Understanding pelvic congestion syndrome: insights and treatments [PODCAST]

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In this insightful podcast episode, we sit down with guest Gloria Salazar, a radiologist, to shed light on a common yet often misunderstood condition affecting women: pelvic congestion syndrome (PCS). Join us as we explore the challenges in diagnosing and treating PCS, the symptoms to look out for, and how it differs from other pelvic venous disorders. Gloria shares her expertise on the innovative diagnostic tools and multidisciplinary approaches being used to tackle PCS. We delve into the effectiveness of minimally invasive treatments like embolization and discuss the latest research findings that demonstrate its safety and efficacy. Discover the importance of raising awareness about PCS and empowering women to seek the care they deserve. Join us as we explore the path towards improved understanding, diagnosis, and treatment of pelvic venous disorders.

Gloria Salazar is a radiologist.

She shares her story and discusses her KevinMD article, “Breaking the silence on pelvic congestion syndrome: Diagnosing and treating chronic pelvic pain with interventional radiology.”

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Transcript

Kevin Pho: Hi and welcome to the show. Subscribe at KevinMD.com/podcast. Get CME for this episode by clicking on the CME link in the show notes. Today we welcome Gloria Salazar. She’s an interventional radiologist. Her KevinMD article is titled “Breaking the silence on pelvic congestion syndrome: Diagnosing and treating chronic pelvic pain with interventional radiology.” Gloria, welcome to the show. So we’ll get into your article in a little bit, but first off, briefly share your story and journey to where you are today.

Gloria Salazar: My career started back in Brazil. I’m originally from Brazil. I did my medical school there, and in 2005 I got the opportunity to come to the United States and subspecialize in interventional radiology. So I previously did my radiology residency in Brazil, and then I moved in 2005 to Boston, where I essentially had my house and my life for 15 years. During those years, I worked very closely with OB/GYNs in developing multidisciplinary clinics for women’s health, in particular in fibroid treatment, as well as pelvic venous disease, or pelvic congestion syndrome.

So more recently, about two years ago, I was offered a leadership position within the University of North Carolina at Chapel Hill in the radiology department, and I’m now the vice chair for diversity and health equity. I continue to work on women’s health issues, but also on procedures and developing clinical guidelines and practices.

Kevin Pho: Before we get into the article, I want to talk about some context. So you are a specialist in pelvic congestion syndrome and the intersection between that and interventional radiology. Now, for those who aren’t familiar with pelvic congestion syndrome, what exactly is that?

Gloria Salazar: So pelvic congestion syndrome is a term that was essentially used for about 25 years to recognize the role of pelvic varices in causing pelvic venous pain. So essentially, women who are multiparous, who have compression syndromes such as iliac vein stenosis, can develop varices over time, over their lifetimes. And classically, those presentations are related to women who have more than two or three children, and with each pregnancy, this pelvic pain that is due to varices gets worse and worse.

And so initially, we thought that these pelvic varices were only present due to ovarian vein insufficiency, but now, with the evolution and understanding of this disease process, we know that actually you can also have the stenosis associated with it. So this is basically what we’ve learned in interventional radiology over the years in treating women with chronic pelvic pain that otherwise would not be diagnosed, because pelvic varices are also very common in imaging studies. Initially, we thought that these pelvic varices perhaps wouldn’t cause chronic pain, but now we understand that there is a subset of women that go on to develop severe chronic pain that impairs their quality of life.

Kevin Pho: I’m a primary care physician. So how would patients like this present in my office? What kind of story would they have? What kind of symptoms would they typically present with in my office?

Gloria Salazar: So these patients, essentially, are very frustrated, because they have undergone an extensive workup. They have seen multiple different specialties and specialists for different causes of chronic pelvic pain. I mean, chronic pelvic pain is a broad umbrella of a diagnosis, and there are several different categories that we can actually look for.

But these patients would present to your clinic with a history of at least five years of chronic pelvic pain that started off perhaps with the second or third pregnancy. And that pain would essentially worsen with prolonged periods of standing, just as varicose veins in the leg would essentially perform in a patient with that condition. In the case of the pelvic varices, that pain is located at the suprapubic area and very often located at the left lower or right lower quadrant. And so the postural aspect or characteristic of that pain is very indicative of varices, because the patients do report that in the morning they feel better, and they do feel better when they lie flat or they elevate their legs. That’s one characteristic.

The second one would be what we often call the post-coital pain. Those patients have a tremendous amount of pain during sexual intercourse, but the characteristic of venous pain in this situation is a patient who actually would have prolonged pain after sexual intercourse, sometimes even lasting days after the event.

And the last piece would be related to the characteristic that is non-cyclic, which means that this type of pain, the chronic pain due to venous pain or varices, actually is present throughout the month. It’s not only related to the cycle. Perhaps it worsens during the menstrual cycle, but it’s always present. And it also depends on how much the patients work on their feet. If they are teachers, nurses, people who work in the kitchen, or hairdressers, they would feel even more impacted in terms of quality of life.

So these would be the three things that perhaps we would look for in terms of symptoms and history. But the last piece would be that they are very frustrated, and they’re often diagnosed with associated depression sometimes, or often mislabeled with psychiatric conditions, because, as you can imagine, they go to different providers and nobody really can find out what’s the problem, why they’re having chronic pelvic pain, given that the diagnostic or the clinical workup doesn’t find anything palpable for those patients to be treated for in the future.

Kevin Pho: So if one were to suspect pelvic congestion syndrome, what would be the next diagnostic steps?

Gloria Salazar: Most of those patients would have undergone an endovaginal ultrasound. As we know, for example, fibroids are very prevalent in the population in general. Other conditions that cause chronic pelvic pain, such as endometriosis, also are sort of coexistent with pelvic varices. But I would say that some of those patients would have an endovaginal ultrasound showing the varices at the ovarian locations, at the periovarian locations, and also vessels crossing inside of the uterus. So you could actually see those varices.

The problem is that those imaging findings are not often reported, and for years, we didn’t really think those pelvic varices could cause such an amount of pain. So in terms of diagnosis, I would say ultrasound is the next step. The endovaginal ultrasound could show you the presence of varices, and that would be a first step for you to get those patients in the right direction in terms of diagnosing them.

Kevin Pho: Now, of course, you talk more about that in your KevinMD article, “Breaking the silence on pelvic congestion syndrome: Diagnosing and treating chronic pelvic pain with interventional radiology.” How did your article come together?

Gloria Salazar: It was a great opportunity to shine a light on this, what we call a silent condition, because there is still a lack of awareness of this disease. There is a lack of education as well, in terms of how to diagnose, and also there is a lack of high-quality studies, large data series. And partly, we’ve been treating this condition for over 25 years, and we do have publications on the topic, but because it is a disease that affects not only the ovarian veins, for example, but also the internal iliac veins and different anatomical locations, it does create a little bit of a challenge for us to do high-quality research and understand which treatments work the best.

But aside from that, the reason for the article was really to shine a light on this disease process that affects perhaps millions of women. We don’t know the incidence of pelvic venous disease very well. Of course, my practice is filled with them, because that’s my specialty, but I will tell you that these women suffer for 10, 15 years, with significant impact on their marital life and on their work life, and they go undiagnosed. And when they get treated with the proper treatment, they really change their lives completely.

So the article was really an intention to bring awareness of this disease, as well as to bring out the importance of working in a multidisciplinary setting. I think that has been demonstrated in different disease processes. Working in a multidisciplinary way, with gynecologists working together with interventionalists as well as urologists, because sometimes we have to have urologists on board, is extremely important for those patients to get the right and proper care.

Kevin Pho: So tell us some of these treatment options once this is diagnosed.

Gloria Salazar: The traditional treatment option that has been described over 25 years has been embolization, essentially closing the veins that are supplying those varices in the pelvic area and in the uterus. And closing the veins essentially eliminates that space that the patients have. Think about it as a reservoir that is not flowing, and the blood just gets stuck in the lowest dependent portions, and over time that just gets inflamed. There are a lot of theories about how inflammatory markers play a role in why those patients develop pain, but we’re still studying those as part of research. But for the most part, what we do understand does help improve the pain is closing those pelvic connections, and those veins are no longer useful anyway. Those veins are essentially dead spaces in the pelvic area.

So we close them by using coils, which are metallic materials, or metallic sort of coiling embolization devices, to close off the vessels. We also use sclerosants. Sclerosants have been used for years in medicine for different varicose vein treatments, and we use similar medications in that territory. And there are other potential areas for different types of materials to be utilized here, but essentially the main procedure is closing the vessels that are causing the problem. That’s the majority of it.

But in a subset of patients, we do need to look for compression and stenosis, and that is where we need to have a thorough evaluation of the anatomy of the patient in terms of looking for those areas. I have had patients that I had to treat, for example, with venous stents to open up their vessels and relieve that pressure that the varices are causing in the uterus, by actually doing the opposite of closing vessels: opening up vessels. So those are sort of the two major treatments that we have for patients, with embolization being the one that has been most studied in the literature.

Kevin Pho: So from a patient perspective, tell us what it’s like to go through some of these procedures.

Gloria Salazar: So the benefit of having an interventional radiologist evaluating you is that you essentially are going to have a minimally invasive procedure, which means that we’re going to go inside of your vessels. In this case of pelvic venous congestion, we’re going to go inside of your veins. And so we can do the procedure as an outpatient procedure. There’s no requirement for general anesthesia. Obviously, there are some patients that are very anxious and do require general, because they simply want to be out for the procedure, but 95 percent of the time, patients just require conscious sedation, which is a form of sedation that we give through an IV in the arm, and we use two medications for the patients to be sleeping. So that’s sort of the preparation.

In terms of the procedure, it takes an average of one and a half to two hours. Sometimes it takes one hour for us to just embolize those two vessels, if we already know what we’re looking for and if the patient does not have associated, let’s say, iliac stenosis or any stenosis. And so for those patients, in about an hour and a half, you can get the procedure done. We can place the coils, we can close the vessels for you, and then you will have a small incision in your neck. This can be done from the neck, or this can be done from the groin, as well as from an arm vein, depending on the anatomy. And those incisions are extremely small, like millimeters.

You essentially leave the hospital the same day, two hours after the procedure is finished. We will give you medication for pain, which is not that significant. It’s more of an inflammation pain, for which some of us will give a course of steroids for a couple of days, as well as non-steroidal anti-inflammatory medication. So it’s a same-day procedure with minimally invasive implications, and you leave the hospital walking on your own, with a Band-Aid either in the neck or in the groin.

Kevin Pho: And in general, how successful are these procedures in terms of relieving chronic pelvic pain?

Gloria Salazar: So that goes back to the article at hand, in terms of talking about the large data series and the quality of research that we have had available to us thus far. We do have most of the data being retrospective series, the largest being like 200 patients, 250 patients. And as we know, in medicine, we look for level A data. But for the retrospective series, and for a systematic review analysis of the literature on the embolization procedure, what we found is that regardless of the technique, whether you use coils, sclerosants, or both, patients essentially have an improvement of the pain about 75 percent of the time. So essentially, you do have a reduction that sustains over time. It’s just not 100 percent all the time.

Now, it’s important to note that there is a lot of variation in the technique, or there has been a lot of variation in technique reported in the literature, so that skews the results perhaps a little bit. And it’s also important to know that the outcome metrics that were used in those studies are all based on visual analog scores, which we all use in our practice in different areas of medicine, and we know that these tools are not all that accurate to measure not only pain but also clinical outcomes.

And so the visual analog scores are from 0 to 10, and what we’ve observed is that they do go down significantly from baseline before treatment. In a subset of patients, perhaps it doesn’t go all the way down to zero, and part of it is perhaps we did not look for the compression or the stenosis, because of this evolution in understanding of the disease. But essentially, 75 percent substantial pain relief is what I describe to my patients. And we talk about the clinical outcomes, and we talk also about the need for second procedures, because if they don’t improve 100 percent or significantly with the first procedure, then we want to look for other areas that perhaps are causing the pelvic pain.

Kevin Pho: We’re talking to Gloria Salazar. She’s an interventional radiologist. Her KevinMD article is titled “Breaking the silence on pelvic congestion syndrome: Diagnosing and treating chronic pelvic pain with interventional radiology.” Gloria, are procedures like this typically available in a community setting? Or do they have to go to an academic medical center or tertiary medical center for this?

Gloria Salazar: That is a great question, and I think the question has to really be tied into the areas where we provide interventional radiology within our country. Unfortunately, we know that interventional radiologists perhaps are not available in all the community hospitals, in the way that some major academic centers are performing those procedures. But what we would like to see is that at least the diagnosis is made and we can create the referral patterns for those areas, or centers of excellence.

I actually see patients not only from North Carolina but from all over the state, or different states. And even within North Carolina, we have rural areas where we’re working on awareness and having the patients referred to me. Sometimes they live three, four hours away. We try to provide telemedicine consults ahead of time, just to make sure. But these are procedures that are likely going to be in hospitals that have an IR service that is well developed, which I think most of the major hospitals in the community have.

I think we need a little bit more awareness and education work in terms of helping the primary care physicians, as well as the gynecologists in the community, to try to get those patients screened and then sent out for further evaluation. So locally, this is what we’re working on here in North Carolina, providing this not only for women’s health but also for other types of disease processes that we can help.

But it is still, I think, an issue. I think this is an issue for our whole U.S. health care system: Whenever we have a procedure that requires some sort of innovation, or some sort of device, or some sort of technology, which is what we use in interventional radiology (in this case, we use C-arms, we use fluoroscopy, we use different devices to close those vessels up), it requires a little bit of foundation and structure.

Kevin Pho: And my final question, Gloria: Tell us some of your take-home messages that you want to leave with the KevinMD audience.

Gloria Salazar: I think women’s health has been unfortunately neglected, not only here in this country but, I think, internationally. That’s the scene. We do still see issues with maternal mortality, not only here in our country but all over the world. And for me personally, it’s very rewarding to work with those patients who have poor quality of life, and they have a reason for why they’re having chronic pelvic pain.

So when these patients improve from a nine, the improvement of pain is very quick, rapid, I would say like a couple of months or weeks, and they are extremely grateful, not only for the fact that we diagnose them but also that we’re treating them in the proper manner. So essentially, their lives are changed by this procedure. And if they have been in pain for 10, 15 years, that’s quite significant for women.

So my take-home message is, let’s think about pelvic varices as a potential diagnosis, particularly if you have done the workup and you cannot find any apparent reason for pelvic pain, particularly if the patient has had multiple pregnancies, and also if the patient has postural pain that is worse at the end of the day and is relieved by lying flat, or in the mornings they don’t have any pain at all. So these are sort of, I would think, generic tips, I would say, for patients who are having chronic pelvic pain that perhaps could be due to venous disease, so that they can be diagnosed first and then treated properly.

Kevin Pho: Gloria, thank you so much for sharing your time and insight. Thanks again for being on the show.

Gloria Salazar: Thank you so much for having me.

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