Pelvic Congestion Syndrome: An uncommon cause of Pelvic Pain

What if you have chronic pelvic pain and you don’t have endometriosis? OR, What if you have endometriosis but the endometriosis treatments are not working for you?

Is it possible that there is another less common cause of your pelvic pain?

Firstly, when doctors say chronic – they mean more than 6 months and in terms of pelvic pain, they mean pain even when you don’t have your period.

More and more people are starting to hear about Pelvic Congestion Syndrome.  So, what is it, what causes it and most importantly what can be done about it?

Pelvic congestion syndrome is  like having  varicose veins around your ovaries and uterus.  It is thought to be caused by failure of the valves in the uterine veins to stop backflow of blood.  This in turn allows backflow of blood in the pelvis causing the veins to swell and twist into grape like structures much like hemorrhoids around your ovaries and uterus.  This can be extremely painful.

So, why does pelvic congestion syndrome occur?

1.      Pelvic congestion syndrome is commonly associated with multiple pregnancies, although can be seen after just one pregnancy

-          Blood vessels get at least 50% bigger during pregnancy to deliver all the extra blood needed to supply the growing baby.  Sometimes, the walls of the veins don’t go back to their normal size after the baby is born.

2.      Women with polycystic ovaries are at increased risk

-          It is thought that their hormonal irregularities cause increased endometrial thickness and enlargement of the ovaries.

3.      Oestrogen

-          Raised levels of oestrogen increase the risk.

-          Rates of this condition fall as well as symptoms after menopause.

4.      Family history

-          Women with a family history of this condition have an increased risk.

Whilst the presence of these dilated pelvic veins does not always cause pain, it is thought that their presence might also be associated with an increased risk of chronic abdominal pain, leg swelling and varicose veins.

Chronic pelvic congestion is when these pelvic veins cause pain. Symptoms of this are varied but include:

·         Pelvic pain

o   May be intermittent

o   May be worse with standing, walking or prolonged sitting

o   May be worse after sexual intercourse or orgasm due to the increased pelvic blood flow

o   May be worse after intense exercise

·         Left lower abdominal pain is particularly common

·         Lower back pain

·         Blood in the urine – this is because the renal vein (vein from the kidney can get compressed)

·         Urinary frequency and urgency – this can feel a bit like having a urinary tract infection

·         Heavy periods

·         Severe period pain the week before a period

·         Pelvic floor problems like urinary leakage especially when laughing, coughing or sneezing

·         Increased irritable bowel type symptoms – diarrhoea or constipation

·         Some women may also get varicose veins around the vagina and legs

·         Many women feel better when they are lying down

The diagnosis of pelvic congestion syndrome is relatively straight forward in that large grapelike veins can be seen around the ovaries and uterus on a transvaginal ultrasound, a  CT or MRI.  However, it does require a high degree of suspicion.  The doctor requesting the test needs to be thinking about the possibility of pelvic congestion syndrome and the radiologist needs to be looking for it.

It is important to note that if these dilated veins are discovered incidentally and you are not having any pain, you do not need to do anything about them.

There has also been some talk in the literature about whether intrauterine devices (IUD’s) cause an increased risk of these dilated veins.  However, there is no clear evidence of this.  In fact, it might be that we see more IUD’s in women with these veins in an attempt to control heavy bleeding and pain.

Treatment of pelvic congestion syndrome is relatively straightforward bearing in mind that the causes of chronic pelvic pain are often multifactorial and this may well be just one contributing factor.

Management includes:

·         Ruling out or treating other causes of pelvic pain

·         Seeing a pelvic floor physiotherapist for pelvic floor symptoms such as bladder control

·         Seeing a dietitian or gastroenterologist for any irritable bowel symptoms

·         Hormonal treatments aimed at lowering oestrogen levels. E.g. progesterone injection (Depo-Provera), Implanon (contraceptive rod) or stronger medications which stop ovulation.

·         Seeing a vascular surgeon for treatment of the dysfunctioning veins and stopping the backflow of blood, thereby relieving symptoms caused by congestion and swelling and internal bleeding.

·         Rarely, a gynecologist may need to perform keyhole surgery or a laparoscopy to tie off the veins to prevent back flow of blood.  It is exceedingly rare to need a hysterectomy for this condition.

References

1.      HealthED. Dr Sarah Tedjasukmana and Helen Tobler

2.      Sydney Fibroid Clinic