Women who suffer from pelvic congestion syndrome (PCS) don’t have to suffer in silence; once diagnosed, there are a variety of treatment options available.

Until fairly recently, pelvic congestion syndrome or PCS has been a poorly understood medical condition.

PCS presents a wide variety of symptoms, which causes it to be frequently misdiagnosed. Symptoms such as painful periods, heavy and/or prolonged periods and painful sex are very similar to other more common gynaecological issues like fibroids, ovarian cysts and endometriosis.

However, PCS is not a gynaecological condition but a vascular one. If you have visible varicose veins and also experience the above symptoms, it is likely that you may have PCS.

How is PCS diagnosed?

Women with chronic pelvic pain are typically referred to their gynaecologists first, who look for gynaecological causes for the pain.

But, according to Dr Sriram Narayanan, Senior Consultant Vascular and Endovascular Surgeon, at the Harley Street Heart and Vascular Centre in Gleneagles Hospital in Singapore, standard gynaecological tests, scans and laparoscopes cannot detect PCS, which requires a real-time assessment of blood flow in the veins of the pelvis.

“Fortunately, gynaecologists are becoming more aware of PCS and are starting to refer women to vascular specialists once they have ruled out the potential gynaecological causes for chronic pelvic pain, and suspect that the patient might have PCS,” says Dr Sriram.

Once the case is in the hands of a vascular team, the following assessments are carried out:

  1. The PCS Score, measured on a scale from 0 to 6. Scores of 4 or more make PCS highly likely and patients are then assessed by another duplex ultrasound scan.
  2. The Duplex Ultrasound Scan has two components – an abdominal scan and a pelvic scan done either trans-vaginally (internally) or as an external pelvic scan. Unlike a gynaecologist who performs the ultrasound to look for anomalies in the pelvic organs, a vascular and endovascular specialist would look at the veins in the pelvis, their volume and distribution, and the nature and direction of the blood flow in those veins. A combination of solid organ ultrasound and colour doppler scanning, which is a specialist vascular technique of scanning, is used.
  3. The veins on the legs are assessed to look for swelling of the ankles and feet. Varicose veins in the legs can point to a more extensive form of diseases in the veins.
  4. A catheter angiography will be recommended if the ultrasound scan indicates that the PCS is being caused by tortuous, twisted or kinked pelvic veins, slow or reversed flow in the left ovarian or internal iliac vein, abnormally dilated veins or the rarer Nutcracker syndrome. This is the same technology used to examine and treat blood vessels around the heart or other key areas of the body to check for abnormalities. The use of catheters makes it possible to combine diagnosis and treatment in a single procedure.

Treatment options for PCS

Dr Sriram Narayanan

Not all patients require an intervention for PCS. Depending on the severity of the symptoms and degree of blood pooling in the pelvis as seen upon assessment, as well as the stage of a woman’s life (if she is a a teenager, young mother, or is nearing menopause, etc.), PCS can be managed by simpler medical measures.

There are several treatment options available, depending on what is causing the symptoms:

Hormonal medications: A gynaecologist may prescribe them to reduce blood flow and congestion of the varicose veins. But some women do not like to take hormonal drugs, and for others they may be ineffective.

Catheter based therapies: These minimally-invasive procedures require a small catheter to be inserted into a vein in the thigh, and guided to the problem area using X-ray. No incisions or stitches are required, and the patient usually feels no internal sensation while this is happening. Most of the time patients only require intravenous (IV) medications, though some may need a full anaesthetic.

There are two different catheter-based treatments:

Embolisation of the ovarian vein: This is the most common procedure today. It simply seals off or plugs up the incompetent and dilated varicose veins so they can no longer become engorged with blood and cause pain or heavy periods.

Vein stent: If the problem is severe compression of the iliac vein, the large vein that drains blood from both the legs and pelvis, then a vein stent is used. This is a specially designed metal tube that is inserted in the vein to open it up, relieve pressure and improve blood flow.

In very severe cases, patients may need both these treatments, but such instances are rare. Catheter procedures are usually done early in the day, and patients are kept overnight for observation. After the procedure, patients are recommended another two to three days of rest at home, and most of them are back at work and living life as normal after that.

“However, the PCS pain does not disappear completely overnight even after these procedures. It can take one or two menstrual cycles for the procedure to be fully effective, but after that most patients are pain-free,” adds Dr Sriram.

PCS by itself does not usually lead to a medical emergency, however if symptoms get worse, then it is time to visit your healthcare provider or gynaecologist. Those who experience a sharp, sudden pain that doesn’t go away should visit a healthcare provider immediately.