In Reply to: Case 797_10 -- Ovarian vein embolization posted by Editor on July 17, 1997 at 17:06:17:
This is indeed an interesting case because it and
the discussion that has ensued makes it clear that
we do not yet know very much about this condition.
I have accumulated a bit of experience regarding venographic diagnosis and percutaneous therapy of this vexing condition, which is at best dimly perceived by that bastion of progressive thinking, the obstetric and gynecologic community.
First of all let me say that the best way to think about this condition is as "female varicocele". Remember that varicoceles are common, sometimes painful and often recurrent with either surgical or interventional therapy.
This all started about 8 years ago when I was sent a lady who had been referred to him with massive pelvic varicosities which had been seen at surgery and were felt to be the cause of her persistent pelvic pain. Hysterectomy had already been performed without effect. Someone had suggested that the pelvic venous congestion syndrome was responsible, even though the classic finding of labial varices was absent. I did an ovarian venogram and found massive brisk reflux down the left ovarian vein into huge pelvic floor, periovarian and broad ligament varices with flow out the contralateral internal iliac vein. Many of the pelvic varices remained filled for as long as ten minutes after injection. I came up with the idea of embolizing the ovarian veins just as I embolized internal spermatic veins in men for treatment of symptomatic varicocele. Lo and behold, it worked with complete elimination of the pain syndrome that this lady referred to as "10 on a scale of 10".
A few other patients followed with some success; we wrote up our early case experience with 3 patients in Obstetrics and Gynecology (83:892-896, 1993). Since then I've treated about 30 patients with ovarian vein embolization and am currently evaluating my results. The treatment has undoubtedly been successful in those women who have the disorder and I believe that the advantages of embolotherapy make it clearly the treatment of choice but the problem seems to be that we do not currently know how to find these women reliably.
To date I can state the following about the syndrome:
1. The syndrome is very real and completely unappreciated by the people who see women with pelvic pain. These women are miserable and frustrated.
2. The women are usually premenopausal and virtually all have had children.
3. The symptom complex is somewhat diverse but the complaints that seem to me to be most compatible with the disorder (and therefore drive the need for ovarian venography which is the only non-laparoscopic test that I have found useful) are:
Severe deep pelvic pain often described as burning which may localize or be diffuse often rated 8 - 10 on a scale of 10
Pain which interestingly radiates down the legs
Pain worse at either midcycle or associated with menses
Dyspareunia
Surprisingly, many of these ladies complain of constipation
4. Physical examination only very rarely is revealing and only one of my patients has had vulvar or anterior abdominal wall varicosities.
5. Between one-third and one-half of my patients have been sent to me because ovarian/pelvic varices are seen at laparoscopy. I however would not recommend laparoscopy as the principal diagnostic test. Ovarian venography is the test of choice.
6. The findings at ovarian venography which prompt embolotherapy (usually done at the same session) are: ovarian vein enlargement (thumb-sized ovarian veins are the rule) and brisk marked or massive reflux without the application of valsalva maneuvers.
7. I usually embolize bilaterally even though the majority of patients really only reflux from the left side (analogous to the male)
8. If the above clinical and venographic findings apply, my success rate has been very good (over 80% with complete or near complete relief of symptoms). When I have pushed the envelope and done patients without markedly positive venography I have been disappointed. Not known yet is the duration of the response (currently under investigation. I have noticed however that recurrences after successful treatment definitely occur; I've seen them after the patient became pregnant or after estrogen replacement therapy has been initiated.
9. What is the incidence of this disorder? I'm not certain but in men varicocele is a reasonably common condition (I think varicocele is seen in 10 - 25%) and it is said that 10% of those men are symptomatic. Since this condition is essentially identical to varicocele, the number of symptomatic women MAY be quite large but I'm not at all certain of this. On the other hand I genuinely hesitate to tackle the world of pelvic pain; I got mentioned a few times on TV and in print for my work in this area and found myself literally inundated with telephone calls from women with pelvic pain.
Arteriography is not necessary in these patients.
Regarding the question of noninvasive tests, I think that a well and expertly done transvaginal doppler exam can find these patients but I haven't resorted to doing this routinely.
I think that the IR community should be more aggressive because we definitely have something to offer by way of diagnosis and therapy.