Pelvic Congestion Syndrome: Symptoms and Treatment

What is pelvic congestion syndrome?

Pelvic congestion syndrome is pelvic pain lasting six months or more that is thought to come from enlarged veins around the ovaries and uterus. The valves in these veins stop working properly, blood pools, and the veins stretch, much like varicose veins in the legs.¹

The name is changing. Specialists now use the term pelvic venous disorders and classify each case by its symptoms, where the enlarged veins are, and what is causing them. The aim is to describe patients more precisely, because “pelvic congestion syndrome” has been used loosely for several different problems.²

Symptoms

• A dull, aching or heavy pain low in the pelvis, on one or both sides
• Pain that builds through the day and is worse after long periods of standing or sitting
• Pain that eases when lying down
• Pain that flares before or during periods, and during or after sex
• Varicose veins on the vulva, buttocks or upper thighs

It is mostly diagnosed in women who have had more than one pregnancy and haven’t yet reached menopause.¹

How certain is the diagnosis?

This is the difficult part, and it is worth knowing before you go looking for a scan. Enlarged pelvic veins are common in women who have no pain at all. A large UK review of the evidence found some support for a link between leaking pelvic veins and chronic pelvic pain, but concluded that it couldn’t be stated with confidence that the veins are the cause, because the studies were small and defined the condition in different ways.³

Chronic pelvic pain is common in its own right, and it often has more than one cause.⁴ Endometriosis, adenomyosis, bladder pain, irritable bowel and pelvic floor muscle pain can all produce a similar ache, and they are usually checked first.⁶

How is it diagnosed?

• Ultrasound, usually transvaginal, to look at vein size and whether blood is flowing backwards
• MRI or CT to map the veins and rule out other causes
• Venography, where dye is injected through a thin tube placed in the vein. It is the most accurate test and is generally done only when treatment is planned¹

Treatment

• Pain management. The same approaches used for other long-term pelvic pain, including pelvic floor physiotherapy, pacing, and psychological support for living with pain⁶
• Hormonal treatments that lower oestrogen can reduce symptoms for some women, mainly in the short term³
• Embolisation. A radiologist passes a thin tube into the affected veins and blocks them with tiny coils or a foam. In a review of 22 studies covering about 1,300 women, around three in four had substantial early pain relief, and the benefit generally lasted. Complications were uncommon⁵

The catch is the quality of that evidence. Almost all of it comes from case series without a comparison group, and there has been no good randomised trial. The reviewers’ own conclusion was that embolisation appears to help most women and is safe, but that the evidence is low quality.^3,5 It is reasonable to ask a specialist how confident they are that your veins explain your pain before agreeing to a procedure.

When to see a doctor

See a doctor for any pelvic pain that has lasted more than a few months, pain that is getting worse, pain during sex, or new varicose veins around the vulva or upper thighs.

Seek urgent care for sudden severe pelvic pain, pain with fever, or pain with heavy bleeding.

References

1. Basile A, Failla G, Gozzo C. Pelvic Congestion Syndrome. Semin Ultrasound CT MR. 2021;42(1):3-12.
2. Meissner MH, Khilnani NM, Labropoulos N, et al. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. J Vasc Surg Venous Lymphat Disord. 2021;9(3):568-584.
3. Champaneria R, Shah L, Moss J, et al. The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness. Health Technol Assess. 2016;20(5):1-108.
4. Latthe P, Latthe M, Say L, et al. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health. 2006;6:177.
5. Daniels JP, Champaneria R, Shah L, et al. Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review. J Vasc Interv Radiol. 2016;27(10):1478-1486.e8.
6. healthdirect. Persistent pelvic pain.