The Outcome of Treatment for Pelvic Congestion Syndrome

Introduction

Chronic pelvic pain in women is a fairly common disorder in gynaecology clinics and several different causes may be responsible for this. Pelvic congestion syndrome was originally described by Gooch in 1831. ¹ Taylor ² described the syndrome in detail and attributed this to ‘vascular disturbance’ due to an imbalance of the sympathetic and parasympathetic nervous systems. He was unable to provide reliable recommendations as to treatment mentioning that passage of time, unilateral and bilateral oophrectomy and hysterectomy had all been used with some degree of success. Others have believed that this was a psychiatric condition. ³ However, it has been recognized for many years that this condition is associated with dilation of ovarian and pelvic veins. ⁴

Treatment for this condition was originally based on the management of possible associated gynaecological conditions, hormone treatment and by hysterectomy. Hobbs ⁵ described a method of management by ligation of the ovarian veins. He emphasizes that ovarian veins often comprise many multiple channels, each of which must be ligated to abolish all venous reflux filling the pelvic veins. Access to the ovarian veins was obtained via an open operation using a retroperitoneal approach which caused few postoperative symptoms. His usual practice was to use bilateral ovarian vein ligation as the condition is often bilateral, even when this has not been demonstrated by preoperative venography. Hobbs ⁶ reported relief of symptoms in most patients but no randomized clinical trials of this treatment have ever been conducted or further clinical series published.

Ma this et al. ⁷ were able to report that, for surgeons skilled in laparoscopic surgery, the ovarian veins could be ligated via a transperitoneal route using a laparoscope. Gargiulo et al. ⁸ have reported the outcome of bilateral laparoscopic ovarian vein ligation in 26 women. They found that this resulted in remission from symptoms of pelvic congestion syndrome for one year in all these patients. Subsequently this treatment was used by a number of surgeons but no clinical trial or large series of cases has been reported and so it remains an unproven method of management.

The main problem appears to be that relatively few patients present with symptoms of sufficient severity to necessitate intervention. Perhaps this still reflects the possibility that pelvic congestion syndrome is an under-diagnosed condition.

Modern treatment of pelvic congestion syndrome

In 1993, Edwards et al. ⁹ reported a case of pelvic congestion syndrome which was managed by embolization of the ovarian veins using an interventional radiology technique. Treatment in this patient resulted in long-term freedom from symptoms. This report has been followed by widespread adoption of therapeutic ovarian vein embolization for the treatment of pelvic congestion syndrome.

The midterm outcome of this treatment has been reported by Venbrux et al. ¹⁰ In this clinical series, 56 patients underwent ovarian vein embolization for pelvic congestion syndrome. In all these patients technical success of the intended treatment was achieved in that the ovarian veins were occluded at the end of the treatment sessions. The effect on symptoms was measured using a visual analogue scale. This showed an average score of 7.8 before treatment commenced falling to 2.7 at 12 months of follow-up. Overall, the mean follow-up was an average of 22 months. Two patients experienced embolization of radiological occlusion coils to the pulmonary circulation, but these were retrieved. No disturbance of menstrual function was reported among this cohort.

Kim et al. ¹¹ have reported long-term results of ovarian embolization in 2006 for patients treated between 1998 and 2003. One hundred and twenty-seven patients underwent treatment, with 108 receiving embolization of the internal iliac vein in addition to the ovarian veins. The pretreatment visual analogue pain score fell from 7.6 before treatment to 2.9 after treatment. Eighty-three percent of patients showed clinical improvement after treatment with 13% unchanged and 4% worse.

Kwon et al. ¹² have reported the outcome of ovarian vein embolization in a cohort of patients treated between 1998 and 2005. In all, 67 patients were treated with follow-up extending up to six years in some patients. Eighty-two percent of patients reported a good symptomatic outcome and did not pursue further treatment. The remaining 12 patients’ symptoms were not improved and required surgical treatment in nine and drug treatment in three. No serious adverse event was reported from this series.

Embolization of pelvic veins is regarded as minimally invasive but is not without complications. Coils may become displaced and migrate to the pulmonary circulation. ¹⁰ A case has been reported of a coil placed to occlude the obturator vein migrating to protrude into the femoral vein. ¹³

Migration of coils and thrombophlebitis are possible complications which should be borne in mind when advising patients concerning this type of procedure.

Very few clinical trials have been performed in this field to compare different types of treatment regimen. Chung and Huh ¹⁴ undertook a randomized trial comparing the efficacy of ovarian vein embolization to hysterectomy with unilateral or bilateral oophrectomy Their main outcome measure was the pain score recorded on a visual analogue scale. The initial mean pain score was 7.8 falling to 3.2 after 12 months in the ovarian vein embolization group. In the hysterectomy with bilateral oophrectomy group this fell to 4.6 after one year and 5.6 in the unilateral group. He concluded that ovarian vein embolization offered superior relief of symptoms compared with either of the other treatments.

Only one clinical trial has investigated the use of drug treatments in any detail. Soysal et al. ¹⁵ randomized 47 patients with pelvic congestion syndrome to receive wither goserelin (a gonadorelin analogue which results in suppression of ovarian function) or medroxyprogesterone for six months. They reported that the mean pelvic symptom score fell from 10.9 before treatment to 5.1 after six months of treatment and 6.2 after a further six months after medroxyprogesterone treatment. In the goserelin group, the mean score fell from 10.2 to 2.3 after six months treatment and was 2.5 a further six months following completion of treatment. The authors concluded that gonadorelin analogues deserve further investigation for use in this application but note that ovarian vein embolization has become the predominant treatment. No further publications on the use of hormone treatments have been published.

Patients with ovarian vein reflux without pelvic congestion syndrome

Among patients presenting to clinics with clinical varicose veins, ovarian vein reflux is a common feature arising in at least one in six patients. ¹⁶ However, pelvic congestion syndrome is far less common than this and the need for ovarian vein embolization in such patients has not been reliably established. No published study has compared the outcome of treatment of varices in the lower limb alone with ovarian vein embolization undertaken alone in such patients.

Greiner and Gilling-Smith ¹⁷ have reported a series of 24 women presenting with recurrent varicose veins after surgery in whom ovarian and pelvic vein reflux were found to be the sources of the varicose veins following pelvic and ovarian vein phlebography. However, half of this group had symptoms of pelvic congestion syndrome. Treatment was undertaken by embolization of all sources of venous reflux and lower limb varices. Two weeks later, varicose vein surgery was undertaken to remove recurrent lower limb varicosities. At follow-up four years later, only two patients reported any symptoms but four had skin changes attributable to venous disease. In general, a satisfactory outcome was obtained. The authors attributed their success to treatment of the pelvic veins although all patients underwent treatment of both pelvic and leg veins.

Combinations of pelvic vein embolization and treatment of varicose veins of the legs have been advocated by some authors. ¹⁸ Ovarian vein embolization was used in combination with varicose vein treatment in the lower limbs, leading to good outcomes. However, this clinical series has not established the need for treatment of the ovarian and pelvic veins. None of the patients reported pelvic symptoms and successful treatment of leg veins may have been achieved in many without resorting to embolization of pelvic veins. In this series two patients suffered embolization of coils to the lungs and one to the femoral vein, confirming that although in general this treatment is safe and effective it is not without potentially serious complications and therefore should only be used for well-established indications.

Conclusions

Pelvic congestion syndrome has been treated in a number of different ways over the years. The mechanisms resulting in this condition are reasonably well established, although it is unclear as to why pelvic varices are relatively frequent among varicose vein patients whereas pelvic symptoms commonly attributed to these varices are much less frequent. The treatment of this condition has not been subjected to careful analysis in large randomized clinical trials. In fact, most of the evidence on which modern treatments are based comes from clinical series undertaken in tens of patients. Although apparently effective treatments have been devised it is not clear as to which could be considered the best option.

Gynaecologists commonly undertake hysterectomy, sometimes combined with oophrectomy in order to treat this condition. This does not always provide relief of symptoms. Surgical ligation of ovarian veins was originally described by Hobbs ⁶ in order to address the venous incompetence. He concluded that, providing all incompetent ovarian veins were ligated, a good symptomatic outcome could be achieved. No further clinical series has been published.

Ligation of the ovarian veins by laparoscopic means has also been recorded. This seems likely to be able to achieve the same effect as open surgical ligation, providing that all affected veins can be identified and ligated. However, no clinical series has been published in which this strategy has been evaluated. The value of this treatment has not been established in clinical practice.

A small number of case reports and clinical series have appeared reporting the outcome of ovarian and pelvic vein embolization using interventional radiology techniques. The outcome measures are based on pelvic pain scores and visual analogue scale assessment of symptom relief. In general, the results of treatment appear to be satisfactory but no clinical trial has compared embolization with surgical or laparoscopic vein ligation.

One clinical trial has evaluated the relative efficacy of hormonal manipulation with a gonadorelin analogue and medroxyprogesterone. Substantial relief of symptoms as assessed by pain scores was achieved by treatment with the gonadorelin analogue and to a lesser extent with medroxyprogesterone. Neither of these treatments has been licensed for the treatment of pelvic congestion syndrome.

The American Venous Forum has published guidelines concerning treatment of many vein problems. ¹⁹ These make detailed recommendations concerning the investigation and treatment of pelvic congestion syndrome. They conclude that ovarian and pelvic vein embolization has become the standard of treatment for this condition but that the evidence to support this is weak (grade 2B). It is clear that current treatments are based on empirical practice rather than on detailed evidence from clinical trials. Limited evidence of the long-term efficacy of embolotherapy is available and it is highly desirable that a more detailed analysis of the outcome of current treatments is undertaken.

Competing interests: None to declare.