Abstract
Objective
To investigate the efficacy of medical management by flavonoid in women with pelvic congestion syndrome (PCS) by comparison of the changes in venous size and quality of life (QoL) before and after treatment.
Materials and methods
Eleven women who met the diagnostic criteria of PCS were enrolled in the study. Flavonoid 500 mg twice or 1000 mg once daily was prescribed. Objective outcome was evaluated by measurement of ovarian vein diameter via transvaginal ultrasound in each case before and after 3–6 months of the treatment. PCS related symptoms were evaluated by Pelvic Varicose Vein Questionnaire (PVVQ), and Visual Analog Scale (VAS) as subjective outcomes. Wilcoxon signed rank test was used to compare the differences pre- and post-treatment. Data analysis was performed using SPSS 22.0. Statistical significance was defined as P value < 0.05.
Results
From January 2022 to September 2023, 11 women met the criteria and were diagnosed with pelvic congestion syndrome. The age ranged from 40 to 72 years old with mean of 57 y/o. 90.9 % of the subjects (10/11) reported significant decreases in VAS (mean = 5.9 pre-vs. 2.5 post-treatment, p = 0.005) and PVVQ (mean = 51.6 pre-vs. 30.5 post-treatment, p = 0.005). Transvaginal ultrasound also showed significant decreases in ovarian vein diameter, from 8.1 mm to 6.2 mm (p = 0.016).
Conclusion
Our study demonstrated that medical treatment with flavonoids significantly reduced of ovarian venous diameter in patients with pelvic congestion syndrome. Additionally, the impaired quality of life was markedly improved proven by the significant decreases of PVVQ and VAS scores following treatment. Based on these findings, we suggest that flavonoids may be considered as first-line treatment for patients with pelvic congestion syndrome in routine clinical practice.
Introduction
Chronic pelvic pain (CPP) is one of the most common symptoms in gynecology outpatient clinics, yet its etiologies varied. 15 %–40 % of the patients reporting CPP are believed to experience pain secondary to pelvic congestion syndrome (PCS), a common cause of CPP in women of reproductive age [ ]. Clinical manifestations of PCS include non-cyclic pain, a dull bursting or aching of lower abdominal or bearing down sensation of heaviness in the pelvis, chronic pelvic pain persisting over 6 months, increased pain when increased abdominal pressure. Symptoms of PCS also worsen at the end of the day, with each subsequent pregnancy, and during or after sexual intercourse. The pain can be unilateral or bilateral [ ]. Other causes of CPP in gynecology include endometriosis, adenomyosis, pelvic inflammatory disease, painful bladder syndrome, and others. Except for the gynecological causes, irritable bowel syndrome, musculoskeletal pelvic floor pain, and peripheral neuropathy had the same symptoms with CPP [ , ]. Pelvic congestion syndrome should be considered a different diagnosis from these diseases.
PCS is a form of chronic venous disease which means a kind of varicose veins in the pelvis. Though a variety of surgical, endovascular, and conservative treatments are available for varicose veins in clinical practice, medical treatment for varicose vein became quite common because of more conservative treatment options [ ]. Several studies have demonstrated the efficacy of venoactive drugs, such as flavonoids, in the treatment of pelvic congestion syndrome [ , ]. Flavonoids are commonly employed for hemorrhoids, lower extremity varicose veins, as well as chronic venous insufficiency [ , ]. It exhibits various effects on venous tone, epithelium, and venous valve. They affect venous tone by regulating noradrenergic signaling and decreasing the metabolism of norepinephrine. Chronic inflammation in both large and small venous vessels and valves can impair venous function. Flavonoids can reduce venous inflammation by inhibiting leukocyte rolling, adhesion, and migration in animal studies [ , ]. It also has antioxidant properties, such as normalization of prostaglandin and thromboxane synthesis, reduction in the microvascular permeability, protection of endothelial cells from lipid peroxidation [ , ].
As PCS is also one kind of chronic venous disease, we hypothesized that the related dilated pelvic veins could be reduced by the application of flavonoids making it an effectively conservative treatment of PCS. The aim of the study was to investigate the efficacy of medical management with flavonoid in women with PCS by comparison of the changes in venous size and quality of life before and after treatment.
Materials and methods
Study design
This retrospective study was conducted at Taipei City Hospital, Renai Branch, a single-center facility. Inclusion criteria involved the presence of symptoms indicative of pelvic congestion syndrome (PCS), such as bearing down sensation, abdominal/pelvic fullness, vulvar swelling pain, for at least 6 months alongside the identification of pelvic varicose veins through transvaginal ultrasound. PCS diagnosis was established if patients exhibited symptoms with either the ovarian vein showing dilation exceeding 5 mm or the pelvic plexus veins exhibited dilation exceeding 5 mm. The subjects must be capable of completing the activities required in the questionnaire. Although PCS was mostly documented in childbearing aged women, we did not set a specific age range for our study except for those who were under 18 years old due to the limited sample size. Once the patients were diagnosed as PCS, they were prescribed with flavonoid (Diosmin 500 mg twice daily or Daflon 1000 mg once daily) for a minimum duration of four months. Those who didn’t meet the aforementioned criteria were excluded. The objective outcomes were evaluated by the difference of ovarian venous size and subjective outcomes were investigated by validated questionnaires before and after 3–6 months of the treatment.
Assessment of subjective and objective outcomes
The PCS related symptoms were assessed using the Pelvic Varicose Vein Questionnaire (PVVQ) and the visual analog scale (VAS) for subjective outcome measurement. The PVVQ evaluates four key dimensions of quality of life (QoL) in patients with PCS: pain syndrome, physical well-being, social well-being, and psychological well-being. Each dimension includes five questions, making 20 questions in total. Each question is rated on a 5-point scale, yielding a summary score ranging from 20 to 100, with higher scores indicating poorer QoL [ ] ( Appendix1 ). The VAS is a self-reported scale represented by a horizontal or vertical line, typically 10 cm in length, where the patients marked a point indicating their perceived pain level [ ] ( Appendix 2 ).
For the objective outcomes, bilateral ovarian and pelvic plexus veins were measured by transvaginal ultrasound. The largest diameters in each subjects were recorded and compared. The ultrasound examination was performed by the same physician (the corresponding author) to reduce the potential bias. The subjective and objective outcomes were investigated before and after 3–6 months of the treatment.
Statistical analysis
The data was shown in mean ± standard deviation. Statistical analysis was performed using SPSS 22.0 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). Wilcoxon signed rank test was utilized to compare the differences of pelvic vein diameter, PVVQ scores, and VAS scores before and after medical treatment. Statistical significance was determined with a P value of <0.05.
Results
From January 2022 to September 2023, 11 women met the inclusive criteria and were diagnosed with pelvic congestion syndrome. All of them received flavonoid 500 mg twice a day or 1000 mg daily for a minimum of four months. The age of the subjects ranged from 40 to 76 years old with mean of 57 y/o. Eight of them were postmenopausal and the other three were premenopausal. The average parity was 2.3. Among the 11 subjects, three were concomitant with endometriosis, one with myoma uteri, one with adenomyosis, two with interstitial cystitis, and six with urge urinary incontinence. The average follow-up duration was 11.6 months (4.5–24 months). The baseline clinical characteristics and demographic profiles were listed in Table 1 .
| Subject | Parity | Menopause | Age (y/o) | Gynecologic disease | Urologic disease | Metabolic disease | Others |
|---|---|---|---|---|---|---|---|
| 1 | 2 | No | 40 | Endometriosis under Visanne | SUI | GDM, PIH | No |
| 2 | 2 | No | 48 | No | No | No | No |
| 3 | 7 | Yes | 76 | No | No | Lipid, DM | Bladder cancer s/p OP in 2019 |
| 4 | 2 | Yes | 59 | No | IC, SUI | No | No |
| 5 | 1 | Yes | 65 | No | USI s/p MUS | No | Parkinson |
| 6 | 2 | No | 44 | Endometriosis under Visanne | USI s/p MUS | No | No |
| 7 | 3 | Yes | 50 | Endometrioma s/p LAOC, | IC | No | s/p appendectomy |
| 8 | 3 | Yes | 72 | Adenomyosis s/p subtotal hysterectomy | No | No | No |
| 9 | 2 | Yes | 55 | No | SUI | No | No |
| 10 | N/A | Yes | 59 | Myoma | N/A | N/A | N/A |
| 11 | N/A | Yes | 59 | N/A | UUI | Lipid | N/A |
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