How should I evaluate and manage pelvic vascular congestion (pelvic congestion syndrome) in a reproductive‑age woman with chronic pelvic pain that worsens with prolonged standing, sexual activity, or during the luteal phase, and no identifiable uterine, ovarian, or gastrointestinal pathology?

Pelvic Congestion Syndrome: Evaluation and Management

Initial Diagnostic Approach

Begin with transvaginal ultrasound with Doppler imaging as your first-line diagnostic test to confirm pelvic congestion syndrome in this reproductive-age woman with characteristic positional and hormonal pain patterns. 1

Key Diagnostic Imaging Features

• Ultrasound with Doppler is the initial imaging study of choice and should demonstrate:

  • Engorged periuterine and periovarian veins ≥8 mm in diameter 2, 1
  • Low-velocity flow (<3 cm/s) 1
  • Altered flow with Valsalva maneuver 2, 1
  • Retrograde (caudal) flow in ovarian veins 2, 1
  • Direct connection between engorged pelvic veins and myometrial arcuate veins 2

• MRI/MR angiography serves as the problem-solving examination when ultrasound is nondiagnostic or inconclusive 2

  • Time-resolved post-contrast T1-weighted imaging directly demonstrates ovarian vein reflux and offers superior flow directional assessment compared to static imaging 2, 1
  • Diagnostic performance is comparable to conventional venography 2, 1

• CT with contrast can identify engorged periuterine/periovarian veins and detect anatomical variants including left renal vein compression (nutcracker syndrome) or May-Thurner syndrome 2, 1

Important Clinical Associations to Evaluate

• Look for morphologic findings of polycystic ovarian syndrome on imaging (enlarged ovaries with exaggerated central stroma and multiple small peripheral follicles), which occurs frequently in PCS patients but typically without hirsutism or amenorrhea 2, 1

• Examine for lower extremity varicose veins, particularly affecting posterior thigh, vulva, and inguinal regions, as these frequently coexist with pelvic congestion 1

• Screen for coexisting nonthrombotic iliac vein lesions, as patients with both gonadal vein reflux and iliac vein stenosis experience markedly worse symptom severity 1

Treatment Algorithm

Proceed directly to ovarian vein embolization (OVE) as first-line definitive therapy once diagnosis is confirmed, as this has superseded conservative and medical management. 3

Endovascular Treatment

• Ovarian vein embolization achieves:

  • Technical success rates of 96-100% 3
  • Long-term symptomatic relief in 70-90% of cases 3, 4
  • Low complication rates 3

• Internal iliac vein embolization should be added to ovarian vein embolization when internal iliac vein reflux is identified, as this combination has been shown to be safe and effective 1

• Trans-catheter venography remains the gold standard for definitive diagnosis and is performed immediately before embolization 3, 5

Pathophysiological Considerations Guiding Treatment

• Ovarian vein incompetence is the predominant cause, characterized by retrograde flow in dilated ovarian veins due to valvular insufficiency 1

• Estrogen overstimulation plays a significant contributory role by promoting increased pelvic blood flow and nitric oxide-mediated smooth muscle relaxation 2, 1

  • Symptoms may subside after menopause due to decreased estrogen stimulation 2, 1

• Mechanical venous obstruction from nutcracker syndrome (left renal vein compression between SMA and aorta) or May-Thurner syndrome (left common iliac vein compression) can cause increased pelvic venous pressure 1

Critical Clinical Pitfalls

• Do not dismiss the diagnosis based on absence of visible varicosities, as incompetent and dilated pelvic veins are common findings even in asymptomatic women—correlation with characteristic symptom pattern is essential 6

• Recognize the lack of clear definitions and high-quality evidence in this clinical domain, which contributes to underdiagnosis 2, 3

• Avoid prolonged conservative management once diagnosis is confirmed, as medical and surgical treatments have been shown to be less effective than transcatheter embolization 4

• Screen for psychiatric comorbidity (anxiety, depression), as underdiagnosis and delayed treatment of this chronic pain condition frequently leads to these complications 3