From the Guidelines
Pelvic congestion syndrome should be treated with ovarian vein embolization as the primary minimally invasive procedure for patients with severe symptoms or those not responding to medication, as it has been shown to be safe and effective in reducing pelvic pain. Treatment typically begins with non-surgical approaches including nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for pain management 1. Hormonal treatments such as medroxyprogesterone acetate (30-50mg daily) or combined oral contraceptives can help reduce symptoms by decreasing blood flow to the pelvic veins. Lifestyle modifications including regular exercise, avoiding prolonged standing, and elevating the legs when possible can help manage symptoms. Pelvic floor physical therapy may also provide relief.
The condition occurs predominantly in women of childbearing age and is thought to result from hormonal influences on the venous system, with estrogen causing relaxation of vessel walls, combined with anatomical factors that increase pressure in pelvic veins. Multiple pregnancies can increase the risk due to repeated venous distension and hormonal changes. Internal iliac vein embolization (in addition to ovarian vein embolization) has been shown to be safe and effective in treating pelvic venous insufficiency and reducing pelvic pain in most women undergoing treatment for pelvic congestion syndrome 1.
Some studies have also explored surgical options, such as left renal vein bypass, transposition, and external stent placement, as well as percutaneous endoluminal left renal vein stenting, although these are less commonly recommended due to associated morbidity 1. Laparoscopic left ovarian vein surgical ligation has also been described, with reported complete resolution of symptoms in some patients. However, ovarian vein embolization remains the preferred minimally invasive treatment option, given its efficacy and safety profile, as supported by recent studies 1.
From the Research
Definition and Prevalence of Pelvic Congestion Syndrome
- Pelvic congestion syndrome is a condition characterized by chronic pelvic pain in women, often associated with pelvic varicosities, and is considered the second most frequent cause of chronic pelvic pain after endometriosis 2.
- The syndrome is estimated to account for approximately 10% of outpatient gynecologic visits 2.
Symptoms and Diagnosis
- Symptoms of pelvic congestion syndrome may include pelvic pain, dyspareunia, dysuria, dysmenorrhea, external varices, and various psychosocial symptoms 2, 3.
- Diagnosis of the syndrome can be challenging, but it is typically based on imaging studies such as Doppler ultrasound, CT scan, and MRI, with transcatheter venography considered the gold standard for diagnosis 4.
- The diagnosis should remain on the differential for chronic pelvic pain, despite being difficult to make 5.
Treatment Options
- Treatment options for pelvic congestion syndrome include medical, surgical, and endovascular therapy, with transcatheter pelvic vein embolization being a safe, effective, and durable therapy for the treatment of the condition 4, 6.
- Endovascular treatment with interventional radiology is favored over surgical management, with high success rates and low occurrence of complications 5.
- Minimally invasive interventions have become the method of first choice for the treatment of pelvic congestion syndrome, with embolization being an effective and safe treatment option 6.
Efficacy and Outcomes
- Complete or partial symptom improvement has been reported in 68.2-100% of patients undergoing transcatheter embolization, with a consistent reduction in visual analog pain scores after treatment 2.
- However, 6-31.8% of patients may not experience substantial relief from pelvic venous embolization, highlighting the need for further research into disease-specific quality of life measures and procedural variability 2.