Pelvic Congestion Syndrome (PCS)

Pelvic Congestion Syndrome (PCS) is a chronic medical condition caused by varicose veins in your pelvis. Similar to varicose veins in the legs, the valves in the pelvic veins become weak or damaged, allowing blood to pool backwards (reflux). This causes the veins to become enlarged, twisted, and painful.

Think of it as “haemorrhoids of the pelvis.” It is a common but frequently underdiagnosed cause of chronic pelvic pain in women of childbearing age. The pain often worsens with activities that increase pelvic pressure, like standing, and may improve when lying down.

Common Symptoms

The primary symptom is chronic pelvic pain, present for 6 months or more. Symptoms often worsen as the day progresses or after long periods of standing.

Chronic, Dull, Aching Pain: In the lower abdomen, pelvis, lower back, or buttocks. Often described as a feeling of “heaviness,” “pressure,” or “fullness.”
Pain That Worsens: With standing, prolonged activity, lifting, during or after sexual intercourse, and just before or during your menstrual period.
Pain That Improves: When lying down flat.
Visible Varicose Veins: May appear on the vulva, vagina, buttocks, or inner thighs.
Other Symptoms: Bloating, irritable bowel-like symptoms, increased urinary frequency, and mood changes linked to chronic pain.

Causes & Risk Factors

PCS is primarily caused by venous insufficiency where the one-way valves in your pelvic veins fail, causing blood to flow backwards and pool.

Risk Factors Include

Pregnancy: Increased blood volume and pressure from the growing uterus can stretch and damage pelvic vein valves. Symptoms often begin or worsen after pregnancy.
Hormonal Influence: Oestrogen can relax vein walls. PCS is rare before puberty and after menopause.
Multiple Pregnancies.
Polycystic Ovaries (PCOS) or Conditions with Increased Ovarian Vein Blood Flow.
Fullness (Congestion) in Ovarian Veins: Often due to valve failure where the ovarian vein joins the kidney vein.
Anatomical variations

Diagnosis

PCS is a diagnosis of exclusion, meaning other causes of pain (like endometriosis, fibroids, or IBS) must be ruled out first. There is no single definitive test.

Diagnostic Pathway

Detailed History & Pelvic Exam: Your doctor will note the pattern of your pain.
Pelvic Ultrasound (Transvaginal/Transabdominal): The first-line imaging test. It can show enlarged, refluxing ovarian or pelvic veins. It should be performed both lying down and standing.
Advanced Imaging (If Ultrasound is Suggestive):

CT or MR Venography: Provides a detailed 3D map of the pelvic veins to confirm dilated veins and rule out other conditions.
Diagnostic Venography: A radiologist injects contrast dye through a catheter to visualise vein reflux in real-time is the gold standard. This is often done at the same time as a planned treatment procedure.

Management & Treatment Options

Treatment aims to relieve symptoms by blocking or removing the malfunctioning veins. The best approach depends on symptom severity and your family plans.

Conservative & Medical Management (First-Line)

Medications: Prescribed to manage pain (e.g., NSAIDs like ibuprofen) or to suppress ovarian function and shrink veins (e.g., GnRH agonists or certain progestins).
Compression Wear: Wearing supportive leggings or medical-grade compression tights can help improve blood flow and reduce heaviness.
Pelvic Floor Physiotherapy: To manage associated muscle tension and pain.
Lifestyle Modifications: Regular exercise (especially swimming, cycling), elevating hips when resting, and managing constipation.
Minimally Invasive Interventional Treatment (moderate-to-severe PCS)
Pelvic Vein Embolisation: A day-case procedure performed by an Interventional Radiologist.
- A tiny catheter is threaded into the faulty veins via a vein in the neck or groin.
- The problematic veins are then blocked using coils, plugs, or a special glue (sclerosant).
- Blood is naturally redirected to other healthy veins.
- Recovery is quick, with most women resuming normal activities within a week.
Surgical Treatment (Rarely Needed):

Laparoscopic Vein Ligation: Tying off the affected veins.
Hysterectomy with Oophorectomy: Only considered in severe, debilitating cases unresponsive to other treatments, and when family is complete. This is a last resort.

Possible Complications & Long-Term Outlook

Impact on Quality of Life: Chronic pain can significantly affect mental health, relationships, and daily activities.
Progression of Varicose Veins: May worsen in the vulva, buttocks, and legs over time.
After Treatment: Pelvic vein embolization has a high success rate (up to 80-90% symptom improvement). Symptoms may not disappear completely but are usually significantly reduced.

Frequently Asked Questions (FAQs)

Q: Is PCS the same as endometriosis or fibroids?
A: No. These are separate conditions, though they can co-exist and cause similar pain. A thorough evaluation is needed to distinguish them. PCS pain is uniquely linked to posture (worse standing, better lying down).

Q: Will getting pregnant make PCS worse?
A: Very likely, yes. Pregnancy increases pelvic pressure and blood volume, which typically aggravates PCS symptoms. Discuss management strategies with your doctor before planning a pregnancy.

Q: Is the embolization procedure safe?
A: Yes, it is considered very safe and effective. It is minimally invasive, preserves the uterus and ovaries, and has a low risk of major complications.

Q: Does PCS affect my fertility?
A: No. PCS does not directly impact your ability to conceive. However, the associated pain may affect sexual intimacy. Treating PCS can improve comfort.

Q: Is this condition “all in my head”?
A: Absolutely not. PCS is a very real, physical condition caused by identifiable vein dysfunction. Your pain is valid. Seeking a specialist familiar with PCS is crucial for proper diagnosis.

eGynaecologist Advice

You should seek a specialist consultation with a gynaecologist or vascular specialist experienced in PCS if you have chronic pelvic pain (>6 months) that worsens with standing, improves lying down, and is not explained by other diagnoses.

You should ask your gynaecologist to consider a referral to an Interventional Radiologist for discussion of Pelvic Vein Embolisation if conservative measures fail and your quality of life is significantly impacted. This is often the most effective long-term solution.