What is PCS?

Pelvic congestion syndrome, also known as pelvic venous insufficiency (PVI), is a condition where there is abnormal blood flow in the veins in your pelvis. This is usually associated with chronic pain but may present itself with other symptoms as well. The pain and other symptoms last longer than 6 months and are not associated with your menstrual cycle of pregnancy. The abnormal blood flow is caused by problems in the veins going to your ovaries and pelvis. The veins are designed to transport blood away from these areas, but in the case of PCS, this mechanism doesn’t work as it should. This results in pooling of blood in your pelvis, widening of the veins, eventually leading to pain.

Who is affected by PCS?

PCS occurs mostly in women between the ages of 20-45, and usually in those that have given birth more than once. Other risk factors are: Polycystic ovarian syndrome (PCOS) Varicose veins A family history of varicose veins It is unusual for women who’ve gone through menopause to have pelvic congestion syndrome. Approximately 40% of visits to the gynaecologist involve chronic pelvic pain complaints. Studies estimate that up to 30% of these visits are likely to be related to pelvic congestion syndrome.

What are the symptoms of PCS?

The pelvic pain in PCS is usually described as dull, achy or heavy pain. It is rarely characterised as a sharp or intense pain, but this pain can be associated with PCS too. The pain is most commonly reported on the left but may also occur on the right or on both sides. The onset of pain is often during or soon after pregnancy and can worsen with subsequent pregnancies. Pain in PCS may often feel worse: At the end of the day Before and during your period (hormones influence the blood flow in your pelvis) During intercourse and afterward When you stand or sit for prolonged periods Sometimes the pain is less when you lie down Other symptoms may include: Constipation or diarrhea Incontinence (stress incontinence) Pain when peeing Varicose veins in pelvis, behind, thighs, vulva and vagina

What is the cause of PCS and the pain associated with it?

It is unclear from research what causes pelvic congestion syndrome, but it is known that problems with blood flow in your ovarian veins and pelvic veins play a role. Normally, the blood flows from your pelvis back towards your heart through veins. These veins are designed in such a way that the blood only goes in one direction: back to the heart. In PCS, these valves no longer function properly. This leads to blood flowing in the opposite direction (this is called reflux), causing the veins to widen and become filled with blood. The blood pools in your pelvis and causes pain. This pain may be caused by stretching of the vein, and possibly also the vein becoming so big they touch the nerves in your pelvis, triggering pain. The malfunction of the veins might be caused by pregnancy (due to the vessels growing up to 50% larger than normal), and some theories suggests that estrogen may alter the vessel structure as well.

What can we do to treat PCS?

It is not possible to restore the veins to their original form and function. The goal of treating PCS is to minimise/manage the symptoms, and in some people the symptoms can nearly completely resolve. Unfortunately, research does show that complete resolving of symptoms is rare. Several types of medication (mostly suppressing estrogen) are known to help in reducing PCS symptoms, but these medications also have side-effects. Surgical treatments are often invasive and require laparoscopy to tie off the veins or in very rare case remove your ovaries, uterus and fallopian tubes. At SIIR, we offer ovarian vein embolisation, a minimally invasive procedure to help minimise PCS. This procedure is explained below.

Ovarian vein embolisation (OVE)

Ovarian vein embolisation is a minimally invasive, image-guided procedure for treating dysfunctional veins going to your ovaries and pelvis. It works by blocking up these veins, preventing reflux (backflow of blood into the veins) and thereby reducing pooling of blood in your pelvis. The interventional radiologist will insert a small plastic tube (a catheter) into the vein in your groin or neck and guide this catheter (by using x-rays) into the veins going to your ovaries/pelvis. Tiny metal springs called coils are then inserted into the vein, which will cause the vein to react and shrink, preventing blood from flowing back into the veins and pooling in the pelvis. These coils can’t be removed, so they will stay in the vein.

Who may benefit?

You may be suitable for OVE if you: Have been diagnosed with PCS Have not had relief from medications or if medication is not suitable for you Prefer a non-surgical, outpatient option for relief of the PCS-symptoms

How the procedure is performed

The procedure is performed by an interventional radiologist Done under local anesthesia with sedation for comfort A small catheter is inserted into the vein in your groin (sometimes in the neck, but this is usually not necessary) A small tube is guided to the vein connecting your left ovary to the main vein and dye is injected to identify which vessels need treatment. Tiny metal springs (coils) are inserted into the vein to block the malfunctioning vein. The same process is repeated on the right. A final check is done with dye to make sure the interventional radiologist is happy with the result. Once the catheter is removed from your groin, the interventional radiologist will compress the groin for a few minutes to make sure no blood leaks from the insertion site. You will have to rest in bed for a few hours to recover from the procedure. If you feel well, you can go home within a few hours after the procedure is finished.

Risks

OVE is a safe procedure for treating pelvic congestion syndrome. The most reported complications are bruising in the groin or neck after accessing the vein and and mild discomfort/cramping in the days following the procedure. Rare complications include allergic reactions to the dye or migration of the coils. We advise a period of at least 1 week of no strenuous exercise, heavy lifting or other strenuous activities that increase the pressure in your tummy to give the coils time to settle. In about 5% of cases there is a recurrence of symptoms, in which case another treatment can often be performed to deal with this.

Health insurance coverage for OVE

Southern Cross insurance does not cover OVE. NIB and AIA do cover OVE. Please discuss your coverage with your doctor and insurance provider before the procedure.

OVE and pregnancy

You should not have this procedure during pregnancy, as the radiation that is used will harm your unborn child. While women can become pregnant after OVE and have successful pregnancies, no scientific studies have fully established the effects of OVE on fertility and pregnancy. If you have had an OVE and become pregnant after this, there is a risk that the symptoms return after your child is born. Please discuss the latest clinical data with your doctor before deciding to proceed with OVE.