Pelvic Congestion Syndrome (PCS)

Pelvic Congestion Syndrome (PCS), also known as pelvic venous insufficiency, is a medical condition where varicose veins form in the pelvis (around the uterus and ovaries), leading to persistent lower abdominal pain.

Pelvic varicose veins form due to refluxing blood from dilated ovarian veins. This leads to a chronic pooling of blood and build up of pressure in the pelvis, typically resulting in constant dull ache in the lower abdomen and other life-disruptive symptoms.

PCS predominantly affects women of childbearing age (20 to 45 years) and is uncommon after menopause. It is a major under-diagnosed cause of chronic pelvic pain- research suggests it may account for up to 30% of chronic pelvic pain cases. In other words, many women suffering from pelvic pain for years might actually have PCS without knowing it.

At Dr Darryl Lim’s clinic in Singapore, we aim to raise awareness of PCS and provide effective, minimally invasive endovascular treatments. In this article, we explain the symptoms to watch for, how PCS is diagnosed, and the advanced treatment options available. Patients in Singapore, as well as those from neighbouring countries like Indonesia, Malaysia, and Cambodia- can find relief through our specialized care.

Causes and Risk Factors

Several factors can contribute to this problem:

• Pregnancy-related changes: Pregnancy is a leading factor. During pregnancy, blood volume increases and veins must expand (up to 50% wider) to handle the flow. High estrogen and progesterone levels relax vessel walls. These normal changes can stretch veins and permanently damage valves. Women who have had multiple pregnancies are at higher risk, as repeated stretching leaves pelvic veins dilated even after delivery. This is why PCS is more common in women with two or more children.
• Hormonal influences: The female hormone estrogen can weaken vein walls. Conditions or treatments that increase estrogen (e.g. multiple IVF cycles or certain hormonal medications) might predispose a woman to PCS. PCS is rare after menopause, suggesting estrogen during reproductive years plays a role.
• Venous Compression Syndromes: In some women, anatomical compression of certain veins can trigger PCS, by impeding venous blood return from the pelvis. Two key examples are Nutcracker syndrome and May-Thurner syndrome. 

These compressions create high back-pressure in the pelvic veins, leading to varicose veins and congestion upstream. Women with these conditions can develop PCS symptoms even without pregnancies or hormonal factors.

• Genetic and other factors: A family history of varicose veins or inherently weak connective tissue may increase risk. Some women are simply more prone to vein valve failure. Having leg varicose veins at a young age or visible vulvar varicosities can correlate with higher PCS risk. 

Very often, multiple factors overlap- for instance, a woman with a mild vein compression who then undergoes pregnancies may experience a “perfect storm” leading to PCS. It’s worth noting that other pelvic conditions (like endometriosis or fibroids) can coexist with PCS and sometimes confuse the picture, although they do not cause PCS.

Causes and Risk Factors

Key characteristics of PCS pain include:

• Worse when standing or late in the day: Prolonged standing or sitting makes the pain intensify (gravity causes blood to pool). Many women feel increased pelvic heaviness by day’s end, with relief when lying down or when waking in the morning.
• Pain that flares during or after intercourse: PCS often causes pain during sexual intercourse (dyspareunia) and a lingering ache for hours afterward due to engorged pelvic veins. 
• Menstrual cycle related pain flares: While PCS pain isn’t directly caused by menstruation, many patients report their pelvic pain flares during their menses. Hormonal changes that occur around this period can cause veins to further dilate, exacerbating the congestion.
• Pain radiating pain to the lower back and legs: The dull pelvic ache can radiate to the lower back, hips, or thighs, sometimes mimicking back pain or sciatica. A heavy, dragging sensation in the legs may accompany it in some cases.
• Feeling of fullness or pressure: Many women describe a feeling of pelvic fullness or pressure. There may be a sense of bloating in the lower abdomen.

Beyond pain, PCS can produce other signs and symptoms that are often overlooked or attributed to other issues:

• Visible varicose veins in unusual areas: Varicose veins may appear on the buttocks, upper thighs, vulva, or around the genital area. These are important clues- varicosities in such locations strongly suggest internal pelvic vein congestion as the source of the problem. For example, some women with PCS develop prominent vulvar varicose veins, especially during or after pregnancy.
• Urinary or bowel symptoms: Because congested pelvic veins can affect adjacent organs, women might notice bladder or bowel issues. For example, PCS can contribute to an irritable bladder (needing to urinate frequently or urgently) and irritable bowel symptoms (episodes of diarrhea or constipation). In some cases, stress incontinence (leaking urine when coughing or laughing) or mild pain with urination can occur.
• Pelvic tenderness: On physical examination by a gynecologist, there may be tenderness when pressure is applied over the ovaries or along the pelvic side walls/floor. This tenderness, together with the above symptoms (pain pattern, varicosities), raises suspicion for PCS.
• Emotional impact: Living with unrelenting pelvic pain can take an emotional toll. Many women with PCS report fatigue, mood changes, anxiety or depression as a result of their chronic pain and its effect on daily life. 

Bottom line: If you have pelvic pain that worsens with standing or after sex and isn’t explained by other gynecological issues, PCS could be the culprit. Recognizing the symptom pattern is the first step toward getting proper help.

How Pelvic Congestion Syndrome is Diagnosed

Diagnosing PCS can be challenging because its symptoms often mimic other gynaecological disorders (e.g. endometriosis, uterine fibroids). In Singapore, patients often first consult a gynaecologist for chronic pelvic pain. If initial evaluations are inconclusive, it’s important to consider congested pelvic veins as a possible cause. Dr. Darryl Lim takes a comprehensive approach, usually in collaboration with a gynaecologist. 

The typical diagnostic process includes:

• Detailed Medical History: Dr Lim will discuss your symptoms, their pattern, and what worsens or relieves the pain. Clues like pain relief when lying down, or pain flares after standing, raise suspicion for a venous cause. We also review obstetric history (pregnancies), menstrual cycle, and any prior pelvic diagnoses or surgeries.
• Physical Examination: A gentle pelvic exam is performed to check for any tenderness or pelvic organ enlargement. Tenderness along the ovarian vein path (deep in the left/right lower abdomen) can suggest PCS. Visible varicose veins on the buttocks, thighs or vulva are also looked for. If such veins are present, it strengthens the case for pelvic vein congestion as the source of pain.
• Pelvic Ultrasound Scan (Doppler): An ultrasound scan is usually the first-line imaging test for PCS. This is performed by the sonographer via both transabdominal and transvaginal approaches to visualise the ovarian veins and uterine region. This non-invasive scan can show dilated pelvic veins and detect reflux (backward blood flow) in real time. This scan is convenient, safe, and radiation-free. Do note that in some, the pelvic veins may be hard to visualize if they are located deep or if bowel gas interferes.
• CT or MRI scans: If ultrasound is inconclusive or more detail is required, a CT scan or MRI of the abdomen and pelvis is usually performed. These provide a detailed map of the pelvic blood vessels and can confirm enlarged ovarian veins or pelvic varices that ultrasound might miss. They can also simultaneously check for other pelvic pathology (like endometriosis or fibroids) to ensure nothing is overlooked. Also, CT/MRI can also detect the anatomical compression syndromes (May-Thurner or Nutcracker) if present. 
• Diagnostic Venography: The gold standard for confirming PCS is an ovarian venogram- an X-ray of the pelvic veins using contrast dye. This is an invasive test, typically done by Dr Lim in a X-ray imaging laboratory. Under local anesthesia, a thin catheter is inserted (usually via a vein in the groin or neck) and guided to the ovarian veins. Contrast dye is injected to make the veins visible on X-ray. Venography can directly show refluxing blood and enlarged pelvic veins, providing definitive diagnosis. The advantage is that if significant varices are seen, treatment (embolization) can be done in the same session, sparing the need for a subsequent extra procedure. In practice, venography is often reserved for when non-invasive tests strongly suggest PCS and the plan is to proceed with an intervention.

Throughout the evaluation, Dr Lim will exclude other causes of pelvic pain (differential diagnosis), as some gynaecological conditions can cause similar symptoms. Only by ruling out or treating other issues can we confidently pinpoint PCS as the true cause of pain and target it appropriately.

Treatment Options for Pelvic Congestion Syndrome 

Pelvic Congestion Syndrome is very treatable, especially with modern endovascular (minimally invasive) therapies. Dr. Darryl Lim, a vascular and endovascular surgeon in Singapore, specialises in advanced procedures that avoid the need for large incisions or open surgery. Treatment plans are tailored to each patient’s needs, taking into account symptom severity, reproductive goals, and the specific vein abnormalities present. From conservative approaches to targeted interventions like embolization, women now have a range of effective options to achieve lasting relief.

In general, treatment of PCS falls into a few categories:

1. Conservative Management: For mild cases or as an initial approach, conservative measures can help manage symptoms. This includes pain relief medications (NSAIDs like ibuprofen or acetaminophen) to reduce pelvic ache, lifestyle changes such as avoiding prolonged standing/heavy lifting (to minimize pelvic vein pressure), taking breaks to elevate legs or lie down during the day, doing regular low-impact exercise (walking, swimming, yoga) to improve circulation, and weight management (to reduce pressure on pelvic veins).

Some women may also benefit from wearing compression garments (if PCS results in varicose veins in the thighs or legs). Graduated compression stockings (thigh-high) can aid leg vein blood return. While these measures don’t fix the underlying vein reflux, they can provide partial symptomatic relief and improve quality of life.

2. Medical Therapy (Hormonal): Hormonal medications can be used to alleviate PCS symptoms, particularly if there are no plans for pregnancy in the near term. Because estrogen seems to contribute to vein dilation, drugs that suppress ovarian estrogen production can lead to “shrinkage” and decreased congestion of the pelvic varices.

Examples include medroxyprogesterone acetate or GnRH agonists, which induce a temporary menopause-like state with low estrogen. Birth control pills are sometimes used to blunt hormonal fluctuations. These therapies often help reduce pelvic vein engorgement and pain. However, do note that hormonal treatment is usually a short-term or adjunct solution- symptoms often recur when medication is stopped, and long-term use can carry side effects. Dr. Darryl Lim works closely with gynecologists when using this option, to ensure the therapy aligns with the patient’s reproductive plans and health profile.

3. Minimally Invasive Interventional Procedures: Endovascular treatments address the root cause by closing off the problematic veins so blood can reroute through healthy veins. Dr. Lim typically performs these procedures under light sedation and local anesthesia. The mainstay interventions for PCS include ovarian/pelvic vein embolization and, if needed, venous stenting for any compression syndromes.

(I) Ovarian and Pelvic Vein Embolization

Embolic agents may include tiny metallic coils and/or a sclerosing substance (a medical glue or irritant foam) injected through the catheter. The coils act like plugs that induce clotting, while the sclerosant irritates the vein lining to scar it closed. By closing off these faulty veins, blood can no longer pool in the pelvis and is rerouted to healthier veins. Without the high-pressure from venous reflux, there should be significant improvement in the pelvic pain.

The procedure itself usually takes around 1-2 hours, and patients can either go home the same or next day. Studies show a high success rate for ovarian vein embolization- around 80% of patients have significant pain relief after the procedure. Some patients report improvement within days, with full benefits realized over a few weeks as the congested veins completely close and shrink. Notably, embolization preserves the ovaries and uterus, so future fertility is retained; women can still become pregnant afterward, although it’s usually recommended to wait a few months post-procedure before trying to conceive.

(II) Iliac Vein Stenting (for May-Thurner Syndrome)

If diagnostic imaging reveals an underlying May-Thurner syndrome (i.e. compression of the iliac vein leading to venous hypertension)- this can be a contributory cause to the pelvic congestion. In such cases, concomitant treatment of this compression is important.

Iliac vein stenting involves placing a metal stent in the compressed segment of the vein to prop it open. This can be done in the same sitting as the embolization procedure. By relieving the iliac vein blockage, normal blood outflow from the legs and pelvis is restored, which in turn lowers the pressure in the pelvic veins downstream. Do note that not every PCS patient will require a stent- only those with a significant venous compression documented on imaging. Dr. Lim will only proceed with stenting if indicated, but having the capability to stent means we can comprehensively treat patients who have both Pelvic Congestion Syndrome and May-Thurner Syndrome.

(III) Renal Vein Stenting (for Nutcracker Syndrome)

In some patients- especially those with symptoms on the left side (blood in urine, left flank pain)- Nutcracker syndrome may be the culprit. This is when the left renal vein is compressed, which in turn causes left ovarian vein reflux and varicose veins in the pelvis. For confirmed Nutcracker syndrome causing significant symptoms, renal vein stenting is a potential treatment option.

In this procedure, a stent is placed in the left renal vein to relieve the pinched segment and restore normal blood flow from the kidney. By doing so, the backpressure into the ovarian vein is reduced, which can alleviate pelvic congestion. A common approach is to embolize the ovarian vein and stent the renal vein if the patient has Nutcracker-related pelvic congestion. Stenting the renal vein is also minimally invasive, done via a keyhole technique similar to iliac stenting.

4. Open Surgery: In the vast majority of cases, the minimally invasive treatments discussed above are suffice to relieve PCS. Open surgery is often a last resort- for example in instances where symptoms are refractory. Surgical options include ovarian vein ligation (tying off or removing the ovarian veins through an abdominal incision), or left renal/gonadal vein transposition (in the case of Nutcracker Syndrome). Open surgeries are typically associated with a longer post-operative recovery period. Fortunately, such invasive measures are seldom required nowadays, given the high success rates of keyhole techniques.

Treatment Outcomes and Post-Op Recovery Process

Most women experience significant improvement in symptoms after appropriate therapy. Ovarian vein embolization and related endovascular procedures have reported success rates in medical literature of about 70–85% in terms of symptom relief.

One major advantage of the minimally invasive treatments is the quick recovery time. Unlike open surgery, these procedures don’t involve large incisions and are essentially “scarless”. Most patients can go home the same or next day after an embolization or stenting procedure. 

After treatment, it’s normal to have mild soreness at the catheter entry site (often the groin or neck) or a transient deep ache in the pelvis for a few days. This post-procedure pain is usually mild and well-managed with painkillers and rest. There may also be some low-grade fever or backache for a short time as the veins occlude and undergo a minor inflammatory response. This is known as the “post-embolization syndrome” and is typically very manageable.

Patients are generally advised to take it easy for a couple of days. Light activities can often be resumed within 1–2 days, and most women are back to their normal routine within a week. Heavy exercise or lifting may be restricted for about 1-2 weeks to allow the veins to heal. 

Dr. Lim provides individualized guidance on activity resumption and any medications (for example, if a stent is placed, you may take blood thinners temporarily as mentioned). Follow-up scans are scheduled to monitor the progress of the closed veins.

Symptom relief is not always immediate, but many women start noticing improvement in pelvic pain within days to a few weeks after embolization. Full relief can take up to 3 months as the varicose veins gradually shrink and the pelvic circulation reroutes. Patience is key- the outcome is often very rewarding after those initial weeks. In successful cases, women report being able to stand or exercise longer without pain, and an end to the daily ache that was limiting their life.

Of course, individual results vary. A small subset of patients may experience only partial relief or recurrence of symptoms down the line. If pelvic pain persists despite an initially successful procedure, further evaluation will be done to investigate other pain sources or any residual veins that might need treatment. 

Insurance and Subsidy Considerations in Singapore

Treatment for pelvic congestion syndrome in Singapore can be accessible and affordable, especially with insurance or Medisave support. Here are some key points regarding costs and coverage:

Miscellaneous: Always discuss with the clinic’s billing staff about your coverage. Even if your doctor is not on the insurer’s direct panel, the clinic can assist with LOG requests to check your reimbursement coverage. There are also MOH fee benchmarks available publicly (for example, code SI703O covers ovarian vein embolization for PCS) that show typical price ranges for a range of procedures- useful if you want to gauge costs.

Compassionate, Specialized Care in Singapore

Living with chronic pelvic pain can feel isolating- but Pelvic Congestion Syndrome is a treatable condition, and with the right care, most patients can regain control of their comfort and quality of life. 

Dr. Darryl Lim combines clinical expertise with a personable approach. Our clinic emphasizes patient education- we take time to explain findings and involve you in decision-making for your care. We also welcome collaboration with your gynecologist or primary physician, ensuring a multidisciplinary approach for optimal outcomes.