What is pelvic venous congestion?

The veins that drain the pelvis — the ovarian (gonadal) veins and branches of the internal iliac vein — have one-way valves that keep blood flowing back to the heart. When those valves fail, blood refluxes downward and pools in the deep pelvis. The veins enlarge into varicose-like channels around the uterus, ovaries, and broader pelvis. The pressure and engorgement irritate adjacent nerves and tissues, producing chronic pelvic pain.¹

The same mechanism can produce vulvar varicosities, perineal varices, and atypical-distribution varicose veins on the inner thigh and posterior leg. It’s also a recognized cause of recurrent leg varicose veins after prior saphenous ablation — when the source has actually been the pelvis all along.²

Typical symptoms

The classic symptom pattern includes:

• Chronic pelvic pain for at least 6 months — usually a dull, heavy ache rather than a sharp pain
• Pain worse with prolonged standing or at the end of the day, better when lying down
• Dyspareunia (painful intercourse) and post-coital ache that can last hours into the next day
• Pain that worsens around menstruation (dysmenorrhea)
• Pelvic heaviness or pressure
• Vulvar, perineal, or atypical lower-extremity varicose veins
• Symptoms after pregnancy — the condition is most common in multiparous women, as pregnancy increases pelvic venous pressure and damages valves

How it’s diagnosed

Pelvic venous congestion is a diagnosis of pattern. The history is more specific than any single imaging test, but imaging confirms the venous reflux and rules out other contributors. Workup typically includes a transvaginal and transabdominal pelvic Doppler ultrasound, MR venography (MRV), or CT venography (CTV) to demonstrate dilated, refluxing ovarian and pelvic veins. Other primary pain generators — endometriosis, adenomyosis, uterine fibroids, interstitial cystitis, and pelvic floor dysfunction — are evaluated and excluded by gynecology and pelvic pain teams before embolization is considered. Selective venography during the procedure itself provides definitive confirmation.

Related conditions: nutcracker and May-Thurner syndromes

Two anatomic compression syndromes commonly contribute to pelvic venous congestion and are evaluated during workup:

• May-Thurner syndrome — the right common iliac artery compresses the left common iliac vein where it crosses in front of it, slowing venous return from the left pelvis and leg. When identified, an iliac vein stent is often placed alongside ovarian vein embolization to address both problems.
• Nutcracker syndrome — the left renal vein is compressed between the aorta and the superior mesenteric artery, backing pressure into the left ovarian vein. In selected patients, ovarian vein embolization addresses the pelvic symptoms; severe cases may require renal vein stenting or surgical bypass by vascular surgery.

How the procedure works

Ovarian and pelvic vein embolization is performed in a hospital interventional suite under local anesthesia with light sedation. Through a small needle access in the neck or groin, a thin catheter is advanced under live X-ray imaging to the ovarian and internal iliac veins. Selective venograms confirm reflux and map the abnormal channels. The refluxing veins are then closed with a combination of microcoils, vascular plugs (such as Amplatzer Vascular Plug), and foam sclerotherapy with sodium tetradecyl sulfate or polidocanol. If May-Thurner or nutcracker compression is identified, additional treatment such as iliac vein stenting may be performed in the same session. There are no incisions, no hysterectomy, no removal of any pelvic organ. Total procedure time is typically 60 to 90 minutes, and most patients are discharged the same day.

What the research shows

Published series have consistently shown meaningful reductions in chronic pelvic pain and dyspareunia after ovarian and pelvic vein embolization, with sustained benefit over long-term follow-up.^3,4 The procedure does not damage the ovaries themselves and is not associated with infertility, premature menopause, or hormonal disruption — many patients have completed pregnancies after embolization.

References

1. Meissner MH, Khilnani NM, Labropoulos N, et al. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: a report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. J Vasc Surg Venous Lymphat Disord. 2021;9(3):568–584.
2. Hartung O, Grisey A, Boufi M, et al. Pelvic venous outflow obstruction in patients with chronic pelvic pain: prevalence and management with iliac vein stenting. J Vasc Surg Venous Lymphat Disord. 2021;9(2):450–457.
3. Kim HS, Malhotra AD, Rowe PC, Lee JM, Venbrux AC. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 2006;17(2 Pt 1):289–297.
4. Daniels JP, Champaneria R, Shah L, et al. Effectiveness of embolization or sclerotherapy of pelvic veins for reducing chronic pelvic pain: a systematic review. J Vasc Interv Radiol. 2016;27(10):1478–1486.e8.

Frequently asked questions

What is pelvic congestion syndrome?

Pelvic congestion syndrome — also called pelvic venous disease — is chronic pelvic pain caused by abnormal flow in the ovarian and pelvic veins. The valves in those veins fail, blood pools in the pelvis, and the resulting venous engorgement causes a heavy, achy pelvic pain that classically worsens with prolonged standing, at the end of the day, around menstruation, and after intercourse. It’s most common in women who have had multiple pregnancies.

What are the typical symptoms?

Chronic pelvic pain lasting more than 6 months, pelvic heaviness or pressure, pain that worsens with prolonged standing or at the end of the day, dyspareunia (painful intercourse) and post-coital ache, dysmenorrhea (painful periods), and sometimes vulvar or atypical lower-extremity varicose veins. Some patients also have urinary urgency or pain with bowel movements.

How is it diagnosed?

Diagnosis combines a careful history with imaging — most often transvaginal and transabdominal pelvic Doppler ultrasound, MR venography, or CT venography. Other causes of chronic pelvic pain (endometriosis, adenomyosis, fibroids, interstitial cystitis, pelvic floor dysfunction) are evaluated and excluded by gynecology and pelvic pain teams before embolization is considered. Selective venography during the procedure itself is the definitive confirmation.

How does the procedure work?

Through a small needle access in the neck or groin, a thin catheter is advanced under live X-ray imaging into the ovarian and internal iliac veins. Selective venograms confirm reflux, and the abnormal veins are closed using a combination of microcoils, vascular plugs, and foam sclerotherapy. When May-Thurner or nutcracker compression is identified as a contributor, additional treatment such as iliac vein stenting may be performed in the same setting. The procedure typically takes 60 to 90 minutes, and most patients go home the same day.

What is May-Thurner syndrome and how does it relate to pelvic congestion?

May-Thurner syndrome is compression of the left common iliac vein by the right common iliac artery as it crosses in front of it. The compression slows venous return from the left pelvis and leg, contributes to pelvic venous congestion, and can cause left-leg swelling and DVT. When May-Thurner is identified during workup, an iliac vein stent is often placed alongside ovarian vein embolization to address both problems.

What is nutcracker syndrome?

Nutcracker syndrome is compression of the left renal vein between the aorta and the superior mesenteric artery. The pressure backs up into the left ovarian vein, contributing to pelvic venous congestion. Treatment depends on severity — in selected patients, ovarian vein embolization addresses the pelvic symptoms, and renal vein stenting or surgical bypass is considered for severe cases by vascular surgery.

Will the procedure affect fertility, hormones, or menstruation?

Ovarian vein embolization closes the abnormal refluxing veins; it does not damage the ovaries themselves and is not associated with infertility, premature menopause, or hormonal changes in published series. Many patients have completed pregnancies after embolization.

Is this related to varicose veins on my legs?

It can be. When varicose veins on the inner thigh, posterior leg, vulva, or perineum follow an atypical distribution — or when leg varicose veins return after a prior saphenous ablation — pelvic vein reflux is sometimes the actual source. Treating the pelvic source first can give the leg vein treatment a chance to hold.

Who performs ovarian and pelvic vein embolization?

The procedure is performed by interventional radiologists. Workup and follow-up are coordinated with the patient’s gynecology, vascular surgery, urogynecology, and pelvic pain medicine teams as appropriate.