It has been estimated
the 15-30% of women will experience chronic
pelvic pain in their lifetime, defined as
pain that occurs between menstrual cycles
and is of at least six months duration.
Some possible causes of pain may be endometriosis,
fibroids and uterine prolapse. But when
examination and testing has ruled out other
possibilities, pelvic congestion may be
playing a significant role in this severe
pain. Studies have shown that up to 30%
of women with chronic pelvic pain have pelvic
congestion syndrome (PCS) as the sole cause
of their pain and another 15% have PCS along
with some other pathology.
Pelvic congestion syndrome is caused by
venous leakage similar to varicose veins
in the legs. In this case, blood leaks and
pools in the veins of the ovaries and uterus,
possibly extending into the veins of the
vagina, vulva and legs. This pooling blood
leads to distention and inflammation of
the veins, producing symptoms.
Symptoms
-Pelvic or low back pain
or pressure that worsens with prolonged standing
or at the end of a day and is often relieved
when lying down
-Pain often worsens and becomes severe around
menstrual periods
-Pain during or up to 24 hrs after intercourse
-Bladder pressure with feeling of need to
frequently urinate
-Varicose veins around the vulva or in the
upper legs
Up to 15% of women have these leaking veins
in the pelvis. Most patients are pre-menopausal
and typically have had at least one previous
pregnancy. The exact cause of pelvic congestion
is unknown. However, it is known that 6-15%
of women have abnormal valves in the ovarian
veins. Pregnancy may make these valves vulnerable
to further dysfunction. It is also thought
that hormonal dysfunction may play a role
in the developing venous leakage as the problem
is rarely newly diagnosed in women after menopause.
Figure 1 - MRI exam
shows abnormal dilated vein draining
the left ovary (arrow)
When considering the possibility of pelvic
congestion syndrome as a cause of pelvic pain,
other possible causes should also be given
consideration. These are often evaluated by
the gynecologist utilizing physical examination,
ultrasound imaging and, possibly, endoscopic
examination.
In evaluating possible pelvic congestion syndrome,
the interventional radiologist will often
order an MRI or ultrasound examination to
specifically look at venous blood flow in
the pelvis (figure 1). If PCS is felt to be
a likely possible cause of the pelvic pain,
there is a good chance that interventional
treatment will provide relief of symptoms.
Unlike several other causes of pelvic pain,
hysterectomy will not provide definitive relief
of symptoms associated with PCS. It has been
estimated that ¼ of all patients with
PCS have had previous hysterectomy.
Ovarian
Vein Embolization Procedure
Ovarian vein embolization
is performed by an interventional radiologist
for treatment of PCS. It is performed under
local anesthesia with light sedation and usually
takes only about 1 hour to perform, often
on an outpatient basis with no overnight hospital
stay. After a tiny nick is made in the skin
at the top of one leg, a tiny plastic cathetter
is guided into a vein at the top of the leg
under ultrasound guidance. This small catheter
is then positioned under x-ray guidance into
the ovarian vein coming from each kidney.
X-ray contrast is then injected with multiple
x-ray pictures obtained to visualize the veins
of the ovaries and the pelvis and determine
the direction of blood flow in these veins.
If it is felt that blood flow direction is
abnormal, the interventional radiologist will
proceed to embolization. Very tiny metal coils
or special glue-like substances are injected
thorugh the catheter to block the vein so
that blood can no longer leak backwards through
the vein (figure 2). The other veins of the
pelvis usually then handle the normal ovarian
venous blood flow without difficulty.
A.
B.
Figure
2 – X-ray contrast
injected prior to embolization
shows filling of leaking
left ovarian vein (arrow)
and numerous engorged veins
in the pelvis. The vein
was then easily closed with
multiple small metal coils.
Most patients experience some mild cramping
the evening of the procedure, usually handled
with mild pain medication, typically with
no further pain by the next morning. Symptoms
may regress quickly, although the majority
of patients will experience maximal symptom
relief after 1-2 menstrual periods, with some
patients continuing to improve progressively
over a period of up to six months after the
procedure.
