You may be familiar with varicose veins in the legs – those pesky enlarged and swollen blood vessels that are often blue, green or dark purple in appearance.
But did you know you can get varicose veins in your pelvic area, too?
Like the version seen in legs, these engorged veins in the lower abdomen are also created when an increased blood pressure blows out the tiny valves in the veins (valves are what allow blood to flow up against gravity and back to your heart).
When that happens, the flow is affected and blood starts to pool in the affected vein, leading to a condition known as pelvic congestion syndrome (PCS).
If it sounds painful, it’s because it is – some women who have these pelvic varicose veins do indeed experience painful periods, revealed Dr Sriram Narayanan, a senior consultant as well as vascular and endovascular surgeon at Gleneagles Hospital’s The Harley Street Heart and Vascular Centre.
WHY PCS IS DIFFICULT TO DETECT?
But it’s not easy to find out if one is suffering from PCS. That's because the symptoms can be mistaken for a range of issues, from gynaecological to even gastrointestinal ones, such as the diarrhoea or constipation of irritable bowel syndrome, said Dr Narayanan.
Pelvic pain, heavy and/or prolonged periods and painful intercourse are also some of PCS’ symptoms but they can just as well be seen in patients with endometriosis, fibroids or ovarian cysts.
Furthermore, PCS can occur concurrently with ovarian cysts, which is another reason it often takes several years before a patient is diagnosed, he added. “Some studies indicate that around half of women with PCS have cystic changes on their ovaries.”
The nature of the pain caused by PCS varies widely, too. “It may be unilateral or bilateral; it can be acute and severe, or chronic and dull,” said Dr Narayanan. The pain is often worse at the end of the day or after a long period of standing.
That’s not all. Research has found that about 30 per cent to 40 per cent of patients are without symptoms, said Dr Narayanan, adding that the vascular issue is sometimes only discovered when patients receive CT scans for other purposes.
As pelvic congestion syndrome is a chronic condition, we would expect a patient to have had pelvic pain for at least six months and for her abdomen, especially in the area of her ovaries, to be tender.
And that is if the patient even sees a doctor to begin with. “Women put up with a lot of gynaecological problems, partly to avoid embarrassment, partly being told by their mothers, grandmothers and even doctors that painful periods, uncomfortable or painful intercourse, and post-partum incontinence are just part of being a woman,” he said.
COULD YOU BE SUFFERING FROM IT?
“As PCS is a chronic condition, we would expect a patient to have had pelvic pain for at least six months and for her abdomen, especially in the area of her ovaries, to be tender,” said Dr Narayanan.
Another important clue that a pelvic pain may be due to PCS is if the patient has visible, surface varicose veins in the legs, especially in the upper thigh or groin area, he said. “Those with varicose veins high up in the thighs, groin and vulvar region, and at the back of the thighs have a higher chance of having PCS.”
Your risk is also higher if you have given birth. The pelvic veins get stretched during pregnancy and may not be able to regain their original shape and size after childbirth, said Dr Narayanan.
“In most cases, varicose veins of the leg tend to improve in the months after delivery as may the veins in the pelvis. However, in many others, the dilated veins persist both in the legs and in the pelvis,” he said.
HOW IS THE CONDITION DIAGNOSED?
Most patients are referred to vascular specialists after the gynaecologist has ruled out potential issues with the reproductive system after an ultrasound scan. “They may also have either ruled out hormonal and intrauterine therapies or tried them without success,” said Dr Narayanan.
He explained that the vascular team would conduct more ultrasound scans, which can consist of an abdominal scan and a pelvic scan done either transvaginally, or for unmarried patients, externally.
Even though these scans also use ultrasound like the gynaecologist’s, vascular specialists would study the veins in the pelvis rather than the reproductive organs.
The legs’ veins are also assessed as such varicose veins can sometimes point to issues such as slow blood flow, abnormally dilated veins or the rare Nutcracker syndrome, said Dr Narayanan.
If problems are detected, a catheter angiography may be used to examine the veins in greater detail. This involves inserting a thin catheter into an artery through an incision in the skin. A dye that's visible by X-ray is injected through the catheter into the blood vessels, and an X-ray machine rapidly takes a series of images or angiograms of the vessels.
An intravascular ultrasound or IVUS catheter is then used to deliver ultrasound probes to examine the walls of the veins, their sizes and the surrounding disease very precisely, said Dr Narayanan.
“The use of these catheters makes it possible to combine diagnosis and treatment in a single procedure. So, if the angiograms and IVUS confirm the problem indicated by the ultrasound, we can perform the treatment straight away as part of the same procedure.”
It may take one or two menstrual cycles for the procedure to be fully effective but after that, most patients are pain-free.
WHAT ARE THE TREATMENT OPTIONS?
Dr Narayanan said that not all patients with PCS need procedural intervention. Depending on the severity of the symptoms, the degree of blood pooling in the pelvis, and the stage of the woman’s life, PCS may be managed by simpler medical measures.
For instance, a gynaecologist might prescribe hormonal medications to reduce blood flow and congestion of the varicose veins.
When a procedure is needed, the most commonly used is embolisation, said Dr Narayanan, which seals off or plugs up the incompetent and dilated varicose veins, so that they are no longer engorged with blood, and cause pain and heavy periods.
If the problem is a severe compression of the iliac vein (the large vein that drains blood from both the legs and the pelvis), a vein stent may be inserted into the vein to open it up, relieve the pressure and improve the blood flow. “In very severe cases, patients may need both treatments, but such instances are rare,” said Dr Narayanan.
He added that the pain caused by PCS doesn't disappear immediately after the procedure. "It may take one or two menstrual cycles for the procedure to be fully effective but after that, most patients are pain-free.”