Women with painful, heavy periods could be experiencing a vascular problem rather than a gynaecological one

Menstrual cramps affect up to 91% of women of reproductive age, with up to 29% of women experiencing severe pains. It is also estimated that one in three women have heavy menstrual bleeding (HMB), while up to 21% of women suffer painful intercourse. If women have a combination of painful menstrual cramps, prolonged HMB, and uncomfortable sex, a doctor’s first instinct may be to associate them with gynaecological problems. However, they may also be caused by a vascular issue, such as pelvic congestion syndrome (PCS), resulting in misdiagnosis and mistreatment of a patient’s condition.

Dr Sriram Narayanan

“Until recently, PCS was a poorly understood, ill-defined disorder. Since it shares many symptoms with common gynaecological conditions, such as ovarian cysts and polyps, fibroids, and endometriosis, women with chronic pelvic pain are normally referred to gynaecologists, who, unwittingly, look for gynaecological causes of the pain. However, standard gynaecological tests, such as scans and laparoscopies, cannot detect PCS, potentially leading to incorrect diagnosis and treatment,” says Dr Sriram Narayanan from the Harley Street Heart & Vascular Centre.

What is PCS?

PCS affects women during their reproductive years and is more common among women who have given birth. It is caused by a pooling of blood in the veins due to a problem with the valves regulating blood flow in the ovarian, parauterine, or gluteal veins, which carry blood from the pelvic region back to the heart. This poor valve function causes blood to back up and veins to swell, resulting in varicose veins deep in the pelvis.

Dr Sriram elaborates, “These swollen veins are what cause HMB and chronic pelvic pain. The nature of this pain can vary widely; it may be unilateral or bilateral, it can be acute or severe and chronic or dull. It is also typically worse right before and on the first two days of a period. Other PCS symptoms may mimic symptoms of urinary tract infection, such as blood in the urine as well as of irritable bowel syndrome (IBS), including diarrhoea and constipation.”

How PCS and common gynaecological symptoms differ

PCS symptoms differ subtly from other causes of chronic pelvic pain. For instance, women with PCS experience painful sex. While several gynaecological conditions can cause pain during coitus, most present as discomfort in the vagina due to dryness or damage to the vagina’s walls. With PCS, the pain is felt more deeply and is usually present before sex, worsened by sex, and also results in a prolonged, throbbing ache afterwards. Another major indicator of PCS is visible varicose veins, especially in the upper thigh, groin, or vulvar area.

When asked how doctors can tell the difference between PCS and other causes of chronic pelvic pain, Dr Sriram says, “PCS presents with pain in the lower back and abdomen which flares at the beginning of one’s period, without evidence of inflammatory conditions such as polyps, fibroids or endometriosis.”

“Another way PCS pain differs is the way it is exacerbated by fatigue and standing for long periods due to the pressure of backed up blood. Ironically, one of the reasons PCS is hard to diagnose is because women lie on their backs during gynaecological exams, thereby taking the pressure off veins and temporarily reducing pain and swelling.”

Causes and risk factors of PCS

A combination of mechanical factors causes PCS such as compression of the renal and iliac veins by overlying arteries, together with genetically faulty valves in the veins. There are also hormonal factors including high oestrogen levels or multiple pregnancies that promote dilated ovarian veins.

Dr Sriram says, “Since PCS is caused by various factors that act together including multiple pregnancies, it is usually seen in women in their forties who have had one or more children. Nevertheless, PCS can also affect younger, nulliparous women at any reproductive age. Other associated risk factors include polycystic ovaries, hormonal dysfunction and varicose veins in the legs. You may also have a higher risk of PCS if your family members have it.”

Can PCS be prevented?

Apart from the sound advice of maintaining a healthy weight with a healthy diet and regular exercise, there is no specific lifestyle choice that prevents PCS. However, women should understand that chronic menstrual cramps, prolonged HMB and painful intercourse are not normal and usually signs of an underlying condition. While problems associated with the intimate region may be embarrassing to discuss, it is imperative that women report any gyneacological or vascular symptoms to their doctor early because prompt diagnoses is the best way to prevent disease progression, improve symptoms and enhance quality of life.