Pelvic congestion syndrome is a real disease entity that affects up to 16% of American women, and can be successfully treated with transfemoral embolotherapy, according to researchers who presented data at the annual meeting of the Society of Interventional Radiology.
About 10% of gynecologic visits are due to chronic, noncyclic pelvic pain of greater than 6 months' duration, and a third of gynecologic laparoscopies are performed to investigate such pain. The differential diagnosis usually includes endometriosis, fibroids, adenomyosis, cysts, and tumors, among other potential causes. Pelvic congestion syndrome (PCS)—pelvic vein insufficiency that causes pooling of blood in the uterine and ovarian veins—is not often on the list, said Hyun S. “Kevin” Kim, M.D., of Johns Hopkins University, Baltimore
Even standard imaging studies don't always identify the disorder, Dr. Kim said in an interview.
“Only 40% of laparoscopic studies were able to visualize abnormal veins. On MRI, only 59% were diagnosed.”
Because PCS is difficult to diagnose, many physicians write off the symptoms—dull, typically unilateral pain that worsens during the day and with standing, dyspareunia, and dysuria—as psychosomatic, Dr. Kim said.
Varicocele, the male counterpart of PCS, has no such stigma, he added. In men, the gonadal vein terminates in the testicle, so the painful venous abnormalities are usually visually apparent. “This condition is accepted in men, because it occurs outside the body and we can see it. In women it's hidden, and this, I think, is part of the reason for misdiagnosis or underdiagnosis.”
The best way to diagnose PCS is with direct venography, said Dr. Kim, who presented the results of his long-term follow-up study on transcatheter embolization for the disorder at the meeting.
He performed 262 transfemoral ovarian venographies on 131 women (mean age 34 years) with chronic pelvic pain. Overall, 20% had a prior hysterectomy. About one-third of the patients had previous pregnancies; the rest were nulliparous. Venography confirmed the clinical suspicion of PCS in 127 of those women. The diagnostic criteria for PCS are:
▸ Ovarian vein, uterine vein, and utero-ovarian arcade venous engorgement greater than 5 mm in diameter.
▸ Free reflux of contrast in ovarian vein with incompetent valves.
▸ Filling of veins across the midline or filling of vulvar and/or thigh varicosities.
▸ Stagnant clearance of contrast from pelvic veins (more than 1 minute).
Patients with a confirmed diagnosis underwent baseline levels of follicle-stimulating hormone, estradiol, and luteinizing hormone, and transcatheter embolotherapy of the insufficient veins. This was done as an outpatient procedure. There were no major complications.
By a mean 45 months' follow-up, there was a mean pain decrease of 4.7 points on a visual analog scale. Most of the patients (85%) reported improvement, which was significant in 80%, moderate in 14%, and mild in 6%. There was no change in 12%, and pain was worse in 3%.
Women who reported pain improvement also reported significant improvement in symptoms such as dyspareunia, urinary frequency, and menstrual pain. A comparison of patient subgroups showed no differences in outcome between the nulliparous women and those with prior pregnancy.
There were no differences between preoperative and follow-up hormone levels; four patients attempted to conceive after the procedure, and two successful pregnancies resulted.