It has been said that 15-20% of women in the United States between the ages of 18 and 50 years have experienced chronic pelvic pain.
What Causes Chronic Pelvic Pain in Women?
There are several conditions that may cause chronic pelvic pain in women. These include, among others, gynecologic problems such as endometriosis, uterine fibroids, adenomyosis, and pelvic congestion syndrome and non-gynecologic problems including irritable bowel syndrome, inflammatory bowel disease, interstitial cystitis, postoperative adhesions, and musculoskeletal disorders such as fibromyalgia.
Chronic pelvic pain is a source of much frustration for patients since its cause can be difficult to diagnose and treat. Up to 20% of patients remain symptomatic after undergoing multiple diagnostic and therapeutic procedures. Therefore, this can potentially lead to long-term disability and depression.
Pelvic Congestion Syndrome
Pelvic Congestion Syndrome is one possible cause of chronic pelvic pain. It is most commonly seen between the ages of 20 and 45 years and in women with multiple pregnancies. It is felt that the hormonal changes associated with pregnancy can lead to increased pressure within the ovarian veins. This can weaken the wall of the vein and lead to disruption of the valves within the ovarian veins.
In normal veins, blood flows from the pelvis up towards the heart in the ovarian vein and is prevented from flowing backwards by valves within the vein. If the valves are not working, blood can flow down towards the pelvis, which can cause pooling of blood within and enlargement of the pelvic veins. This can result in chronic pain.
The diagnosis is often missed because women lie down during pelvic examinations, which relieves the pressure from the ovarian veins. Therefore, the pelvic veins are not as enlarged as they are when patients are standing.
What are the Symptoms of Pelvic Congestion Syndrome?
Patients with Pelvic Congestion Syndrome typically complain of non-cyclical dull pain that is worse after prolonged standing and during or after intercourse. It also tends to worsen just before the onset of a menstrual period. Patients can also complain of a swollen vulva/vagina and varicose veins involving the buttocks, vaginal area, and upper thighs. Other complaints include a backache, lethargy, and depression.
Diagnosis of Pelvic Congestion Syndrome
- Ultrasound: Performance of a pelvic ultrasound is an important first step in the diagnosis of Pelvic Congestion Syndrome because it can often exclude many of the more common causes of chronic pelvic pain. It is possible with both transabdominal and transvaginal ultrasound to directly visualize the dilated pelvic veins that are seen in Pelvic Congestion Syndrome. This may be negative because it is typically performed with the patient lying down, which lowers the pressure within and decreases the size of these abnormal veins.
- CT or MRI: It is possible with both of these tests to directly visualize the abnormal veins within the pelvis that are seen in Pelvic Congestion Syndrome. Since CT is associated with radiation exposure, it is not recommended for use in pregnant women. Both CT and MRI can detect the enlarged veins, but they cannot identify whether or not there is reversal of flow within the ovarian vein.
- Gonadal Venography: This is considered the most definitive diagnostic test for Pelvic Congestion Syndrome because it can identify the abnormal veins and the reversal of flow within the affected veins since it can be performed on an examination table that can tilt into an upright or semi-upright position. This is performed by placing a catheter (tube) directly into the abnormal ovarian vein. The catheter enters the venous system from the groin (common femoral vein) or neck (internal jugular vein). Once the catheter is within the vein, x-rays are used to guide the catheter into the ovarian vein. At this point, an iodine-based dye is injected into the vein and images are obtained to confirm the abnormal appearance and reversal of flow within the vein.
Interventional Treatment of Pelvic Congestion Syndrome
Ovarian Vein Embolization: In this procedure, a catheter (tube) is placed directly into the abnormal ovarian vein. The catheter enters the venous system from the groin (common femoral vein) or neck (internal jugular vein). Once the catheter is within the vein, x-rays are used to guide the catheter into the ovarian vein.
At this point, an iodine-based dye is injected into the vein and images are obtained to confirm the reversal of flow within the vein. Small metal coils or plugs are then inserted to block flow into the vein. This prevents the reversal of flow in the abnormal vein, which reduces the pressure within the enlarged pelvic veins.
If reversed flow is present within the other ovarian vein or within the internal iliac veins, these vessels can be embolized as well. This procedure is typically performed as an outpatient procedure, with most patients going home after a few hours of observation and returning to normal activity within 24 hours.
After ovarian vein embolization, approximately 75% of patients will report improvement in their symptoms. Multiple sessions may be required because multiple veins may need to be embolized. The complication rate associated with this procedure is low, with rare complications including dye allergy, migration of coils into the lungs, and rupture of the ovarian vein.