Pelvic congestion syndrome

Pelvic congestion syndrome (PCS) is chronic pelvic pain caused by varicose veins in the pelvis. The veins that drain the ovaries and uterus have one-way valves, like the veins in your legs. When those valves weaken, blood flows backward and pools. The veins stretch and swell, much like varicose veins in the legs, and the congestion causes a dull, heavy ache.

The veins most often involved are the ovarian veins, also called gonadal veins, especially the left one. Branches of the internal iliac veins deeper in the pelvis can be involved too.

The main symptom is pelvic pain lasting more than 6 months. It is usually a dull ache or heaviness rather than a sharp pain, and it has a typical pattern.

Many women with PCS see several doctors over years before the diagnosis is made. Pelvic pain has many possible causes, and pelvic veins are easy to miss because they often shrink when you lie down for a scan.

Diagnosis starts with ruling out other causes of pelvic pain, such as endometriosis, fibroids, ovarian cysts, infection and bowel or bladder conditions. This is usually done with your gynecologist. Then we look at the veins.

On the venogram, dye injected into a healthy ovarian vein flows up toward the heart. In pelvic congestion, the dye flows backward down a widened ovarian vein and fills a cluster of twisted veins around the uterus, sometimes crossing to the other side of the pelvis.

Treatment is aimed at relieving pain. If your symptoms are mild, pain medicine may be enough. If pain affects your daily life, work or relationships, closing the leaky veins is often the most effective option.

Ovarian vein embolization is the most common procedure for PCS. It uses small metal coils, sometimes with a foam medicine called a sclerosant, to block the faulty veins. Blood then drains through other, healthy veins. Published studies report that roughly 3 in 4 women have meaningful pain relief.

1. 1
   Get comfortable

   You change into a gown and an IV is placed. You receive moderate sedation, which keeps you relaxed and drowsy while you breathe on your own.

2. 2
   Enter a vein

   We numb the skin at the neck, arm or groin and place a thin tube into a vein using ultrasound. The tube is guided into the pelvic veins with X-ray, and dye maps the leaky veins.

3. 3
   Close the veins

   We place small coils along the leaky ovarian vein and may inject foam into the swollen veins around the uterus. The coils stay in place permanently and cannot be felt.

4. 4
   Finish and recover

   The tube is removed and pressure is applied. There are no stitches. You rest for a few hours and go home the same day.

The procedure usually takes 1 to 2 hours. Some women need both sides treated, and a few need a second session.

1. First 1–3 days
   Pelvic cramping, back or flank ache is common. Anti-inflammatory pain relievers usually control it. Rest, and avoid heavy lifting.
2. Within a week
   Most women are back at work and normal activity within 2 to 5 days.
3. Weeks to months
   Pain relief builds gradually as the veins shrink. Many women notice a clear change over 1 to 3 months.
4. Follow-up
   A clinic visit to check how you are doing. If pain continues, we may look for other veins that need treatment.

Many of the women I see with pelvic congestion have been told for years that their pain is in their head or just part of being a woman. When I watch the dye flow backward into a web of swollen veins on the venogram, it is often a relief for them to finally see the cause. I am honest that not everyone improves, but for the right patient, closing those veins can give back comfortable days.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos