Pelvic venous disorders (PeVD) are not well represented in obstetrics and gynaecology journals

Introduction

Pelvic venous disorders (PeVD), previously called pelvic congestion syndrome (PCS), ¹ is a collection of symptoms and signs related to pelvic “varicose veins”. These may be caused by pelvic venous reflux, or pelvic venous obstruction resulting in dilation and reflux. Although recent research has started showing that this can cause problems in males,^2–4 it has generally been thought to be a condition affecting females. Indeed, recent definitions of PeVD/PCS restrict the condition to the female sex: “Pelvic congestion syndrome (PCS) is a common cause of chronic pelvic pain in women of reproductive age.” ⁵ In this context, chronic pelvic pain (CPP) is also defined in terms of the female sex, referring to pain that is present for 3-6 months, intermittent or constant, and “occurring throughout the menstrual cycle, and without any association with pregnancy”. ⁵

As such, one would expect that most academic publications on PCS and PeVD would appear in female health journals, primarily those focused on obstetrics and gynaecology or gynaecology alone. However, it has been the authors impression that considerable amounts of the research into PCS/PeVD has been performed in specialties related to vascular surgery, venous surgery or interventional radiology, and that gynaecologists appear to be less interested in this condition.

The aim of this study was to analyse which journals have published articles on PCS and PeVD over the last decade, and to look for any trends as to which specialties are showing an interest in these patients.

Methods

An online search was performed on PubMed^® (https://pubmed.ncbi.nlm.nih.gov/ - NIH National Institutes of Health, USA) for “pelvic congestion syndrome” or “PCS” then filtered for relevance to “pelvic veins” in July 2024, and for “pelvic venous disorders” or “PeVD” then filtered for relevance to “pelvic veins” in September 2024.

Results from 2013 to 2024 were recorded. For each article, the specialty of each journal in which it was published, was noted. The different journals were then grouped into the following:

• obstetrics and gynaecology (and gynaecology only)

Each article was then examined to identify whether it was an:

• original article - containing new information (prospective or retrospective clinical studies)

As a review of already published literature, this study did not need ethical approval.

Results

We found 281 articles published for PCS between 2013 and July 2024, and 38 articles for PeVD between 2013 and September 2024, giving a total of 319 overall. Over this period there was a general increase in the number of published articles (Figure 1).OPEN IN VIEWER

Between 2019 and 2024, an increasing number of articles have been using the term “PeVD” instead of “PCS”.

Over the period studied, only 36 of the 319 (11.3%) were published in journals related to obstetrics and/or gynaecology, compared to 65 (20.4%) in radiology journals, 45 (14.1%) in vascular journals and 51 (16.0%) in venous journals (Figure 2).OPEN IN VIEWER

The proportion of articles published in obstetric and/or gynaecology journals has not changed significantly over the time course of the study (Figure 3) with a mean of 11.3% of articles each year appearing in these journals.OPEN IN VIEWER

With regards the article types, the number reporting original research increased over the period, with some annual fluctuations (Figure 4). This increased volume of original research was matched by an increase of reviews, editorials, opinion pieces, consensus documents and book chapters. However, the number of case reports have remained relatively stable since 2014.OPEN IN VIEWER

Discussion

Although PCS has been described in the medical literature since 1949, ⁶ it has only really become an area of interest to doctors in the last two decades, with increasing interest by journals and conferences in the last decade or so. As such, we decided to set our search from 2013 to the present day, to capture how the interest in this condition is progressing.

We searched the term “pelvic congestion” as this has been used since 1949, but also “pelvic venous disorder” which was introduced by the UIP consensus document in 2019. ¹ As can be seen in Figure 1, this new name is growing fast in acceptance as the term to be used for this condition in medical journals.

Most articles appear in “other” journals, which comprise many diverse areas of interest. Such areas included general medical journals, nephrology, gastroenterology, urology, paediatrics, and even aerospace medicine. However, of the more focused groups, 33.2% of the articles appeared in journals relating to blood vessels (vascular, venous and angiology). We will discuss the relevance of this below.

As the standard methods of diagnosing and treating these patients are primarily radiological, it is not surprising that the next largest group is the radiology journals with 20.4% of the published articles.

However, what is both surprising and worrying, is that journals relating to female health, obstetric and/or gynaecological journals only accounted for 11.3% of the total articles on PCS and PeVD. When this is compared to the 33.2% in those journals related to blood vessels, there appears a worrying discrepancy between the doctors that women with CPP or other symptoms and signs of PCS/PeVD seek out for help (gynaecologists), and those who are actually reading the articles on the condition (vascular surgeons, venous surgeons, phlebologists and angiologists).

It is difficult to establish the actual prevalence of PeVD and also how often pelvic venous incompetence (PVI) causes CPP. It is reported that up to 40% of all gynaecology out-patient visits are for CPP, ⁷ and between 30 and 40% of women with CPP have PeVD/PCS. ⁸ Confusing these statistics is the reported prevalence of the asymptomatic adult female population having PVI.^9,10 However, these data should be viewed with some suspicion at present as they are derived from very small study populations, using radiological criteria for dilation and reflux rather than duplex ultrasound evidence. Also, experience has shown that many “asymptomatic” patients feel relief after PVE for leg varicose veins of pelvic origin. ¹¹

It is clear that CPP is a common problem, and a large proportion of these cases are due to PeVD. Despite this, few gynaecologists recognise venous disease as a possible cause of the problems in these patients. ¹² Indeed, current literature on CPP in women lists a multitude of possible causes, ranging from gynaecological (i.e.,: endometriosis, adenomyosis, adhesions) and non-gynaecological, to somatic, neuropathic and nociplastic pain. ¹³ However, nowhere in this list are venous disorders quoted. Hence it is often left to patients to do their own searching for an answer and to find doctors who can diagnose and treat PCS/PeVD, as evidenced by the number of women spending years in pain before being cured. ¹¹

One possible limitation of these results is that the acceptance of articles into a journal is the choice of the editor and doesn’t necessarily reflect the interests and research done by doctors in that specialty. However, generally this is not the case, and the evidence presented in the previous paragraph goes against this being a solely editorial bias.

In conclusion, although PCS/PeVD is currently recognised as a predominantly female condition, it is very underrepresented in journals relating to women’s health, namely obstetrics and/or gynaecology. The specialty areas where most articles appear is in journals related to vascular surgery, venous surgery and medicine. This gives rise to concern that women suffering from pelvic pain due to PCS/PeVD tend to consult gynaecologists, rather than vascular and venous specialists who are more actively involved in researching and understanding the condition.