Almost one in three women will experience chronic pelvic pain in their lifetime. Chronic pelvic pain accounts for 15 percent of outpatient gynecologic visits. Women who visit a number of doctors without getting relief or even a diagnosis for chronic pelvic pain might even question if their pain is real. Rest assured the probability that something is wrong is actually high, but often missed or misdiagnosed.
The chronic pain that we're talking about is associated with a disease known as pelvic congestion syndrome (PCS) and is usually dull and aching. This pain is usually felt in the lower abdomen and lower back and often increases under the several conditions:
• After intercourse
• Menstrual periods (abnormal menstrual bleeding)
• When fatigued or when standing (worsening at the end of the day)
• Irritable bladder
• Vaginal discharge
• Varicose veins on vulva, buttocks or thighs.
The causes of chronic pelvic pain vary, but are often associated with the presence of ovarian and pelvic varicose veins. Pelvic congestion syndrome is similar to varicose veins in the legs. The tiny valves in the veins that help return blood to the heart (against gravity) become weak and fail to close properly. Blood begins to flow backwards and pools in the vein causing pressure and swelling.
Varicose veins in your pelvis cause not only pain, but can affect the uterus, ovaries and vulva. We find as many as 15 percent of women between the ages of 20 and 50, have varicose veins in their pelvis, although not all of these women will experience symptoms. Women with pelvic congestion syndrome are typically less than 45 years old and in their child-bearing years.
Risk factors for PCS include:
• Two or more pregnancies and hormonal increases (Pelvic congestion syndrome is unusual in women who have not been pregnant)
• Fullness of leg veins
• Polycystic ovaries
• Hormonal dysfunction
The diagnosis if often missed because women lie down for a pelvic exam, relieving pressure from the ovarian veins, that no longer bulge with blood as they do while the woman is standing.
After ruling out abnormalities or inflammation by a thorough pelvic exam, PCS can then be diagnosed through several minimally invasive methods.
Pelvic venography: Perhaps the most accurate method for diagnosis, a venogram is performed by injecting contract dye in the veins of the pelvic organs to make them visible during an X-ray.
MRI: May be the best non-invasive way of diagnosing pelvic congestion syndrome. The exam needs to be done in a way that is specifically adapted for looking at the pelvic blood vessels. A standard MRI may not show the abnormality.
Pelvic ultrasound/transvaginal ultrasound: Usually not very helpful in diagnosing pelvic congestion syndrome unless done in a very specific manner with the patient standing while the study is being done. Ultrasound may be used to exclude other problems that might be causing pelvic pain.
If the diagnosis is PCS, an embolization should be done. Embolization is a minimally invasive procedure performed by interventional radiologists using imaging for guidance. This outpatient procedure, involves a thin catheter, about the size of a strand of spaghetti, inserted into the femoral vein in the groin and guides it to the affected vein using X-ray. To seal the faulty vein and relieve painful pressure, a sclerosing agent (the same type of material used to treat varicose veins) is introduced to close the vein. After treatment, patients can return to normal activities immediately.
Living with chronic pelvic pain is difficult and affects not only the woman directly, but also her family, friends, and her general outlook on life. If you have pelvic pain that worsens throughout the day when standing, you may want to seek a second opinion with an interventional radiologist, who can work with your gynecologist to determine if PCS is a problem for you.
Dr. James Bergh, MD, is an Interventional Radiologist at St. Mary’s Medical Center and can be reached at 816-655-5708.