Pelvic Congestion Syndrome

Pelvic congestion syndrome is a poorly understood and frequently misdiagnosed disorder of the pelvic venous circulation, which causes chronic pelvic pain in women in premenopausal age. It is characterised by pelvic varicosities, pelvic pain worsened by prolonged standing, coitus, menstruation, and pregnancy.1

There are four main types of pelvic venous circulatory disorders2:

1. Vulval varices without symptoms of pelvic congestion.
2. Isolated insufficiency of the hypogastric vein and its tributaries
3. Predominant gonadal venous insufficiency. The gonadal veins may reach considerable size and carry a large volume of blood, which floods the pelvic veins and may trickle down to the extremities
4. Obstruction to the gonadal outflow by mesoaortic compression of the left renal vein (nutcracker syndrome)

It’s main presentation is as chronic pelvic pain and it must be differentiated from other  gynaecologic, urinary, gastrointestinal, musculoskeletal and neurologic disorders and indeed can have  co-occurrences.

Valve insufficiency, venous obstruction, and hormones all may play a role in the development of congestion of the pelvic veins. The pain associated with pelvic congestion likely arises from increased dilatation, concomitant with stasis, leading to the release of local pain- producing substances.

The typical clinical features include1:

• Pelvic pain lasting 3–6 months;
• Pain as a dull ache or heaviness sensation, predominantly unilateral, sometimes bilateral
• Pain can be exacerbated before or during menses and because of any factor which increases abdominal pressure, such as long-time standing position, walking, lifting, and postural changes;
• Pain is worse during and after coitus, during pregnancy and worsens with subsequent pregnancies;
• Symptoms are generally most severe at the end of the day and diminished with supine positioning;
• It can take several hours to subside.
• It can be related to the presence or history of vulvovaginal, gluteal, perineal, or lower limb varices

Transvaginal pelvic ultrasound must be performed as a process of differential diagnosis and to evaluate dilated uterine and ovarian veins, changes in the ovaries and uterine enlargement. A 1990 study3 hypothesised that if  ovarian hormones are implicated in the mechanism of pelvic congestion, given its chronicity, hypertrophy will occur in target organs such as the uterus and endometrium and the ovaries will also show structural abnormalities. The study did find that pelvic congestion is associated with enlargement of the uterus, thickening of the endometrium and cystic changes in the ovary. Uterine enlargement may occur as a result of engorgement of uterine veins and may also be due to increased exposure to, or sensitivity to, oestrogen.

Seeking a specialist in Gynaecological ultrasound*is essential for illumination of this condition Computed tomography (CT) and magnetic resonance imaging (MRI) are also reported to be used as non-invasive investigations. Ovarian and iliac catheter venography is the gold standard diagnostic test for pelvic congestion1. It can be incidentally seen on laparoscopy but is often missed with procedural limitations.

Symptoms are reportedly improved by progestins e.g. Medroxyprogesterone acetate – Depo-Provera, combined oral contraceptives, nonsteroidal anti-inflammatories, gonadotropin-releasing hormone (GnRH) agonists., venoconstriction, and/or occlusion of varicose veins by medical or surgical as well as interventional radiological treatment. At the time of writing, pelvic venous embolisation was considered the best available medical treatment for PCS but there is limited evidence of the long- term efficacy.1

Naturopathic considerations:

Naturopathic practice is perfectly placed to support pelvic congestion syndrome. Considerations include identifying and removing disturbing factors such as inflammatory diet, excess alcohol consumption, poor movement and stress. The structural integrity of the venous and lymphatic systems are weakened in pelvic congestion syndrome and there are numerous options in herbal medicine to consider:

Calendula offinicalis  (Calendula): Calendula is particularly indicated for pelvic congestion due to poor circulation/ lymphatics through the pelvic area4

Ceanothus americanus (Red root): Lymphatic disorders: fibrocystic breast disease, lymphadenitis, lymphatic congestion, oedema, pelvic congestion5

Cinnamon aromaticum (Cinnamon) : A warming circulatory stimulant to the pelvic area to relieve pelvic congestion4

Thuja occidentalis: Thuja may be considered to reduce congestion in the pelvic area4

Aesculus hippocastanum (Horsechestnut): Increases venous tone, improves capillary resistance, decreases capillary permeability, improves circulation by toning veins; decreases oedema resulting from lymphatic congestion or inflammation6

Ruscus aculeatus (Butcher’s broom): Improves venous tone, decreases oedema associated with venous stagnation and inflammation6

There are several formulations in TCM that could be considered such as Tao Hong Si Wu Tang. It’s indicated for conditions characterised by pain due to blood stasis, together with blood deficiency. The formula is composed of Blood tonics, such as Rehmannia root (di huang), Angelica root (dang gui) and white Paeonia root (bai shao). The remaining herbal ingredients act to promote blood circulation and alleviate pain7

This condition is often overlooked as a serious contributor to chronic pelvic pain and can be ignored when (if) it arises on a pelvic ultrasound. Diagnosis is important so having referral networks is paramount to expedite the process and rule out other causes for pelvic pain. In the reports I have seen (performed by an extremely skilled sonographer) it is often found with adenomyosis – a plausible correlation when thinking holistically about the drivers and adaptations of the condition.

*Dr. Anjana Thottungal: Perth Obstetrics and Gynaecology Ultrasound

References:

1. Borghi, C., & Dell’Atti, L. (2016). Pelvic congestion syndrome: the current state of the literature. Archives of gynaecology and obstetrics, 293(2), 291-301.

2. Scultetus, A. H., Villavicencio, J. L., Gillespie, D. L., Kao, T. C., & Rich, N. M. (2002). The pelvic venous syndromes: analysis of our experience with 57 patients. Journal of vascular surgery, 36(5), 881-888.

3. Adams, J., Reginald, P. W., Franks, S., Wadsworth, J., & Beard, R. W. (1990). Uterine size and endometrial thickness and the significance of cystic ovaries in women with pelvic pain due to congestion. BJOG: An International Journal of Obstetrics & Gynaecology, 97(7), 583-587.

4. Gilmour, K. (2018). Bridging the Gap: Endometriosis. Melbourne, Australia: OptimalRx

5. Gilmour, K. (2018). Herbal Dispensary Update. Melbourne, Australia: OptimalRx

6. Bone, K., Simon Mills, M. C. P. P., & FNIMH, M. (2012). Principles and practice of phytotherapy: modern herbal medicine. Elsevier Health Sciences.

7. BLOOD MOVING 2 Formula (Tao Hong Si Wu Tang) Sunherbal: sunherbal.com

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