Pelvic congestion syndrome (PCS) is caused by varicose veins in the pelvis — engorged, incompetent pelvic veins that pool blood and cause a chronic, dull, aching pelvic pain. It is estimated to cause up to 30% of chronic pelvic pain in women — yet it is one of the most frequently missed diagnoses in gynaecology, because standard pelvic ultrasound often does not detect it and it is not widely known among patients.

Dr. Shachi Singh, consultant gynaecologist at Prakash Hospital, Sector 33, Noida, explains.

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What Pelvic Congestion Syndrome Is

Just as varicose veins develop in the legs when venous valves fail and blood pools in dilated veins, the same process can occur in the pelvic venous system — specifically the ovarian and uterine veins. The ovarian veins drain blood from the ovaries upward toward the kidneys (left side) and the inferior vena cava (right side). When the valves in these veins become incompetent, blood flows backward (retrograde flow) and pools in the ovarian and pelvic venous plexus — producing dilated, tortuous pelvic varicosities.

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Who Gets Pelvic Congestion Syndrome

Multiparous women (those who have had multiple pregnancies): Each pregnancy significantly increases pelvic blood flow and stretches the pelvic veins. The hormonal environment of pregnancy (high progesterone) further relaxes vascular smooth muscle. Multiple pregnancies cumulatively damage venous valve competence.

Women with polycystic ovaries: The enlarged ovaries and increased blood flow to the ovarian plexus may contribute.

Connective tissue disorders: Lax connective tissue (as in Ehlers-Danlos syndrome) allows venous dilation.

Tall women: Left ovarian vein is particularly long — increased hydrostatic pressure contributes to valve failure (the "nutcracker" anatomy where the left ovarian vein is compressed between the aorta and superior mesenteric artery can also contribute).

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Symptoms

The characteristic pelvic aching: Dull, heavy, aching pain — typically in the lower abdomen and pelvis, often bilateral or predominantly left-sided (left ovarian vein involvement is most common). The aching worsens with:

• Prolonged standing or sitting — positional dependence is characteristic. The pain worsens as blood pools in the dilated veins with gravity. Many women are significantly worse by the end of a working day.
• Just before and during menstruation — hormonal changes alter venous tone
• During and after sexual intercourse (post-coital aching) — the aching that follows intercourse and persists for hours is one of the most characteristic features of PCS. Deep dyspareunia during intercourse is also common.
• Premenstrually
• With fatigue and physical exertion

Relieves with: Lying down (reducing gravitational pooling), particularly lying on the front or in positions that reduce pelvic venous pressure.

Associated features:

• Varicose veins of the buttocks, inner thighs, or vulva (vulvar varicosities) — visible sign of pelvic venous incompetence extending to superficial veins
• Urinary urgency and frequency from pressure on the bladder
• Irritable bowel symptoms from pressure on the pelvic colon

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Diagnosis

Transvaginal Doppler ultrasound: More sensitive than standard ultrasound. Identifies dilated pelvic veins (diameter above 5 to 8 mm), retrograde flow on Doppler, and multiple tortuous veins around the ovary (the "ovarian bag of worms" appearance when severe). Performed in upright or Valsalva position enhances detection.

MRI pelvic venography: Provides detailed mapping of pelvic venous anatomy — sensitive and specific for PCS. Increasingly used for diagnosis before interventional treatment.

Conventional venography (gold standard): Catheter-based injection of contrast into the ovarian veins under fluoroscopy — the definitive diagnostic procedure, usually performed at the same time as treatment.

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Treatment

Medical management: Medroxyprogesterone acetate (high-dose progestogen) reduces pelvic blood flow and alleviates symptoms in many women. GnRH analogues produce temporary suppression of pelvic blood flow. Medical treatment manages symptoms but does not treat the underlying venous incompetence.

Ovarian vein embolisation (OVE): The definitive minimally invasive treatment. An interventional radiologist threads a catheter through the femoral or jugular vein to the ovarian veins under X-ray guidance. Coils and/or sclerosant are placed to occlude the incompetent veins. Performed under local anaesthesia and sedation as an outpatient procedure. Significant improvement in pelvic pain in approximately 75 to 85% of treated women.

Surgical ligation: Laparoscopic or open ligation of the ovarian veins — technically more challenging and less commonly performed since embolisation became available.

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Gynaecological Care in Noida and Greater Noida

Dr. Shachi Singh at Prakash Hospital, Sector 33, Noida, investigates chronic pelvic pain including pelvic congestion syndrome and coordinates appropriate specialist referral for treatment for women across Noida and Greater Noida.

To book a consultation with Dr. Shachi Singh, call: +91 97023 46853

Clinic Hours: Monday to Saturday, 9 AM – 6 PM | Sunday, 10 AM – 2 PM

Clinic Address: D-12A, 12B, Sector-33, G.B. Nagar, Noida, Uttar Pradesh 201301

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This blog is for educational purposes only. Please consult Dr. Shachi Singh for assessment specific to your symptoms.