Updated:
by
Sanjiv Lakhanpal, MD, FACS
Medically reviewed by Sanjiv Lakhanpal, MD, FACS
You have tracked your pelvic pain symptoms for months, maybe even years. You have described your discomfort at appointment after appointment. You may have gotten a diagnosis, or you may not. Either way, you are still living with it: a dull, heavy ache that drags through your lower pelvis, builds as the day goes on, and eases only when you finally lie down.
It flares after standing too long, worsens during or after intercourse, and tends to peak in the days before your period. Sometimes it spreads to your lower back, your buttocks, or your thighs. Sometimes it comes with bloating, fullness, or an urgent need to urinate. You have been describing all of this for a long time, and you still do not have the answers you are looking for.
If chronic pelvic pain is part of your daily life, there is a condition that may not yet have come up during these health checks: pelvic congestion syndrome (PCS).
It is not a rare condition. However, it is widely overlooked. And understanding how PCS differs from endometriosis could be the turning point in finally getting the right care.
We consulted vein expert Sanjiv Lakhanpal, MD, FACS, Founder, President, and CEO of Center for Vein Restoration (CVR), America’s largest physician-led vein center. The board-certified vein physicians at CVR firsthand how often PCS goes undetected in women who have already been through extensive evaluation.
"The women who come to us have often done everything right. They tracked their symptoms, advocated for themselves, and followed every recommendation. PCS gets missed not because patients failed to speak up, but because the venous system is rarely part of the conversation until a vein specialist is involved."
— Dr. Sanjiv Lakhanpal
Founder, President, and CEO, Center for Vein Restoration
📍Find a Center for Vein Restoration near you HERE
📞 Call Center for Vein Restoration at 240-249-8250
📅 Or, book an appointment at CVR online HERE
PubMed Central confirms that chronic pelvic pain affects approximately 15 percent of women between the ages of 18 and 50 in the United States. It accounts for up to 40 percent of outpatient gynecology visits and up to 40 percent of all diagnostic laparoscopies performed each year. Yet in up to half of all cases evaluated, surgery does not identify a clear cause.
That gap matters. Because when the root cause goes unidentified, pain often goes untreated, or worse, it gets treated for the wrong condition.
Endometriosis is typically the first thing considered when a woman reports pelvic pain, and rightly so. But research published in PMC via the National Institutes of Health shows that PCS accounts for up to 30 percent of all chronic pelvic pain cases, yet it remains significantly underdiagnosed. PubMed Central
Endometriosis is an estrogen-dependent condition in which tissue similar to the lining of the uterus grows outside of it, attaching to the ovaries, fallopian tubes, or other pelvic structures, according to Mayo Clinic. Because this tissue responds to hormonal changes the same way the uterine lining does, it builds up and breaks down with each menstrual cycle, causing inflammation, scarring, and significant pain.
Pain from endometriosis is usually cyclic, meaning it tracks the rhythm of your period. It tends to be most intense just before and during menstruation. Other common symptoms include painful intercourse, painful bowel movements, and, in some cases, difficulty conceiving. Confirming an endometriosis diagnosis typically requires laparoscopy, a minimally invasive procedure that allows a physician to view the tissue directly.
PCS is a vascular condition. That means its origin is in the veins, not in hormonal tissue growth.
Inside healthy veins, tiny valves open and close to keep blood moving in the right direction. In PCS, those valves in the pelvic and ovarian veins stop functioning properly. Blood flows backward and pools, causing the veins to enlarge and press against nearby nerves. The result is a deep, persistent ache that many women describe as pressure, heaviness, or fullness in the lower pelvis.
Unlike endometriosis, PCS pain tends to be noncyclic. It does not follow menstrual timing. According to NIH StatPearls, PCS is prevalent in approximately two to 24 percent of women aged 18 to 50, and it accounts for 10 to 20 percent of gynecologic consultations. Yet only 40 percent of suspected cases are ever referred to a specialist for further evaluation.
PCS has a recognizable pattern of symptoms that sets it apart:
That last cluster of signs is particularly important. Endometriosis is not typically associated with the appearance of varicose veins, making visible pelvic or thigh varicosities a meaningful signal that the pain may have a vascular cause, according to Healthline.
You know your body. If something on that list felt familiar, it is worth following up. CVR's vein specialists are trained to evaluate the venous causes of pelvic pain that other exams routinely miss.
Endometriosis and PCS share enough symptoms that even experienced clinicians can mistake one for the other. Both cause chronic pelvic pain. Both can make intercourse painful. Both can affect quality of life in significant ways. And both can involve changes around the menstrual cycle.
Research published in Endovascular Today notes that endometriosis, fibroids, and pelvic inflammatory disease are usually considered first when a woman reports pelvic pain. In contrast, pelvic venous congestion is rarely included in the initial differential diagnosis. This is not a failure of individual physicians. It reflects a gap in awareness that has historically left PCS out of the standard workup, adds Endovascular Today.
There is also a diagnostic blind spot worth understanding. Standard laparoscopy, the gold standard tool for diagnosing endometriosis, is notoriously unreliable for finding pelvic congestion syndrome. During the procedure, the patient is lying flat and under anesthesia. Pelvic veins decompress in that position and may appear completely normal, even when reflux and pooling are significant under everyday, upright conditions. A negative laparoscopy does not rule out PCS, per Endometriosis Surgical Specialists International (ESSI).
Yes. Endometriosis and PCS can be diagnosed together. Healthline emphasizes that when this happens, inflammation from one condition can compound the swelling and inflammation of the other, worsening overall symptoms.
This is exactly why a complete vein evaluation matters.
Treating endometriosis alone will not resolve symptoms that have a vascular origin, and treating PCS will not address endometrial tissue growth. When both are present, both need to be identified.
👉 Book your consultation with a CVR vein specialist today and discover how simple relief can be.
If endometriosis has been ruled out, or if you have already received treatment for it but still have significant pelvic pain, a board-certified vein specialist should be part of your care team.
Vein specialists are trained to evaluate whether your symptoms have a vascular origin. Duplex ultrasound and other non-invasive imaging tools can identify venous reflux, vein dilation, and other hallmarks of PCS that standard gynecologic exams and laparoscopy can miss.
"Pelvic pain with a vascular origin is very real, very treatable, and very often missed. When we look at the complete picture, including the venous system, we frequently find the answers that women have been searching for across years of care."
— Dr. Sanjiv Lakhanpal
Living with unresolved pelvic pain is not just physically exhausting. It affects work, relationships, sleep, and the ability to trust that your health concerns are being taken seriously.
The board-certified vein specialists at Center for Vein Restoration are trained to determine whether your pain has a vascular component. With 120+ locations nationwide, CVR physicians can evaluate your symptoms, order the right imaging, and help you understand whether PCS is part of the picture, even if you have already received other diagnoses.
Q: What is the main difference between endometriosis and pelvic congestion syndrome?
A. Endometriosis is a hormonal condition in which tissue similar to the uterine lining grows outside the uterus, causing inflammation and pain that usually tracks with the menstrual cycle. Pelvic congestion syndrome is a vascular condition caused by faulty vein valves that allow blood to pool in the pelvis. PCS pain tends to be noncyclic and typically worsens over the course of the day, especially with prolonged standing or sitting.
Q: Can you have both endometriosis and pelvic congestion syndrome?
A. Yes. Both conditions can occur at the same time, and when they do, each one can make the other worse. This is one reason why pelvic pain sometimes continues even after successful endometriosis treatment. A thorough evaluation that looks at both gynecologic and vascular causes is important.
Q: Will a laparoscopy show if I have pelvic congestion syndrome?
A. Not reliably. Laparoscopy is the gold standard for diagnosing endometriosis, but it is a poor tool for detecting PCS. During the procedure, patients are lying flat under anesthesia, which causes pelvic veins to decompress. Affected veins may appear normal in that position even when they are significantly dysfunctional under everyday conditions. A negative laparoscopy does not rule out PCS.
Q: How is pelvic congestion syndrome diagnosed?
A. A vein specialist will typically begin with a review of your symptom pattern and a duplex ultrasound to evaluate blood flow in the pelvic veins. Additional imaging, including MRI or catheter venography, may be ordered to confirm the diagnosis. These tools can detect the venous reflux and dilation that characterize PCS.
Q: What type of doctor treats pelvic congestion syndrome?
A. PCS is best evaluated and treated by a board-certified vein specialist or interventional physician with expertise in pelvic venous disease. Because PCS involves the vascular system rather than gynecologic tissue, it falls outside the typical scope of a gynecologist or primary care provider. The specialists at Center for Vein Restoration are trained to evaluate exactly this kind of vascular pelvic pain.
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