What is ovarian vein reflux?

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What is Ovarian Vein Reflux

Ovarian vein reflux is retrograde (backward) blood flow in the ovarian veins caused by absent or incompetent venous valves, resulting in venous dilation (typically ≥8 mm diameter) and contributing to pelvic congestion syndrome. 1

Pathophysiology and Mechanism

  • Ovarian vein incompetence represents the predominant cause of pelvic venous congestion, characterized by retrograde flow in dilated ovarian veins due to valvular insufficiency. 1

  • The condition manifests as dilated periuterine and periovarian veins with slow or reversed blood flow (<3 cm/s), creating venous pooling in the pelvis. 1

  • Estrogen overstimulation plays a significant contributory role by promoting increased blood flow to pelvic organs and indirectly regulating nitric oxide-mediated smooth muscle relaxation in pelvic vessels, which exacerbates venous dilation. 1

  • The left ovarian vein is most frequently affected (54.6% of cases), followed by the right internal iliac vein (54.6%), with combined reflux in multiple pelvic veins occurring in approximately 50% of patients. 2, 3

Clinical Presentation and Associations

  • The cardinal presenting symptom is chronic pelvic pain, usually described as a dull ache lasting ≥6 months, without evidence of inflammatory disease. 4

  • Pelvic congestion frequently coexists with lower extremity varicose veins of pelvic origin, particularly affecting the posterior thigh, vulva, and inguinal regions through venous escape points from the internal iliac system. 1

  • Clinical signs may include vulval varicosities extending onto the medial thigh and long saphenous territory, though such signs are not always present. 4

  • The condition is strongly associated with multiparity (≥2 pregnancies), present in 72% of affected patients, and recurrent varicose veins following previous saphenous vein surgery (75% of cases). 2

  • Symptoms frequently improve after menopause owing to the decline in estrogen-driven vascular effects. 1

Diagnostic Criteria and Imaging

  • Ultrasound with Doppler is the initial imaging study of choice, with findings including engorged periuterine and periovarian veins (≥8 mm diameter), low-velocity flow, altered flow with Valsalva maneuver, and retrograde (caudal) flow of the ovarian veins. 1

  • Transvaginal duplex ultrasonography appears to be the gold standard for haemodynamic evaluation of pelvic venous reflux, with no false-negative diagnoses and only one false-positive in 100 sequential patients when compared to treatment outcomes. 5

  • MRI/MR angiography has diagnostic performance comparable to conventional venography and can directly demonstrate ovarian vein reflux, particularly with time-resolved post-contrast sequences that visualize flow direction. 1

  • CT with contrast may demonstrate engorged periuterine and periovarian veins and can identify venous anatomic variants such as nutcracker syndrome (left renal vein compression) or May-Thurner syndrome (left common iliac vein compression). 1

Associated Conditions and Complications

  • Nutcracker syndrome occurs when the left renal vein is compressed between the superior mesenteric artery and aorta, causing increased pressure that transmits to pelvic veins via the left ovarian vein. 1

  • Iliac vein stenosis is an underdiagnosed contributor, with 80% of patients with pelvic venous insufficiency demonstrating iliac stenosis >50% by intravascular ultrasound, indicating that venous outflow obstruction plays a larger role than previously recognized. 6

  • Patients with both gonadal vein reflux and nonthrombotic iliac vein lesions experience markedly worse symptom severity than those with isolated ovarian vein reflux. 1

Treatment Implications

  • Internal iliac vein embolization (in addition to ovarian vein embolization) has been shown to be safe and effective for treating pelvic congestion syndrome. 1

  • In patients with combined ovarian vein reflux and iliac vein outflow obstruction, pelvic venous outflow lesions should be treated first, with ovarian vein reflux treated only if symptoms persist. 6

  • Isolated ovarian vein embolization significantly improves symptoms (mean symptom score decreased from 5.2 to 1.2, p<0.0001) in patients with isolated ovarian vein incompetence, while conservative treatment shows no improvement. 2

  • Combined reflux in more than one pelvic vein requires comprehensive treatment, as isolated treatment of ovarian veins alone does not improve symptoms when internal iliac vein reflux coexists. 2

References

1
Guideline

Pelvic Congestion Syndrome Diagnosis and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Research

Pelvic venous incompetence: reflux patterns and treatment results.

European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 2009

6
Research

Iliac vein stenosis is an underdiagnosed cause of pelvic venous insufficiency.

Journal of vascular surgery. Venous and lymphatic disorders, 2018

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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