Pelvic Varicose Veins: What They Are and Who to See

Pelvic varicose veins are a pathological dilation of the venous plexuses in the pelvic area, manifesting as chronic pelvic pain and heaviness in the lower abdomen. This is not “leg varicose veins that spread upward”: it is a separate condition diagnosed and treated by gynecologists and vascular surgeons specializing in pelvic phlebology. If you suspect this problem, you should start with a gynecologist, not a phlebologist, although in some cases a phlebologist may suspect the pathology during an examination of the lower limb veins.

What Happens in Pelvic Varicose Veins

In the female pelvis, there is a powerful venous plexus — the ovarian (gonadal) veins. Normally, blood drains from the ovaries and uterus upward through these veins. In varicose veins, the valves in the veins stop working, blood stagnates, and the veins become dilated and deformed. This condition is called pelvic venous congestion syndrome.

Imagine pinching a water hose — the pressure inside rises, and the walls stretch. The same happens to the pelvic veins. But unlike the legs, where a dilated vein is visible to the eye, here everything is hidden deep inside. So a woman may see gynecologists for a long time complaining of pain, while the cause is in the vessels.

An important point: pelvic varicose veins are not the same as vulvar varicose veins (of the external genitalia). Vulvar varicose veins are dilation of the subcutaneous veins in the perineal area, visible to the naked eye. They often appear during pregnancy due to the pressure of the growing uterus on the veins. Pelvic venous congestion syndrome, on the other hand, is an internal problem and is more difficult to diagnose.

Why It Is Confused with Gynecology

The symptoms of pelvic varicose veins are very similar to those of many gynecological conditions:

• aching pain in the lower abdomen that worsens after prolonged standing or sitting;
• heaviness and fullness in the pelvic area;
• pain during or after sexual intercourse;
• painful menstruation;
• increased pain in the second half of the cycle.

Because of this picture, a woman sees a gynecologist. And that is correct — the gynecologist should rule out inflammatory diseases, endometriosis, cysts, and other causes of pain. But if the gynecologist finds everything normal while the pain persists, they may suspect a vascular origin.

There is a subtlety here. In classical medicine, pelvic venous congestion syndrome is considered a “diagnosis of exclusion.” That is, it is diagnosed only after all gynecological causes have been ruled out. So the patient’s journey usually looks like this: gynecologist → pelvic ultrasound → exclusion of gynecological pathology → referral to a vascular surgeon.

What Diagnostics Are Needed

The gold standard for diagnosing pelvic varicose veins is a pelvic vein duplex ultrasound. The examination is performed with a transvaginal probe (in women) or transabdominally. The doctor assesses the diameter of the ovarian veins, blood flow velocity, and the presence of reflux — reverse blood flow.

Normally, the diameter of the ovarian vein should not exceed 5–7 mm. If the vein is dilated to 8–10 mm or more, and Doppler shows reverse blood flow — that is pelvic varicose veins.

In complex cases, venography — an X-ray examination with contrast — may be required. But this is rather an exception, used before surgery for precise planning. In most cases, a high-quality ultrasound is sufficient.

Speaking of ultrasound quality. A routine pelvic ultrasound performed by gynecologists is aimed at assessing the uterus and ovaries. The vessels are examined “along the way,” often not with the thoroughness needed. Therefore, for diagnosing pelvic varicose veins, it is better to see a specialist who specifically deals with venous pathology. I perform duplex ultrasound of the lower limb veins and can assess the condition of the pelvic veins, but there is a nuance that I will discuss below.

Who Treats Pelvic Varicose Veins

This is the most important question, and I want to answer it honestly. I am a phlebologist specializing in lower limb varicose veins. I perform EVLA, sclerotherapy, mini-phlebectomy, and CLaCS for leg veins. Pelvic varicose veins are an adjacent area, and here I am at the boundary of my competence.

Here is how things stand in real practice:

• Gynecologist — the first doctor to see. They rule out gynecological pathology and may suspect a vascular problem.
• Vascular surgeon specializing in pelvic phlebology — a doctor who deals specifically with pelvic veins. There are few such specialists in Tashkent, but they exist. They perform endovascular embolization of the ovarian veins — a procedure that “disconnects” the dilated vein from the bloodstream.
• General phlebologist — may suspect the problem and refer to the appropriate specialist, but may not always offer surgical treatment.

Why is this? Because access to the ovarian veins is not like a subcutaneous vein in the leg that can be operated on under local anesthesia. These are deep vessels that require X-ray surgical equipment and interventional radiology skills. Such procedures are performed in a hospital setting, under angiographic guidance.

I do not perform ovarian vein embolization. My specialization is lower limb veins. But I know well how to distinguish leg varicose veins from pelvic pathology, because these conditions often coexist. If a patient comes to me with leg varicose veins and complaints of lower abdominal pain, I will refer her for additional examination.

The Connection with Leg Varicose Veins

There is an important point that is rarely discussed. Pelvic varicose veins and leg varicose veins are not always separate diseases. A significant proportion of women with leg varicose veins also have pelvic venous congestion. Why is this?

The venous system of the lower limbs and pelvis is connected. There are veins that link these basins — for example, the vein running from the ovary to the thigh veins. If there is congestion in the pelvis, blood may “drain” through these connecting veins downward, provoking varicose veins in the legs. Varicose veins along the inner thigh and in the perineal area are especially characteristic.

Therefore, during examination, I always ask patients about lower abdominal pain, even if they came with complaints about leg veins. Conversely, if a woman has leg varicose veins and pelvic pain at the same time, I recommend a pelvic ultrasound, even if a gynecologist previously found no pathology.

If leg varicose veins are combined with pelvic varicose veins, both conditions need treatment. The sequence of treatment depends on the situation. Sometimes the pelvic congestion is addressed first, and the leg varicose veins become less pronounced. Sometimes the opposite — the legs are operated on first, and the pelvis is treated later. This is decided by the doctor after a full examination.

Vulvar Varicose Veins During Pregnancy

A separate story is vulvar varicose veins during pregnancy. This is dilation of the veins of the external genitalia, which appears in many women during pregnancy. Causes:

• pressure of the growing uterus on the pelvic veins;
• hormonal changes that relax the vein walls;
• increased volume of circulating blood.

Vulvar varicose veins look like nodular bluish veins in the labial area. They can cause a feeling of fullness, itching, and discomfort when walking. This condition usually resolves after childbirth, when the uterine pressure disappears and hormonal levels normalize.

What to do about vulvar varicose veins during pregnancy? In most cases — observation and symptomatic treatment: compression stockings, cold compresses, lying with the pelvis elevated. Surgical treatment is not performed during pregnancy unless there is a threat of thrombosis. After childbirth, the veins usually shrink, and if a cosmetic defect remains, it can be removed with sclerotherapy or mini-phlebectomy.

Important: vulvar varicose veins during pregnancy are not the same as pelvic varicose veins. These are different conditions, although they can coexist. Vulvar varicose veins are visible to the eye; pelvic ones are not.

When to See a Doctor Urgently

There are symptoms for which you should not delay seeing a doctor. If you have sudden sharp pain in the lower abdomen or pelvic area, asymmetric swelling of one leg, redness, or a lump along a vein — this may be a sign of thrombosis. Pelvic vein thrombosis is a rare but dangerous condition that requires emergency medical care.

Also, be alert to:

• bloody discharge outside of menstruation;
• a sharp increase in pain that is not relieved by painkillers;
• fever accompanying pelvic pain.

In these cases, do not wait for a scheduled appointment — call an ambulance or go to the nearest hospital.

The Bottom Line

If you have lower abdominal pain and the gynecologist finds no pathology — do not fixate on the idea that “it’s all in your head.” Pelvic venous congestion is a real condition that is well diagnosed with proper ultrasound. Start with a gynecologist, and if they rule out their pathology, ask for a referral to a vascular surgeon who deals with pelvic veins.

If you have leg varicose veins and pelvic pain at the same time — tell your phlebologist. These conditions may be related, and they may need to be treated comprehensively. During my consultations, I always pay attention to such combinations and, if necessary, refer patients to colleagues who specialize in pelvic phlebology. You can book an appointment by phone at +998 99 883-93-21 or through the website.

Remember: pelvic varicose veins are not a sentence. This is a condition that can be diagnosed and treated. The key is to find the right specialist and not be afraid to ask questions.

This article is for informational purposes only and does not replace a consultation with a qualified physician. If you are experiencing symptoms, please see a specialist.