Pelvic congestion syndrome (PCS) is a cause of long-term pelvic pain that comes from the veins rather than from the womb, ovaries, bowel or bladder. It happens when veins in the pelvis widen and blood flows backwards through them instead of draining away. Many women live with it for years before anyone suggests looking at their veins. This guide explains what it is, how it feels, who gets it and what can be done.
What is pelvic congestion syndrome?
In simple terms, PCS is varicose veins inside the pelvis that cause pain. Doctors usually define it as pelvic pain lasting at least six months, associated with widened, refluxing veins around the womb and ovaries.
You may also hear it called pelvic venous congestion syndrome, pelvic vein incompetence or pelvic congestion disorder. Specialist societies now group it with related conditions under the umbrella term pelvic venous disorders. These include varicose veins of the vulva and upper thigh, nutcracker syndrome and May-Thurner syndrome.
How pelvic veins become “congested”
Blood from the pelvic organs drains through a network of veins on each side of the womb. From there it travels up through the two ovarian veins, which run from the ovaries to the area of the kidneys, and sideways through the internal iliac veins.
Like leg veins, the ovarian veins have small one-way valves. Problems start when:
- The valves fail. Blood falls back down into the pelvis (reflux). This is the most common finding, especially in the left ovarian vein.
- A vein further up is squeezed. If the left kidney vein or the left iliac vein is compressed by an artery, blood backs up and finds a way out through pelvic veins instead.
Either way, the pelvic veins stretch, twist and hold more blood. Standing makes it worse because gravity adds to the pressure. That is why the pain tends to build through the day.
Symptoms
The pain is usually described as a dull, dragging, aching or heavy feeling low in the pelvis, on one or both sides. Typical features include:
- Pain that gets worse after standing or walking for a long time, or by the end of the day
- Relief when lying down, especially with the hips raised
- Pain during sex, or a deep ache that lasts for hours afterwards
- Pain that is worse just before or during a period
- Visible varicose veins on the vulva, upper inner thigh, buttocks or back of the thigh
- An urgent need to pass urine, or aching in the lower back or hips
For the full picture, including less typical symptoms, see pelvic congestion syndrome symptoms.
Who gets it?
PCS mainly affects women of reproductive age, typically in their twenties to forties, before menopause. The biggest risk factor is pregnancy: during pregnancy the pelvic veins widen considerably, by up to about half, and they do not always shrink back afterwards. The more pregnancies, the higher the risk.
Other factors that may contribute include oestrogen, which relaxes vein walls, a family history of varicose veins, and anatomy that squeezes veins higher up. Read more about what causes pelvic congestion syndrome.
Men can have the same kind of vein reflux. It usually shows up as a varicocele, a cluster of widened veins around the testicle.
Why it is often missed
Several things make pelvic congestion easy to overlook:
- Scans are usually done lying down. In that position the pelvic veins drain and can look normal.
- Veins are not always the focus. A routine pelvic ultrasound looks at the womb and ovaries, not at blood flow in the veins.
- The symptoms overlap. Endometriosis, adenomyosis, fibroids, irritable bowel syndrome, bladder pain syndrome and pelvic floor muscle problems can all cause similar pain, and more than one can be present.
- Widened veins are common. Some women have large pelvic veins and no pain, so finding them does not prove they are the cause.
For this reason, good care looks at the whole picture rather than at the veins alone. Our guide to chronic pelvic pain explains the other causes doctors consider.
How it is diagnosed
Diagnosis combines your story, an examination and imaging. A duplex ultrasound, often through the vagina as well as the abdomen, is usually the first test. It shows how wide the veins are and which way the blood is flowing. CT or MR venography can map the veins and look for compression. A venogram, an X-ray of the veins using contrast dye, gives the clearest picture and is usually done at the start of treatment. See how pelvic congestion syndrome is diagnosed.
Treatment options
Treatment is about relieving symptoms. Widened veins that cause no trouble do not need treating. The main options are:
- Embolisation. A specialist passes a thin tube into a vein, usually in the neck or groin, and closes the faulty veins from the inside with tiny coils, plugs or a sealing foam. It is usually done as a day case. See ovarian vein embolisation.
- Medicines. Hormonal treatments that reduce ovarian activity can ease pain for some women, though side effects limit how long they can be used. Simple painkillers may help.
- Stenting. If a vein higher up is compressed, a stent may be considered to hold it open.
- Surgery. Surgery to tie off veins, or hysterectomy, is now rarely used for this condition.
The evidence for embolisation is encouraging, with many women reporting less pain in studies. But many studies are small and not randomised, and not everyone improves. Compare the options in our guide to pelvic congestion syndrome treatment. Patient information from a Singapore vascular surgeon’s clinic gives another overview of the condition.
When to see a doctor
See a doctor if you have pelvic pain that has lasted for months, pain that affects sex, work or sleep, or new varicose veins around the vulva or upper thighs. You can use our pelvic symptom check to organise your thoughts before an appointment.
Get urgent medical help for sudden severe pelvic or abdominal pain, heavy vaginal bleeding, fever with pelvic pain, fainting, or pain or bleeding when you might be pregnant. In Singapore, call 995 in an emergency.
Frequently asked questions
What is pelvic congestion syndrome?
It is chronic pelvic pain, lasting six months or more, that is associated with widened (varicose) veins in the pelvis. The veins have faulty valves or are compressed further up, so blood flows backwards and pools, causing a heavy, aching pain.
Is pelvic congestion the same as pelvic venous congestion syndrome?
Yes. Pelvic congestion syndrome, pelvic venous congestion syndrome and pelvic vein incompetence all describe the same problem. Doctors increasingly use the wider term pelvic venous disorders, which also includes related conditions such as nutcracker and May-Thurner syndromes.
How common is pelvic congestion syndrome?
Exact numbers are not known because it is under-diagnosed and studies define it differently. Chronic pelvic pain is common, and estimates suggest pelvic vein problems may explain up to about a third of cases, although figures range widely between studies.
Can pelvic congestion syndrome go away on its own?
Symptoms often ease after menopause, when the ovaries become less active, and they may vary with the menstrual cycle. Some women manage well with self-care and medicines. For others, symptoms persist until the faulty veins are treated.
Is pelvic congestion syndrome dangerous?
It is not usually dangerous to life, but it can seriously affect quality of life, work and relationships. See a doctor promptly about any new pelvic pain, and urgently about sudden severe pain, heavy bleeding or fever.
Sources and further reading
This article is general information, not personal medical advice. Please speak to a doctor about your own symptoms. How we create our content.