For some, it takes years of circulation through various doctor practices. Chronic pelvic pain, passed from gynecology to gastroenterology and back again, often without a diagnosis, until patients begin to search for answers themselves.
Many ultimately presenting to interventional radiology for pelvic congestion syndrome (PCS) do so as self-referrals, having effectively diagnosed their condition online before finding a clinician willing to treat it, noted Assoc. Prof. Dr. Florian Wolf, MBA, vice director of the division of cardiovascular imaging and interventional radiology at the Medical University of Vienna in Austria, the moderator at an ECR 2026 session on gynecological interventional radiology.
Wolf's observation reflects a broader pattern: rare is the patient who arrives via a direct referral from another specialist.
PCS is increasingly recognized as a significant contributor to chronic pelvic pain and is often cited as one of the leading causes after endometriosis, although its true prevalence remains uncertain. Described in the 19th century, it is still considered by some gynecologists not to be a pathology at all.
The condition is clinically defined as noncyclical pelvic pain lasting more than six months, driven by dilated ovarian and pelvic veins. It may be primary, due to valve insufficiency, or secondary to upstream venous compression syndromes such as Nutcracker or May-Thurner.
Diagnosis and staging
While diagnosis has evolved, it remains inconsistently applied. Ultrasound, specifically transvaginal imaging with Valsalva maneuver, and where feasible in a standing position, serves as the first step. MRI is used to confirm findings and exclude competing diagnoses such as endometriosis. Increasingly, phlebography is performed in the same session as treatment rather than as a standalone diagnostic step.
The Symptoms, Varices, Pathophysiology (SVP) score offers a standardized framework for evaluation, designed to objectify what has historically been dismissed as subjective symptomatology. It is not yet universally adopted, but its proponents argue it addresses one of the core barriers to taking PCS seriously: the absence of an agreed objective baseline. The lack of standardized evaluation has long contributed to delayed diagnosis and skepticism, reinforcing the diagnostic loop patients experience before reaching interventional radiology.
Embolization achieves technical success rates above 95%, with clinical improvement in more than 75% of patients at one year and complication rates below 3%. The procedure is typically performed as a day case, with patients returning to normal activity within days. Distal sclerotherapy using 3% polidocanol is combined with proximal coil embolization, using either resorbable or nonresorbable agents.
"It's a vascular disease, not a gynecological disease," said Francesco Giurazza, MD, PhD, of the Azienda Ospedaliera Antonio Cardarelli in Naples, Italy.Photo courtesy of Claudia Tschabuschnig
One unresolved question is whether to routinely treat the hypogastric trunks in the same session, there is no consensus yet. For secondary PCS, in cases of Nutcracker syndrome, the emphasis is on stenting the compressed vein rather than relying on embolization alone. As Francesco Giurazza, MD, PhD, of the Vascular and Interventional Radiology Department, Azienda Ospedaliera Antonio Cardarelli in Naples, Italy, put it: "It's a vascular disease, not a gynecological disease."
Fibroid embolization and fertility
If PCS illustrates the diagnostic gap, uterine fibroid embolization (UFE) highlights how technical refinement continues to shape an already established therapy, particularly as fertility preservation becomes a more prominent consideration.
"MRI is here essential as a pre- and post-interventional imaging tool," said Dr. Geert Maleux, MD, PhD, of University Hospitals Leuven in Leuven, Belgium.Photo courtesy of Claudia Tschabuschnig
UFE is widely practiced, but procedural nuance matters. Dr. Geert Maleux, MD, PhD, of University Hospitals Leuven in Leuven, Belgium, demonstrated how 3D angiography can optimize oblique projections, reducing radiation exposure compared to multiple 2D acquisitions. Identifying vascular supply remains critical.
Hypovascular myomas, although uncommon, can lead to incomplete treatment if ovarian artery contribution is missed. This occurs in fewer than 3% of cases but has outsized implications: when the uterine artery blush appears thin, aortography should be performed to identify alternative supply, including variants arising from accessory renal arteries.
Choice of embolic agent continues to evolve. Nonspherical PVA particles and calibrated microspheres (500 to 900 microns) remain standard, now joined by resorbable microspheres. Clinical outcomes, including pain control, infarction rates, and analgesia requirements, appear comparable between materials. The distinction lies in vascular recovery: resorbable agents allow full uterine artery recanalization within six weeks, a potentially meaningful factor for patients seeking pregnancy after the procedure.
Pregnancy remains possible after UFE even with nonresorbable microspheres. In a series of more than 200 patients, Maleux reported that approximately 40% of those attempting conception after UFE were successful. Complication rates remain low, under 2% in over 300 cases, with only a single reported infection related to necrotic myoma. As Maleux noted, "MRI is here essential as a pre- and post-interventional imaging tool."
Both PCS embolization and UFE show that interventional radiology can deliver effective, minimally invasive solutions to conditions that often fall through the cracks of traditional referral pathways. What remains is the structural gap, and the question of when referral patterns will finally reflect what IR can already do.
