The Management of
|Justin Wasserman, MD|
Vulvovaginal Pain Disorders and
|Howard Glazer, PhD|
Pelvic Varicosities and
|Eleanor Brosius, MS|
RELATED DISORDERS (Page 10)
Pelvic Varicosities and Pelvic Pain
veins deep in the abdomen can be the cause of some some women's pelvic
pain. Ovarian vein venography and embolization, a relatively new
technique performed by interventional radiologists, can find and
repair bulging veins in the abdomen. There is no way to know before the
procedure if one is a candidate for treatment, but if needed, the
embolization is performed at the same time.
Pelvic Congestion Syndrome
Chronic pelvic pain due to varicose veins in the pelvis is called Pelvie Congestion Syndrome (PCS). Patients with PCS report that their pain worsens towards the end of the day, after standing for long periods, and during or after sexual intercourse. Some women describe a feeling of that their uterus is falling out. It is more common in those who have varicose veins in other parts of the body. The pain varies in intensity and is often described as throbbing, aching, pressure or heaviness. After lying flat all night, some patients with PCS report they feel better in the morning. The pain is often worse before or during menses, and, in some cases, there is a sense of urinary urgency or [increased] frequency.
The traditional therapies for PCS include medications and surgeries. Ovarian vein venography and embolization tends to be better tolerated, minimally invasive, and treats the sources of the pain.
The first thing to do if you suspect that you have PCS is to set up a consult with a physician who performs venography and embolization. The doctor may want you to have an ultrasound or laparoscopy to rule out other possibilities. After the two of you agree to proceed and make the necessary decisions (e.g. intravenous sedation or not), you should submit documentation for insurance pre-approval.
Live Action X-ray Diagnosis
The procedure starts with the patient lying in a horizontal position. Doctors thread a small catheter through a vein (neck or groin) until it reaches the ovarian veins, and a special dye is injected. Continuous x-rays on a video monitor show the dye being released, enabling the doctors to see the shapes of the vessels and the direction of the blood flow.
Veins have valves in them which keep the blood moving forward between beats. If the valves are functioning properly, the x-ray monitor shows normally shaped vessels and the blood quickly flowing back to the heart. If the valves are not doing their job, however, the dye enables the doctor to see that the blood is not efficiently returning to the heart. If the blood pools and flows backward, the the vein can bulge under the pressure, becoming varicosed.
To be absolutely sure this is the case, the x-ray equipment and the table the patient is lying on are tilted to a half standing position. The more dye is released to see if it flows up or down. The patient is also asked to bear down to see if it makes the situation worse. The doctors assess other veins in the area, checking the left and right sides separately.
If the venography shows that the large bulging veins might be responsible for pelvic pain symptoms, metal coils are inserted to clot off the veins that are varicosed. These darcon coated metal coils are injected through the catheter to interrupt blood flow, produce a clot, and block the vein off permanently. This is called embolization. Fortunately, these left and/or right ovarian veins can be sacrificed. One doesn't need them to function well.
As the body adjusts and the blood finds new ways to flow, there can be some painful recovery time. Others notice immediate relief. Doctors warn that it can take a few menstrual cycles to really assess the amount of improvement. The coils remain in the patients and the treatment does not affect fertility.
Roughly 80 percent of women who undergo embolization experience partial to complete relief. Some women also experience a partial return of symptoms months later. While it isn't going to help everyone, it is an effective treatment for many women who have varicose veins in the pelvis.
Not for Women Only
Interventional radiologists have performed similar procedures on men for the last 25 years. Men's varicose veins are visible on the scrotum and may be responsible for pain and infertility.
For More Information:
Keith Sterling, MD
Society for Cardiovascular Venography and Interventional Radiology
Website: www.scvir.org [in 2007, now www.sirweb.org]
Physician referral by specialty and zip code.
Cordts, P. R. et al "Pelvic congestion syndrome:
Early clinical results after transcatheter ovarian vein embolization."
J Vascular Surg 1998;28:862-68.
Available at the journal's Website.