Many women experience pelvic pain at one time or another in their lives. Pelvic pain can be caused by many different factors such as endometriosis, adenomyosis, ovarian cysts, or uterine fibroids. Some pelvic pain can be difficult to diagnose, and it can be frustrating if ultrasounds or other diagnostic tests do not lead to a conclusive cause for the pain. If you are frustrated by chronic pelvic pain, you may have pelvic congestion syndrome (PCS).
Quick Answer: It could be pelvic congestion syndrome if you have a dull, heavy ache in the lower pelvis that has lasted six months or more, gets worse as the day goes on or after standing, sitting or intercourse, and eases when you lie down. Other clues are pain that started with pregnancy, varicose veins in the vulva, buttocks or upper thighs, and an irritable bladder. Because ordinary pelvic ultrasounds are done lying down, these enlarged veins are often missed. A targeted vascular evaluation, sometimes followed by venography, can confirm the diagnosis.
Pelvic congestion syndrome is a disorder where the veins in the pelvis which drain blood from the uterus and ovaries become enlarged and stop working efficiently. This causes the blood to pool in these veins which can cause pain and heaviness in the lower abdomen.
Here are some signs that you may be dealing with Pelvic Congestion Syndrome.
- Your pain began during or shortly after pregnancy
Pregnancy hormones cause your veins to dilate which can worsen the symptoms of pelvic congestion. Also, the weight of the fetus on the veins in the pelvis can cause them to work less efficiently. This can cause more pain during pregnancy and even after delivery. - You have varicose veins in the groin, buttocks, or vaginal/vulvar area.
These veins can develop at any time but often are first noticed during pregnancy. They typically resolve after delivery but can be a sign that the veins higher up in your pelvis are diseased. - Your pelvic pain worsens after intercourse or after prolonged periods of standing or sitting.
Other causes of pelvic pain such as ovarian cysts and endometriosis can worsen during or just before your menstrual cycle but if the pain worsens after you stand for long periods or after intercourse, the pain could be from Pelvic congestion. - You experience frequent urination or sudden urge to urinate.
Dilated veins in the pelvis can irritate the bladder causing a sudden urge to urinate or more frequent urination. - You also have varicose veins in your legs or a family history of varicose veins.
Varicose veins are the result of a genetic predisposition to the veins become large and stretched out. If you have a family history of varicose veins or have bulging veins in your legs, you may be at higher risk for the veins in your pelvis also becoming diseased. However, it is important to note that you can have PCS without outward signs of varicose veins.
Meet your vein specialist
Dr. Syed Raza, MD
Vascular & Interventional Radiology · Founder, Premier Vein & Vascular Center
Fellowship-trained interventional radiologist, board certified in diagnostic and interventional radiology with a Certificate of Added Qualification (CAQ) in interventional radiology, and a Fellow of the Royal College of Radiologists (UK). Member of SIR and RSNA. Former Chief of Interventional Radiology at UTMB Galveston and Memorial Hermann Memorial City, with 15+ years treating varicose veins, venous reflux and peripheral arterial disease.
What Pelvic Congestion Syndrome Feels Like
The signs above are the classic clues, but it helps to know how women actually describe the pain in clinic. Most do not call it sharp. They talk about a heavy, dragging or full feeling deep in the pelvis, sometimes more on one side, that is mild in the morning and builds through the day. Many say it feels like their pelvis is “swollen” by evening, and that lying down with their hips raised brings relief within half an hour.
That pattern follows the physics of the problem. The ovarian and pelvic veins are supposed to carry blood upward toward the heart. When the valves inside them leak, or a vein upstream is compressed, blood pools in the pelvis whenever you are upright. The longer you stand or sit, the more the veins fill and stretch, and the more they ache. When you lie flat, gravity stops working against you and the veins drain.
Pain often extends to the lower back, hips or upper thighs. Some women notice an aching after intercourse that can last hours or into the next day, which is one of the more specific features of a venous cause.
Is It Pelvic Congestion Syndrome or Something Else?
Chronic pelvic pain has many possible causes, and more than one can be present at the same time. Pelvic congestion syndrome is often considered only after other conditions have been ruled out, which is part of why the diagnosis can take years. The comparison below shows the patterns that help point toward one cause or another. It is a guide, not a diagnosis.
| Condition | Typical pain pattern | Other clues |
|---|---|---|
| Pelvic congestion syndrome | Dull, heavy ache that worsens through the day and with standing; eases lying down; aching after intercourse | Began with or after pregnancy; vulvar, buttock or thigh varicose veins; urinary urgency |
| Endometriosis | Cramping pain closely tied to periods; pain with deep intercourse during the act | Painful bowel movements around periods; sometimes difficulty conceiving |
| Uterine fibroids | Pressure or fullness; cramping with periods | Heavy or long periods, enlarged uterus, frequent urination from pressure |
| Adenomyosis | Deep, crampy pain, often worse with periods | Heavy periods and a tender, enlarged uterus |
| Ovarian cyst | One-sided pain; sudden sharp pain if it twists or bursts | Seen clearly on routine ultrasound |
| Bladder pain syndrome | Pain as the bladder fills, eased by emptying | Frequency and urgency without infection |
| Irritable bowel syndrome | Cramping related to bowel movements | Bloating, alternating constipation and diarrhea |
If you have uterine fibroids, those are also treated by interventional radiologists without surgery, and you can read about the options on our fibroid treatment page.
Why Pelvic Congestion Syndrome Is So Often Missed
Women with PCS frequently tell us they have seen several doctors, had normal scans and been told the pain has no clear cause. There are understandable reasons for this.
- Position during testing. Routine pelvic ultrasounds and CT scans are done lying down, when the veins are at their emptiest and smallest.
- Different specialties. Pelvic pain is usually assessed by gynecologists, while the veins are the territory of vascular and interventional specialists, so the venous cause may not be considered.
- Overlapping symptoms. PCS shares features with endometriosis, bladder and bowel conditions, and these are often investigated first.
- No visible signs. As noted above, some women have no visible varicose veins at all, so there is no outward hint of a vein problem.
None of this means earlier evaluations were wrong. It means the veins need to be looked at specifically, with tests designed to show them.
A Simple Self-Check Before Your Visit
Keeping a short symptom diary for two to four weeks can make your first appointment far more useful. Try noting:
- When the pain starts each day and when it is worst
- How it changes with standing, sitting, walking and lying down
- Whether it is related to your menstrual cycle, and how
- Pain during or after intercourse, and how long it lasts
- Bladder symptoms, such as urgency or frequent urination
- Any visible veins in the vulva, buttocks, inner thighs or the back of the legs
- Pain medicines you have tried and what helped
Bring a list of previous scans, procedures and diagnoses as well. Knowing what has already been ruled out saves time and avoids repeating tests.
How Pelvic Veins Connect to Leg and Vulvar Varicose Veins
The pelvic veins do not exist in isolation. They connect with the veins of the vulva, buttocks and upper thighs through small channels that normally carry very little blood. When the pelvic veins are congested and their valves leak, blood is pushed downward through these connections. That is how varicose veins appear in unusual places, such as the labia, the crease of the buttock, the back of the thigh or the inner upper thigh.
This matters for two reasons. First, veins in these locations are a useful clue that the pelvis is involved, even when the main complaint is the legs. Second, it explains why some women have leg varicose veins that keep coming back after treatment. If the pelvic source is still feeding them, treating only the leg veins leaves the pressure in place.
Not every woman with pelvic vein reflux has pelvic pain. Some only notice varicose veins in the legs or vulva, while others have significant pain with no visible veins at all. Both pictures are part of the same family of conditions, which specialists now group under the term pelvic venous disorders. During evaluation, we look at the pelvic veins and leg veins together, so that the treatment plan addresses the source first and the visible branches afterward. Treating in that order usually gives the most lasting result and avoids repeat procedures on veins that would simply refill.
How We Evaluate Suspected Pelvic Congestion Syndrome
At Premier Vein & Vascular Center, evaluation is focused on finding out whether the pelvic veins are the source of your pain, and if so, which ones.
- Focused history. We go through your pain pattern, pregnancies, menstrual history, previous gynecologic evaluations and treatments, bladder and bowel symptoms, and family history of varicose veins.
- Examination. We look for varicose veins in the vulva, buttocks, inner thighs and legs, check for swelling and review any leg vein symptoms.
- Targeted imaging. A duplex ultrasound of the leg and groin veins can show whether pelvic veins are feeding varicose veins below. Imaging of the pelvic and abdominal veins, often with MRI, is used to look for enlarged pelvic veins and for compression of the major veins that drain the pelvis.
- Venography when appropriate. If the imaging and symptoms point toward PCS, catheter venography confirms which veins are refluxing and is usually performed together with treatment.
- A clear plan. We explain the findings and how confident we are that the veins are the main cause, discuss options, and coordinate with your gynecologist or primary care doctor so care is joined up.
Treatment Options if It Is Pelvic Congestion Syndrome
Treatment depends on how much the symptoms affect your life and what the imaging shows. Conservative measures include pain relief, rest periods lying down during the day, and hormonal treatment prescribed by your gynecologist. These can ease symptoms but do not fix the underlying veins.
For women whose imaging confirms refluxing pelvic veins, the main treatment is ovarian and pelvic vein embolization. It is a minimally invasive outpatient procedure performed by an interventional radiologist through a small needle puncture in a vein, usually in the neck or groin. Under X-ray guidance, the faulty veins are closed from the inside so that blood drains through healthy veins instead. Patients go home the same day, and the procedure does not involve removing the uterus or ovaries.
When pelvic veins are feeding varicose veins in the legs, those leg veins are often treated afterward with sclerotherapy or other office procedures. Our pelvic congestion syndrome page explains the procedure in more detail.
Seek emergency care if you have:
- Sudden, severe pelvic or abdominal pain, especially with fever, vomiting or fainting
- Heavy vaginal bleeding that soaks through a pad every hour, or bleeding during pregnancy
- Sudden swelling, pain and warmth in one leg
- Sudden shortness of breath or chest pain
- Pelvic pain with a positive pregnancy test
When to See a Specialist in Houston About Pelvic Pain
If you have had pelvic pain for six months or longer, especially if it worsens with standing and began around pregnancy, and other causes have been ruled out or treated without relief, it is reasonable to ask whether your veins could be involved. Dr. Syed Raza is a fellowship-trained interventional radiologist, board certified in diagnostic and interventional radiology by the American Board of Radiology and a Fellow of the Royal College of Radiologists (UK), and former Chief of Interventional Radiology at UTMB Galveston and Memorial Hermann Memorial City. Image-guided treatment of pelvic veins is part of his interventional radiology practice. Women from across Houston and Katy come to our vein and vascular clinic in Houston for evaluation. Same-week appointments are usually available, and most insurance plans, including Medicare, are accepted. You can also read our varicose vein FAQs if you have leg veins as well.
Talk With a Specialist at Premier Vein
Have questions about your symptoms or treatment options? Dr. Syed Raza and the team at Premier Vein & Vascular Center can evaluate your concerns and explain your options clearly. Same-week appointments are usually available, and most insurance plans are accepted.
Frequently Asked Questions
How do I know if my pelvic pain is from veins?
Vein-related pelvic pain is usually a dull, heavy ache that worsens with standing or sitting and as the day goes on, and eases when you lie down. Aching after intercourse and varicose veins in the vulva or thighs are also suggestive. Imaging of the pelvic veins is needed to confirm it.
Can pelvic congestion syndrome show up on a normal ultrasound?
Often it does not. Routine pelvic ultrasounds are done lying down, when the veins are least full. Targeted vein imaging, MRI and venography are better at showing enlarged or refluxing pelvic veins.
Who should I see for pelvic congestion syndrome?
A gynecologist usually evaluates chronic pelvic pain first to look for other causes. If pelvic veins are suspected, an interventional radiologist or vascular specialist can perform vein imaging and minimally invasive treatment, ideally working with your gynecologist.
Can pelvic congestion syndrome happen after menopause?
It is most common in women of childbearing age who have had children, and symptoms often lessen after menopause as hormone levels fall. However, refluxing pelvic veins can persist and continue to feed leg or vulvar varicose veins.
Is pelvic congestion syndrome dangerous?
Pelvic congestion syndrome is not usually dangerous, but it can cause long-lasting pain that affects work, relationships and quality of life. Sudden or severe pelvic pain is not typical of PCS and needs urgent medical assessment.
Do I need a hysterectomy for pelvic congestion syndrome?
Most women do not. Pelvic vein embolization treats the faulty veins directly through a small needle puncture and leaves the uterus and ovaries in place. Surgery is generally reserved for specific situations discussed with your gynecologist.
Trusted Health Resources
- Varicose Veins and Spider Veins, MedlinePlus (NIH)
- Chronic Venous Insufficiency, Society for Vascular Surgery