It is estimated that a third of all women will experience chronic pelvic pain during their lifetime. Chronic pelvic pain is defined as “non-cyclic” pain lasting greater than six months. A multidisciplinary team approach is needed to treat this often complex medical condition. After a physical examination, a Pap test to rule out cervical cancer, and routine laboratory bloodwork, a cross-sectional imaging study is obtained to be certain that there is not a pelvic tumor. If the clinical symptoms are those of chronic pelvic pain, worse when sitting or standing, and sometimes also associated with varicose veins in the thigh, buttock regions, or vaginal area, the possibility of ovarian vein and pelvic varices must be considered.

Pelvic ultrasound (US) and/or computed tomography (CT) scan are usually the first imaging modalities in the evaluation of patients with chronic pelvic pain. Both provide excellent resolution of the uterus. Although a CT scan has greater sensitivity for showing varicosities throughout the lower pelvis, US with Doppler examination provides dynamic information about visualized venous blood flow.4 Criteria for the sonographic diagnosis of varices includes (1) the visualization of dilated ovarian veins greater than 4 mm in diameter, (2) dilated tortuous arcuate veins in the myometrium that communicate with bilateral pelvic varicose veins, (3) slow blood flow (less than 3 cm/s), and reversed caudal or retrograde venous blood flow particularly in the left ovarian vein

Treatment options for PCS remained elusive until recently, due to controversial diagnostic methods and poor understanding of its etiology ranging from psychosomatic origin to vascular causes. Since Topolanski-Sierra first noted an association in the 1950s between chronic pelvic pain and ovarian and pelvic varices,11 many treatment modalities have been proposed. Medical management with hormone analogues and analgesics, surgical ligation of ovarian veins, hysterectomy with or without bilateral salpingo-oophorectomy and transcatheter embolization have been described in the literature as treatment options for patients with PCS today.

Medical treatment of PCS includes psychotherapy, progestins, danazol, phlebotonics, gonadotropins receptor agonists (GnRH) with hormone replacement therapy (HRT), dihydroergotamine, and nonsteroidal antiinflammatory drugs (NSAIDS). Specifically, the literature supports use of medroxyprogesterone acetate (MPA), or the GnRH analogue goserelin in an effort to suppress ovarian function and/or increase venous contraction. MPA may be given orally 30 mg/day for 6 months. Goserelin acetate is dosed as an injection of 3.6 mg monthly over a 6-month period. As chemical ovarian ligation has numerous side effects, estrogen replacement or “add-back” therapy is frequently required as well.12

• Pelvic Congestion Syndrome: Diagnosis and Treatment
• Medscape: Pelvic Congestion Syndrome