Update on Pelvic Vein Congestion

Introduction:

Pelvic congestion syndrome (PCS) is characterized by chronic pelvic discomfort exacerbated by prolonged standing and coitus in women who have periovarian varicosities on imaging studies. The etiology of PCS is unclear and the optimum treatment is uncertain. Development of an evidencebased approach to managing these patients has been limited by the absence of definitive diagnostic criteria.

Epidemiology:

It is difficult to establish the true incidence of PCS, given the lack of definitive diagnostic criteria. It primarily affects multiparous women in the reproductive age group. No cases have been reported in menopausal women. PCS may account for up to 30 percent of patients presenting with chronic pelvic pain in whom no other obvious pathology can be found.

Pathogenesis:

The etiology of PCS is unclear. Multiple investigators have observed gross dilatation, incompetence, and reflux of the ovarian veins in women with PCS and have thus attributed PCS to underlying venous pathology. In this model, anatomic and/or hormonal factors lead to venous insufficiency of the ovarian veins and/or internal iliac veins, resulting in periovarian pelvic varicosities. Tuboovarian varicoceles have been termed the female equivalent of testicular varicocele.

Ovarian vein dilatation, stasis, and/or reflux on pelvic venography are common findings in multiparous premenopausal women, and most of these women are asymptomatic. Why these findings are associated with chronic pelvic pain in some women, but not in others, is unclear. A causal relationship has not been proven, but is supported by limited data showing pain relief upon administration of venoconstrictors or ovarian vein ligation/embolization. Other small studies of women with chronic pelvic pain, venous congestion, and reflux by either Doppler ultrasound and/or venography and no evidence of pelvic pathology at laparoscopy have reported improvement in pain after sclerotherapy, embolization, or venous ligation.

The higher prevalence of PCS in multiparous women may be related to the 50 percent increase in pelvic vein capacity during pregnancy, which may lead to venous incompetence and reflux in the non-pregnant state. The increased frequency of PCS symptoms on the left side may be due to extrinsic compression of the left renal vein between the aorta and superior mesenteric artery (“nutcracker phenomenon;” ie, pelvic congestion, left flank pain, and hematuria), or because valvular incompetence of the ovarian vein due to absent ovarian vein valves is more common on the left. Ovarian vein valves are missing in 15 percent of women on the left side and 6 percent of women on the right and nearly one-half of these women have valvular incompetence on at least one side.The absence of PCS in menopause has been attributed to the decline in estrogen, which acts as a venous dilator. This hypothesis is supported by observations that pharmacologic or surgical induction of a hypoestrogenic state may result in improvement or resolution of symptoms.

Clinical Manifestations:

PCS is characterized by pelvic pain of at least six months duration. It often first manifests during or after a pregnancy, and worsens with subsequent pregnancies. The pain varies in severity, but is usually described as a dull ache or heaviness that increases premenstrually; with prolonged standing, postural changes, walking, or activities that increase intraabdominal pressure; and after intercourse (postcoital ache). It is usually unilateral, but can be bilateral or shift from one side to the other. The patient may also complain of sharp exacerbations of pain, dysmenorrhea, deep dyspareunia, and urinary urgency. Gluteal, vulvar, and/or thigh varices may also be present.

Treatments:

 Invasive treatments for PCS have not been subjected to randomized clinical trials. The efficacy of these therapies is supported only by observational data and case series. The studies generally lack consistency; patients have varied symptoms and lack standardized diagnosis. These reports also lack a control group, involve different venography, embolization and surgical techniques, and fail to provide standardized evaluation of symptoms before and after treatment. The reported technical success rates of embolization for treatment of PCS range from 89 to 100 percent with clinical success rates of 58 to 100 percent over a follow-up period of up to five years. Surgical ligation of the ovarian vein has been associated with improvement in pain in about 75 percent of patients. The effects of hysterectomy are unclear; one study reported improvement after hysterectomy in 75 percent of patients with PCS, while another found no improvement.

References:

  1.  Robinson JC. Chronic pelvic pain.Curr Opin Obstet Gynecol 1993; 5:740–743.
  2. Kim HS, Malhotra AD, Lee ML, Venbrux AC. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol 2006; 17:289–297.
  3. Richet MA. Traite pratique d’anatomie medico-chirurgicale [Treatise on practical medical-surgical anatomy]. Paris:Balliere et fils, 1857.
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Increased Likelihood of Varicose Veins during Pregnancy

Varicose veins may be thought of as a problem only for senior citizens, but this isn’t so. Under certain circumstances, such as pregnancy, they can develop in younger women as well. The good news is that they typically go away or greatly improve after birth, especially in cases where they weren’t present to begin with. In situations where they don’t improve sufficiently after the blessed event, there are treatment options.

Veins return blood to the heart from all parts of the body. The blood carried by veins is under much less pressure than blood in the arteries. Because of this, venous blood moves slowly and can sometimes pool up in certain veins. Those in the legs are particularly susceptible to the condition, because the blood must move against gravity in addition to already being under less pressure.

Veins contain small valves to keep the blood from backing up, but sometimes these weaken and begin to fail. In this case, blood pools significantly in an area of vein, enlarging and discoloring it, forming a varicose vein. Sometimes these are painless yet at other times they can ache or feel hot or itchy. In any case, though, few care for the way they look.

One of the risk factors for varicose veins is being overweight. Unfortunately that includes carrying the extra weight of a developing baby – even if the total weight is normal for any given point in the pregnancy. It doesn’t seem fair, does it? In particular, the growing uterus and baby inside it press upon the main vein carrying blood back from the legs, the inferior (lower) vena cava. This exacerbates the situation, but fortunately expectant moms can do plenty of things to prevent or minimize varicose veins.

For example, speaking of the vena cava, it can be helpful to sleep on one’s left side as much as possible. This is because it takes some weight off that major vein, which is located to the right of the body’s center. In theory, sleeping on one’s stomach can also help, except that this becomes essentially impossible as the baby grows. Even when not sleeping, it helps to raise one’s feet when sitting. So, if you don’t have one already, get a hold of and use a nice foot-stool for all it’s worth. An expectant mom is not only ‘eating for two,’ but also resting for two!

It’s also better to not cross one’s legs or ankles while sitting, as some smaller veins can be directly pressed upon by this. This isn’t normally a problem, except when doing everything one can to prevent or minimize varicose veins. And since this condition is basically a problem of circulation, anything one does to improve circulation is all to the good. Chief among these is getting some daily exercise – even if it’s just a good walk of twenty minutes or more each day. If you must sit or stand in one place for long periods, make a point to take regular breaks for moving around.

Wearing compression stockings or hosiery can help. Though pregnant women should eat heartily, it’s good for overall health as well as for varicose veins to try to limit weight gain to the doctor-recommended amounts. Of course, continued exercise after the baby arrives is also important. Taking at least a couple of daily walks will be enjoyable for both mom and baby in addition to being good for their health. If all else fails, get the doctor’s advice on the various treatment options for varicose veins. Help is there if and when it’s needed!

By Marc Castro
http://www.doctorqa.com

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