Pelvic congestion syndrome is chronic pain exacerbated by standing or sexual intercourse and associated with varicose veins in or near the ovaries.
Pelvic congestion syndrome is a common cause of chronic pelvic pain. Varicose veins and venous insufficiency are common in the ovarian veins but are often asymptomatic. The reason some women develop symptoms is unknown. Most women with pelvic congestion syndrome are aged 20 to 45 years and multiparous. One theory is that ovarian venous engorgement leads to intimal stretching, with distortion of endothelium and smooth muscle cells in blood vessels, leading to release of vasoactive substances that cause inflammation and pain.
Symptoms and Signs of Pelvic Congestion Syndrome
In women with pelvic congestion syndrome, pelvic pain develops after at least one pregnancy. Pain tends to worsen with each subsequent pregnancy.
Typically, the pain is a dull ache, but it may be sharp or throbbing. It is worse at the end of the day (after women have been sitting or standing a long time) and is relieved by lying down. The pain is also worse during or after sexual intercourse. It is often accompanied by low back pain, aches in the legs, and sometimes abnormal uterine bleeding (1).
The pain tends to be unilateral but may be bilateral.
Women may also have varicose veins in the buttocks, thighs, vagina, or vulva.
Pelvic examination detects tender ovaries and cervical motion tenderness.
Symptoms and signs reference
1. Bendek B, Afuape N, Banks E Desai, et al: Comprehensive review of pelvic congestion syndrome: Causes, symptoms, treatment options. Curr Opin Obstet Gynecol 32 (4):237–242, 2020.
Diagnosis of Pelvic Congestion Syndrome
Clinical criteria
Ovarian varicosities, detected during imaging
Diagnosis of pelvic congestion syndrome requires that pain be present for > 6 months and that ovaries be tender when examined.
Ultrasonography is done but may not show varicosities in women when they are recumbent.
Some experts recommend additional tests (eg, venography, CT, MRI, magnetic resonance venography) if necessary to confirm pelvic varicosities. Pelvic varicosities may be confirmed by selectively catheterizing specific veins and injecting a contrast agent (venography).
If pelvic pain is troublesome and the cause has not been identified, laparoscopy may be done.
Treatment of Pelvic Congestion Syndrome
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Medroxyprogesterone acetate or gonadotropin-releasing hormone (GnRH) agonistsMedroxyprogesterone acetate or gonadotropin-releasing hormone (GnRH) agonists
Treatment of pelvic congestion syndrome includes NSAIDs, sometimes with high-dose medroxyprogesterone acetate or GnRH agonists. IV dihydroergotamine and medroxyprogesterone have been used. High-quality evidence about treatment options is lacking.Treatment of pelvic congestion syndrome includes NSAIDs, sometimes with high-dose medroxyprogesterone acetate or GnRH agonists. IV dihydroergotamine and medroxyprogesterone have been used. High-quality evidence about treatment options is lacking.
If these medications are ineffective and the pain persists and is severe, endovascular embolization or sclerotherapy may be considered.
Varicosities detected during venography may be embolized with small coils or an embolic agent after local anesthesia and IV sedation are used. This procedure reduces the need for analgesics by up to 80%.
Key Points
Pelvic congestion syndrome is the result of dilated pelvic vessels.
Symptoms develop only in some women with pelvic varicosities.
Pain is usually unilateral and worsened by standing and by sexual intercourse; other symptoms include low back pain, leg pain, and sometimes abnormal menstrual bleeding.
Imaging alone is nondiagnostic; do not treat an isolated finding of dilated pelvic veins.
Try treating with NSAIDs with medroxyprogesterone acetate or GnRH agonists Try treating with NSAIDs with medroxyprogesterone acetate or GnRH agonists
If pain persists and is severe, consider endovascular embolization or sclerotherapy.
