Approximately 13-40% women suffer from chronic pelvic pain (pain lasting more than 6 months) caused by reflux in ovarian veins also known as pelvic venous congestion syndrome.
Quick Answer: Pelvic venous congestion (pelvic congestion syndrome) is a cause of chronic pelvic pain in women in which faulty valves in the ovarian or pelvic veins let blood flow backward and pool, so the pelvic veins swell much like varicose veins in the legs. It typically causes a dull, dragging ache that worsens with standing, at the end of the day, around periods and after intercourse, and eases when lying down. It is diagnosed with ultrasound, MRI or CT and confirmed with venography, and it is commonly treated with ovarian vein embolization, a minimally invasive outpatient procedure.
The underlying cause is defective valves in ovarian veins causing the blood to flow in reverse direction. This reversal of blood flow in ovarian veins leads to pooling of blood in pelvis leading to classical symptoms of pelvic heaviness and dull aching pain. Pain is usually worse during menstrual cycle.
Pelvic venous congestion is equivalent of varicose veins in the legs, where the incompetent veins cause veins on legs to become dilated and bulging on the skin surface. Similarly in pelvic venous congestion veins in pelvis become dilated and as the condition progresses, veins around vagina, vulva and upper thighs may also become visibly dilated and painful.
Meet your vein specialist
Dr. Syed Raza, MD
Vascular & Interventional Radiology · Founder, Premier Vein & Vascular Center
Fellowship-trained interventional radiologist certified by the American Board of Radiology and the Royal College of Radiologists (UK). 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.
Who Gets Pelvic Venous Congestion?
Typically women who have been pregnant and who may have 2-3 children. It can also occur in younger women without pregnancy if they have varicose veins of the legs. Occasionally it will be seen in women with polycystic ovaries. Common symptoms of pelvic venous congestion are as following. The varicose veins in the pelvis surround the ovary and can also push on the bladder and rectum. This can cause the following symptoms:
- Pelvic pain or aching around the pelvis and lower abdomen
- Dragging sensation or pain in the pelvis
- Feeling of fullness in the legs
- Worsening of stress incontinence
- Worsening in the symptoms associated with irritable bowel syndrome
Pain is usually commonest symptom and present for over 6 months duration. The pain is usually on one side but can affect both sides. The pain is worse on standing, lifting, when you are tired, during pregnancy and during or after sexual intercourse. The veins are also affected by the menstrual cycle/hormones and therefore the pain can increase during the time of menstruation. The pain usually is improved by lying down.
How Is It Diagnosed?
Ultrasound may be a good starting point. This may be initially diagnosed with CT scan or MRI scan of the abdomen. Venography remains the gold standard of diagnosis for pelvic venous congestion. Using femoral or jugular vein access, a small tube or catheter is placed in the ovarian veins and dye is injected under x-ray fluoroscopy. This clearly shows the dilated ovarian veins and varicosities in pelvis.
What Is the Treatment of Pelvic Venous Congestion Syndrome?
Treatment is performed in our office cath lab and involves venography followed by placement of catheter into lower part of ovarian vein. injection of sclerosants into ovarian veins as well as placement of small metal coils is performed to stop these veins from refluxing. In most cases you can go home after an hour of the procedure.
Useful Links http://www.radiologyinfo.org/en/info.cfm?pg=ovariveinembol
What Is Pelvic Venous Congestion?
The pelvis is drained by a network of veins around the uterus, ovaries, bladder and rectum. Blood from these veins flows upward through the ovarian veins and the internal iliac veins toward the heart. Like the leg veins, the ovarian veins contain small one-way valves. When those valves are missing or stop closing, blood falls back into the pelvis every time you are upright, and the veins around the ovaries and uterus gradually enlarge.
Doctors now often use the broader term pelvic venous disorders, because pelvic vein problems can come from more than one source. In addition to ovarian vein reflux, a narrowed or compressed vein can block outflow and push blood into the pelvic veins. The best-known example is compression of the left iliac vein by the artery crossing over it, sometimes called May-Thurner anatomy. A compressed left renal vein, which the left ovarian vein drains into, can do the same. Identifying which of these is present matters, because it changes the treatment.
Why Pelvic Venous Congestion Is Often Missed
Many women we see have lived with pelvic pain for years and have already had several tests that came back normal. There are a few reasons this condition is easy to overlook:
- Imaging is usually done lying down. Pelvic veins fill when you stand and empty when you lie flat, so a standard scan can look normal even when the veins are significantly enlarged during the day.
- Symptoms overlap with common conditions. Endometriosis, fibroids, ovarian cysts, irritable bowel syndrome and bladder pain can all cause similar complaints.
- It is not well known. Many patients have never heard of pelvic veins as a cause of pain, and the topic is not always considered in routine gynecologic evaluation.
- Pain is often attributed to past childbirth or stress, especially in women with two or more children.
An evaluation that specifically looks at the veins, ideally with imaging that accounts for posture and the Valsalva maneuver, is often what finally provides an answer.
Pelvic Venous Congestion vs. Other Causes of Pelvic Pain
Pelvic venous congestion can exist alongside other conditions, so it is rarely a diagnosis made in isolation. The comparison below shows how its pattern differs from some common alternatives.
| Condition | Typical pain pattern | Helpful clues | Main tests |
|---|---|---|---|
| Pelvic venous congestion | Dull, dragging ache, worse by evening and after standing; eased by lying down | Pain after intercourse, vulvar or thigh varicose veins, often after pregnancies | Duplex ultrasound, MRI or CT, venography |
| Endometriosis | Cyclical pain, often severe with periods | Painful periods since young adulthood, fertility problems | Pelvic ultrasound, MRI, laparoscopy |
| Uterine fibroids | Pressure, heaviness, cramping | Heavy or prolonged periods, enlarged uterus | Pelvic ultrasound, MRI |
| Irritable bowel syndrome | Cramping linked to bowel movements | Bloating, alternating constipation and diarrhea | Clinical diagnosis after excluding other causes |
| Bladder pain syndrome | Pain as the bladder fills, relieved by emptying | Urgency and frequency without infection | Urine tests, urology assessment |
If fibroids are part of the picture, they can also be treated by an interventional radiologist; our fibroid treatment page explains the options.
The Link Between Pelvic Veins and Leg Varicose Veins
Pelvic venous congestion does not always stay in the pelvis. When the pelvic veins are under high pressure, blood can escape downward through small connecting veins into the vulva, the inner and back of the thigh and the buttock. These veins often look different from typical leg varicose veins, appearing in places that do not follow the usual saphenous vein pattern.
This connection matters for anyone who has had leg vein treatment that did not last. If varicose veins keep returning on the upper inner thigh or back of the leg, the source may be in the pelvis. In that situation, treating the pelvic reflux first and then treating the remaining leg veins, for example with ultrasound-guided foam sclerotherapy, gives the best chance of a lasting result.
How We Evaluate Pelvic Venous Congestion
At Premier Vein & Vascular Center, the evaluation is designed to confirm whether pelvic veins are responsible for your symptoms and to find exactly where the reflux or blockage begins.
- Focused history. We ask about the type and timing of your pain, how it relates to standing, periods and intercourse, the number of pregnancies, bladder and bowel symptoms, previous gynecologic evaluation and any leg or vulvar veins.
- Examination. We look for visible veins on the vulva, buttocks and thighs and examine the leg veins standing.
- Duplex ultrasound. Ultrasound of the abdomen, pelvis and legs assesses vein size and the direction of flow, including in the ovarian and iliac veins, and checks whether leg varicose veins connect to pelvic sources.
- Cross-sectional imaging when needed. MRI or CT can show enlarged pelvic veins and look for vein compression or other causes of pain.
- A clear plan. We explain the findings, how confident we are that the veins are causing your symptoms, and whether venography and treatment make sense. We coordinate with your gynecologist so other causes of pain are not missed.
Keeping a symptom diary before your visit
Because pelvic vein pain follows patterns, a simple diary kept for two to four weeks before your appointment can be very helpful. Note when the pain starts each day, how it changes after standing, lifting or exercise, whether it eases when you lie down, how it relates to your menstrual cycle and intercourse, and any bladder or bowel symptoms. Patients who bring this information often help us reach a clearer answer more quickly, and it gives a useful baseline for judging improvement after treatment.
Treatment Options for Pelvic Venous Congestion
Conservative measures
For milder symptoms, pain relievers, avoiding long periods of standing, lying down with the hips raised during flares, and pelvic-support garments can help. Some women benefit from hormonal medicines prescribed by their gynecologist, which reduce ovarian activity and vein congestion, though symptoms often return when they are stopped.
Ovarian and pelvic vein embolization
For women with persistent symptoms and confirmed reflux, embolization is usually the treatment of choice. As described above, the enlarged ovarian vein is closed from the inside with small coils and a sclerosing medicine, and the same approach can be used for refluxing internal iliac vein branches when needed. Because it is done through a small puncture in a vein in the groin or neck, there are no surgical incisions and the uterus and ovaries are left in place.
Treating vein compression
When imaging shows a significant narrowing of the iliac vein causing outflow obstruction, a different approach, such as placing a stent inside the vein, may be considered. This is assessed individually, since many people have mild compression on imaging without symptoms.
You can read more about the procedure and who is a good candidate on our pelvic congestion syndrome page.
What Recovery After Embolization Feels Like
Patients usually go home the same day. Over the first few days, it is common to have pelvic aching or cramping, lower back discomfort and sometimes a low-grade temperature as the treated veins close. This is usually managed with anti-inflammatory medicine and rest. Many women return to desk work within a few days and to full activity within one to two weeks. Improvement in pelvic pain tends to be gradual over the following weeks to months rather than immediate.
As with any procedure, there are risks, including bruising at the puncture site, reaction to contrast dye and, rarely, movement of a coil. These are discussed in detail before treatment so you can make an informed choice.
Seek emergency care right away if you have:
- Sudden, severe pelvic or abdominal pain, especially on one side
- Pelvic pain with fever, chills or foul-smelling discharge
- Heavy vaginal bleeding that soaks a pad every hour, or bleeding with dizziness or fainting
- Pelvic pain with a positive or possible pregnancy
- Sudden leg swelling and pain, chest pain or shortness of breath
When to See a Pelvic Vein Specialist in Houston
If you have had pelvic aching for six months or more that worsens through the day and eases when you lie down, if other causes have been looked for without a clear answer, or if you have varicose veins on the vulva, buttocks or upper thighs, a pelvic vein evaluation may help. Dr. Syed Raza is a fellowship-trained interventional radiologist who previously led interventional radiology at UTMB Galveston and Memorial Hermann Memorial City, and he performs pelvic venography and embolization. Our team at Premier Vein & Vascular Center in Houston works with your gynecologist so that your care is coordinated. Same-week appointments are usually available, and most insurance plans, including Medicare, are accepted.
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
Is pelvic congestion syndrome the same as varicose veins?
It is closely related. Pelvic congestion syndrome is caused by the same kind of valve failure that creates leg varicose veins, but the enlarged veins are inside the pelvis around the ovaries and uterus. The two often occur together.
Can pelvic congestion syndrome go away on its own?
Symptoms may ease after menopause, when hormone levels fall, but the faulty veins themselves do not repair. Many women choose treatment because the pain affects daily life for years before then.
Does ovarian vein embolization affect fertility?
Embolization closes the abnormal vein while leaving the ovaries and uterus in place, and other veins continue to drain the ovary. Women planning future pregnancies should discuss their plans with the treating physician before the procedure.
Why does pelvic congestion pain get worse after intercourse?
Intercourse increases blood flow to the pelvis, and when the veins cannot drain properly, the extra congestion causes a deep ache that can last for hours afterward. This pattern is one of the characteristic features of the condition.
Can men get pelvic venous congestion?
The equivalent condition in men is a varicocele, enlarged veins around the testicle caused by reflux in the testicular vein. Pelvic congestion syndrome as described here is a condition of women.
How do I know if my pelvic pain is from veins?
Clues include a dull, heavy ache that builds when standing and eases when lying down, worsening around periods and after intercourse, and visible veins on the vulva or thighs. Imaging that specifically looks at the pelvic veins is needed to confirm it.
Is ovarian vein embolization painful?
The procedure is done under local anesthesia with sedation, so most women feel only pressure at the puncture site. Pelvic cramping and aching for a few days afterward are common and are usually managed with anti-inflammatory medicine.
Trusted Health Resources
- Varicose Veins and Spider Veins, MedlinePlus (NIH)
- Chronic Venous Insufficiency, Society for Vascular Surgery