Pelvic congestion syndrome

Specialty: Gynecology and breast.

• Dull postural pelvic pain
• painful pelvic varicose veins
• chronic venous pelvic pain

Why it occurs

• Pelvic varicose veins (dilation and valvular incompetence of the ovarian and internal iliac veins)
• Multiparity (permanent venous anatomical structural changes)
• Extrinsic venous compression (May-Thurner syndrome or nutcracker/Nutcracker syndrome)
• Chronic estrogenic influence (vasodilatory of the pelvic venous beds)

Initial workup

Transvaginal and transabdominal gynecological ultrasound with color Doppler to identify dilated pelvic venous plexuses (>5-6 mm in diameter) with reversed or slowed flow. Angio-CT or Angio-MRI of the pelvis to visualize the venous anatomy and rule out vascular compression syndromes. Retrograde pelvic venography (diagnostic and therapeutic reference standard if embolization is performed).

Standard management

• Medroxyprogesterone acetate 30 mg orally daily for 3 to 6 months to induce ovarian estrogenic suppression and reduce venous flow
• Goserelin 3.6 mg subcutaneous monthly as a GnRH analogue to induce temporary therapeutic hypoestrogenism
• Micronized purified flavonoids (Daflon 500 mg every 12 hours orally) as a symptomatic venotonic
• Gabapentin or Amitriptyline if there is a component of secondary chronic neuropathic pain (note: percutaneous transcatheter embolization of incompetent ovarian veins offers high rates of therapeutic success).