Updated: Oct 30, 2020
Pelvic congestion syndrome is characterized by chronic pelvic pain due to venous insufficiency and the subsequent development of pelvic and ovarian varicosities. Interventional approaches are used to treat gonadal reflux and May-Thurner syndrome, however, optimal treatment regimens have yet to be defined. Dr. Brooke Spencer discusses the complexities of treating PCS, how PCS manifestations present in her clinic, and why interventional procedures can lead to life-changing improvements for cases of chronic pelvic pain.
The BackTable Brief
Anatomical complexities of the pelvic venous system make it difficult to treat PCS definitively, which is evidenced by decreased efficacy of gonadal vein embolization in women compared to men.
Treating superficial venous problems of the leg without addressing underlying deep venous obstruction leads to recurrent issues; similar problems occur in the pelvis when gonadal veins are embolized without treatment of deep pelvic obstructions.
Manifestations of PCS may include vascular migraines, postural orthostatic tachycardia syndrome, IBS symptoms and recurrent UTIs.
Prevalence of PCS may be underestimated; PCS has varied presentations including chronic pelvic pain that may be treated with endovascular interventions.
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What are the difficulties in treating pelvic congestion syndrome?
Successful pelvic congestion syndrome treatment is complicated by the intricate pelvic venous anatomy. Treatment of PCS through May-Thurner stenting and gonadal vein embolization is possible, yet clear indications for treatment options remain unclear. Dr. Brooke Spencer compares PCS treatment to treating venous reflux within the leg; treating pelvic venous reflux and varices may temporarily fix the problem, however, delayed venous dilation and recruitment leads to recurrent issues.
[Isabel Newton] Let's talk a little bit about pelvic congestion syndrome. It has garnered a lot of attention because it's probably a whole lot more prevalent than it is recognized. You're doing some work now and seeing the ramifications of what this is, and how it may be responsible for a larger swath of problems than we know. Can you speak to that?
[Brooke Spencer] One thing we have to look at is why the results in gonadal vein embolization and its treatment are less successful in women than they are in men. So the data is better in varicocele than it is in gonadal vein embolization, and I think the reason for that is that the venous system is a complex, intricate, connected system, and the gonads are inside a woman, and in a man, they're outside. So they're an end organ in men, and they aren't in women.
It's the same concept of treating a saphenous vein in the leg without treating the May-Thurner. If you treat the venous reflux and the pelvic varices to some degree without treating an obstructed deep venous system, and you have elevated venous pressures … six months, a year, two years later, those veins will find a way to dilate, recruit blood flow, and be abnormal again. I don't have a complete dataset to tell you that the answer is we're missing May-Thurner all day long, every day in these pelvic congestion patients. That we're only treating their gonadal venous reflux, and we're not treating their underlying venous obstruction … but I truly believe that, and I don't know whether the data will bare that out.
So the next question that we have to ask becomes the same question in the leg. Do you treat the superficial vein or the deep vein first, or do you treat both? And the same question exists with pelvic congestion, but we have to start at least having the conversation.
Is it the May-Thurner that's making these people symptomatic, or is it the gonadal reflux? There are millions of women walking around with dilated gonadal veins after pregnancy, and not all of them are symptomatic, and not all of them are abnormal. There are millions of women walking around with May-Thurner. Not all of them are symptomatic, and not all of them are physiologically significant. So we need to do a lot better data and research on who needs to have their gonadal vein embolized and who needs to have their May-Thurner stented, but I think the next step in that process in figuring this out is to recognize the myriad of symptoms that are exacerbated if not caused by pelvic venous disease.
What are the manifestations of pelvic congestion syndrome?
Manifestations of PCS may include vascular migraines, postural orthostatic tachycardia syndrome (POTS), IBS symptoms, and recurrent urinary tract infections (UTIs). For example, women with recurrent UTIs are often on prophylactic antibiotics without UTI resolution. Dr. Spencer notes that after stenting the iliac vein for chronic DVTs, the recurrent UTIs resolve. She believes a further understanding of PCS will improve treatment outcomes of the aforementioned manifestations.
Starting at the top of the patient: migraine headaches. Everybody talks about vascular migraines, but nobody talks about the fact that a severe May-Thurner causes collateral blood flow through the epidural veins and probably increases the pressure around the spinal canal and around the dura thereby increasing intracranial pressures to some degree. A lot of the chronic migraines resolve or improve significantly after treating pelvic venous disease but particularly when treating May-Thurner.
And then the next thing is there's a guy, Danny Chan, in Texas who has been treating POT Syndrome. Postural orthostatic tachycardia syndrome is a syndrome where you stand up and your heart races. The cardiologists are not talking about the fact that this may be related to pelvic venous disease. It's significantly more common in women who've had children. So if you stand up and all your blood pools in your pelvis, you're going to get a release of epinephrine, you're going to have an anxious feeling, your heart's going to race, and that's what's happening in a lot of these women.
Now do we have proof that that's physiologically what's happening completely? No, but in a lot of these patients, they can't find an ablative pathway. They don't understand why this is happening. Now you treat their pelvic venous disease, and it's resolving in a lot of the patients that he's treating. So I think that still needs to be studied more. A lot of these women are put on anti-anxiety medications, but if you talk to them, they say when this happens, they feel anxious, but they are mentally and emotionally not feeling anxious. They don't need anti-anxiety medicine to fix their mental problems. They need to have the physical problem that's causing this fixed, and I think it's a release of epinephrine that creates that feeling.
And then the bladder and bowel symptoms that are very similar to the IBS, I've got a bunch of GI docs now who are really interested. We have a bunch of GU docs and interstitial cystitis, right? If you have a bunch of dilated veins in and around the base of your bladder, you're going to get irritation just like everything else. I've seen patients with chronic venous obstructions from DVT who've been on long term prophylactic antibiotics for innumerable recurrent urinary tract infections never have an infection again when you stent their iliac vein. These are patients who've had chronic DVT with a completely occluded iliac vein. It wasn't a question of, does this person have pelvic congestion? These are just chronic, severe venous obstructions, and you treat them, and they're like, "Why? I've never had another urinary tract infection, and I'm not on my antibiotics anymore."
Think about anterior shin lesions. We pretty much all recognize that when somebody has a big, red anterior shin lesion, cellulitis, there may be a venous component. I think the same thing is happening in the pelvis with the bowel and the bladder.
Treating Pelvic Congestion Syndrome to Improve Quality of Life
Data regarding treatment options and outcomes for PCS is limited, and its prevalence is likely underestimated. Dr. Spencer predicts many women have treatable yet undiagnosed PCS, which presents in various ways, most commonly as pelvic pain.
[Isabel Newton] Do you think that there's going to be a push towards greater recognition of pelvic congestion syndrome and treatment of it, or do you think that there's a lot more work that has to be done?
[Brooke Spencer] Well, I think there's a lot more work that has to be done, but I think this is like a billion-dollar industry. I think there are millions of women walking around with this problem who are fairly easily fixed, and think there are going to be a lot of naysayers at first, and I think it's going to take a long time. It's going to take some very good data, which is going to be very expensive and difficult to obtain, but if we can obtain it I think that people will start to believe.
I have a 44-year-old woman who since age 15 has had severe pelvic pain. She had three endometriosis surgeries. The first one, one ovary removed, then endometriosis burn, then her uterus and the other ovary removed. She's had colonoscopies and has been on narcotics. She has been depressed and in horrible chronic pain, and I talked to her about the possibility of May-Thurner because her GYN have started sending a lot of patients to me with chronic pelvic pain that hasn't been explained by other things. She ended up having a 75% stenosis with mild cross-collateral filling.
So I put a stent in her, and I won't say she was pain-free immediately. She had good days and bad days for about a month or a month and a half and then was completely pain-free for three months until she did some weird movement, and then she had a little bit of pain on and off again, and then that's going away.
So she's off all narcotics, off all pain medication, her depression is lifted, she feels like a new person, and it's given her life back. There will be people out there who say that I like to put stents in, right? But I like to put stents in because it's changing people's lives, and I don't think this is a placebo effect. These patients have had colonoscopies, they've had surgeries, they've had many other things that could be considered an intervention that could lead to them saying "I feel better" out of nowhere. So I don't know why placing a stent would be different than those in terms of how much it's changing their life. I mean, they come into the office crying in tears of joy and sobbing, and their life has changed, their relationships with their husband has changed, the dyspareunia gone. All of these things that were severely impacting their lives are improved, so I'm a big believer.
Dr. Brooke Spencer is a practicing interventional radiologist at Minimally Invasive Procedure Specialists group in Denver, CO.
Dr. Isabel Newton is a practicing interventional radiologist at UC San Diego Health in San Diego, CA.
Cite this podcast:
BackTable, LLC (Producer). (2018, October 9). Ep 33 – Building a Comprehensive Vein Practice [Audio podcast]. Retrieved from https://www.backtable.com/podcasts
The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.