At Center for Diagnostic Imaging (CDI) Vascular Care, outpatient interventional procedures, such as embolization, offer convenient, innovative alternatives to conventional pelvic congestion syndrome and uterine fibroid treatments, providing symptom relief without invasive surgery.
Chronic pelvic pain and other symptoms associated with pelvic congestion syndrome and uterine fibroids greatly affect women’s quality of life and their ability to stay active. Surgical solutions, such as hysterectomy, often require long recovery periods, may be appropriate only for women who have completed childbearing and may have unintended complications. For example, women who’ve had a hysterectomy before age 50 to resolve heavy menstrual bleeding, pelvic pain or other symptoms are more likely to develop heart disease than similarly aged peers and may have an elevated risk of pelvic floor disorders.
The interventional treatments available at CDI Vascular Care for female reproductive health concerns, including uterine fibroids and pelvic congestion syndrome, present attractive alternatives to hysterectomy, surgical ligation and other open operations because they are less invasive and enable women to keep their uterus.
Identifying Uterine Fibroids
According to the Agency for Healthcare Research and Quality, it is estimated that in the United States 26 million women between the age of 15 and 50 have uterine fibroids. These benign, smooth muscle tumors of the uterus may cause heavy menstrual bleeding as well as bulk symptoms, such as pelvic pain, bloating, constipation, urinary urgency and/or frequency, and pain during intercourse, according to Rochelle Wolfe, MD, interventional radiologist with CDI Vascular Care.
Dr. Wolfe notes that while most women will not exhibit every fibroid-related symptom, the diagnosis is usually confirmed with imaging. The diagnostic process usually begins with a transvaginal ultrasound. This ultrasound gives physicians an indication of whether or not women have fibroids or if other etiologies are responsible for their pain.
Women may also have an MRI with contrast, which allows interventional radiologists to more clearly delineate the size and number of fibroids, as well as determine where the fibroids are located and whether the fibroids have a vascular supply that is amenable to treatment prior to embolization.
Updates in Fibroid Care
Uterine fibroid embolization (UFE) is an interventional therapy that disrupts blood flow to fibroids. Once a fibroid no longer receives adequate blood supply, the fibroid shrinks in size, alleviating symptoms over time.
CDI Vascular Care interventional radiologists perform UFE under conscious sedation and local anesthesia. The physicians at CDI utilize a novel approach to access fibroids’ blood supply through the radial artery in the wrist, rather than the traditional approach through the femoral artery.
“We insert a small sheath into the radial artery and use fluoroscopic guidance to move a small catheter from the access site through the brachial artery and into the aorta,” Dr. Wolfe says. “We then move the catheter through the iliac arteries in the pelvis and select the uterine artery. Once our catheter is in place, we inject small particles mixed with contrast to obstruct blood flow to the fibroids. This process is then repeated for the contralateral uterine artery.”
UFE takes roughly one to 1.5 hours. Following the procedure, patients are monitored for a few hours and then discharged to home. A superior hypogastric nerve block is commonly performed during the procedure to help manage post-procedural pain. Most women recover from the procedure and are back to work and normal daily activities within one week.
According to Dr. Wolfe, approximately nine out of 10 women will experience significant improvement or their symptoms will go away completely following UFE.
Finding the Right Treatment
UFE is an advantageous treatment for many women with symptomatic uterine fibroids, but it is not the only option. Noninvasive treatment options include medical management with gonadotropin-releasing hormone agonists, Levonorgestrel IUD and other medications such as tranexamic acid. Additional invasive treatment options include endometrial ablation, myomectomy — surgical removal of fibroids only — and hysterectomy. To help women determine the option that may be best for them, Dr. Wolfe participates in shared decision-making with women and their primary care physicians and OB-GYNs.
“Women should be fully educated about all of their options for fibroid treatment,” Dr. Wolfe says. “UFE is an effective, durable option, and all women who are seeking treatment for fibroids are potential candidates. The only absolute contraindications to fibroid embolization are an active pelvic infection, pregnancy and evidence of a gynecologic malignancy.”
Exploring Pelvic Congestion
Another common cause of pelvic discomfort, pelvic congestion syndrome occurs when varicose veins develop within the pelvis. The condition usually affects women of childbearing age and causes persistent or sporadic pain that is frequently reported as a dull aching or throbbing sensation in the pelvis.
“Pelvic pain associated with pelvic congestion syndrome is typically better in the morning, worsens as the day goes on and is aggravated by physical activity or lifting heavy objects,” says Michael Cumming, MD, medical director of vascular services and interventional radiologist, CDI Vascular Care. “Women often notice that pain is worse during menstruation, and they may also experience pain during intercourse as well as symptoms of irritable bowel or bladder. In severe cases, varicose veins may be visible near the vagina or labia.”
Two types of pelvic congestion syndrome affect women: primary and secondary. Primary pelvic congestion syndrome occurs when the valves within the gonadal or ovarian veins fail and is more common in women who have a family history of varicose veins or who have given birth. Multiple pregnancies especially raise the risk of varicosities.
Secondary pelvic congestion syndrome stems from anatomical abnormalities that interfere with normal circulation, including iliac vein compression syndrome and nutcracker syndrome. Iliac vein compression syndrome occurs when the right common iliac artery compresses the left common iliac vein against the lumbar spine, raising the risk of pelvic varicosities and deep vein thrombosis, according to an article published in Seminars in Interventional Radiology. In cases of nutcracker syndrome, according to Dr. Cumming, the left renal vein is compressed between the aorta and superior mesenteric artery. Patients with both variations are prime candidates for diagnostic and interventional procedures offered at CDI Vascular Care.
“Compared with a typical hospital setting, CDI Vascular Care offers a high level of endovascular work in a friendly, comfortable and less-expensive outpatient environment. Our team is completely aligned on a patient-centered approach, and patients get to see the same team members during diagnosis, treatment and follow-up care, providing a soothing, consistent environment for healing.”
— Michael Cumming, MD, medical director of vascular services and interventional radiologist, CDI Vascular Care
Understanding Chronic Pelvic Pain
As many as 39.1 percent of women experience chronic pelvic pain — pain that lasts at least six months — at some point during their lifetime, according to the Seminars in Interventional Radiology article. Because chronic pelvic pain is linked to a variety of reproductive and digestive conditions, including endometriosis, uterine fibroids, pelvic congestion syndrome, vulvodynia and irritable bowel syndrome, finding the underlying cause of pain can be challenging.
“Even when they undergo multiple investigations, such as diagnostic laparoscopy, approximately 60 percent of women with chronic pelvic pain never receive a diagnosis explaining why they’re having pain,” Dr. Cumming says. “These women may end up having a hysterectomy because no one can determine why they’re in pain.”
Dr. Cumming estimates that as many as 15 percent of women with undiagnosed pelvic pain have pelvic congestion syndrome, which remains an often-unrecognized source of chronic pelvic discomfort. He believes a pelvic congestion syndrome workup is a reasonable step for all women of childbearing age who have had routine gynecologic evaluations for chronic pelvic pain that uncovered no specific cause for their symptoms.
To determine if pelvic congestion syndrome is responsible for a woman’s pelvic pain, specially trained CDI Vascular Care technologists perform a transvaginal ultrasound with Doppler. This test allows physicians to visualize the venous structures within the pelvis and determine if she has primary or secondary pelvic congestion syndrome.
“The first goal of this ultrasound is to determine if varicosities are present, and the second is to determine why they’re present,” Dr. Cumming says. “We look at the direction of blood flow in the gonadal veins, as well as the direction of blood flow within the iliac veins. Four veins can be involved in pelvic congestion syndrome. To treat these veins appropriately, we need to understand how they’re working and which ones may need treatment.”
Based on the results of the ultrasound, the next step may be a CT or MR venogram to help distinguish between nutcracker syndrome and iliac vein compression syndrome. Finally, physicians follow the CT or MR venogram with a diagnostic venogram, during which interventional radiologists insert a catheter and inject contrast dye into the vein.
“This test enables us to look at the veins and determine how blood is moving within them,” Dr. Cumming says. “As part of that, we may also perform an intravascular ultrasound, which gives us the best picture when determining whether patients have significant compression that might be causing pelvic congestion syndrome. If what we see during these invasive studies matches what we learned during the earlier tests, we move forward with treatment at that time.”
“CDI Vascular Care is more like a family than a big institution. We manage pre- and post-procedural care and follow up with women over time. It’s a very clinical-based practice, and we’re extremely invested in the health and outcomes of the women we treat.”
— Rochelle Wolfe, MD, interventional radiologist, CDI
A Minimally Invasive Solution
Pelvic vein embolization has transformed the approach to treating pelvic congestion syndrome and is indicated for women with primary pelvic congestion syndrome and nutcracker syndrome. During the procedure, interventional radiologists typically enter the venous system through the right internal jugular vein and use embolic agents or devices to occlude the responsible veins. Conscious sedation and local anesthesia are used to keep women comfortable during the embolization, which may take 45 to 60 minutes depending on the number of abnormal veins requiring treatment.
“Most women experience low-grade pelvic discomfort, which is manageable with anti-inflammatory medication, after the procedure and are back to work within one week,” Dr. Cumming says. “We expect that eight to nine out of 10 women will have symptom improvement or resolution after embolization.”
In cases of iliac vein compression syndrome, venoplasty and stenting of the left iliac vein are usually indicated. Like embolization, the procedure is performed under conscious sedation and local anesthesia. It takes roughly 30 to 45 minutes, and because it is minimally invasive, women experience little pain and scarring and can quickly return to daily activities.
“I believe the only way to approach pelvic congestion syndrome is with minimally invasive techniques,” Dr. Cumming says. “There’s no reason for a more invasive procedure to address these varicosities.”
CDI Vascular Care provides vascular procedures at CDI Vascular Care in St. Louis Park and CDI in Blaine, Lakeville, Maple Grove and Woodbury. For more information about pelvic vein embolization, UFE or other available services, visit cdivascularcare.com.