Could Your Pelvic Pain Be Pelvic Venous Disease?

When pelvic pain drives a woman to seek medical help, it’s disheartening to leave without answers. Unfortunately, this has been the experience for many of the estimated 3 million women in the U.S. suffering from pelvic venous disease (PeVD).

“Too often, women with chronic pelvic pain are told their symptoms are normal or nothing can be done,” says vascular surgeon Marissa Famularo, DO, with LVPG Vascular Surgery. “Most patients suffer for years before getting a diagnosis. Pelvic venous disease is real, and we have effective treatments that can make a big difference.”

The most common symptom of PeVD is dull, aching pelvic pain, often described as heaviness or pressure in the pelvis. These symptoms have traditionally been called “pelvic congestion syndrome.” This pain typically:

• Worsens throughout the day, especially after prolonged standing.
• Intensifies during or after sex.
• May increase before menstruation.
• Can improve when lying down.

PeVD can have other symptoms including left flank pain, and varicose veins on the vulva, perineum or outer thighs.

Venous insufficiency in the left ovarian vein is one common cause of PeVD. The ovarian vein should carry blood up toward the chest, but when it is insufficient, blood can travel down toward the pelvis instead. This can lead to dilation and congestion of the ovarian and pelvic veins, resulting in pain and heaviness.

Stenosis or compression of the left renal vein is another, less common, cause of PeVD. Sometimes, when this vein is compressed, the pelvic veins cannot drain properly and become enlarged. Rarely, compression of the left renal vein can even cause the veins in the kidney to become dilated and congested. When this happens, it is sometimes called “nutcracker syndrome.”

Diagnosis begins with listening to women and taking their symptoms seriously,” Dr. Famularo says.  Imaging, including pelvic ultrasound, MRI, CT scans and venograms, can help confirm a suspected diagnosis.

She goes on to say it’s “important to remember some imaging studies can miss pelvic varicose veins, which are hard to see unless the study is specifically designed to look for them. Having your imaging ordered, performed and reviewed at a hospital familiar with PeVD is extremely important.”

Pelvic pain is complex, and PeVD often overlaps with other conditions, such as endometriosis, irritable bowel syndrome and interstitial cystitis. All potential causes of pain need to be considered and managed appropriately, so often several specialists may collaborate on your care.

Your care team might include:

• Gynecologists experienced in complex pelvic pain
• Vascular surgeons trained in minimally invasive vein procedures and traditional open surgery
• Urogynecologists
• Interventional radiologists

Treatment for PeVD depends on your specific anatomy, symptoms and goals, and includes both medical and surgical options.

Treatment options include:

Conservative therapies:

• Hormonal medications to decrease the size and dilation of affected veins.
• Nonhormonal medications to support vein function and health.
• Pain management using various analgesic options.
• Physical therapy focused on pelvic floor support.
• Image-guided injections.

Minimally invasive procedures:

• Ovarian vein embolization, a catheter-based procedure that blocks off problematic veins to stop blood pooling and reduce pain
• Venous stenting, used in cases where a vein is compressed

Traditional surgical procedures:

• Renal vein transposition
• Ovarian vein transposition

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