Continuing Education Activity

Pelvic congestion syndrome is a common cause of chronic pelvic pain in women of reproductive age. Chronic pelvic pain is defined as intermittent or constant, lasting for 3 to 6 months, present in the pelvic or abdominal region, occurring throughout the menstrual cycle, and without any association with pregnancy. This activity outlines the evaluation and management of pelvic congestion syndrome, highlighting the role of the interprofessional team in the care of patients with this condition.

Objectives:

• Identify the pathophysiology of pelvic congestion syndrome.
• Assess imaging findings, such as those from Doppler ultrasound, MRI, or venography, to confirm the presence of pelvic congestion syndrome.
• Apply the management options available for pelvic congestion syndrome.
• Implement interprofessional team strategies for improving care coordination and communication to advance the care of pelvic congestion syndrome and improve outcomes.

Introduction

Pelvic congestion syndrome is a pelvic venous syndrome that is frequently misdiagnosed and difficult to manage. This syndrome is a relatively common cause of chronic pelvic pain in women of reproductive age, accounting for nearly 10% to 20% of gynecologic consultations. However, only 40% of these cases are referred to subspecialists or specific care teams for further evaluation. Although the etiology of pelvic congestion syndrome still remains unclear, it is thought to result from a combination of factors, including genetic predisposition, anatomical abnormalities, hormonal factors, damage to the vein wall, valve dysfunction, reverse blood flow, hypertension, and dilatation[1][2]. Although transcatheter venography represents the gold standard for pelvic congestion syndrome diagnosis, it is performed after inconclusive noninvasive imaging, such as Doppler ultrasound, computed tomography (CT) scan, and magnetic resonance imaging (MRI). Once the diagnosis is confirmed, the treatment options for pelvic congestion syndrome include medical, surgical, and endovascular therapies. Medical and surgical treatments are less effective compared to transcatheter pelvic vein embolization. This latter has been proven to be a safe, effective, and durable therapy for treating pelvic congestion syndrome.[3]

Etiology

Pelvic congestion syndrome, also known as pelvic venous insufficiency, is due to the incompetency of the internal iliac vein, the ovarian vein, or a combination of the venous structures of the pelvis. This syndrome is often the underlying cause of otherwise unexplained chronic pelvic pain. Nearly 10% of women have isolated ovarian varices, and of this 10%, about 60% have pelvic congestion syndrome.[4] Chronic pelvic pain is characterized as more than 6 months of persistent or intermittent pain localized in the pelvis.[5] The overall prevalence of pelvic congestion syndrome ranges from 6% to 27% worldwide and remains a significant challenge for women's healthcare providers. Chronic pelvic pain may be caused by pelvic congestion syndrome in up to 30% of women.[6] More recently, pelvic congestion syndrome is estimated to be present in up to 75.5% of patients with pelvic varicose veins, as reported in a 10-year retrospective analysis of a 600-female patient cohort conducted by Gavrilov et al.[7]

The exact etiology of pelvic congestion syndrome is unclear and is most likely dependent on multiple factors. The congestion of the pelvic veins can be due to hormones, venous insufficiency of the valves, venous obstruction, and secondary to concurrent medical conditions, such as peripheral artery disease. The release of pain-inducing substances due to increased dilatation of the veins along with stasis is a likely cause of the pain in pelvic congestion syndrome.[8]

Epidemiology

Pelvic congestion syndrome mainly affects premenopausal, multiparous women.[9] There has been no reported occurrence of the syndrome in menopausal women.[10] In patients with chronic pelvic pain, the prevalence of the disease is nearly 30%.[11]

Pathophysiology

In pelvic congestion syndrome, the abnormal dilation of the interlinked venous channels of the internal iliac and ovarian veins is often implicated. The ovarian plexus drains into the ovarian veins on both sides, whereas the hemorrhoidal, utero-ovarian, sacral, and vesicular venous plexuses drain into the internal iliac veins. The broad ligament has the internal iliac and ovarian veins running through it.[2]

There can be incompetence of the internal iliac veins and the inferior vena cava. However, most of the cases of the pelvic varices are identified in the ovarian veins. Moreover, about 60% of these develop pelvic congestion syndrome.[12] In the majority of pelvic congestion syndrome cases, incompetency of the internal pudendal and broad ligament parametrial branches are involved. The pelvic venous reflux into the lower limb or vulvar varicosities is often associated with the incompetency of the branches of the circumflex femoral and obturator veins.[13]

The primary vein insufficiency is due to either the absence of the venous valves or the incompetency of the valves. In such patients, the congenital absence of the ovarian valves has been reported in 6% of patients on the right side and 13% to 15% on the left side. There are incompetent valves in 35% to 46% of women on the right and 41% to 43% on the left. The inclination of multiparous women to develop pelvic congestion syndrome can be due to the 50% increased pelvic vein capacity due to physiological changes during pregnancy. These changes can lead to retrograde blood flow and incompetency of the valves. Even 6 months after pregnancy, these vascular changes can persist.[14]

Secondary pelvic vein incompetence is often due to external compression of the vein, leading to venous outflow obstruction. Different causes of external compression include the nutcracker phenomenon, also known as left renal vein entrapment syndrome. This phenomenon is due to the compression of the left renal vein between the superior mesenteric artery and the abdominal aorta. Similarly, the compression of the left common iliac vein by the right internal iliac artery in May-Thurner syndrome can also lead to such results.[15][16] Regional overload in the venous channels can lead to pelvic venous congestion. This regional overload might be due to left renal vein thrombosis (with renal cell carcinoma), tumor thrombosis in the inferior vena cava, cirrhosis, congenital malformations of arteriovenous and venous channels, and retro aortic left renal vein.[17] 

Both varicoceles and pelvic congestion syndrome are considered diseases of the pelvic veins, which include the gonadal veins, tributaries of the internal iliac veins, and parametrial and uterine veins in females. The course of the spermatic and ovarian veins may explain the seemingly left-sided prevalence of both conditions. The left gonadal vein drains into the higher-pressure left renal vein, as opposed to the right renal vein, which drains directly into the inferior vena cava.[18]

Improvement of symptoms after menopause indicates the influence of hormones on pelvic congestion syndrome. Estrogen is a venous dilator and can thus produce the venous dilation implicated in the pathophysiology of pelvic congestion syndrome.[10] However, despite the lack of clinically confirmed cases of postmenopausal pelvic congestion syndrome systematically reported to date, isolated references of postmenopausal patients who fulfill diagnostic criteria and experience a lasting alleviation of symptoms after respective standard treatment strongly suggest its incidence[19].

History and Physical

The concurrent presence of venous varices with pelvic pain in premenopausal women does not always mean that they are causally related. Even in asymptomatic females, the dilation and incompetency of pelvic veins are common findings, making it challenging to identify which patients have chronic pelvic pain due to pelvic congestion syndrome.

The pain associated with pelvic congestion syndrome presents as a dull ache or a sensation of heaviness in the pelvis, lasting for 3 to 6 months, and can be unilateral or bilateral. However, the pain can switch from one side to the other. Factors such as walking, postural changes, lifting, and long-standing positions increasing the abdominal pressure can exacerbate the pain. The paint is often exacerbated before or during the menstrual period. The intensity of pain worsens with each subsequent pregnancy and during or after sexual intercourse. The time of the day also affects the intensity, with the pain worsening at the end of the day.[20]

If the findings of characteristic pelvic pain are present, a physical examination can help in formulating the final diagnosis. The uterine tenderness, ovarian tenderness, and cervical motion tenderness on direct palpation during bimanual examination in a patient presenting with a complaint of chronic pelvic pain support the diagnosis of pelvic congestion syndrome. 

In a study involving 57 females with pelvic pain, the combination of a history of postcoital pain with tenderness over the adnexa during physical examination demonstrated 77% specificity and nearly 94% sensitivity in differentiating pelvic congestion syndrome from other pathologies of pelvic origin.[11]

Evaluation

The presence of characteristic pelvic venous changes on imaging supports the diagnosis of pelvic congestion syndrome, but it is not necessary to form the final diagnosis. Dilated ovarian veins with incompetency of the valves are commonly found in asymptomatic women.[21]

Patients with pelvic congestion syndrome, in whom an intervention is planned, require evaluation for pelvic venous reflux with ultrasound, retrograde internal iliac or ovarian venography, CT, or MRI.[22]

Ultrasound

Pelvic ultrasound is the first-line imaging modality for pelvic congestion syndrome. Ultrasound helps rule out the presence of pelvic masses or uterine problems as the underlying cause of pelvic pain. The pelvic anatomy, ovarian changes, uterine enlargement, and dilated uterine and ovarian veins can be evaluated using color-Doppler and conventional B-mode ultrasounds.[23] 

Retrograde flow of blood with an increase in the size of the left ovarian vein and a decrease in velocity of the blood flow can be observed using ultrasonography. Enlarged, tortuous pelvic venous channels can be noted. The incompetency of valves in the pelvic varicose veins can be noted using Valsalva's maneuver. These varicoceles show variable duplex waveforms on such maneuvers. Polycystic changes of the ovary are also observed in patients with pelvic congestion syndrome.[8][11]

Criteria for varices: The diagnosis of pelvic congestion syndrome can be confirmed using ultrasound findings. Criteria include an ovarian vein diameter of ≥6 mm, a slow blood flow of <3 cm/s, and retrograde venous blood flow in the left ovarian vein combined with the clinical vulval varicosities with the 3 Ds (dysmenorrhea, dysuria, and dyspareunia). The criteria for pelvic ultrasound diagnosis of varices include the visualization of dilated ovarian veins >6 mm, although 7 mm has also been suggested as a cutoff. A study reported a positive predictive value of 83.3% for an ovarian vein diameter of 6 mm in diagnosing pelvic congestion syndrome.[24]

Computed Tomography and Magnetic Resonance Imaging

The anatomical details of the pelvic vasculature and tissue of the pelvic cavity can be easily visualized using CT and MRI. As CT uses radiation, it is not recommended in premenopausal women.[25]

Magnetic resonance venography is a promising noninvasive imaging technique for diagnosing pelvic vasculature varices. However, its specificity for venous pathologies is low, as the patient is in a supine position for this examination.[26]

The direction and velocity of flow in different vascular channels can be assessed with phase-contrast velocity mapping, which is an MRI-based technique. This technique can be used to evaluate pelvic veins.[27] 

Venography

Ovarian and iliac catheter venography is considered the gold standard for diagnosing pelvic vascular congestion. The ovarian veins are catheterized using percutaneous jugular and femoral pathways. The distension of the venous channels is better assessed when a venogram is performed during Valsalva. Venographic diagnostic findings of pelvic congestion syndrome include incompetent pelvic veins (with a diameter of more than 5-10 mm) and congestion of flow in venous channels of ovarian, pelvic, vulvovaginal, and thigh veins. Venous reflux in ovarian veins can also be noted.[25]  

Laparoscopy

Chronic pelvic pain is a significant cause of gynecologic diagnostic laparoscopies. According to certain reports, more than 40% of such laparoscopic procedures are due to chronic pelvic pain.[28] The rate for the occurrence of pathological findings identified on laparoscopies in women with chronic pelvic pain ranges between 35% and 83%. In 20% of these cases, pelvic congestion is also identified.[29]

Treatment / Management

Pelvic Congestion Syndrome Without Vulvar Varices

Medical management is typically the first-line treatment for pelvic congestion syndrome due to its non-invasive nature and lower associated risks. This approach is often combined with pelvic floor physical and cognitive behavioral therapies.[30] Up to 70% of pelvic congestion syndrome-affected females may be adequately managed through these conservative treatment approaches, although few studies assess long-term efficacy.

Medical treatments: Pharmacological options for managing pelvic congestion syndrome include gonadotropin-releasing hormone (GnRH) agonists, danazol, combined oral contraceptives, progestins, phlebotonics, and nonsteroidal anti-inflammatory drugs.[31] Etonogestrel implant, goserelin, and medroxyprogesterone acetate have also been successful in alleviating the pain associated with pelvic congestion syndrome.[8] Improved pain relief is observed when medroxyprogesterone is combined with psychotherapy.[32] Goserelin, a GnRH agonist, has better results in controlling the pain compared to medroxyprogesterone acetate. However, it cannot be continued beyond 1 year because it is a GnRH agonist.[8] 

Invasive treatments: Women who do not respond to medical therapy may consider more invasive treatments; however, the optimal procedure remains unclear due to a lack of randomized trials. These treatments include both surgical and non-surgical approaches. Surgical treatment has traditionally been considered the preferred approach for both conditions, although clinical practice is increasingly leaning towards percutaneous embolization as the definitive management for pelvic congestion syndrome.[30] Broadly, non-surgical procedures include embolization or sclerotherapy of the ovarian veins with or without the internal iliac veins.[28][33][34][35][36][37][38][39][34][28]

Surgical procedures for pelvic congestion syndrome include laparoscopic or open ligation of the ovarian veins [40][23][41][42] and hysterectomy with bilateral salpingo-oophorectomy for women who have completed childbearing.[34][43] However, the results of these treatments were not favorable.[22]

Overall, interventional coil embolization of ovarian veins may be considered a safe and effective gold standard to alleviate symptoms of venous congestion and thus applies to pelvic congestion syndrome in certain cases.[44] A systematic review involving 473 patients who underwent interventional coil embolization reported clinical alleviation of symptoms in 82.1% to 100% of cases.[45] Complications were reported to be rare and comparably mild, such as local hematoma after cannulation. Recurrence rates were reported to be minimal. Laborda et al [46] reported a remission of pain in 93.9% of patients with a follow-up of 5 years, with approximately one-third of patients achieving complete symptom relief.

Pelvic Congestion Syndrome with Vulvar Varices

If vulvar varices are present, evidence from case reports and small series shows that the treatment of ovarian vein reflux reduces the size of vulvar varicosities.[40][23] Surgical approaches and embolization likely result in similar outcomes, although some data are inconsistent.[47] The ablation of incompetent veins can also be achieved by endovascular procedures using a minimally invasive approach. These procedures can be performed in an outpatient setting, leading to comparatively quick recovery and fewer complications.[48] Various agents, such as platinum embolization coils, glue, foam, or liquid sclerosants, can be used to induce endothelial damage in the incompetent vessels.[49]

Differential Diagnosis

The differential diagnoses for pelvic congestion syndrome align closely with those for chronic pelvic pain and should be evaluated similarly. The differential diagnoses include diseases of the urinary tract and gastrointestinal tract, musculoskeletal disorders, disorders of neurological origin, gynecological problems, and mental health disorders. Painful bladder syndrome, pelvic inflammatory disease, interstitial cystitis, endometriosis, pelvic neuralgia, irritable bowel syndrome, myofascial pain, and pelvic floor myalgia are the common causes of chronic pelvic pain. Accurately diagnosing the underlying cause of chronic pelvic pain remains challenging, even with advanced laparoscopic and diagnostic imaging techniques.[2][4]

Staging

Various grading systems have been developed to assess pelvic venous reflux and pelvic congestion syndrome.[30]

Yang et al [50] proposed a grading system for ovarian venous reflux to aid in pelvic congestion syndrome diagnosis based on the vasculature involved in time-resolved MR angiography. In this system, grade 1 reflux denotes isolated reflux of the left ovarian and parauterine veins, and grade 2 reflux is more severe and indicates a combination of grade 1 features and reflux in the right ovarian and internal iliac veins. Vulvar and thigh varices may also be present in grade 2 pathology.

Pelvic congestion syndrome may also be graded based on the pattern and duration of pelvic venous reflux, with increased grades associated with worsening symptoms. According to Gavrilov et al,[51] patients with pelvic varicosities may be subdivided into type I (reflux duration 1–2 s), type II (3–5 s), and type III (>5 s or spontaneous reflux in the absence of a loading test).

Prognosis

Response to Medical Management

Dihydroergotamine, an alpha-blocker, provides substantial relief in up to 95% of patients with pelvic congestion syndrome with chronic pelvic pain and can lead to a mean reduction of 35% in pelvic vein diameter. However, its adverse effects include dyspepsia, arrhythmias, and angina, which may limit its use.[52] A combination of medroxyprogesterone acetate and psychotherapy can be effective in up to 73% of patients, with similar results observed using progesterone implants, such as ImplanonTM or NexplanonTM[53]. 

Response to Invasive Treatments

Although studies are limited, a study conducted by Gavrilov et al [54] involving 277 female patients found that gonadal vein resection was superior to embolization with coils in terms of pelvic pain relief at 30 days (100% versus 73%), postoperative complications (11% versus 56%), and 3-year recurrence rate (5% versus  11%). The most common complication in both methods was pelvic vein thrombosis.

Overall, although cases of pelvic congestion syndrome are heterogeneous, available treatments provide pain relief for up to 70% of patients, with pain expected to improve following menopause.

Complications

Surgical treatments for pelvic congestion syndrome are associated with an increased rate of recurrent pelvic pain (20%) or residual pain (33%). Moreover, these procedures often result in aesthetic damage and prolonged hospitalizations.[55] The loss of gonadal function leading to the need for hormonal replacement is also an important complication of ovarian vein ligation and oophorectomy.[43]

Consultations

As treatment for pelvic congestion syndrome often requires interventional procedures when medical management fails, timely coordination and consultation with endovascular specialists is essential.

Deterrence and Patient Education

Pelvic congestion syndrome is prevalent in approximately 2.1% to 24% of women aged 18 to 50, highlighting the importance of educating patients with pelvic congestion syndrome. Patients should be educated regarding treatment adherence and informed of any relationship between their symptoms and menstrual cycle. When using bilateral oophorectomy, there is often a need for hormonal replacement. The patients should also be educated about these complications.[56]

Enhancing Healthcare Team Outcomes

Chronic pelvic pain accounts for approximately 10% to 20% of gynecologic consultations. Nearly 40% of these cases are referred to specialists for further evaluation. The diagnosis of pelvic congestion syndrome requires high clinical suspicion on the clinician's part. After diagnosis, medical or surgical management may be necessary. The radiological approach for embolization is also considered.

Given the complexity of PCS, effective management requires collaboration among an interprofessional team. This team typically includes primary care clinicians, gynecologists, and interventional radiologists. Coordination among these specialists is essential to achieving optimal patient outcomes and ensuring that all aspects of care are addressed in a timely and integrated manner.[57] This interprofessional collaboration is critical for improving patient outcomes and minimizing complications associated with the condition.

Review Questions

• Access free multiple choice questions on this topic.
• Click here for a simplified version.
• Comment on this article.

References

1.

Bałabuszek K, Toborek M, Pietura R. Comprehensive overview of the venous disorder known as pelvic congestion syndrome. Ann Med. 2022 Dec;54(1):22-36. [PMC free article: PMC8725876] [PubMed: 34935563]

2.

Koo S, Fan CM. Pelvic congestion syndrome and pelvic varicosities. Tech Vasc Interv Radiol. 2014 Jun;17(2):90-5. [PubMed: 24840963]

3.

Strong SM, Cross AC, Sideris M, Whiteley MS. A Retrospective Cohort Study of Patient Risk Factors and Pelvic Venous Reflux Patterns on Treatment Outcomes With Pelvic Vein Embolisation. Vasc Endovascular Surg. 2024 Oct;58(7):733-741. [PubMed: 38907671]

4.

Daniels J, Gray R, Hills RK, Latthe P, Buckley L, Gupta J, Selman T, Adey E, Xiong T, Champaneria R, Lilford R, Khan KS., LUNA Trial Collaboration. Laparoscopic uterosacral nerve ablation for alleviating chronic pelvic pain: a randomized controlled trial. JAMA. 2009 Sep 02;302(9):955-61. [PubMed: 19724042]

5.

Lamvu G, Carrillo J, Ouyang C, Rapkin A. Chronic Pelvic Pain in Women: A Review. JAMA. 2021 Jun 15;325(23):2381-2391. [PubMed: 34128995]

6.

Messina ML, Puech-Leão P, Simões RDS, Baracat MCP, Soares JM, Baracat EC. Pelvic congestion syndrome as a differential diagnosis of chronic pelvic pain in women. Clinics (Sao Paulo). 2024;79:100514. [PMC free article: PMC11550204] [PubMed: 39471531]

7.

Gavrilov S, Karalkin A, Mishakina N, Efremova O, Grishenkova A. Relationships of Pelvic Vein Diameter and Reflux with Clinical Manifestations of Pelvic Venous Disorder. Diagnostics (Basel). 2022 Jan 07;12(1) [PMC free article: PMC8774919] [PubMed: 35054312]

8.

Soysal ME, Soysal S, Vicdan K, Ozer S. A randomized controlled trial of goserelin and medroxyprogesterone acetate in the treatment of pelvic congestion. Hum Reprod. 2001 May;16(5):931-9. [PubMed: 11331640]

9.

Beard RW, Reginald PW, Wadsworth J. Clinical features of women with chronic lower abdominal pain and pelvic congestion. Br J Obstet Gynaecol. 1988 Feb;95(2):153-61. [PubMed: 3349005]

10.

Raffetto JD, Qiao X, Beauregard KG, Khalil RA. Estrogen receptor-mediated enhancement of venous relaxation in female rat: implications in sex-related differences in varicose veins. J Vasc Surg. 2010 Apr;51(4):972-81. [PMC free article: PMC2847594] [PubMed: 20347696]

11.

O'Brien MT, Gillespie DL. Diagnosis and treatment of the pelvic congestion syndrome. J Vasc Surg Venous Lymphat Disord. 2015 Jan;3(1):96-106. [PubMed: 26993690]

12.

Liddle AD, Davies AH. Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology. 2007;22(3):100-4. [PubMed: 18268860]

13.

Lopez AJ. Female Pelvic Vein Embolization: Indications, Techniques, and Outcomes. Cardiovasc Intervent Radiol. 2015 Aug;38(4):806-20. [PMC free article: PMC4500858] [PubMed: 25804635]

14.

Ahlberg NE, Bartley O, Chidekel N. Right and left gonadal veins. An anatomical and statistical study. Acta Radiol Diagn (Stockh). 1966 Nov;4(6):593-601. [PubMed: 5929114]

15.

Birn J, Vedantham S. May-Thurner syndrome and other obstructive iliac vein lesions: meaning, myth, and mystery. Vasc Med. 2015 Feb;20(1):74-83. [PubMed: 25502563]

16.

Gulleroglu K, Gulleroglu B, Baskin E. Nutcracker syndrome. World J Nephrol. 2014 Nov 06;3(4):277-81. [PMC free article: PMC4220361] [PubMed: 25374822]

17.

Winer AG, Chakiryan NH, Mooney RP, Verges D, Ghanaat M, Allaei A, Robinson L, Zinn H, Lang EK. Secondary pelvic congestion syndrome: description and radiographic diagnosis. Can J Urol. 2014 Aug;21(4):7365-8. [PubMed: 25171280]

18.

Graif M, Hauser R, Hirshebein A, Botchan A, Kessler A, Yabetz H. Varicocele and the testicular-renal venous route: hemodynamic Doppler sonographic investigation. J Ultrasound Med. 2000 Sep;19(9):627-31. [PubMed: 10972559]

19.

Bartl T, Wolf F, Dadak C. Pelvic congestion syndrome (PCS) as a pathology of postmenopausal women: a case report with literature review. BMC Womens Health. 2021 Apr 27;21(1):181. [PMC free article: PMC8077810] [PubMed: 33906668]

20.

Jung SC, Lee W, Chung JW, Jae HJ, Park EA, Jin KN, Shin CI, Park JH. Unusual causes of varicose veins in the lower extremities: CT venographic and Doppler US findings. Radiographics. 2009 Mar-Apr;29(2):525-36. [PubMed: 19325063]

21.

Tu FF, Hahn D, Steege JF. Pelvic congestion syndrome-associated pelvic pain: a systematic review of diagnosis and management. Obstet Gynecol Surv. 2010 May;65(5):332-40. [PubMed: 20591203]

22.

Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, Lohr JM, McLafferty RB, Meissner MH, Murad MH, Padberg FT, Pappas PJ, Passman MA, Raffetto JD, Vasquez MA, Wakefield TW., Society for Vascular Surgery. American Venous Forum. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011 May;53(5 Suppl):2S-48S. [PubMed: 21536172]

23.

Leung SW, Leung PL, Yuen PM, Rogers MS. Isolated vulval varicosity in the non-pregnant state: a case report with review of the treatment options. Aust N Z J Obstet Gynaecol. 2005 Jun;45(3):254-6. [PubMed: 15904458]

24.

Park SJ, Lim JW, Ko YT, Lee DH, Yoon Y, Oh JH, Lee HK, Huh CY. Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. AJR Am J Roentgenol. 2004 Mar;182(3):683-8. [PubMed: 14975970]

25.

TAYLOR HC. Vascular congestion and hyperemia; their effect on function and structure in the female reproductive organs; etiology and therapy. Am J Obstet Gynecol. 1949 Apr;57(4):654-68. [PubMed: 18113696]

26.

Beard RW, Reginald P, Pearce S. Pelvic pain in women. Br Med J (Clin Res Ed). 1987 Jan 10;294(6564):124. [PMC free article: PMC1245138] [PubMed: 3105653]

27.

Veltman LL, Ostergard DR. Thrombosis of vulvar varicosities during pregnancy. Obstet Gynecol. 1972 Jan;39(1):55-6. [PubMed: 5008285]

28.

Tropeano G, Di Stasi C, Amoroso S, Cina A, Scambia G. Ovarian vein incompetence: a potential cause of chronic pelvic pain in women. Eur J Obstet Gynecol Reprod Biol. 2008 Aug;139(2):215-21. [PubMed: 18313828]

29.

Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES. Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women. AJR Am J Roentgenol. 2001 Jan;176(1):119-22. [PubMed: 11133549]

30.

Galea M, Brincat MR, Calleja-Agius J. A review of the pathophysiology and evidence-based management of varicoceles and pelvic congestion syndrome. Hum Fertil (Camb). 2023 Dec;26(6):1597-1608. [PubMed: 37190955]

31.

Cheong YC, Smotra G, Williams AC. Non-surgical interventions for the management of chronic pelvic pain. Cochrane Database Syst Rev. 2014 Mar 05;2014(3):CD008797. [PMC free article: PMC10981791] [PubMed: 24595586]

32.

Farquhar CM, Rogers V, Franks S, Pearce S, Wadsworth J, Beard RW. A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion. Br J Obstet Gynaecol. 1989 Oct;96(10):1153-62. [PubMed: 2531611]

33.

d'Archambeau O, Maes M, De Schepper AM. The pelvic congestion syndrome: role of the "nutcracker phenomenon" and results of endovascular treatment. JBR-BTR. 2004 Jan-Feb;87(1):1-8. [PubMed: 15055326]

34.

Chung MH, Huh CY. Comparison of treatments for pelvic congestion syndrome. Tohoku J Exp Med. 2003 Nov;201(3):131-8. [PubMed: 14649734]

35.

Venbrux AC, Chang AH, Kim HS, Montague BJ, Hebert JB, Arepally A, Rowe PC, Barron DF, Lambert D, Robinson JC. Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain. J Vasc Interv Radiol. 2002 Feb;13(2 Pt 1):171-8. [PubMed: 11830623]

36.

Freedman J, Ganeshan A, Crowe PM. Pelvic congestion syndrome: the role of interventional radiology in the treatment of chronic pelvic pain. Postgrad Med J. 2010 Dec;86(1022):704-10. [PubMed: 21106807]

37.

Kwon SH, Oh JH, Ko KR, Park HC, Huh JY. Transcatheter ovarian vein embolization using coils for the treatment of pelvic congestion syndrome. Cardiovasc Intervent Radiol. 2007 Jul-Aug;30(4):655-61. [PubMed: 17468903]

38.

Pieri S, Agresti P, Morucci M, de' Medici L. Percutaneous treatment of pelvic congestion syndrome. Radiol Med. 2003 Jan-Feb;105(1-2):76-82. [PubMed: 12700549]

39.

Kim HS, Malhotra AD, Rowe PC, Lee JM, Venbrux AC. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 2006 Feb;17(2 Pt 1):289-97. [PubMed: 16517774]

40.

Mathis BV, Miller JS, Lukens ML, Paluzzi MW. Pelvic congestion syndrome: a new approach to an unusual problem. Am Surg. 1995 Nov;61(11):1016-8. [PubMed: 7486415]

41.

Gargiulo T, Mais V, Brokaj L, Cossu E, Melis GB. Bilateral laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic congestion syndrome. J Am Assoc Gynecol Laparosc. 2003 Nov;10(4):501-4. [PubMed: 14738638]

42.

Belenky A, Bartal G, Atar E, Cohen M, Bachar GN. Ovarian varices in healthy female kidney donors: incidence, morbidity, and clinical outcome. AJR Am J Roentgenol. 2002 Sep;179(3):625-7. [PubMed: 12185031]

43.

Beard RW, Kennedy RG, Gangar KF, Stones RW, Rogers V, Reginald PW, Anderson M. Bilateral oophorectomy and hysterectomy in the treatment of intractable pelvic pain associated with pelvic congestion. Br J Obstet Gynaecol. 1991 Oct;98(10):988-92. [PubMed: 1751445]

44.

Hanna J, Bruinsma J, Temperley HC, Fernando D, O'Sullivan N, Hanna M, Brennan I, Ponosh S. Efficacy of embolotherapy for the treatment of pelvic congestion syndrome: A systematic review. Ir J Med Sci. 2024 Jun;193(3):1441-1451. [PMC free article: PMC11128397] [PubMed: 38294607]

45.

Brown CL, Rizer M, Alexander R, Sharpe EE, Rochon PJ. Pelvic Congestion Syndrome: Systematic Review of Treatment Success. Semin Intervent Radiol. 2018 Mar;35(1):35-40. [PMC free article: PMC5886772] [PubMed: 29628614]

46.

Laborda A, Medrano J, de Blas I, Urtiaga I, Carnevale FC, de Gregorio MA. Endovascular treatment of pelvic congestion syndrome: visual analog scale (VAS) long-term follow-up clinical evaluation in 202 patients. Cardiovasc Intervent Radiol. 2013 Aug;36(4):1006-14. [PubMed: 23456353]

47.

Scultetus AH, Villavicencio JL, Gillespie DL, Kao TC, Rich NM. The pelvic venous syndromes: analysis of our experience with 57 patients. J Vasc Surg. 2002 Nov;36(5):881-8. [PubMed: 12422096]

48.

Gandini R, Konda D, Abrignani S, Chiocchi M, Da Ros V, Morosetti D, Simonetti G. Treatment of symptomatic high-flow female varicoceles with stop-flow foam sclerotherapy. Cardiovasc Intervent Radiol. 2014 Oct;37(5):1259-67. [PubMed: 24190634]

49.

Bittles MA, Hoffer EK. Gonadal vein embolization: treatment of varicocele and pelvic congestion syndrome. Semin Intervent Radiol. 2008 Sep;25(3):261-70. [PMC free article: PMC3036435] [PubMed: 21326516]

50.

Yang DM, Kim HC, Nam DH, Jahng GH, Huh CY, Lim JW. Time-resolved MR angiography for detecting and grading ovarian venous reflux: comparison with conventional venography. Br J Radiol. 2012 Jun;85(1014):e117-22. [PMC free article: PMC3474099] [PubMed: 21385913]

51.

Gavrilov S, Moskalenko YP, Mishakina NY, Efremova OI, Kulikov VM, Grishenkova AS. Stratification of pelvic venous reflux in patients with pelvic varicose veins. J Vasc Surg Venous Lymphat Disord. 2021 Nov;9(6):1417-1424. [PubMed: 34023538]

52.

Gavrilov SG, Temirbolatov MD. [Varicose veins of small pelvis as a cause of vulvar varicosity and varicose veins of lower extremities]. Angiol Sosud Khir. 2017;23(4):171-180. [PubMed: 29240072]

53.

Shokeir T, Amr M, Abdelshaheed M. The efficacy of Implanon for the treatment of chronic pelvic pain associated with pelvic congestion: 1-year randomized controlled pilot study. Arch Gynecol Obstet. 2009 Sep;280(3):437-43. [PubMed: 19190927]

54.

Gavrilov SG, Mishakina NY, Vasilyiev AV, Kirsanov KV. Retrospective Analysis of Complications After Gonadal Vein Interventions for Pelvic Venous Disorder. J Surg Res. 2023 Mar;283:249-258. [PubMed: 36423473]

55.

Monedero JL, Ezpeleta SZ, Perrin M. Pelvic congestion syndrome can be treated operatively with good long-term results. Phlebology. 2012 Mar;27 Suppl 1:65-73. [PubMed: 22312070]

56.

Ahangari A. Prevalence of chronic pelvic pain among women: an updated review. Pain Physician. 2014 Mar-Apr;17(2):E141-7. [PubMed: 24658485]

57.

Latthe P, Latthe M, Say L, Gülmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health. 2006 Jul 06;6:177. [PMC free article: PMC1550236] [PubMed: 16824213]

Disclosure: Chu-Hsuan Kuo declares no relevant financial relationships with ineligible companies.

Disclosure: Daniel Martingano declares no relevant financial relationships with ineligible companies.

Disclosure: Omer Saadat Cheema declares no relevant financial relationships with ineligible companies.

Disclosure: Paramvir Singh declares no relevant financial relationships with ineligible companies.