What is the most common cause of bilateral enlarged ovarian veins?

Causes of Bilateral Enlarged Ovarian Veins

The most common cause of bilateral enlarged ovarian veins is pelvic venous congestion syndrome (PVCS), characterized by incompetent and refluxing pelvic veins that lead to venous stasis and congestion. 1

Pathophysiology of Enlarged Ovarian Veins

Bilateral enlarged ovarian veins typically result from:

1. Valvular Dysfunction:

   • Incompetent valves in ovarian veins allow retrograde (backward) blood flow
   • Results in venous stasis and engorgement of pelvic veins
   • Typically defined as ovarian veins ≥6-8mm in diameter 1

2. Hormonal Factors:

   • Estrogen stimulation plays a significant role 1
   • More common in premenopausal women (21%) than postmenopausal women (10%) 2
   • Symptoms may subside after menopause in some women 1

3. Mechanical Factors:

   • Compression of the left renal vein can cause asymmetric left-sided pelvic varicosities 1
   • Increased intra-abdominal pressure (pregnancy, obesity) can exacerbate the condition

Diagnostic Criteria and Imaging Findings

Diagnostic imaging criteria for enlarged ovarian veins include:

• Ultrasound findings:

  • Dilated, tortuous pelvic veins >4-8mm in diameter
  • Slow or reversed blood flow (<3 cm/s)
  • Dilated arcuate veins in the myometrium communicating with pelvic varicosities 1
  • Altered flow with Valsalva maneuver 1

• CT/MRI findings:

  • Ovarian vein diameter ≥6mm is considered pathologic 2
  • Engorged periuterine and periovarian veins 1
  • Venous anatomic variants may be present 1

Associated Conditions and Clinical Correlations

1. Pelvic Congestion Syndrome:

   • Chronic pelvic pain (>6 months duration) without inflammatory disease 3
   • Pain worsens with standing, walking, and during pre-menstrual period
   • Post-coital ache, dysmenorrhea, dyspareunia are common 3
   • Present in approximately 18% of women with dilated pelvic veins 2

2. Polycystic Ovarian Morphology:

   • Many women with pelvic venous disorders have morphologic findings of polycystic ovaries
   • Enlarged ovaries with exaggerated central stroma and multiple small peripherally located follicles
   • However, clinical features of PCOS (hirsutism, amenorrhea) are rare 1

3. Lower Extremity Manifestations:

   • Vulvar, thigh, or buttock varicosities may develop 4
   • Patients may present with lower extremity symptoms related to pelvic venous insufficiency 1

4. Urological Symptoms:

   • Hematuria, dysuria, and urinary frequency without infection 2
   • Bladder irritability is common 3

Clinical Pearls and Pitfalls

• Diagnostic pitfall: Dilated ovarian veins can mimic cystic adnexal masses on gray-scale ultrasound; Doppler assessment is crucial for differentiation 1

• Underdiagnosis: PVCS is frequently overlooked as a cause of chronic pelvic pain, leading to delayed diagnosis and treatment 3, 2

• Patient demographics: Most common in multiparous premenopausal women, with 8% of all premenopausal women potentially affected 2

• Evaluation approach: When bilateral enlarged ovarian veins are detected, assessment should include both pelvic and lower extremity symptoms, as they frequently coexist 1

• Imaging technique: Evaluation in both supine and semi-standing positions with Valsalva maneuver increases diagnostic sensitivity 1

By understanding these patterns and associations, clinicians can better recognize and address bilateral enlarged ovarian veins and their clinical implications.