What is the appropriate management and treatment for ovarian congestion syndrome?

Management of Pelvic Congestion Syndrome (Ovarian Congestion Syndrome)

Ovarian vein embolization is the primary treatment for pelvic congestion syndrome, achieving approximately 75% substantial pain relief that is generally sustained over time, with internal iliac vein embolization added when needed for comprehensive pelvic venous insufficiency treatment. 1

Diagnostic Confirmation

Before proceeding with treatment, confirm the diagnosis through imaging:

• MRI/MR venography or CT venography are the standard diagnostic modalities to identify pelvic varices and ovarian vein incompetence 2, 3
• Diagnostic venography at the time of planned embolization confirms incompetent ovarian veins and identifies additional pelvic venous pathology requiring treatment 2, 4
• Look specifically for enlarged ovarian veins (>6mm diameter), retrograde flow, and dilated pelvic venous plexuses on imaging 3

Primary Treatment: Ovarian Vein Embolization

The most effective current treatment is transcatheter embolization of incompetent ovarian and pelvic veins:

• Bilateral ovarian vein embolization using coils (stainless steel or platinum microcoils) with or without sclerosant achieves 75% early substantial pain relief in most patients 1, 5
• Add internal iliac vein embolization when pelvic venous insufficiency extends beyond the ovarian veins, which has been shown safe and effective for reducing pelvic pain 1
• Foam sclerotherapy techniques using 3% sodium tetradecyl sulfate or polidocanol can be combined with coil embolization, with stop-flow balloon occlusion techniques optimizing sclerosant delivery to high-flow pelvic varicoceles 1

Expected Outcomes and Follow-up

• Immediate relief: 88.9% of patients experience >80% symptom relief immediately post-procedure 4
• Sustained benefit: Pain relief generally increases and is sustained over time, with most patients maintaining improvement at 5-year follow-up 1
• Repeat interventions: Generally low rates, though 30% may experience mild symptom recurrence at midterm follow-up 1
• Common transient side effect: Colic-like pain that spontaneously resolves within 5 minutes post-sclerotherapy 1

Technical Considerations

• Approach: Femoral venous access is standard for bilateral ovarian vein embolization 5, 4
• Embolization materials: 0.035-inch stainless steel coils or 0.018-inch platinum microcoils, often combined with absorbable gelatin sponge or foam sclerosant 1, 4
• Coil migration risk: <2% with modern techniques 1
• Treat tributaries: Embolize incompetent hypogastric vein tributaries when identified as contributing to symptoms 4

Alternative and Adjunctive Surgical Options

While embolization is preferred, surgical options exist for specific scenarios:

• Laparoscopic ovarian vein ligation achieved complete symptom resolution in small case series (23/23 patients), but is more invasive than embolization 1
• Open surgical ovarian vein removal showed symptomatic improvement in two-thirds of patients historically, but has been largely replaced by endovascular techniques 1
• Left renal vein stenting for nutcracker syndrome causing pelvic venous disease, though evidence for improvement in pelvic symptoms is limited 1

When Surgery May Be Considered

• Failed embolization with persistent symptoms (though second embolization may be effective in select patients) 1
• Anatomic variants preventing endovascular access 4
• Patient preference after informed discussion of risks and benefits 6

Critical Pitfalls to Avoid

• Do not perform second embolization reflexively: If there is no improvement after initial embolization, a second procedure is unlikely to be effective, and alternative diagnoses should be reconsidered 1
• Do not overlook iliac vein pathology: Treating only ovarian veins when internal iliac vein incompetence exists will result in incomplete symptom relief 1
• Do not use iliac or renal vein stenting for lower extremity varicose veins: No high-quality data demonstrates benefit for pelvic-origin lower extremity varicose veins, despite theoretical rationale 1
• Ensure proper patient selection: Rule out other causes of chronic pelvic pain before attributing symptoms to pelvic congestion syndrome 6, 2

Long-term Monitoring

• Symptom recurrence: Monitor at 1,3,6, and 12 months post-procedure, as most recurrences occur within the first year 1
• Repeat imaging: Consider if symptoms recur to identify untreated venous pathology or recanalization 1
• Fertility and ovarian function: Limited data suggest no concerns regarding post-treatment impact on menstruation, ovarian reserve, or fertility 1