From the Guidelines
Pelvic varices are best treated with ovarian vein embolization, which has been shown to provide significant symptomatic improvement in approximately 75% of women, as demonstrated in a meta-analysis of 21 prospective case series involving 1,308 women 1.
Symptoms of Pelvic Varices
The symptoms of pelvic varices include chronic pelvic pain, dyspareunia, and varicose veins in the pelvic region. These symptoms are often exacerbated by pregnancy and can persist after delivery.
Treatment Options
Treatment options for pelvic varices depend on the severity of symptoms and may include:
- Conservative measures such as pelvic support garments, weight management, and regular exercise for mild symptoms
- Medical therapy with venoactive drugs like micronized purified flavonoid fraction (MPFF) or diosmin for moderate symptoms
- Interventional procedures like ovarian vein embolization, which is the preferred approach for moderate to severe cases, with success rates of 70-85% for pain relief 1
- Surgical options like variceal ligation for cases resistant to other treatments
Embolization Procedure
The embolization procedure involves accessing the femoral or jugular vein under local anesthesia and placing coils or sclerosing agents to close the abnormal veins. This minimally invasive procedure has been shown to provide significant symptomatic improvement in approximately 75% of women, with low repeat intervention rates and minimal risks of complications like coil migration or thrombophlebitis 1.
Sclerotherapy
Sclerotherapy, including foam sclerotherapy, is also an option for treating pelvic varices, particularly for patients with leg, vulvar, and pudendal varicosities of pelvic origin without pelvic venous disease 1. However, the evidence for sclerotherapy is not as strong as that for embolization, and it is often used in conjunction with embolization.
Key Considerations
When treating pelvic varices, it is essential to exclude other causes of symptoms, such as nutcracker syndrome, and to carefully select patients for embolization or sclerotherapy based on their individual symptoms and medical history. Additionally, while the evidence for embolization is strong, there is limited evidence for the use of embolization or stenting to treat pelvic-origin lower extremity varicose veins 1.
From the Research
Symptoms of Pelvic Varices
- Pelvic congestion syndrome is one of many causes of chronic pelvic pain 2
- Ovarian and pelvic varices have long been recognized as a source of chronic pelvic pain in women 3
- Pelvic varices associated with varicose veins in the lower limb can lead to presentation in varicose vein clinics 2
Treatment Options for Pelvic Varices
- Conservative methods of treatment include:
- Non-steroidal anti-inflammatory drugs
- Derivatives of ergot alkaloids
- Hormonal drugs
- Phleboprotectors
- Compression therapy 4
- Percutaneous interventions such as embolization of incompetent veins or stenting for venous stenoses 5
- Embolization of pelvic and ovarian veins is a common treatment used currently 2
- Transcatheter embolotherapy for ovarian and pelvic varices requires selective catheterization of the ovarian and internal iliac veins, followed by contrast venography and embolization 3
- Pelvic vein embolization (PVE) is also used to treat pelvic venous congestion syndrome (PVC) and refluxing pelvic veins associated with leg varicosities 6
Limitations and Future Research
- There is a critically scarce number of studies dedicated to the treatment of pelvic varicose veins, underlying the necessity of carrying out large multidisciplinary studies 4
- The necessity to address both vein reflux and central venous stenosis in patients with pelvic venous disease is still to be elucidated 5
- Limited clinical evidence supports the use of embolotherapy in the management of pelvic congestion syndrome 2
- A satisfactory 'proof' of clinical efficacy remains deficient until higher-level evidence is presented 6