I Think I Have Pelvic Congestion Syndrome. What Next?

If you think you might have Pelvic Congestion Syndrome (PCS) due to pelvic pain that is associated with enlarged veins in the groin, buttocks or vaginal area, or pain that worsens after prolonged standing or after intercourse, you need to be evaluated by a vein specialist who has experience in diagnosing and treating PCS.

The first step in diagnosing PCS is a thorough medical history and physical exam. Your vein specialist will ask you questions about the nature and timing of your pain, and examine you for outward signs of vein disease. If you have not had an ultrasound of your pelvic area, your doctor may recommend this to evaluate for enlarged pelvic veins. A CT scan or MRI with contrast can also be helpful in finding enlarged pelvic veins. The definitive way to diagnose and treat PCS is with a venogram, which is a test that uses intravenous dye and x-ray machines to look for the specific veins that are dilated and causing your pelvic pain. Once the diseased veins are identified, small coils and/or medication can be injected directly into the veins to cause them to shut down and divert the blood to healthier veins. This can be done in the office of an experienced interventional radiologist who has the proper equipment. Not all vein doctors specialize in PCS, so it is important to find one that is comfortable with the diagnosis and treatment of this condition.

What Pelvic Congestion Syndrome Is and Why It Happens

Pelvic congestion syndrome is, at its core, a vein problem in an unusual place. The ovarian veins and the internal iliac vein branches drain blood from the uterus, ovaries and surrounding tissue. Like leg veins, they rely on one-way valves to keep blood moving toward the heart. When those valves fail or the veins become stretched, blood flows backward and pools in a tangle of enlarged pelvic veins.

Those dilated veins are sensitive to stretch. When you stand for a long time, at the end of the day, after exercise or after intercourse, more blood collects in them and the result is a dull, dragging ache deep in the pelvis. Lying down usually brings relief because gravity stops working against the veins.

Pregnancy is the most common trigger. During pregnancy the volume of blood in the pelvis rises substantially, hormones relax vein walls and the growing uterus presses on the veins. After one or more pregnancies, some women are left with veins that never fully return to normal. Less often, a narrowed vein further up, such as compression of the left renal vein or the left iliac vein, forces blood to detour through the pelvic veins and causes the same congestion.

It is also worth knowing what PCS is not. It is not a cancer, it is not caused by anything you did, and it is not a sign that your pain is imagined. It is a recognized vascular condition with a clear mechanism, and vascular societies now classify pelvic venous disorders as part of the wider family of vein disease. Having a name for the problem, and a test that shows it, is often a relief in itself for women who have lived with unexplained pain for a long time.

Pelvic Congestion Syndrome Symptoms to Write Down Before Your Visit

Because pelvic pain has many possible causes, the details of your symptoms matter. Keeping a two to four week diary before your appointment gives your specialist far more to work with than memory alone. Note:

• When the pain starts in the day and whether it builds toward evening
• Whether standing, walking, lifting or long car rides make it worse
• Whether lying down with your hips raised makes it better
• Pain during or after intercourse and how long it lasts afterward
• Changes around your period, and whether the pain is one-sided or on both sides
• Urinary urgency, a feeling of fullness or pressure, or low back ache
• Visible veins on the vulva, inner thighs, buttocks or the back of the thighs
• Pregnancies, previous pelvic surgeries and any treatments already tried

Women often tell us they have been told for years that the pain is nothing, or that their tests were normal. A diary that shows a clear pattern of pain worse with standing and better lying down is one of the strongest pointers toward a venous cause.

Is It PCS or Something Else? Common Causes of Chronic Pelvic Pain

Chronic pelvic pain can come from the reproductive organs, bladder, bowel, muscles or nerves, and more than one cause can be present. A gynecologist usually evaluates first, and we often see patients after other causes have been considered. This comparison shows why the pattern of pain is so useful.

If uterine fibroids are part of the picture, they can also be evaluated in our practice, since fibroid embolization is another interventional radiology procedure we perform.

The Link Between Pelvic Veins and Leg Varicose Veins

The pelvic veins and leg veins are connected. When pelvic veins are refluxing, blood can escape downward through small connecting veins in the groin and perineum and feed varicose veins on the vulva, buttocks, back of the thigh or inner thigh. These veins often have an unusual pattern that does not follow the main saphenous veins.

This matters for women who have had varicose vein treatment in the legs and seen veins return quickly, or whose leg veins appeared during pregnancy in atypical places. In some of these patients, the pelvic source has never been addressed. Treating the pelvic veins first, and then the leg veins, can give a more durable result.

Managing Pelvic Congestion Symptoms While You Are Being Evaluated

Testing and scheduling take time, and it helps to have a few practical ways to ease symptoms in the meantime. None of these fix the leaking veins, but many women find them useful day to day.

• Use position to your advantage. Lying down for 15 to 20 minutes with a pillow under your hips during a break or after work lets the pelvic veins drain and often eases the ache.
• Break up long periods of standing. If your job keeps you on your feet, short sitting or walking breaks reduce how much blood pools in the pelvis.
• Consider supportive garments. Some women find that pelvic support or compression shorts reduce the heavy, dragging feeling, particularly if they also have vulvar or thigh veins.
• Pain relief. Over-the-counter anti-inflammatory medicine can help some people, if your doctor confirms it is safe for you.
• Hormonal options. Because estrogen can dilate veins, your gynecologist may discuss hormonal medicines that reduce ovarian activity. These can relieve symptoms for some women but tend to help only while they are taken.
• Stay active. Regular walking, swimming or cycling supports circulation and overall well-being, and many women feel better with gentle core and pelvic floor work guided by a physical therapist.

If symptoms persist despite these measures and the imaging supports a venous cause, that is usually the point at which embolization is worth discussing in detail.

What Pelvic Vein Embolization Is Like

Embolization is the minimally invasive treatment for confirmed pelvic venous reflux. It is performed by an interventional radiologist through a small needle puncture, usually in a vein at the neck or groin, with local anesthetic and often light sedation. No incisions are made in the abdomen.

On the day

A thin catheter is guided under X-ray into the ovarian and pelvic veins. Contrast is injected to show which veins are dilated and refluxing, which is the venogram described above. The faulty veins are then closed with tiny metal coils, a foam sclerosing agent or both, so blood reroutes through healthy veins. The procedure usually takes one to two hours, and most patients go home the same day.

Recovery

Mild pelvic or back aching for a few days is common and usually settles with over-the-counter pain relief your doctor approves. Many women return to desk work within a few days and to full activity within about a week. Improvement in pain is often gradual over the following weeks to months as the treated veins shrink. If leg or vulvar varicose veins remain afterward, they can be treated in the office with sclerotherapy or phlebectomy.

How We Evaluate Suspected Pelvic Congestion Syndrome

At Premier Vein & Vascular Center, evaluation is step by step, using the least invasive test that answers the question first.

1. Focused history. We go through your pain diary, pregnancies, menstrual history, prior gynecologic evaluations and any leg or vulvar veins.
2. Examination. We look for varicose veins on the legs, vulva and buttocks and review previous imaging reports.
3. Imaging. A pelvic and abdominal duplex ultrasound looks at vein size and flow direction. When more detail is needed, MRI or CT venography maps the pelvic veins and checks for compression of the renal or iliac veins. A venous ultrasound of the legs shows whether pelvic reflux is feeding leg veins.
4. A clear plan. If the findings fit PCS, we explain whether venography and embolization are likely to help, what to expect, and how it fits with care from your gynecologist.

Questions to Ask a Pelvic Vein Specialist

Because PCS is less familiar than leg vein disease, it is reasonable to ask a few direct questions: How often do you diagnose and treat pelvic venous disorders? Which imaging will you use to confirm the diagnosis? Will you check for vein compression higher in the abdomen? What symptoms are likely to improve, and which ones may not? How will any leg or vulvar veins be handled afterward? A specialist who answers clearly and does not promise a guaranteed outcome is usually a good sign.

Pelvic Congestion Syndrome Care in Houston

If you live in Houston, Katy or the surrounding area and have pelvic aching that is worse with standing, pain after intercourse, or unusual varicose veins on the vulva or thighs, an evaluation by an interventional radiologist can help clarify whether your veins are the cause. Dr. Syed Raza is a fellowship-trained interventional radiologist and former Chief of Interventional Radiology at UTMB Galveston and Memorial Hermann Memorial City. Our vein and vascular clinic in Houston usually offers same-week appointments and accepts most insurance plans, including Medicare. You can read more on our pelvic congestion syndrome treatment page.

Frequently Asked Questions

What does pelvic congestion pain feel like?

Most women describe a dull, heavy or dragging ache low in the pelvis or lower back that builds through the day and after standing, and eases when lying down. Pain during or after intercourse is common, and some women also notice varicose veins on the vulva, buttocks or thighs.

Can pelvic congestion syndrome be seen on an ultrasound?

A pelvic duplex ultrasound can often show enlarged pelvic veins and reflux, but a normal ultrasound does not fully rule PCS out, partly because veins look smaller when you are lying down. MRI or CT venography and, ultimately, a catheter venogram give more detailed information.

Is pelvic vein embolization safe?

Embolization is a well-established, minimally invasive procedure performed through a small needle puncture. As with any procedure there are risks, such as bruising at the access site or, rarely, coil movement, which your specialist will review with you in advance.

Will pelvic congestion syndrome go away after menopause?

Symptoms often ease after menopause as estrogen levels fall and the pelvic veins are under less hormonal influence. However, many women do not want to wait years for relief, and some continue to have symptoms or leg and vulvar varicose veins afterward.

Can I get pregnant after pelvic vein embolization?

Embolization treats the veins and does not remove or close the ovaries or uterus. Women who are planning a pregnancy should discuss timing and any concerns with their specialist and gynecologist before treatment.

Who treats pelvic congestion syndrome?

Pelvic congestion syndrome is usually diagnosed and treated by an interventional radiologist or a vein specialist with experience in pelvic venous disease, working alongside the patient’s gynecologist to rule out other causes of pelvic pain.

Trusted Health Resources

1. Varicose Veins and Spider Veins, MedlinePlus (NIH)
2. Chronic Venous Insufficiency, Society for Vascular Surgery