Gonadal Vein Embolization

F ifteen percent of all outpatient gynecologic visits and 30% of patients who present with pelvic pain are secondary to pelvic congestion syndrome (PCS). Unfortunately, this disease is often overlooked, with patients frequently undergoing an exhaustive evaluation before being diagnosed with PCS. Pelvic congestion with varices was first described more than 150 years ago, and the symptoms were considered psychosocial more than 50 years ago;1 even still, there are often delays in diagnosis because general practitioners are not aware of the syndrome and typically refer patients to psychologists or other counselors. The underlying pathophysiology of PCS was first described around the same time, with further anatomical understanding developed in more recent decades. Negative psychosocial associations with the term pelvic congestion syndrome has led to pelvic venous insufficiency being the preferred term for describing the underlying pathophysiology of the condition.1 Although the etiology of PCS is poorly understood, the primary abnormality is the absence of functioning valves in the ovarian or internal iliac vein branches. This likely congenital absence of valves or hereditary predisposition is the most common explanation. The condition is worsened with each successive pregnancy due to increased blood flow and hormonal fluctuations. Subclinical thrombosis of these veins may further contribute to the development of the syndrome. Other less common etiologies are secondary to uterine malposition and nutcracker syndrome (eg, left renal vein compression between the aorta and the superior mesenteric artery).