Pelvic venous disorders in women: Diagnosis and management for gynecologists.

Pelvic venous disorders are associated with a broad spectrum of symptoms that may overlap with several other conditions. Symptoms of PeVD include pain exacerbated by prolonged standing or sitting and relieved by lying down, dyspareunia, post‐coital ache, dysmenorrhea, left flank pain, and intermittent hematuria. The type and location of symptoms depend on whether the obstruction is uncompensated, with pressure transmitted to distal venous reservoirs, or compensated, resulting in decompression through the development of varicosities. 9 A strong positive predictor for PeVD is the combination of post‐coital ache and ovarian tenderness on clinical examination, which demonstrates a sensitivity of 94% and a specificity of 77% for the diagnosis. 13 Some clinical manifestations of pelvic venous disorders may closely resemble those of other pathologies, necessitating a systematic approach to differential diagnosis. 4 , 13 Gynecologic conditions that may present similarly include endometriosis, adenomyosis, ovarian cysts, pelvic inflammatory disease, and pelvic adhesions. Urological pathologies to consider include urinary tract infection, nephrolithiasis, and interstitial cystitis. Gastrointestinal conditions such as irritable bowel syndrome, inflammatory bowel disease, constipation, appendicitis, and diverticulitis may produce overlapping symptoms. Importantly, musculoskeletal etiologies represent a frequently underrecognized source of CPP. These include pelvic floor myalgia and dysfunction, abdominal wall myofascial pain, piriformis syndrome, symphysis pubis dysfunction, sacroiliac joint dysfunction, nerve entrapment syndromes (e.g., iliohypogastric, ilioinguinal, genitofemoral, and pudendal neuropathy), and coccydynia. 3 , 5 , 14 Psychiatric conditions including somatization disorders, depression, and a history of trauma may also contribute to the clinical presentation. In addition, chronic overlapping pain conditions and pain sensitization may coexist in patients with PeVD and influence symptom severity and distribution. Therefore importantly, a comprehensive assessment should also include screening for mood symptoms, trauma history, and relevant psychosocial stressors. Consequently, pelvic venous disorders are considered a diagnosis of exclusion, requiring systematic evaluation to rule out these other etiologies. 4 This section outlines the initial clinical evaluation for suspected PeVD, with imaging approaches addressed in subsequent sections. A comprehensive physical examination should include both pelvic vascular and musculoskeletal components. 13 , 14 The pelvic and vascular examination should include a bimanual examination to assess for ovarian point tenderness, along with a thorough survey for varicose veins in the pelvic and lower extremity regions. Large veins crossing the mons pubis are pathognomonic for iliac vein occlusion, while varicosities on the upper inner and posterior thigh are pathognomonic for pelvic venous insufficiency. The musculoskeletal physical examination should include palpation of pelvic floor muscles to assess for trigger points and hypertonicity. Carnett's test should be performed to differentiate abdominal wall pain from visceral pain. Evaluation of spinal and sacroiliac joint mobility helps identify potential musculoskeletal pain generators. Assessment for nerve entrapment should include examination of the iliohypogastric, ilioinguinal, and genitofemoral nerves. Hip range of motion and pain provocation tests may identify referred pain from hip pathology. Combining symptom patterns with these comprehensive physical findings confers a strong clinical suspicion and appropriate indication to proceed with diagnostic testing. The 2024 SOGC guideline recommends imaging and encourages gynecologists to consult interventional radiology when vascular etiologies are suspected or when conservative management is unsuccessful. 3

A 42‐year‐old G1P1 woman presented with a two‐year history of CPP. She described a dull ache, primarily localized to the left lower abdomen, rated up to 10/10 at its worst, that intensified at the end of the day and was exacerbated by prolonged standing, walking, and lifting. The pain improved with lying down. She endorsed occasional pain after sexual intercourse. Prior workup had excluded other common causes of CPP: she was evaluated for gynecologic causes, including infectious etiologies, and was treated for bacterial vaginosis; however, her symptoms persisted despite adequate therapy. Gastrointestinal evaluation for inflammatory bowel disease and irritable bowel syndrome, including colonoscopy, was unremarkable. Targeted urologic evaluation did not identify urinary tract infection or interstitial cystitis/bladder pain syndrome, and assessment for other contributors (e.g., endometriosis and pelvic floor dysfunction) did not reveal an alternative primary pain generator. Given her work as a member of janitorial staff, strenuous job demands frequently exacerbated her symptoms. Her gynecologic examination was otherwise unremarkable, and a pelvic ultrasound performed at an external institution reported no abnormal findings. A Doppler ultrasound was subsequently performed, revealing venous reflux in the left ovarian and left internal iliac veins. Based on these findings and the severity of her symptoms, she was referred for interventional radiology assessment in accordance with current guidelines for the management of pelvic venous disease (PeVD). Given her clinical presentation and imaging findings, endovascular treatment was recommended. She underwent embolization targeting the bilateral ovarian and internal iliac veins, followed by foam sclerotherapy of the vulvar veins. At 6 months post‐treatment, she reported a 90% improvement in symptoms, with full resolution of dyspareunia.

Pelvic venous disorder management encompasses a variety of treatment strategies, ranging from conservative approaches to invasive interventions, with selection dependent upon symptom severity, the presence of concurrent conditions, and patient‐specific factors. Table  2 summarizes the pathways of when to investigate in‐office versus when it is appropriate to refer for specialist evaluation. When to investigate in‐office versus when to refer for specialist evaluation. Begin in‐office evaluation with physical examination and transvaginal ultrasound if available Initial triage; helps identify obvious gynecologic causes and may detect pelvic varices suggestive of PeVD Refer to interventional radiology or vascular specialist Further imaging (e.g., Doppler US, MRV) may be needed to assess for reflux or obstruction Continue gynecologic workup ± laparoscopy PeVD can coexist with other causes; if pain persists after treatment of other pathologies, consider PeVD Refer early to interventional radiology Patients with high clinical suspicion benefit from early specialist imaging and management planning Refer directly to vascular/interventional radiology for targeted imaging Avoids diagnostic delay; specialists can choose the most appropriate imaging modality (e.g., MRV) Abbreviations: CPP, chronic pelvic pain; DVT, deep vein thrombosis; MRV, magnetic resonance venography; PeVD, pelvic venous disorders; US, ultrasound. Conservative management of PeVD involves concurrently investigating and addressing other conditions that may contribute to the patient's pain. Key approaches include lifestyle modifications such as stress management, regular exercise, and constipation management, as well as psychological support and cognitive behavioral therapy to improve pain coping strategies. Elastic compression stockings have been shown to reduce pain, dyspareunia, swelling, and heaviness, but patient non‐compliance remains a challenge. 19 Given the significant number of CPP patients with concurrent musculoskeletal dysfunction, a comprehensive musculoskeletal assessment and treatment approach is essential to optimal outcomes. 3 , 5 , 14 Pelvic floor physical therapy addresses the musculoskeletal component of the pain syndrome rather than venous pathology directly, and includes the treatment of pelvic floor muscle tension, hypertonicity, and trigger points through myofascial release techniques, biofeedback and relaxation training, and exercises designed to improve muscle coordination while reducing pain. 19 Manual therapy techniques, including visceral manipulation, joint mobilization for sacroiliac and lumbar spine dysfunction, and soft tissue mobilization, may also provide additional benefit. 13 , 14 A trial of conservative management is typically recommended for at least 3 months. If symptoms persist or worsen despite adherence to supportive measures such as pelvic floor physiotherapy and elastic stocking compression therapy, further evaluation including referral for specialized imaging and specialist consultation should be considered. Medical management involves hormonal therapies and non‐steroidal anti‐inflammatory drugs (NSAIDs). Although hormonal suppression with medroxyprogesterone acetate, etonogestrel implants, and goserelin have demonstrated some benefit in small case series, it is theorized that any method achieving ovulatory suppression should confer similar benefits in the treatment of pelvic venous disorders. 11 However, the current evidence for hormonal therapy remains limited to small case series and uncontrolled studies, with no large randomized controlled trials definitively establishing efficacy. While these agents may provide symptomatic relief through reduction in ovarian vein blood flow, they do not directly address the underlying vascular pathology. 11 While hormonal suppression is a mainstay for CPP especially those with endometriosis related pain, evidence supporting its benefit in patients with isolated or predominant PeVD remains limited. Non‐steroidal anti‐inflammatory drugs provide symptomatic relief and may be useful as adjunctive therapy for short‐term pain control. Emerging evidence suggests that micronized purified flavonoid fraction (MPFF), a venoactive agent, may reduce pain, heaviness, and labial edema by improving venous tone. 11 However, data on the efficacy of MPFF for pelvic venous disorders are limited and based primarily on extrapolation from studies of lower extremity venous disease. While this agent may have a role as adjunctive therapy, high‐quality evidence specific to pelvic venous disorders is limited within the current literature. The proposed mechanism of action involves improving venous tone and reducing capillary permeability, which provides a theoretical rationale for its use. 11 Hormonal or venoactive therapies may be trialed for a duration of three to 6 months. If patients do not experience meaningful symptom improvement within this period, or if hormonal suppression is contraindicated or poorly tolerated, consideration should be given to specialized imaging and endovascular treatment options in consultation with interventional radiology. If patients have persistent pain despite a trial of medical therapy, clinicians should reassess for coexisting pain generators (e.g., endometriosis, pelvic floor dysfunction, and chronic overlapping pain conditions) and consider multimodal management alongside consideration of venous‐directed therapies. Surgical intervention is generally reserved for patients with refractory symptoms despite conservative and medical management, or for those with concurrent gynecologic pathology requiring surgical intervention. Hysterectomy with salpingo‐oophorectomy has demonstrated pain relief in some cases; however, up to one‐third of patients experience recurrence or residual pain following hysterectomy. Important considerations include the impact on fertility and induction of surgical menopause with oophorectomy, which may not be an acceptable outcome to certain patients. 11 Laparoscopic ligation of ovarian veins has been attempted in select centers with specific expertise in this technique; however, evidence for its effectiveness is limited to small case series with variable outcomes. 11 Any surgical treatment carries greater risk compared to endovascular intervention, including the requirement for general anesthesia, potential for hospital admission, prolonged recovery period, and higher overall morbidity and mortality rates. Endovascular embolization is a minimally invasive treatment endorsed by the Society for Vascular Surgery and American Venous Forum guideline for chronic venous disorders. The guideline includes recommendations relevant to gonadal and internal iliac venous interventions with a Grade 2B strength of recommendation. 20 Several embolization techniques are in routine use, and each option has distinct advantages and limitations. Coil embolization occludes incompetent veins by deploying metallic coils. It is most commonly performed in the ovarian and internal iliac veins. Coils achieve permanent vessel occlusion and their materials are widely available. The principal disadvantages are the potential for coil migration and the need for larger delivery systems. Vascular plugs are self‐expanding occlusive devices that provide immediate vessel closure. 9 A comparative study reported a lower risk of device migration with plugs than with fibered coils. In contrast, sclerotherapy uses a sclerosing agent such as polidocanol or sodium tetradecyl sulfate, often prepared as foam. It can be used alone or as an adjunct to coils or plugs and is especially useful for vulvar and superficial varices. Expected risks include allergic reactions and thrombophlebitis. 21 In clinical practice, combination therapy is frequently employed, utilizing coils or plugs to occlude main venous trunks and supplementing with sclerotherapy for branch vessels and superficial varicosities. 20 Our case patient received this combined approach and achieved excellent outcomes with minimal complications. Primary cohort studies demonstrate high effectiveness of endovascular embolization. One single‐center study reported long‐term clinical improvement in approximately four fifths of patients. 22 A 202‐patient series documented a clinical success rate of approximately 94% of patients. 23 A recent single‐center retrospective cohort in nulliparous patients reported approximately 90% patient satisfaction after embolization. Notably, the majority of these studies are retrospective in design with inherent selection bias and limited long‐term follow‐up. 24 Moreover, a recent randomized controlled trial of 60 patients revealed statistically significant reduction in pain scores and diminished symptom burden at 12 months post‐intervention. 25 However, approximately 40% of patients in the treatment arm experienced suboptimal responses to embolization, highlighting that this intervention is not universally effective, and that careful patient selection remains important. Based on the current literature, there are certain symptom profiles of PeVD that may respond more favorably to endovascular treatment. For example, post‐coital ache, dyspareunia, positional pain, and visible varicosities. 20 In contrast, certain symptoms demonstrate more variable or poorer responses to endovascular intervention. These include patients experiencing symptoms of non‐positional CPP. These presentations suggest that pain with significant musculoskeletal or neuropathic component(s) demonstrates particularly variable responses to venous intervention alone. 22 , 23 , 25 , 26 This finding is significant; it underscores that venous intervention is not a panacea and that these results align more closely with broader CPP and chronic benign pain literature, where high “cure” rates are rare. The stark difference between studies of venous‐origin pelvic pain reporting 90% success and the more modest outcomes in general pain literature suggests that these outcomes may not always reflect the natural history or the complexity of pain sensitization in the broader CPP and chronic benign pain population. The variability in symptom‐specific responses underscores the importance of comprehensive patient evaluation and the identification of potential coexisting pain generators prior to recommending endovascular intervention. While endovascular embolization offers benefits such as same‐day discharge in most cases and reduced need for reintervention compared to surgical approaches, patients must be counseled regarding potential complications and limitations. Common complications include post‐procedural discomfort typically lasting several days, embolic material migration with coils or foam occurring in 1%–4% of procedures, venous perforation occurring in less than 1% of cases, and thrombophlebitis developing in approximately 2%–5% of patients. 23 , 27 Despite the growing body of supportive evidence, significant gaps remain in our understanding of optimal patient selection, technical approach, and long‐term outcomes. Large‐scale randomized controlled trials with standardized treatment protocols are lacking. The choice between unilateral versus bilateral embolization remains debated, with some studies advocating for comprehensive bilateral treatment to ensure durable symptom relief while others suggest a more selective approach based on imaging findings. Long‐term durability beyond 5 years remains incompletely characterized at present, and factors predicting treatment failure or recurrence have not been definitively established.

AB, JS, and TN conceptualized the study and developed the research idea. TN and IF conducted a targeted narrative literature review and synthesized the evidence. TN drafted the original manuscript and TN and IF created the figures and tables. IF, JS, BL, AB, and MM, reviewed and edited the manuscript. AB and JS provided supervision throughout the project. All authors have read and approved the final version of the manuscript.

The authors have nothing to report.

This manuscript is a narrative clinical review intended to provide practical, gynecologist‐focused guidance on pelvic venous disorders. As such, no primary research involving human participants was conducted, and no new patient data were collected or analyzed. Therefore, institutional review board or ethics committee approval was not required. Accordingly, we did not perform a formal systematic or scoping review. The content synthesizes key society guidelines and seminal clinical studies, with emphasis on diagnostic workflows and management decisions relevant to gynecology practice. Additionally, the relevant terminology is further outlined in the accompanying Supplementary Appendix . A comprehensive search was conducted in Ovid MEDLINE, Ovid EMBASE, Scopus, Web of Science, Embase, and the Cochrane Library from database inception to September 30, 2025, using terms related to pelvic venous disorders, pelvic congestion syndrome, CPP, diagnostic imaging, and treatment modalities. Gray literature including clinical practice guidelines from ACOG, SOGC, Society for Vascular Surgery, and American Vein and Lymphatic Society was searched. Studies were included if they addressed the pathophysiology, diagnosis, classification, or management of pelvic venous disorders in women. Data were extracted on pathophysiological mechanisms, diagnostic test performance, treatment outcomes, and interdisciplinary management strategies. Data were synthesized narratively by two study authors (TN and IF) and organized thematically. 8

Pelvic venous disorders represent a significant yet often overlooked cause of CPP in women. Effective management requires early recognition by gynecologists and primary care providers to initiate the appropriate diagnostic evaluation and treatment pathways. The recent Symptoms‐Varices‐Pathophysiology classification system provides standardized nomenclature that facilitates transdisciplinary communication and research. Diagnostic evaluation should begin with comprehensive clinical assessment followed by Doppler ultrasound as the preferred first‐line imaging modality. Treatment approaches must be individualized, ranging from conservative management with pelvic floor physical therapy to medical therapy, endovascular embolization and/or surgical intervention. Individual patient responses to treatment may vary, and careful patient selection remains important for optimizing outcomes. Clinicians must counsel patients that while endovascular treatment is an important tool, the multifactorial nature of CPP means that procedural success does not always equate to total pain resolution. Maintaining a multidisciplinary lens is essential to address the neuropathic and musculoskeletal components that often persist regardless of venous technical success. As demonstrated in our case presentation, early recognition and timely referral can lead to successful outcomes. Optimal management necessitates transdisciplinary collaboration with interventional radiologists, physical therapists, and allied health professionals. Continued research and standardized classification will ultimately improve care and the quality of life for patients with pelvic venous disorders.

Chronic pelvic pain (CPP) remains a challenging clinical entity affecting approximately 25%–26% of reproductive‐aged women worldwide, with pelvic venous disorders (PeVD) increasingly recognized as a significant but underdiagnosed contributor. 1 , 2 PeVD comprises a spectrum of venous abnormalities including primary venous reflux, venous obstruction, or a combination of both. Historically, these conditions have been labeled as “pelvic congestion syndrome,” a term that inadequately captures the complex pathophysiology involved. 1 , 3 , 4 The risks associated with PeVD include premenopausal status, multiple pregnancies, antecedent venous disorders, previous pelvic surgeries, trauma, and prolonged periods of standing. Despite the evident correlation between these risk factors and PeVD, delays in diagnosis and misinterpretation of symptoms are common, leading to prolonged suffering and suboptimal treatment outcomes for patients. 4 Despite its impact, pelvic venous disorders are underrepresented in gynecology‐focused guidelines. However, both the American College of Obstetricians and Gynecologists (ACOG) and the Society of Obstetricians and Gynecologists of Canada (SOGC) acknowledge pelvic venous congestion as a potential contributor to CPP and emphasize the need for multidisciplinary management. 3 , 5 Emerging CPP literature increasingly uses the term “transdisciplinary” to describe deeper integration of expertise across specialties; in this review, we emphasize this terminology as optimal management of complex conditions like CPP often relies on transdisciplinary and multimodal evaluation and treatment. We also acknowledge the recent 2025 FIGO–International Pelvic Pain Society (FIGO‐IPPS) framework for CPP, including the FIGO‐IPPS “R U MOVVING SOMe” classification system, which includes vascular causes of CPP. 6 These authors define CPP as pain localized to the pelvis that may be cyclical or non‐cyclical and typically lasts 3 months or longer after failed initial therapies. While the FIGO‐IPPS ‘R U MOVVING SOMe’ system provides a broad etiologic framework for classifying all causes of CPP, this review focuses on the American Vein and Lymphatic Society’s Symptoms‐Varices‐Pathophysiology (SVP) classification, which offers more granular phenotyping specific to pelvic venous disorders. While previous comprehensive reviews have established the foundation for understanding pelvic congestion syndrome, this manuscript uniquely addresses the evolving landscape of PeVD from a gynecologist‐centered perspective. 4 Specifically, this review integrates the recently published SVP classification system, incorporates updated SOGC and ACOG guideline recommendations, provides practical decision algorithms for when to investigate versus refer, and emphasizes transdisciplinary collaboration including musculoskeletal and pelvic floor specialists. 3 , 5 , 7 Furthermore, we present a balanced appraisal of treatment evidence, including limitations and complications, to support evidence‐based clinical decision making in the management of this underrecognized condition.

The authors confirm there are no conflicts of interest.

Optimal management of pelvic venous disorders requires a coordinated approach involving multiple medical specialties and allied health professionals. Integrated, multimodal, patient‐centered care is the current standard of care for CPP management. Our patient's referral to interventional radiology, based on updated practice guidelines, underscores the critical role of interdisciplinary collaboration in both diagnosis and definitive treatment. Recent studies have demonstrated that regular joint case conferences wherein gynecologists and interventional radiologists meet to review complex cases can significantly enhance diagnostic accuracy and streamline the management of diagnostically challenging presentations. 28 These multidisciplinary discussions facilitate a more comprehensive evaluation of each patient's condition and help to bridge communication gaps that frequently exist between specialties. The adoption of shared reporting systems that utilize standardized nomenclature, such as the SVP classification system, promotes consistency in documentation and improves the clarity of interspecialty communications. Many institutions have successfully implemented integrated care pathways that leverage electronic consultation systems and formalized referral protocols, leading to measurable reductions in time to diagnosis and improved patient outcomes. Joint continuing medical education (CME) sessions that focus on the latest advancements in the diagnosis and management of pelvic venous disorders serve as an invaluable resource for keeping all stakeholders informed of evolving best practices. 29 Beyond the traditional collaboration between gynecology and interventional radiology, comprehensive management of pelvic venous disorders benefits from inclusion of additional specialists. For example, physiotherapists specializing in pelvic health, who provide critical insight and expertise in the assessment and treatment of musculoskeletal pathologies contributing to CPP.

Data S1.