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Chronic pelvic pain (CPP) is one of the most challenging and often underdiagnosed conditions among women. While many causes are considered, like endometriosis, fibroids, or infections, one crucial and frequently missed reason is Pelvic Congestion Syndrome (PCS).
PCS arises due to ovarian and pelvic varicosities, leading to venous congestion within the pelvis. If not identified early, it can cause long-term discomfort and complications.
Who Is Most Commonly Affected?
If you don’t know, then we must tell you that the Pelvic Congestion Syndrome typically affects the premenopausal, multiparous women (especially for those who have given birth more than once), this is usually occurring between the ages of 40 and 45 years.
There were a lot of hormonal and physiological changes that happen during pregnancy can cause veins in the pelvis to expand and weaken, which gives resulting in poor venous drainage over time.
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Symptoms of Pelvic Congestion Syndrome
Women who have PCS usually it is present with chronic, dull, and non-cyclical pelvic pain. The pain often turns out to worsen:
- After prolonged women face problems in standing or sitting
- This also happens during or after sexual intercourse
- Also affected in their premenstrual phase
- Especially during pregnancy
Other associated symptoms include:
- Menorrhagia is when you have heavy menstrual bleeding
- Dyspareunia is the pain that happens during intercourse.
- Lateral pelvic discomfort
- Urinary symptoms or recurrent infections often occur in this.
- Sometimes, visible vulvar or thigh varicosities
This is quite disturbing; the discomfort is not just physical but also affects the woman’s quality of life, which later on leads to anxiety, fatigue, and reduced activity.
Clinical Signs
During a physical examination, doctors may find:
- Tenderness over the uterus and ovaries
- Varicose veins on the vulva, inner thighs, or buttocks
- Hemorrhoids or visible varicosities in the perineal region
These clues help direct attention toward vascular causes of pelvic pain, which are often overlooked.
Why Is Diagnosis Delayed?
Pelvic Congestion Syndrome is regularly diagnosed late because its symptoms are usually partly covered by other pelvic disorders like endometriosis, fibroids, or urinary tract infections.
The diagnosis is basically made after excluding other causes of chronic pelvic pain.
Investigations and Diagnostic Tests
1. Duplex Ultrasound
The first-line investigation is a Duplex Ultrasound, both abdominal and transvaginal.
It helps visualize the pelvic venous flow dynamically and is a rapid, accessible, and non-invasive outpatient test.
2. Advanced Imaging
If ultrasound reports findings are indeterminate, the following may be used:
- MR Venography – it basically provides detailed imaging of pelvic veins.
- Diagnostic Venography – it is basically considered the gold standard, as it perfectly visualizes the reflux and dilation of ovarian veins.
Management of Pelvic Congestion Syndrome
You know what the management of PCS includes: both medical and interventional approaches, which depend on symptom severity.
1. Psychotherapy
Chronic pain often alters pain perception. Psychotherapy helps patients cope by addressing the emotional and psychological impact of chronic pain.
2. Medical Management
| Therapeutic Approach | Examples | Purpose |
| Hormonal Therapy | Progesterone, Danazol, GnRH agonists, Hormone Replacement Therapy (HRT) | Reduces venous dilatation and pelvic congestion |
| Pain Relief | NSAIDs | It provides symptomatic that give relief from chronic pain |
3. Interventional/Surgical Treatment
The mainstay intervention is Endovascular Embolization.
- Procedure: The dilated ovarian or pelvic veins are sealed using coils or sclerosing agents to stop reflux.
- Advantages:
- This is minimally invasive
- It has lower perioperative morbidity
- The recovery time is too Short
- There is a high success rate for symptom relief
After consolidation, the imaging often shows the resolution of pelvic varicosities, which leads to significant pain improvement.
Venous Thromboembolism: A Related Concern
There is a relatable concern about transitioning from pelvic congestion to a broader vascular concern, Venous Thromboembolism (VTE). It’s basically essential to understand how venous disorders can lead to some serious issues in your body.
VTE basically refers to the formation of a semisolid clot (thrombus) within the venous system, which can block blood flow and give the results of deep vein thrombosis (DVT) or pulmonary embolism (PE).
Complications of Venous Thrombosis
- Immediate: there’s an immediate pain you may suffer with, along with swelling or redness in the affected limb.
- Long-term: Development of post-thrombotic syndrome, which typically leads to chronic pain and venous insufficiency.
Etiology and Pathophysiology: Virchow’s Triad
The development of venous thrombosis is perfectly explained by Virchow’s Triad, which includes these things:
- Endothelial Damage – there is an injury to the vein wall, which is often due to trauma, surgery, or inflammation.
- Venous Stasis – inactive or static blood flow, which is very common and happens during immobilization or long hospital stays.
- Hypercoagulability – this is an increased tendency of the blood to clot due to assumption or acquired factors.
Predisposing Factors for VTE
| Category | Examples |
| Hospitalization | Medical or surgical admissions |
| Trauma | Especially fractures of the pelvis or lower limbs |
| Pregnancy and Postpartum | Hormonal and venous changes increase clotting risk |
| Medications | Oral contraceptives, hormone therapy |
| Systemic Conditions | Heart failure, atherosclerosis, and postoperative immobility |
Among these, endothelial injury remains the most critical risk factor, as it triggers inflammatory changes leading to a procoagulant surface that favors clot formation.
Inherited and Acquired Thrombophilia
You know? Certain individuals have a genetic tendency towards hypercoagulability (thrombophilia).
Examples include:
- Resistance to activated Protein C
- Factor V Leiden mutation
- Prothrombin gene mutation
These conditions may not cause thrombosis alone but act synergistically with other risk factors such as surgery, immobility, or hormonal therapy.
Conclusion
You know that Pelvic Congestion Syndrome and Venous Thromboembolism are very different in presentation, which share a common ground in venous dysfunction.
On the other hand, the PCS manifests as chronic pelvic pain due to some venous dilation and reflux, and VTE, which presents as an acute or chronic thrombotic condition within the veins.
Early recognition of PCS can prevent unnecessary suffering and improve life quality through targeted therapies like embolization.
Similarly, understanding the risk factors and mechanisms of venous thrombosis allows clinicians to prevent life-threatening complications.
In essence, a comprehensive approach to pelvic and venous health, encompassing diagnosis, medical therapy, psychological support, and minimally invasive interventions, remains key to better outcomes for women affected by these underrecognized conditions.
