One in six women in the U.S. suffers from chronic pelvic pain (CPP), yet many receive improper treatment for the condition, or no care at all. They’re frustrated – and rightfully so. Their health care providers are frustrated too because what their patients are experiencing has historically been very difficult to diagnose. It is estimated that about 30 percent of patients with CPP suffer from a condition that can be treated with minimally invasive interventional procedures without the need for hysterectomy It’s known as pelvic congestion syndrome, or PCS.
The condition presents with a wide variety of interrelated symptoms, making it difficult for most providers to accurately diagnosis and treat. Fortunately, progress is being made to develop clear diagnostic criteria, and evaluating effective treatments that are currently available, although many women are unfortunately not aware of these options. With May being National Women’s Health Month, it’s an opportune time to bring this condition to light.
The challenge
PCS is a treatable condition that occurs when enlarged veins develop within the uterus or ovaries. Patients with PCS sometimes endure severe chronic pelvic pain along with enlarged veins on their genitals and thighs. These disorders usually affect women who have previously been pregnant and have experienced a backup of blood flow to the ovarian and pelvic veins, similar to varicose veins in the legs, however, it can also be present in nulliparous and/or older women with iliac venous compression. In addition, it can also be associated with abnormalities in different anatomical locations, such as left iliac and renal veins.
Part of the challenge is that women who have pelvic venous congestion may present with venous dilation (ovarian or internal iliac veins reflux) or venous obstruction (in the renal or common iliac veins), isolated or in combination. Because the name pelvic congestion syndrome fails to completely account for all aspects of the pathophysiology of this condition, we now utilize the more comprehensive term: pelvic venous disorders (PeVD), to fully describe the spectrum of this disease and to improve the proper categorization of patients.
The “three Ps” of pelvic venous disorders
PEVD shares symptoms with other conditions, such as endometriosis, uterine fibroids, and adenomyosis. A diagnosis starts by understanding how and why PEVD happens, identifying the key symptoms, and ruling out other conditions. The most common symptom is the persistence of chronic pelvic pain, which in some cases can last for years. Another symptom is postural pain, which worsens when standing for long periods but is alleviated by lying flat. It can also cause post-coital pain, experienced after sexual intercourse, that can last for days. We call these the “three Ps” of diagnosing PEVD: postural, post-coital, and pelvic pain.
Additionally, we are now able to use a new classification system, created in the just the last year, called the Symptoms-Varices-Pathophysiology tool, to help provide an accurate diagnosis. And PEVD can also be identified and treated with the help of interventional radiologists, who use ultrasound, CT scans, or MRIs to evaluate patients for enlarged veins that could be causing their pain.
Treating PeVD
I’ve found that the best results come from multidisciplinary settings, where gynecologists, vascular surgeons, and interventional radiologists can work together to diagnose and treat patients. Although some major surgical treatments, such as a hysterectomy, are being offered to these patients, they may not always be necessary, particularly given the high morbidity associated with this surgery and its negative implications for women’s long-term mental health. In this setting, IRs can perform a minimally invasive treatment known as embolization, a procedure that places embolic agents (coils and sclerosants) into blood vessels to block blood flow causing the venous congestion in the pelvis. In addition, IR procedures can help diagnose and treat venous compression that sometimes is associated with this disease.
A substantial and growing body of evidence shows that this treatment is safe and effective. In fact, new research on embolization for this condition, presented at the Society of Interventional Radiology’s 2023 Annual Scientific Meeting in March, found the treatment was safe and effective, with 80 percent of patients reporting improvement of symptoms and 82 percent reporting being satisfied at follow-up.
After having children, many women feel like they must suffer in silence with their pain. This should never be the case. There are treatment options to help alleviate symptoms from PEVD, and diagnostic criteria is becoming clearer; in addition, SIR Foundation is sponsoring future studies in this field that will help elucidate which patients will benefit from IR procedures. IRs are moving the field forward, and we want to bring everyone along with us so we can get patients the care they deserve.
Gloria Salazar is a radiologist.
