sessions may be required in the event multiple veins need to be embolized. The success rate of the treatment options makes for a very positive outlook.