From the Guidelines
Prominent paraovarian veins are a significant finding that may indicate pelvic congestion syndrome, a condition characterized by chronic pelvic pain due to venous insufficiency and blood pooling in the pelvic region, and should prompt further evaluation and consideration of treatment options such as embolization or hormonal therapy to improve quality of life and reduce morbidity. The diagnosis of pelvic congestion syndrome is often made based on a combination of clinical symptoms and imaging findings, including the presence of dilated, tortuous pelvic veins on ultrasound, CT, or MRI 1. The management of pelvic congestion syndrome typically involves a multidisciplinary approach, including conservative measures such as pelvic support garments and NSAIDs for pain relief, as well as more definitive treatments such as embolization of the affected veins or surgical ligation in severe cases 1. Hormonal therapy with medroxyprogesterone acetate or combined oral contraceptives may also help reduce symptoms by decreasing pelvic blood flow 1. The use of duplex US is widely agreed upon as the first assessment of the lower extremity venous system, and can help identify the presence of dilated, tortuous pelvic veins and slow or reversed blood flow, which are characteristic of pelvic venous insufficiency 1. Key sonographic criteria for diagnosing pelvic venous insufficiency include a dilated, tortuous pelvic vein >4 mm, slow or reversed blood flow (3 cm/s), and a dilated arcuate vein in the myometrium that communicates with pelvic varicosities 1. Overall, the presence of prominent paraovarian veins should be taken seriously and prompt further evaluation and consideration of treatment options to improve quality of life and reduce morbidity in affected women. Some of the key points to consider when evaluating and managing prominent paraovarian veins include:
- The use of duplex US as the first assessment of the lower extremity venous system
- The presence of dilated, tortuous pelvic veins and slow or reversed blood flow on imaging studies
- The use of conservative measures such as pelvic support garments and NSAIDs for pain relief
- The consideration of more definitive treatments such as embolization or surgical ligation in severe cases
- The potential benefits of hormonal therapy in reducing symptoms and improving quality of life. It is also important to note that the evidence for the management of pelvic congestion syndrome is largely based on case series and observational studies, and further research is needed to fully understand the optimal treatment approaches for this condition 1. However, based on the current evidence, embolization of the affected veins is a effective treatment option for pelvic congestion syndrome, with early substantial pain relief observed in 75% of women undergoing embolization, and sustained over time 1.
From the Research
Significance of Prominent Paraovarian Veins
The significance of prominent paraovarian veins is closely related to Pelvic Congestion Syndrome (PCS), a condition characterized by chronic pelvic pain due to ovarian and internal iliac varices. Key points to consider include:
- PCS contributes to 30-40% of patients presenting with chronic pelvic pain where no other cause is identified 2, 3
- The aetiology of PCS is multifactorial, involving both hormonal and anatomical dysfunction, including reflux or obstruction of the gonadal, gluteal, or periuterine veins 2, 3
- Patients with PCS present with a cluster of symptoms related to pelvic venous congestion, including pelvic pain worse on standing, irritable bowel symptoms, dyspareunia, vulval varicosities, and lower limb venous pathology 2, 4, 5
- Prominent paraovarian veins can be a contributing factor to PCS, as they can lead to pelvic venous insufficiency (PVI) and varicose vein formation 4, 5
- Diagnosis of PCS requires a careful history, physical examination, and noninvasive imaging, such as transvaginal ultrasound, magnetic resonance imaging, or duplex ultrasound 2, 6, 3
- Treatment options for PCS include ovarian vein embolization, which is a safe, minimally invasive, and efficacious treatment, as well as open surgery and endovascular stenting of the left renal vein (LRV) for patients with outflow obstruction due to nutcracker syndrome 2, 4, 3