Pelvic Congestion Syndrome and Menopause: Periods, Ovulation, Perimenopause and After

Many women notice that their pelvic vein pain rises and falls with their hormones. This guide answers common questions about pelvic congestion syndrome menopause changes and the years leading up to them: how symptoms change through the monthly cycle, during perimenopause and after periods stop, what HRT may mean, and which symptoms need checking whatever your stage of life.

Why hormones affect pelvic veins

Pelvic congestion syndrome (PCS) happens when veins around the womb and ovaries widen and blood flows backwards through them. Oestrogen, the main hormone made by the ovaries, relaxes the walls of veins and helps them widen. The ovarian veins also carry blood away from the ovaries themselves, so the veins with the most reflux sit right next to the source of the hormone.

This helps explain why PCS mainly affects women between their first period and menopause, and why symptoms often change with the cycle.

Pelvic congestion syndrome and your periods

The most common pattern is a flare before and during a period. In the days before bleeding starts, blood flow to the pelvis increases. Widened veins fill further, and the dull, heavy, dragging ache becomes more noticeable. Many women also find it builds more quickly when standing at this time of the month.

Some women with PCS report heavier or more painful periods. This is less clear-cut. Heavy, painful periods are also typical of fibroids, adenomyosis and endometriosis, which can exist alongside pelvic vein problems. Our comparison of pelvic congestion and endometriosis explains how doctors tell them apart.

Typical PCS pain does not switch off completely between periods. It usually comes and goes through the whole month, worse after long days on your feet and after sex. The full list of features is in our guide to the symptoms of pelvic congestion.

Pelvic congestion syndrome and ovulation

Some women describe a mid-cycle flare around ovulation. That fits with the hormone changes at that time, but it is hard to prove. A one-sided ache around ovulation is also very common in women without any vein problem, and ovarian cysts can cause similar pain.

A simple way to find your pattern is a pain diary over two or three cycles. Note the day of your cycle, how bad the pain is, and what you were doing. Bring it to your appointment.

Perimenopause: a time of change

Perimenopause is the stage, often lasting several years, when hormone levels swing up and down before periods stop. Periods may become irregular, heavier or lighter, and you may have hot flushes, poor sleep and mood changes.

For women with PCS, this can make symptoms unpredictable. Some months may be better, others worse, as oestrogen rises and falls. Heavy or irregular bleeding is common in perimenopause, but it is still worth mentioning to your doctor, especially if it is very heavy, happens between periods or after sex.

If your symptoms are manageable, it can be reasonable to talk to your doctor about waiting to see how they change as menopause approaches. If they are not, treatment is still an option at this stage.

Pelvic congestion syndrome after menopause

Once periods have stopped, the ovaries make much less oestrogen. For many women, PCS symptoms ease a great deal after menopause, and PCS is less common in older women.

It does not always go away, though. Widened pelvic veins are also seen on scans in older women, and doctors have described women after menopause with typical pelvic vein pain who improved after treatment. In one clinic series of women treated with pelvic vein embolisation, about a quarter were postmenopausal. These reports are small and come from specialist centres, so they cannot tell us how common this is. They do suggest that menopause alone should not rule out the diagnosis.

Equally, new pelvic pain after menopause should not simply be put down to veins. A doctor will want to check for other causes first, including problems with the ovaries, womb, bladder and bowel.

Can pelvic congestion syndrome cause early menopause?

There is no good evidence that PCS brings menopause on early. Menopause before 45 has other causes, and a doctor can check your hormone levels if your periods stop early.

Some treatments do affect the ovaries:

• Removing both ovaries during surgery causes an immediate menopause. This is one reason the operation is rarely used for PCS today. See our page on hysterectomy and pelvic congestion.
• Some hormonal medicines switch the ovaries off for a time, causing a temporary, reversible menopause-like state with hot flushes and other side effects. Our guide to medication and hormonal treatment for pelvic congestion explains the options.

If you are worried about your ovaries or fertility, our page on pelvic congestion and fertility covers what is known.

HRT and pelvic congestion syndrome

Hormone replacement therapy (HRT) replaces the oestrogen your ovaries no longer make, often with a progestogen to protect the womb lining. It can greatly improve menopause symptoms.

Because oestrogen relaxes veins, some women with a history of PCS notice pelvic aching come back or get worse on HRT. Others do not. There is little research on this, so the decision is a personal one to make with your doctor. Points to discuss include:

• How bad your pelvic vein symptoms were, and how they are now
• Whether you have had pelvic vein treatment, such as embolisation
• Your menopause symptoms and how much they affect you
• Any history of blood clots, or a condition such as May-Thurner syndrome

The type of HRT matters for clot risk. According to the NHS, HRT tablets can slightly raise the risk of blood clots, while patches, gels and sprays do not. Your doctor can advise on the right type and dose for you. Do not start, stop or change HRT without advice.

A Singapore vascular surgeon’s article on veins and the menopause gives more background on how hormone changes affect veins.

Bleeding after menopause: always get it checked

Vaginal bleeding after menopause is not a symptom of pelvic congestion. Any bleeding, spotting or pink or brown discharge that happens 12 months or more after your last period needs to be checked by a doctor promptly, even if it happens only once.

Most of the time the cause is not serious, such as thinning of the vaginal lining or a polyp. But it can be an early sign of cancer of the womb, which is much easier to treat when found early. This applies to women taking HRT too, if the bleeding is unexpected for the type of HRT they use.

Living with symptoms through the change

Simple measures help many women whatever their stage of life: lying down with the hips raised when the ache builds, breaking up long periods of standing, staying active, and keeping the bowels regular. Our guide to living with pelvic congestion covers these in more detail.

When to see a doctor

See a doctor if pelvic pain has lasted for months, flares with every period, affects sex, work or sleep, or keeps you from activities you enjoy. Also see a doctor about very heavy or irregular periods, bleeding between periods or after sex, or periods stopping before 45. Our pelvic symptom check can help you organise your symptoms before an appointment.

See a doctor promptly about any bleeding after menopause, persistent bloating, feeling full quickly or unexplained weight loss.

Get urgent medical help for sudden severe pelvic or abdominal pain, very heavy bleeding, fever with pelvic pain, fainting, or a painful, swollen leg or sudden breathlessness. In Singapore, call 995 in an emergency.

This article is general information, not personal medical advice. Please speak to a doctor about your own symptoms. How we create our content.