Chronic pelvic pain is a lot more common than you think. At least 30% of women will experience some form of it, making it one of the leading reasons why women would seek out a gynecologist.

And as of late, doctors have realised that sometimes, women’s pelvic pain can be a vascular (related to the blood vessels) problem instead of a gynecological (related to the female reproductive system) one. It can also lead to a condition called Pelvic Congestion Syndrome (PCS).

While majority of the causes of chronic pelvic pain can be caused by conditions such as fibroids, ovarian cysts and endometriosis, it can often take several, painful years before the correct cause can be identified. Many conditions share very similar symptoms — such as painful periods, heavy or prolonged periods, painful intercourse and irritable bowels — and this can cause your condition to be misdiagnosed, especially if you have PCS.

We got Dr Sriram Narayanan, Senior Consultant Vascular and Endovascular Surgeon at The Harley Street Heart and Vascular Centre at Gleneagles Hospital, to find out more about the condition, and what to do if you have it.

What is Pelvic Congestion Syndrome (PCS), and what causes it?

PCS is caused by a pooling of blood in the veins within the pelvis, which happens where there is a problem with the valves regulating blood flow in certain veins. These veins carry blood from the pelvic region back to the heart, and this poor valve function causes the blood to back up and the veins to swell,” says Dr Narayanan.

He adds that this is basically varicose veins but deep in the pelvis, and that these swollen veins are what cause chronic pelvic pain.

How do I know I have PCS and not a gynaecological problem?

According to him, until recently, PCS was an ill-defined condition as it shares many symptoms with other common gynecological causes of chronic pelvic pain like fibroids, ovarian cysts and endometriosis. Also, standard gynecological tests, scans and laparoscopies used do not detect PCS.

“During a standard gynecological ultrasound scans, the doctor is looking for disease in the solid organs like cysts in the ovaries, and polyps, fibroids and endometrial disease in the uterus, rather than examining the movement of blood through the veins. Fortunately, gynecologists are becoming more aware of PCS and are starting to refer women with otherwise unexplained chronic pelvic pain to vascular specialists.”

What are some of the symptoms of PCS?

The most common symptom is pain in the pelvic region, but the nature of that pain can vary widely and can be acute and severe or chronic and dull.

“The pain is typically worse in the days leading up to a period, and or the first day or two of periods. The symptoms can mimic those of irritable bowel syndrome such as diarrhea and constipation and can also mimic symptoms of urinary tract infection. In severe cases, occasionally, there may be blood in the urine,” explains says Dr Narayanan.

“PCS symptoms do differ subtly from other causes of chronic pelvic pain. For instance, PCS presents with pain but without evidence of inflammatory disease. While several conditions can cause dyspareunia (pain during intercourse), most present as pain in the vagina due to dryness or damage to the walls of the vagina. With PCS the pain is felt more deeply.”

He adds that another way PCS pain differs from other conditions is the way it is exacerbated by fatigue and standing for long periods, which is due to the pressure of backed up blood.

“Ironically one of the reasons it is hard to diagnose is that women lie on their backs for gynecological exams which can take the pressure of the veins and temporarily reduce the pain and swelling; especially if the patient has been lying down for a few minutes before being examined. One of the biggest clues that pelvic pain may be due to PCS, is if the patient has visible, surface varicose veins anywhere else in the legs, especially in the upper thigh or groin or vulva area.”

How is PCS treated?

There are several treatment options for PCS depending on what is causing the symptoms.

A gynaecologist might prescribe hormonal medications to reduce blood flow and congestion of the varicose veins, but because some women do not like to take hormonal drugs or the drugs might be ineffective, minimally invasive catheter-based (plastic tube) therapies may be considered.

But not all patients need an intervention.

“Depending on the severity of symptoms, the degree of blood pooling in the pelvis as seen upon assessment, and patient’s age, PCS may be managed by simpler medical measures. Only the more symptomatic patients are offered a procedure,” says Dr Narayanan.

Featured image: Piyapong Thongcharoen/123RF