Chronic pelvic pain is a very common problem in the United States. It accounts for 10-15% of referrals to gynecologists and pain clinics. For some women, the cause of their pelvic pain is a condition known as pelvic venous disease (PVD), often also known as pelvic congestion syndrome (PCS).
Pelvic pain may go undiagnosed simply because many health care providers are often unfamiliar with it or fail to look for it. Determining the cause of pelvic pain and symptoms can be complicated because there are many possibilities. However, pelvic venous disorder can be readily diagnosed and treated with minimally invasive procedure, including ovarian vein embolization, iliac vein embolization, and iliac vein stenting.
Pelvic venous disease is related to abnormal veins in the pelvis and around the uterus. It is caused by valves in the veins not functioning properly, causing blood to pool in the pelvis – similar to varicose veins in the leg.
In addition to symptoms of pelvic pain, pressure, bloating, and gassiness, women may also note bulging varicose veins in their inner upper thigh or labia.
Is pelvic congestion syndrome common?
Although exact numbers are unclear, given how underdiagnosed pelvic venous disease is, research is increasingly demonstrating that pelvic congestion is much more common than previously believed. It is most common in women of childbearing age and for women who have had more than one pregnancy, typically 3 or more. Genetics also likely plays a role.
Many times, symptoms do not appear until a woman becomes pregnant, and then they continue after the pregnancy. However, women who have not been pregnant can also have pelvic congestion syndrome.
The main symptoms of PCS are pelvic discomfort and bloating. The discomfort is usually described as a dull, throbbing aching and heaviness in the pelvis. Often women feel a “dragging” feeling. It typically worsens as the day goes on, especially for women who sit or stand all day, and then goes away after a night of sleep. It also worsens when bearing down or straining.
Additionally, many women complain of a ‘gassy’ feeling, for which they carry anti-gas medication constantly or have changed their diet, possibly to gluten-free out of frustration and to avoid discomfort. Patients often are diagnosed with irritable bowel syndrome (IBS) or diagnosed themselves with IBS due to the constant GI issues without a cause.
The pelvic pain can also worsen during or following sexual intercourse, during menstrual periods, during urination, and after certain physical activities causing straining. Bulging veins in the inner upper thighs and/or labial region are often seen in pelvic congestion syndrome.
After consulting with one of our interventional radiologist (IR) physicians, a history and physical exam will lead towards the diagnosis. Definitive diagnosis is done with an ultrasound and/or a specialized CT or MRI venogram to evaluate the pelvic veins.
Pelvic venous disease is often a multifactorial disease, meaning there may be multiple issues that lead to the problem and ultimately the symptoms. The most common cause is backwards flow, or reflux in the ovarian veins. Other causes include backwards flow in the internal iliac veins, compression of the left renal vein (called Nutcracker Syndrome), and/or compression of the left common iliac vein (called May Thurner Syndrome).
Ovarian vein embolization is a minimally invasive procedure performed by interventional radiologists by which the abnormal veins in the pelvis are treated, all without a surgical incision.
This is achieved by using a small catheter, or tube, introduced into the neck vein and guided down to the pelvic veins using both real-time imaging. The veins are then treated, often by closing down the abnormally dilated pelvic veins and allowing the blood flow to reroute to normal veins. This procedure prevents the abnormal dilated veins from filling again, resolving the pain and symptoms for most women. The left pelvic veins are the overwhelming cause in most women due to difference in anatomy when compared to the right; however, all the veins are checked for abnormality during the procedure.
During the procedure, contrast injection is performed (called venography), which evaluates for all causes that may lead to pelvic congestion syndrome. Additionally, we typically perform intravascular ultrasound (IVUS) to also evaluate all the veins in a different manner to ensure every abnormal cause is detected.
If you suspect you have pelvic venous disease/pelvic congestion syndrome or have suffered from the above symptoms, you can call our IR clinic yourself to set up a consultation. Initially, at the consultation we talk to you about your symptoms, confirm your diagnosis, and then fully discuss your treatment options to ensure the proper treatment for you. Many women will have imaging performed, including a specialized CT or MRI (called CT Venogram or MR venogram) to evaluate your pelvic and abdominal veins, further understand the extent of the problem, and/or figure out alternative diagnoses. After reviewing the images and determining if ovarian vein embolization and/or other treatment is warranted and will help you, we will discuss the specifics including procedure details, risks, benefits, and alternatives of treatment.
On the day of your scheduled procedure, you will be prepped in the pre-procedure area and brought to the interventional radiology suite. After being sedated and given numbing medicine, a tiny catheter (tube) is introduced into a vein in your neck, and then advanced under image guidance into the abnormal veins in your pelvis. Venography and IVUS are typically performed to diagnose and understand any abnormalities. The abnormal veins are then treated (either by closing down veins with backwards flow or stenting open compressed veins), causing the blood flow to reroute to normal veins. The procedure usually takes 1-2 hours, is performed with conscious sedation rather than general anesthesia, requires no large incisions, and patients go home within a few hours.
All of our pelvic venous disorder procedures are done on an outpatient basis, so you are home the same day. Usually, women are ready to go within a couple of hours, with only a small bandage on their neck. While most women choose to rest and recover for a few days, most women report symptomatic improvement very soon after the procedure. Overall, the procedure is very well tolerated. Often, symptoms will persist or even worsen for the first few weeks before resolving after a few months.
In general, ovarian vein embolization is covered by insurance providers. After your consultation, our providers and office staff will take of all the details by contacting your insurance company to get approval and pre-authorization prior to proceeding.