Pelvic Congestion Syndrome
Long-term pelvic pain caused by enlarged, leaky veins in the pelvis, much like varicose veins in the legs but tucked out of sight. It mainly affects women before menopause, especially after pregnancy, and is often missed for years.
What it feels like. A dull ache or heaviness low in the pelvis, on one or both sides, that builds through the day and with standing, and eases when lying down. Pain during or after sex is common. Some women notice varicose veins on the vulva, buttocks or upper thighs, or bladder and bowel symptoms.
Why it happens. Valves in the ovarian veins don't close properly, so blood pools backwards into the pelvis. Pregnancy stretches these veins and oestrogen relaxes them. Sometimes a vein is squeezed further up, such as the left kidney vein (“nutcracker”) or a pelvic vein crossed by an artery.
Diagnosis. There are no agreed diagnostic criteria, which partly explains the delays. A transvaginal ultrasound with Doppler of the pelvic veins is usually the first test, and it has to be asked for specifically, because it isn't part of a routine pelvic scan. CT or MR venography, or a catheter venogram, is used when treatment is being planned. Chronic pelvic pain has many causes, and enlarged veins also turn up in women without pain, so the scan needs to fit the story.
The pelvic congestion ladder
Start with pain relief and other causes. Hormones can settle it for a while. Embolisation helps most women who have it, though the trials are small.
- Step 1 · Self-carePain relief and taking the pressure offAnti-inflammatories or paracetamol, lying down with your legs up when the ache builds, and supportive compression shorts or tights if they help.
- Works
- Eases symptoms for many; not tested in good trials
- Cost
- About $5–40
- How long
- As needed
- Watch for
- Ask your pharmacist before regular anti-inflammatories if you have stomach, kidney or heart problems.
Gravity is not your friend here. Put your feet up.
- Step 2 · PrescriptionHormone treatment (medroxyprogesterone, GnRH analogues such as goserelin)Lowers oestrogen, which can shrink the veins and ease the ache.
- Works
- Improves pain for many while taking it; in one small trial goserelin did better than medroxyprogesterone
- Cost
- Varies; some are PBS-listed
- How long
- Usually months
- Watch for
- Menopause-like side effects and bone thinning with longer GnRH courses; benefit often fades after stopping.
A hormonal timeout for misbehaving veins.
- Step 3 · SpecialistOvarian vein embolisationAn interventional radiologist blocks the faulty veins with tiny coils or foam through a needle in the neck or groin, usually as a day procedure under local anaesthetic.
- Works
- About 8 in 10 women report less pain in follow-up studies; good placebo-controlled trials are lacking
- Cost
- Varies; specialist and hospital fees in private
- How long
- One procedure; recovery in a few days
- Watch for
- Bruising, coil movement (rare), pain coming back in a minority.
Plumbing work, done through a pinhole.
- Step 4 · SpecialistLook for other causes tooEndometriosis, adenomyosis, pelvic floor muscle pain, bladder pain and IBS can mimic or overlap with it. A pelvic pain team, including a pelvic floor physio, often helps most.
- Works
- Treating every contributor gives the best chance of lasting relief
- Cost
- Varies; Medicare rebates with a care plan
- How long
- Months
- Watch for
- Don't let enlarged veins on a scan end the search if the story doesn't fit.
Pelvic pain is rarely a solo act.
Save your money
Popular, heavily marketed or often asked about, but the evidence is weak or says no.
- Vein supplements and “circulation” herbal productsNo good evidence for pelvic congestion.
- Hysterectomy for this aloneA major operation with no better results than embolisation in the one trial that compared them.
- Repeated ultrasounds without a planA scan helps when it changes treatment. Ask what the result will change.
What you can do
- Keep a pain diary for a month or two: time of day, standing, sex, periods, bladder and bowels. It speeds up diagnosis.
- Ask for a pelvic vein Doppler ultrasound by name if your GP suspects it.
- Take breaks from long periods of standing, and lie down with your legs raised when it aches.
- Pelvic floor physiotherapy helps many kinds of pelvic pain. Pelvic floor exercises.
See your GP if
- Pelvic pain has lasted more than 6 months
- Pain is worse with standing and by evening, or during or after sex
- You have varicose veins on the vulva, buttocks or upper thighs
- Pain is affecting work, sleep, sex or mood
See a doctor the same day for sudden severe pelvic pain, pain with fever, heavy bleeding, a possible pregnancy, or a painful swollen leg or sudden breathlessness.
Common questions
Is pelvic congestion syndrome dangerous?
No. It can be very painful and wearing, but the enlarged veins aren't harmful in themselves and rarely cause blood clots.
Can I have enlarged pelvic veins without symptoms?
Yes, and that's part of the puzzle. Pelvic varices are common in women with no pain, especially after pregnancy, so a scan alone doesn't prove they are the cause.
Does it affect fertility?
There's no good evidence that it does. Embolisation is usually offered to women who have finished having children, so ask about plans for future pregnancy first.
Will it go away after menopause?
Often it eases, because the veins are hormone-sensitive. That's one reason hormone treatments that switch off oestrogen can help.
Which test do I need?
Usually a transvaginal ultrasound with Doppler of the pelvic veins, which has to be specifically requested. CT or MR venography, or a catheter venogram, may follow if treatment is being planned.
Is it the same as endometriosis?
No, but both cause chronic pelvic pain and they can occur together. Endometriosis often needs a laparoscopy to diagnose; pelvic congestion is found with vein imaging.
Helpful resources
- Pelvic Pain Foundation of AustraliaAustralian charity with clear guides on pelvic pain and finding help. Free.
Evidence and more information
- AJGP (2024): Pelvic congestion syndrome
- Irish Journal of Medical Science (2024): Systematic review of embolisation
- Human Reproduction (2001): Goserelin vs medroxyprogesterone trial
maladywise.com/pelvic-congestion-syndrome/