Pelvic Venous Disorder Treatment (Pelvic & Ovarian Vein Embolization) | Minimally Invasive Relief for Chronic Pelvic Pain

A dull ache low in the pelvis that builds through the day and is worst after hours on your feet? Heaviness and pressure that flare before your period, pain during or after intercourse, and gynecological tests that keep coming back normal? Many women live with this for years, moving from one specialist to the next and being told that nothing is wrong. In many of these cases the source of the pain lies in the veins of the pelvis.

This condition is called pelvic venous disorder (PeVD), also known as pelvic congestion syndrome (PCS). This page explains what causes pelvic venous congestion, how it is diagnosed, and how Dr. Adam Farkas, an interventional radiologist, treats it with pelvic and ovarian vein embolization: a catheter-based procedure, without surgery and without incisions.

Pelvic venous disorder is a condition in which the veins of the pelvis become enlarged and incompetent, so blood does not drain properly. Much like varicose veins in the legs, dilated veins with abnormal flow can develop in the pelvis. The resulting venous congestion creates pressure in the pelvis and can cause persistent pain that worsens at certain times of day.

It is most common in women of reproductive age and often appears or worsens after pregnancy. The hallmark symptom is chronic pelvic pain lasting more than six months.

What causes it?

The main cause is failure of the valves inside the pelvic veins, especially the ovarian veins. Healthy valves keep blood moving in one direction, back toward the heart. When they fail, blood flows backward, pools in the veins and stretches them. Pregnancy adds to this: blood volume rises, the growing uterus presses on the veins, and hormonal changes affect the vein wall. Women who have had several pregnancies are therefore at higher risk.

In some women, congestion is caused by compression of a larger vein in the pelvis or abdomen that obstructs drainage. Telling these situations apart matters because it changes the treatment, so it is a central part of the work-up.

• A dull ache, pressure or heaviness in the lower abdomen and pelvis
• Pain that worsens with prolonged standing or toward evening and eases when lying down
• Pain during or after sexual intercourse
• More discomfort before menstruation
• Visible varicose veins in the vulva, buttocks or upper thighs
• Leg varicose veins that keep coming back after treatment
• Symptoms that began or worsened after pregnancy

Because these symptoms overlap with gynecological, urinary and digestive problems, many women go years without an accurate diagnosis. If this description sounds familiar and earlier tests found no explanation, the venous side is worth checking. You can read more about the condition itself on our pelvic congestion syndrome page.

Diagnosis starts with a medical assessment: a detailed conversation about the pain, what makes it worse or better, and your pregnancy history. Imaging follows, such as Doppler ultrasound, CT or MRI of the pelvis. These tests can show enlarged pelvic veins and venous reflux, and help rule out other causes of pain.

In some cases a venogram (diagnostic catheter study of the veins) is performed to map the pelvic veins and the direction of flow precisely. Often the final diagnosis and the treatment are carried out in the same session.

Enlarged pelvic veins can also be seen in women with no symptoms at all. The decision to treat therefore rests on the combination of symptoms, examination and imaging, and never on a scan alone.

Conservative treatment

In mild cases, pain medication, hormonal treatment or lifestyle changes may be tried first. In many women, however, conservative treatment does not fully resolve the problem, because it does not correct the abnormal flow in the veins.

Pelvic and ovarian vein embolization

Pelvic and ovarian vein embolization is a minimally invasive treatment performed by an interventional radiologist. Its goal is to close the abnormal veins so blood is redirected through healthy veins and the congestion that causes the pain is reduced.

The procedure may be appropriate for women with:

• Chronic pelvic pain for more than six months with a pattern that fits venous congestion
• Imaging that shows enlarged pelvic veins and venous reflux
• Partial or no response to medication
• Varicose veins in the groin, vulva or thighs, especially those that appeared during pregnancy
• Recurrent leg varicose veins fed by pelvic veins

It is less suitable, or needs further evaluation, when:

• You are currently pregnant
• The pain is more likely gynecological, urological or bowel-related and imaging shows no clear venous problem
• Congestion is caused by compression of a large vein, which may call for a different treatment
• There is a severe contrast allergy or a medical condition that needs special assessment before a catheter procedure

Suitability is decided only after a consultation and a full review of your imaging.

1. Get in touch. Leave your details or call, and our office will get back to you to schedule an appointment.
2. Consultation in Modiin. Consultations take place at the Elite Medical clinic in Modiin on Mondays. Dr. Farkas reviews your symptoms, imaging and records with you, explains the options and checks whether catheter-based treatment suits you. Please bring a referral letter, imaging discs, blood tests and medical records. A video or phone consultation can also be arranged.
3. Completing the work-up. If imaging is missing, such as a pelvic MRI or Doppler ultrasound, it is ordered before a date is set.
4. Scheduling and preparation. The procedure itself is performed in the angiography suite at Shaare Zedek Medical Center in Jerusalem. You will receive instructions about fasting, regular medications and blood tests.

The procedure is a day procedure performed in an angiography suite under local anesthesia with sedation. General anesthesia is not required.

• A tiny catheter is inserted through a small puncture in a vein at the wrist, arm or groin, under ultrasound and X-ray guidance.
• The catheter is guided to the enlarged ovarian and pelvic veins, and the veins and their flow are imaged.
• The abnormal veins are closed with tiny coils and/or a sclerosing agent.
• Blood now drains through healthy veins and pressure in the pelvis decreases.

The procedure usually takes about 45 minutes to an hour. There are no incisions and no stitches, only a small dressing at the puncture site. After a short observation period, most women go home the same day.

Does it hurt? Discomfort during the procedure is minimal and is reduced with local anesthesia and sedation. This is the most common worry before a catheter procedure, and most patients find it far more tolerable than they expected.

• Mild pelvic discomfort or cramping may occur for several days and is usually controlled with oral pain medication.
• Most patients return to work and daily activities within about 2 to 7 days.
• Improvement is gradual: as pressure in the pelvis decreases, symptoms ease over the following weeks.
• A follow-up visit is scheduled to assess the result, with repeat imaging if needed.

A systematic review published in the Journal of Vascular and Interventional Radiology gathered 21 prospective case series and one randomized trial involving 1,308 women. Early substantial pain relief was reported in approximately 75% of women who underwent embolization. The authors noted that the overall quality of the evidence is low and that more controlled studies are needed [1].

In Dr. Farkas’s clinical experience, the success rate in appropriately selected patients is between 70 and 90 percent. As with any medical treatment, no outcome can be guaranteed, and your personal chances are discussed at the consultation.

Pelvic vein embolization is considered a low-risk procedure, but like any medical procedure it has possible risks:

• Temporary pelvic pain and discomfort in the first days.
• Bruising or tenderness at the puncture site.
• Coil migration, a rare complication. In the systematic review its rate was under 2% [1].
• Reaction to the contrast agent used for imaging.
• Recurrent or partially relieved symptoms, which in some women need further assessment.

Before treatment, Dr. Farkas goes over the risks relevant to your situation and answers your questions.

Enlarged pelvic veins used to be treated surgically: ligation or removal of the ovarian vein through open or laparoscopic surgery, and in severe cases even hysterectomy with removal of the ovaries. Today pelvic vein embolization is an alternative to surgery.

• Anesthesia: embolization uses local anesthesia and sedation; surgery usually requires general anesthesia.
• Incisions: one small puncture, compared with abdominal incisions.
• Hospital stay: embolization is a day procedure; surgery often means a longer stay.
• Recovery: according to Dr. Farkas, embolization involves fewer complications and a much shorter recovery.
• Organ preservation: embolization preserves the uterus and ovaries.

The choice between options is made together with your doctor, based on the diagnosis, your health and your preferences.

In some women, incompetent pelvic veins feed varicose veins in the thighs and legs. Treating only the leg veins may then lead to recurrence, so pelvic veins are worth checking when leg varicose veins keep returning. See non-surgical treatment for varicose veins.

• Do my symptoms fit pelvic venous congestion, or is there another cause to rule out?
• Which imaging do I already have, and what is still missing?
• Is the congestion caused by valve failure or by compression of a larger vein?
• What should I expect on the day of the procedure and the week after?
• What are my personal chances of pain relief, and what happens if symptoms return?

It helps to bring a short pain diary: when the pain appears, how strong it is and what eases it. Pain during intercourse is a recognized symptom of pelvic congestion, and although many women hesitate to mention it, it is an important part of the picture.

Dr. Adam Farkas is Director of the Vascular Interventional Radiology Unit and Vascular Anomalies Clinic at Shaare Zedek Medical Center, Jerusalem, and Chair of the Israel Society of Interventional Radiology. He has performed thousands of catheter-based procedures.

1. Daniels et al. Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review. Journal of Vascular and Interventional Radiology. 2016;27(10):1478-1486. doi:10.1016/j.jvir.2016.04.016