From the Guidelines
The initial management approach for Pelvic Congestion Syndrome (PCS) should prioritize conservative measures and medical therapy, with a focus on reducing symptoms and improving quality of life. The treatment should begin with non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) to manage pain, as well as hormonal therapy with medroxyprogesterone acetate (30-50mg daily), combined oral contraceptives, or gonadotropin-releasing hormone (GnRH) agonists like leuprolide (3.75mg monthly injections for up to 6 months) to suppress ovarian function and reduce pelvic venous distension 1. Some key considerations for managing PCS include:
- Avoiding prolonged standing
- Using compression stockings
- Engaging in regular low-impact exercise to improve venous return
- Pelvic floor physical therapy to manage associated symptoms These conservative approaches work by reducing inflammation, decreasing venous congestion, and modulating hormonal influences that contribute to venous dilation. If symptoms persist after 3-6 months of conservative management, patients should be referred for consideration of interventional procedures such as embolization of pelvic veins, including internal iliac vein embolization, which has been shown to be safe and effective in treating pelvic venous insufficiency and reducing pelvic pain in most women undergoing treatment for PCS 1.
From the Research
Initial Management Approach for Pelvic Congestion Syndrome
The initial management approach for Pelvic Congestion Syndrome (PCS) involves a combination of medical, surgical, and endovascular therapy.
- Medical therapy includes the use of nonsteroidal anti-inflammatory drugs (NSAIDs), ergot alkaloid derivatives, hormonal agents, venoprotective agents, and compression therapy 2.
- Surgical management is also an option, although it is less effective than endovascular therapy 3.
- Endovascular therapy, specifically transcatheter pelvic vein embolization, has been shown to be a safe, effective, and durable treatment for PCS 3, 4.
Diagnosis and Treatment
Diagnosis of PCS requires a careful history, physical examination, and noninvasive imaging 4.
- Transcatheter venography is considered the gold standard for PCS diagnosis, although it is often performed after inconclusive noninvasive imaging such as Doppler Ultrasound, CT scan, and MRI 3.
- Embolotherapy has been demonstrated to be effective in reducing pelvic pain in patients with PCS 4.
Current State of Research
Despite the availability of various treatment options, high-level evidence on the diagnosis and management of PCS is lacking 5, 6.