Pelvic Congestion Syndrome: An Underdiagnosed Pelvic Pain Condition

People with chronic pelvic pain (or menstrual pain) often have many different underlying conditions. [1] We often discuss common gynecological conditions like endometriosis and adenomyosis as main contributors to pelvic and menstrual pain, but we want to shed light on a different condition: pelvic congestion syndrome, or "PCS".

Despite the fact that some estimate that PCS may be found in up to one third of women with pelvic pain, PCS doesn't get talked about as much as endo or adeno. [2] Perhaps this is because most women with menstrual or pelvic pain see gynecologists or general practitioners, rather than physicians who focus on veins like interventional radiologists and vascular surgeons. Not all gynecologists are knowledgeable about PCS and might miss it during diagnosis, so it's important to bring awareness to this common condition.

Tortuous Veins & Pain

Ever seen "spider veins" in someone's legs? These are called "varicosities," or "varicose veins,' and, besides looking unsightly, can cause real medical issues like venous ulcers. [3] Varicose veins are simply veins that have become enlarged and twisted, usually due to damaged venous valves (valves that sit within your veins) and swelling of the vein. Eventually, varicose veins can lead to inflammation, which can lead to pain, aching, and ulcers.

PCS occurs when the veins within your pelvis are dilated and varicose. [4] These veins (the ovarian and pelvic veins) take blood away from the uterus and back to the heart. In PCS, these veins are damaged, which causes the veins to dilate. This dilation causes blood to pool within the pelvis because it can not return to the heart properly (this is called "reflux"). The pooling of blood and stretching of ovarian veins may activate pain sensors in the pelvis, leading to achy or dull pain. Additionally, the pooling of blood can lead to further distension of the veins, which creates a "vicious cycle" where the condition may worsen over time.

Pain from PCS is often worsened by prolonged sitting, having sexual intercourse, menstruation, and pregnancy, and people with PCS often have other symptoms like vulvar swelling, feeling of leg fullness, and other symptoms. [4]

Dilated, tortuous veins on the ovaries & uterus causing PCS

Why does PCS Occur?

Researchers are still determining the exact causes of underlying causes, but there's a correlation between the number of pregnancies you have and the chances you get PCS. During pregnancy, your pelvic veins expand by up to 60% because, well, there's a baby growing right there (and because of hormone fluctuations associated with pregnancy). [5] Importantly, estrogen can cause veins to dilate, and, as you probably know, many women with chronic pelvic pain have high levels of estrogen.

Additionally, some women are simply more susceptible to PCS because of their anatomy. Sometimes, veins can lack valves, or veins may connect in a way that can lead to higher pressures. Some people with PCS may also have vulvar varicosities or leg varicosities that actually arise from their pelvis.

How PCS is Diagnosed and Treated

It can be very difficult to get a PCS diagnosis. Often times, women with pelvic pain find themselves seeing gastroenterologists, gynecologists, and surgeons before ever seeing a vascular specialist. Sadly, right now, PCS is usually only considered when other pelvic pain diseases like fibroids have been "ruled out," so diagnosis can take a very long time. [2] Many times, a referral to an experienced interventional radiologist is necessary to get properly diagnosed & treated, but not all gynecologists have trusted interventional radiologists to refer patients to.

PCS can be diagnosed with imaging, such as transvaginal ultrasound and "magnetic resonance venography," where an MRI of your pelvis is done to see if veins are dilated. Fortunately, many interventional radiologists can perform these imaging procedures, so getting a referral to a radiologist is key if you think you might have PCS. Dilated veins can also be seen during a laparoscopy.

PCS can be treated with hormonal medicines, but also can be treated through a minor procedure called "embolization" performed by an interventional radiologist. [6] Embolization involves collapsing the dilated veins in your pelvis by injecting foam or metal coils inside the veins. Yes, you heard that correctly: a small catheter is inserted into your leg vein, navigated to the dilated veins in the pelvis, and platinum is placed inside the veins. While it sounds pretty crazy, clinical studies have shown emoblization therapy can greatly reduce pain. For example, an analysis of five clinical studies showed pain could be reduced by 2-5 points on a 10 point scale (ie: from 7/10 to 5/10 or 2/10). [7]

Coil and foam embolization for PCS

Want to Share Your PCS Experience?

If you've been diagnosed with PCS and want to share your experience with other patients, shoot us an email at and we’ll be in touch!

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[1] Chronic pelvic pain in women: etiology, pathogenesis and diagnostic approach, Vercellini et. al, Gynecological Endocrinology 2009

[2] Pelvic congestion syndrome: diagnosis and treatment, Ignacio et. al, Semin Intervent Radiol 2008

[3] The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum, Gloviczki et. al, Journal of Vascular Surgery 2011

[4] Pelvic congestion syndrome: etiology of pain, diagnosis, and clinical management, Phillips et. al, J Vasc Interv Radiol 2014

[5] Current concepts of pelvic congestion syndrome and chronic pelvic pain, Perry CP, JSLS 2001

[6] Evaluation of the efficacy of endovascular treatment of pelvic congestion syndrome, Hocquelet et. al, Diagnostic and Interventional Imaging 2014

[7] Pelvic congestion syndrome-associated pelvic pain: a systematic review of diagnosis and management, Hahn and Steege, DARE Quality assessed reviews 2010

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