Many women of child-bearing years feel pain in their pelvic area and don't know what it is. It gets worse as the day goes on, and with each pregnancy. Their doctors also sometimes can't determine the cause. Dr. Kelvin Hong, an assistant professor of radiology and surgery at the Johns Hopkins University's School of Medicine, said it could be pelvic congestion syndrome. And it could get worse over time.
Question: What is pelvic congestion syndrome (PCS)?
Answer: According to the American College of Obstetricians and Gynecologists, pelvic congestion syndrome is one of the recognized causes of chronic pelvic pain. PCS is caused by faulty valves in the veins that drain the female pelvis, resulting in dilation and chronic distension of pelvic veins.
Q: What are the symptoms, and will they diminish on their own?
A: PCS usually strikes women between the ages of 20 and 40. It causes pelvic pain that worsens late in the day, with prolonged standing, and with sexual arousal and activity. It also may worsen during menstruation. It is more common on the left than the right, although it can become bilateral as the disease worsens with deep pelvic burning or pain. Visually, varicose veins can be seen on the genitalia, and PCS is often associated with varicose veins in the legs. Generally, PCS will become worse over time.
Q: Why is it so often misdiagnosed?
A: The common scans done to look for a possible cause for pelvic pain are ultrasound, CT scan or MRI, which are performed when the patient is lying down. In this position, the abnormal pelvic veins associated with PCS tend to be collapsed, causing the problem to be missed. Chronic pelvic pain poses a challenge to both physician and patient, and PCS is no exception. There are 23 listed causes of chronic pelvic pain, with some patients suffering from more than one cause. Aside from a lack of universal awareness of this disease, there is no consensus on the treatment of PCS. Referral to a multidisciplinary group of physicians who deal with chronic pelvic pain is critical to its diagnosis and treatment.
Q: Why does it primarily strike those who have been pregnant?
A: During pregnancy, ovarian pelvic blood flow increases by up to 60 times. Some women naturally have no valves or have incompetent, abnormal valves putting them at greater risk for pelvic congestion syndrome. These incompetent venous valves allow backward flow of blood, putting chronic pressure on pelvic structures. With every subsequent pregnancy, the problem then worsens.
Q: Are there minimally invasive ways to treat it?
A: Various treatments have been shown to improve symptoms, though there is no medical consensus for how to best treat the condition. Critical to its diagnosis and treatment is to first exclude other, more common causes of chronic pelvic pain, such as endometriosis, fibroids and pelvic irritable bowel syndrome. Hormone treatments and surgery are options for treating PCS. Another strategy being used is ovarian vein embolization. This outpatient procedure is minimally invasive and is done using a catheter that's threaded through the femoral vein into the ovarian veins. The advantage of this approach is twofold: It allows the radiologist to perform a venogram, a dye study which confirms the diagnosis. It also allows treatment with occlusion of the abnormal veins with various vein obliteration agents. Consultation with physicians who work in a multidisciplinary group setting (gynecologists, pain specialists, interventional radiologists) for this common female pain syndrome is highly advantageous.
For more information on pelvic congestion syndrome, Johns Hopkins has posted a webinar on its website.