Simultaneous embolisation of uterine arteries and ovarian veins as a management for chronic pelvic pain due to pelvic venous disorders and adenomyosis

Among the recognised gynaecological aetiologies of chronic pelvic pain (CPP) are pelvic venous disorders (PeVD) and adenomyosis [1]. These entities may coex- ist, producing overlapping symptomatology and recip- rocal exacerbation that complicates clinical assessment and management. Case report A 45-year-old multiparous woman (three prior vagi- nal deliveries) was referred for management of CPP. She reported persistent abdominal, lumbar and hip pain, ex- acerbated by prolonged standing and associated with postcoital discomfort. Menstrual symptoms comprised marked dysmenorrhoea and menorrhagia, culminating in anaemia (haemoglobin – Hb, on admission 9.8 g/dl). Simultaneous embolisation of uterine arteries and ovarian veins as a management for chronic pelvic pain due to pelvic venous disorders and adenomyosis Filip Szkodziak1, Sławomir Woźniak1, Piotr Robert Szkodziak1, Krzysztof Pyra2, Tomasz Paszkowski1, Michał Sojka3 13rd Chair and Department of Gynaecology, Medical University of Lublin, Lublin, Poland 2Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Lublin, Poland 3Department of Vascular Surgery, University Clinical Hospital No. 4, Medical University of Lublin, Lublin, Poland

Chronic pelvic pain (CPP) of gynaecological origin encompasses a heterogeneous group of disorders, among which pelvic venous disorders (PeVD) and adenomyosis are recognised contributors. Concomitant PeVD and adenomyosis may potentiate symptom burden and complicate management strategies. A 45-year-old parous woman was referred with a protracted history of CPP manifesting as lower abdominal, lumbar and hip pain, exacerbated by prolonged orthostasis and coital activity. Menstrual symptoms comprised dysmenorrhoea and menorrhagia complicated by iron-deficiency anaemia. Prior conservative measures were ineffective and the patient declined definitive surgical intervention. Transvaginal ultrasonography demonstrated features consist- ent with both adenomyosis and pelvic venous congestion. After multidisciplinary discussion, the patient un- derwent endovascular treatment consisting of concurrent embolisation of the bilateral uterine arteries and ovarian veins, performed by an interventional radiologist. At six-month follow-up the patient reported complete resolution of abdominal, back and hip pain and of menstrual pain and menorrhagia; postcoital ache persisted but was markedly attenuated. Magnetic resonance imaging demonstrated a reduction in the radiological extent of adenomyosis and no evidence of pelvic venous reflux. To our knowledge, this is the first reported case of simultaneous embolisation of the uterine arteries and ovarian veins for CPP attributable to coexisting PeVD and adenomyosis. While these preliminary results are encouraging, the efficacy and safety of this combined endo- vascular approach warrant evaluation in appropriately designed prospective studies. Key words: chronic pelvic pain, embolisation, adenomyosis, pelvic venous disorders. Transvaginal ultrasonography demonstrated findings in keeping with PeVD: dilatation of the left ovarian vein to 7.7 mm (cut-off diameter – 6 mm) (Figure 1 A) with reduced blood-flow velocity of 2.82 cm/s (cut-off velocity – 3.0 cm/s) (Figure 1 B). Concurrent sonographic features of adenomyosis were evident, including myo- metrial cysts (Figure 1 CI), hyperechogenic islands (Fig- ure 1 CII), subendometrial lines and buds (Figure 1 CIII) and an irregular junctional zone (Figure 1 CIV) [2–5]. Over the 24 months preceding hospitalisation the patient received pharmacotherapy with dienogest and venoactive agents, started lifestyle modifications, and underwent pelvic-floor physiotherapy [6, 7]. Despite these measures, symptoms persisted. As conservative management proved ineffective and the patient declined surgical intervention, she was deemed eligible for simultaneous embolisation of the uterine arteries and ovarian veins. Eligibility was de- Corresponding author: Filip Szkodziak, MD, PhD, Third Chair and Department of Gynaecology, Medical University of Lublin, Lublin, Poland, e-mail: [email protected] Submitted: 10.07.2025 Accepted: 14.12.2025 Menopause Review/Przegląd Menopauzalny 25(1) 2026 53 termined in accordance with the Lublin Protocol for Uterine Artery Embolisation by a multidisciplinary team of gynaecologists, interventional radiologists, and an- giologists following pelvic magnetic resonance imaging (MRI) [8]. Simultaneous embolisation of the uterine arteries and ovarian veins was performed by an interventional radiologist under local anaesthesia via a right trans- femoral approach, with catheterisation of the common femoral artery and vein. Venous intervention com- menced with angiography of the left and right ovarian veins, followed by imaging of the iliac venous system; incompetent veins were subsequently embolised using a sclerosing agent in conjunction with a coil. Arterial as- sessment of the uterine vascular bed was then under - taken and uterine artery embolisation for adenomyosis was performed using 500 μm particulate embolic ma- terial (Figures 2 A–D). At completion of the procedure, vascular access was secured by manual compression and application of a pressure dressing. The patient was discharged on postoperative day 2 following an uncomplicated perioperative course. At six-month review, previously reported symptoms – ab- dominal, lumbar and hip pain, dysmenorrhoea, and menorrhagia – had resolved completely. Postcoital ache persisted but with markedly reduced intensity, the Vi- sual Analogue Scale score declining from 7 to 3. After two months of oral iron replacement therapy, Hb con- centration rose to 12.3–9.8 g/dl at admission. Follow-up MRI (Figure 3 A) demonstrated features of adenomyo- sis of diminished severity compared with the previous examination, characterised by lower signal-intensity myometrial foci on T1-weighted sequences (Figure 3 B), and there was no evidence of PeVD. Written informed consent was obtained from the patient for publication of this case report and accompanying images.

The case presented herein delineates a novel ther - apeutic strategy for a patient with CPP. Chronic pelvic pain of complex aetiology is an increasingly prevalent condition in both pre- and post-menopausal women; its heterogeneous pathophysiology, frequent comorbidi- ties and variable clinical presentation render timely diag- nosis and effective management particularly challenging. Whether tumour markers such as CA-125 or CA19-9 should be measured routinely in patients presenting with CPP remains unresolved. In the case reported here, ovarian imaging furnished no oncological concern, and therefore tumour-marker assays were not performed. Furthermore, the embolisation was undertaken in ac- cordance with the Lublin Protocol for Uterine Artery Embolisation, and a preprocedural endometrial biopsy demonstrated normal histology. Nonetheless, when clinical or radiological features raise the possibility of Figure 1. A) Transvaginal ultrasonography (TVUS) examination revealing signs of pelvic venous disorders (PeVD) – dilatation (7.7 mm) of the left ovarian vein (cut-off diameter – 6 mm). B) TVUS examination revealing signs of PeVD – low blood flow (2.82 cm/s) in the left ovarian vein (cut-off velocity – 3 cm/s). C) TVUS examination revealing signs of adenomyosis – myo- metrial cysts (I), hyperechogenic islands (II), subendometrial lines and buds (III) and irregular junctional zone (IV) A C B Menopause Review/Przegląd Menopauzalny 25(1) 2026 54 gynaecological malignancy, assessment of CA-125 and CA19-9 prior to intervention would be a prudent pre- caution [9–11]. To our knowledge, this report constitutes the first description of simultaneous embolisation of the uterine arteries and ovarian veins as a management strategy for CPP secondary to PeVD and adenomyosis. Although the efficacy and safety of this combined endovascular approach require confirmation in appropriately pow- ered, well-designed clinical trials, it appears to repre- sent a promising therapeutic option for patients with CPP of complex, multifactorial aetiology. Figure 2. A) Embolisation of the left uterine artery (I). In the background, spirals used to embolize the left ovarian vein are visible (II). B) Control angiography after the left uterine artery embolisation. No blood flow into the uterine vascular bed was observed. C) Embolisation of the right uterine artery (I). In the background, spirals used to embolize the left ovarian vein are visible (II). D) Control angiography after the right uterine artery embolisation. No blood flow into the uterine vascular bed was observed A C B D Menopause Review/Przegląd Menopauzalny 25(1) 2026 55 Figure 3. A) Pelvic magnetic resonance imaging (MRI) conducted before simultaneous embolisation of uterine arteries and ovar- ian veins revealing features of adenomyosis. B) Pelvic MRI conducted after simultaneous embolisation of uterine arteries and ovarian veins revealing features of less severe adenomyosis (lower signal intensity myometrial foci on T1-weighted imaging) A B Disclosures 1. Institutional review board statement: Not applicable. 2. Assistance with the article: None. 3. Financial support and sponsorship: None. 4. Conflicts of interest: None.

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