Pelvic Congestion Syndrome: The Gynecological Perspective

Background/Objectives: Chronic pelvic pain (CPP) is defined as pelvic pain lasting longer than six months and is a common yet often overlooked condition, affecting over 40% of women worldwide and accounting for about 10% of gynecological consultations. Despite extensive investigation, including laparoscopy, no cause is identified in up to half of cases. Pelvic congestion syndrome (PCS), also referred to as pelvic venous insufficiency (PVI), has been estimated to account for up to 30% of CPP cases, although it remains underdiagnosed. PCS is caused by venous reflux or obstruction in pelvic veins and is characterized by dull, aching pain worsened by standing, intercourse, post-orgasm, and the premenstrual period. It occurs predominantly in premenopausal women, often after pregnancy. This narrative review aims to improve understanding of PCS and provide practical guidance to support diagnosis and treatment in routine gynecologic practice. Methods: We performed a comprehensive review of the current literature focusing on the clinical presentation, pathophysiology and diagnostic and treatment performance of various modalities. Special emphasis was placed on identifying accessible, non-interventional tools suitable for primary gynecological care. Results: PCS, CPP and endometriosis exhibit significant clinical overlap, including dysmenorrhea, dyspareunia and chronic pain. However, pathognomonic features like post-coital pain and pain-exacerbation by prolonged standing, combined with specific ultrasound markers, allow for early differentiation. While laparoscopy is often used to investigate CPP, it has limited sensitivity for PCS due to CO₂-pneumoperitoneum-induced venous compression, and Trendelenburg position, compared to venography, the diagnostic gold standard. In contrast, transvaginal ultrasound (TVUS) serves as a potent first-line tool. Key diagnostic criteria include ovarian vein diameter (>7-8 mm), low flow velocity (<3 cm/s), and myometrial vein dilatation (>5 mm). Furthermore, the frequent co-occurrence of endometriosis and PCS requires a multimodal diagnostic approach to avoid "diagnostic bias." Conclusions: To improve patient outcomes and reduce diagnostic delay, office-based gynecologists should integrate specific vascular TVUS into the routine workup of CPP, not only to diagnose endometriosis but also to identify PCS. Future efforts should focus on standardized TVUS protocols and interdisciplinary care pathways involving gynecologists and interventional radiologists to enable integrated diagnostic and therapeutic approaches for patients with coexisting endometriosis and PCS, addressing both surgical and non-surgical options, as well as the bidirectional relationship and mutual pathophysiological influence between these entities.