Modern ideas about pharmacotherapy of pelvic congestion syndrome in women
https://doi.org/10.21518/akh2024-039
Abstract
Pelvic congestion syndrome (PCS) is not a rare and poorly studied disease. However, the current state of PCS pharmacotherapy is characterized not only by insufficient study of this issue, but also by the presence of conflicting views. The results of key publications prove that the main trend in PCS treatment is associated with invasive methods. At the same time, pharmacotherapy is a successful solution leading to the relief of the main symptoms in most patients with PCS. The current review is based on the analysis of data from known scientific literature and clinical guidelines. It covers various aspects of conservative treatment of patients with PCS and focuses on pharmacotherapy. This publication aims to summarize the known data related to drug correction of PCS, based on evidence-based medicine. The review presents information related to the history of the selection of pharmacotherapy, including combinations of drugs of various groups with the appointment of analgesics, hormonal, psychotropic, venoactive drugs and selective vasoconstrictors. An objective analysis of each of the indicated pharmacological groups of drugs is presented with an assessment of subsequent prospects, including not only known therapeutic agents, but also those not previously used in the therapy of PCS. The drug of choice in the arsenal of the attending physician are vasoactive drugs based on diosmin with the largest evidence base in MPFF. In the presence of severe pain syndrome, short-term administration of analgesics is advisable. The presence of anxiety-depressive disorders, as well as severe CPP, can serve as an indication for taking psychotropic drugs. Further research is needed to expand the potential of pharmacotherapy for patients with PCS.
About the Authors
R. V. Akhmetzianov
Kazan State Medical University;
Interregional Clinical Diagnostic Center
Russian Federation
Russian Federation
Rustem V. Akhmetzianov, Dr. Sci. (Med.), Assistant Professor, Department of Cardiovascular and Endovascular Surgery; Cardiovascular Surgeon
49, Butlerov St., Kazan, 420012, Russia
12a, Karbyshev St., Kazan, 420101, Russia
R. A. Bredikhin
Kazan State Medical University;
Interregional Clinical Diagnostic Center
Russian Federation
Russian Federation
Roman A. Bredikhin, Dr. Sci. (Med.), Professor, Department of Cardiovascular and Endovascular Surgery; Head of the Vascular Surgery Department
49, Butlerov St., Kazan, 420012, Russia
12a, Karbyshev St., Kazan, 420101, Russia
References
1. Gloviczki P, Dalsing MC, Eklof Bo, Gloviczki ML, Lurie F, Wakefield TW (eds.). Handbook of Venous and Lymphatic Disorders. 4th ed. CRC Press; 2017. 48 р. https://doi.org/10.1201/9781315382449.
2. Giacchetto C, Cotroneo GB, Marincolo F, Cammisuli F, Caruso G, Catizone F. Ovarian varicocele: ultrasonic and phlebographic evaluation. J Clin Ultrasound. 1990;18(7):551–555. https://doi.org/10.1002/jcu.1870180705.
3. Howard FM. Chronic pelvic pain. Obstet Gynecol. 2003;101(3):594–611. https://doi.org/10.1016/s0029-7844(02)02723-0.
4. Liddle AD, Davies AH. Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology. 2007;22(3):100–104. https://doi.org/10.1258/026835507780807248.
5. Gavrilov SG, Turischeva OO. Conservative treatment of pelvic congestion syndrome: indications and opportunities. Curr Med Res Opin. 2017;33(6):1099–1103. https://doi.org/10.1080/03007995.2017.1302414.
6. Antignani PL, Lazarashvili Z, Monedero JL, Ezpeleta SZ, Whiteley MS, Khilnani NM et al. Diagnosis and treatment of pelvic congestion syndrome: UIP consensus document. Int Angiol. 2019;38(4):265–283. https://doi.org/10.23736/S0392-9590.19.04237-8.
7. Dai M, Bai M, Chen Y, Li J, Wan T, Jiang H. Application of Comprehensive Pelvic Floor Rehabilitation Therapy in Congestion Syndrome with Pelvic Oblique: A Case Report. Altern Ther Health Med. 2024;30(10):59–65. Available at: https://pubmed.ncbi.nlm.nih.gov/38401109.
8. Gavrilov SG, Karalkin AV, Turischeva OO. Compression treatment of pelvic congestion syndrome. Phlebology. 2018;33(6):418–424. https://doi.org/10.1177/0268355517717424.
9. Haugstad GK, Haugstad TS, Kirste UM, Leganger S, Wojniusz S, Klemmetsen I, Malt UF. Continuing improvement of chronic pelvic pain in women after short-term Mensendieck somatocognitive therapy: results of a 1-year follow-up study. Am J Obstet Gynecol. 2008;199(6):615.e1–8. https://doi.org/10.1016/j.ajog.2008.06.019.
10. Marhic C. Varicose vulvaire et grossesse. Rev Fr Gynecol Obstet. 1991;86(2):184–186. Available at: https://www.pubmed.ncbi.nlm.nih.gov/1767171.
11. Till SR, As-Sanie S, Schrepf A. Psychology of Chronic Pelvic Pain: Prevalence, Neurobiological Vulnerabilities, and Treatment. Clin Obstet Gynecol. 2019;62(1):22–36. https://doi.org/10.1097/GRF.0000000000000412.
12. Ахметзянов РВ, Бредихин РА. Варикозная болезнь таза: современные аспекты диагностики и лечения. Казань: ИД МеДДок; 2022. 136 с.
13. Dzhenina OV, Bogachev VYu, Bodanskaya АL. Vulvar and perineal varicose veins in pregnant women. Ambulatornaya Khirurgiya. 2019;(1-2):14–18. (In Russ.) https://doi.org/10.21518/1995-1477-2019-1-2-14-18.
14. Nicholson T, Basile A. Pelvic congestion syndrome, who should we treat and how? Tech Vasc Interv Radiol. 2006;9(1):19–23. https://doi.org/10.1053/j.tvir.2006.08.005.
15. Speer LM, Mushkbar S, Erbele T. Chronic Pelvic Pain in Women. Am Fam Physician. 2016;93(5):380–387. Available at: https://pubmed.ncbi.nlm.nih.gov/26926975.
16. Bindu S, Mazumder S, Bandyopadhyay U. Non-steroidal anti-inflammatory drugs (NSAIDs) and organ damage: A current perspective. Biochem Pharmacol. 2020;180:114147. https://doi.org/10.1016/j.bcp.2020.114147.
17. Jarrell JF, Vilos GA, Allaire C, Burgess S, Fortin C, Gerwin R et al. No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain. J Obstet Gynaecol Can. 2018;40(11):e747–e787. https://doi.org/10.1016/j.jogc.2018.08.015.
18. Valentine LN, Deimling TA. Opioids and Alternatives in Female Chronic Pelvic Pain. Semin Reprod Med. 2018;36(2):164–172. https://doi.org/10.1055/s-0038-1676102.
19. Meissner MH, Khilnani NM, Labropoulos N, Gasparis AP, Gibson K, Greiner M et al. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. J Vasc Surg Venous Lymphat Disord. 2021;9(3):568–584. https://doi.org/10.1016/j.jvsv.2020.12.084.
20. Farquhar CM, Rogers V, Franks S, Pearce S, Wadsworth J, Beard RW. A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion. Br J Obstet Gynaecol. 1989;96(10):1153–1162. https://doi.org/10.1111/j.1471-0528.1989.tb03190.x.
21. Walton SM, Batra HK. The use of medroxyprogesterone acetate 50 mg in the treatment of painful pelvic conditions: preliminary results from a multicentre trial. J Obstet Gynaecol. 1992;12:(2):50–53. Available at: https://www.tandfonline.com/doi/abs/10.3109/01443619209045614.
22. Reginald PW, Adams J, Franks S, Wadsworth J, Beard RW. Medroxyprogesterone acetate in the treatment of pelvic pain due to venous congestion. Br J Obstet Gynaecol. 1989;96(10):1148–1152. https://doi.org/10.1111/j.1471-0528.1989.tb03189.x.
23. Gangar KF, Stones RW, Saunders D, Rogers V, Rae T, Cooper S, Beard RW. An alternative to hysterectomy? GnRH analogue combined with hormone replacement therapy. Br J Obstet Gynaecol. 1993;100(4):360–364. https://doi.org/10.1111/j.1471-0528.1993.tb12980.x.
24. Shokeir T, Amr M, Abdelshaheed M. The efficacy of Implanon for the treatment of chronic pelvic pain associated with pelvic congestion: 1-year randomized controlled pilot study. Arch Gynecol Obstet. 2009;280(3):437–443. https://doi.org/10.1007/s00404-009-0951-1.
25. Soysal ME, Soysal S, Vicdan K, Ozer S. A randomized controlled trial of goserelin and medroxyprogesterone acetate in the treatment of pelvic congestion. Hum Reprod. 2001;16(5):931–939. https://doi.org/10.1093/humrep/16.5.931.
26. Black CM, Thorpe K, Venrbux A, Kim HS, Millward SF, Clark TW et al. Research reporting standards for endovascular treatment of pelvic venous insufficiency. J Vasc Interv Radiol. 2010;21(6):796–803. https://doi.org/10.1016/j.jvir.2010.02.017.
27. Cheong YC, Smotra G, Williams AC. Non-surgical interventions for the management of chronic pelvic pain. Cochrane Database Syst Rev. 2014;2014(3):CD008797. https://doi.org/10.1002/14651858.CD008797.pub2.
28. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5):2S–48S. https://doi.org/10.1016/j.jvs.2011.01.079.
29. O’Brien MT, Gillespie DL. Diagnosis and treatment of the pelvic congestion syndrome. J Vasc Surg Venous Lymphat Disord. 2015;3(1): 96–106. https://doi.org/10.1016/j.jvsv.2014.05.007.
30. Stones RW, Bradbury L, Anderson D. Randomized placebo controlled trial of lofexidine hydrochloride for chronic pelvic pain in women. Hum Reprod. 2001;16(8):1719–1721. https://doi.org/10.1093/humrep/16.8.1719.
31. Engel CCJr, Walker EA, Engel AL, Bullis J, Armstrong A. A randomized, double-blind crossover trial of sertraline in women with chronic pelvic pain. J Psychosom Res. 1998;44(2):203–207. https://doi.org/10.1016/s0022-3999(97)00215-8.
32. Sator-Katzenschlager SM, Scharbert G, Kress HG, Frickey N, Ellend A, Gleiss A, Kozek-Langenecker SA. Chronic pelvic pain treated with gabapentin and amitriptyline: a randomized controlled pilot study. Wien Klin Wochenschr. 2005;117(21–22):761–768. https://doi.org/:10.1007/s00508-005-0464-2.
33. Beresin EV. Imipramine in the treatment of chronic pelvic pain. Psychosomatics. 1986;27(4):294–296. https://doi.org/10.1016/S0033-3182(86)72705-9.
34. Walker EA, Roy-Byrne PP, Katon WJ, Jemelka R. An open trial of nortriptyline in women with chronic pelvic pain. Int J Psychiatry Med. 1991;21(3):245–252. https://doi.org/10.2190/EXRP-J206-CBWT-UTFK.
35. Brown CS, Franks AS, Wan J, Ling FW. Citalopram in the treatment of women with chronic pelvic pain: an open-label trial. J Reprod Med. 2008;53(3):191–195. Available at: https://www.europepmc.org/article/med/18441724.
36. Hackl H, Lindström B, Orstam S, Palm O, Stafsnes H. Pelvic pain syndrome in women – a psychiatric-gynaecological study. Wien Klin Wochenschr. 1980;92(7):252–255. (In German.) Available at: https://www.pubmed.ncbi.nlm.nih.gov/7395238.
37. Reginald PW, Beard RW, Kooner JS, et al. Intravenous dihydroergotamine to relieve pelvic congestion with pain in young women. Lancet. 1987;2(8555):351–353. https://doi.org/10.1016/s0140-6736(87)92380-4.
38. Stones RW, Rae T, Rogers V, Fry R, Beard RW. Pelvic congestion in women: evaluation with transvaginal ultrasound and observation of venous pharmacology. Br J Radiol. 1990;63(753):710–711. https://doi.org/10.1259/0007-1285-63-753-710.
39. Barthel W. Venous tonus-modifying effect, pharmacokinetics and undesired effects of dihydroergotamine. Z Gesamte Inn Med. 1984;39(17):417–428. Available at: https://www.europepmc.org/article/med/6390997.
40. https://phlebounion.ru/files/uploads/rek-afr/КР%20АФР%20ВРВТ%201_2024.pdf.
41. Akhmetzianov RV. The new patient-oriented tools for clinical assessment of pelvic varicose disease. Phlebolymphology. 2022;29(1):16–26. Available at: https://www.phlebolymphology.org/the-new-patient-oriented-tools-for-clinical-assessment-of-pelvic-varicose-disease.
42. Taskin O, Uryan II, Buhur A, Burak F, Erden F, Atmaca R, Wheeler M. The Effects of Daflon on Pelvic Pain in Women with Taylor Syndrome. J Am Assoc Gynecol Laparosc. 1996;3(4):49. Available at: https://pubmed.ncbi.nlm.nih.gov/9074246.
43. Simsek M, Burak F, Taskin O. Effects of micronized purified flavonoid fraction (Daflon) on pelvic pain in women with laparoscopically diagnosed pelvic congestion syndrome: a randomized crossover trial. Clin Exp Obstet Gynecol. 2007;34(2):96–98. Available at: https://www.pubmed.ncbi.nlm.nih.gov/17629162.
44. Burak F, Gunduz T, Simsek M, Taskin O. Chronic pelvic pain associated with pelvic congestion syndrome and the benefit of Daflon 500 mg: a review. Phlebolymphology. 2009;16:(3):290–294. Available at: https://www.phlebolymphology.org/chronic-pelvic-pain-associatedwith-pelvic-congestion-syndrome-and-the-benefit-of-mpff-500-mg-a-review.
45. Moses VG. Efficiency of Detralex in conservative treatment of varicose veins of the pelvis in women. Farmateka. 2005;(16):48–50. (In Russ.) Available at: https://pharmateca.ru/ru/archive/article/6312.
46. Akhmetzianov RV, Bredikhin RA. Clinical Efficacy of Conservative Treatment with Micronized Purified Flavonoid Fraction in Female Patients with Pelvic Congestion Syndrome. Pain Ther. 2021;10(2):1567–1578. https://doi.org/10.1007/s40122-021-00312-6.
47. Serfaty D, Magneron AC. Premenstrual syndrome in France: epidemiology and therapeutic effectiveness of 1000 mg of micronized purified flavonoid fraction in 1473 gynecological patients. Contracept Fertil Sex. 1997;25(1):85–90. (In French.) Available at: https://pubmed.ncbi.nlm.nih.gov/9064059.
48. Gavrilov SG, Karalkin AV, Moskalenko EP, Belyaeva ES, Yanina AM, Kirienko AI. Micronized purified flavonoid fraction in treatment of pelvic varicose veins. Angiology and Vascular Surgery. 2012;18(1):71–75. (In Russ.) Available at: https://www.angiolsurgery.org/magazine/2012/1/10.htm.
49. Gavrilov SG, Moskalenko YP, Karalkin AV. Effectiveness and safety of micronized purified flavonoid fraction for the treatment of concomitant varicose veins of the pelvis and lower extremities. Curr Med Res Opin. 2019;35(6):1019–1026. https://doi.org/10.1080/03007995.2018.1552043.
50. Gavrilov SG, Karalkin AV, Moskalenko YP, Grishenkova AS. Efficacy of two micronized purified flavonoid fraction dosing regimens in the pelvic venous pain relief. Int Angiol. 2021;40(3):180–186. https://doi.org/10.23736/S0392-9590.21.04579-X.
51. Tsukanov YT, Tsukanov AY, Levdanskiy EG. Secondary Varicose Small Pelvic Veins and Their Treatment with Micronized Purified Flavonoid Fraction. Int J Angiol. 2016;25(2):121–127. https://doi.org/10.1055/s-0035-1570118.
52. Tsukanov YuТ, Tsukanov AIu, Levdansky EG. The results of the Application of the Micronized Purified Flavonoid Fraction for the Treatment of Secondary Varicose Veins in the Small Pelvis. Flebologiya. 2015;9(3):34–40. (In Russ.) https://doi.org/10.17116/flebo20159334-40.
53. Akhmetzianov RV, Bredikhin RA. Clinical efficacy of Detralex in treatment of women with pelvic varicose veins. Angiology and Vascular Surgery. 2018;24:(2):93–99 (In Russ.) Available at: https://www.angiolsurgery.org/magazine/2018/2/9.htm.
54. Shibelgut NM, Zakharov IS, Moses VG, Kolesnikova NB. Quality of life in women with varicose veins of the pelvis. Angiology and Vascular Surgery. 2010;16(2):50–53. (In Russ.) Available at: https://www.angiolsurgery.org/magazine/2010/2/7.htm.
55. Gibson K, Minjarez R. Vascular Disease Patient Information Page: Pelvic venous reflux (pelvic congestion syndrome). Vasc Med. 2019;24(5):467–471. https://doi.org/10.1177/1358863X19868282.
56. Durham JD, Machan L. Pelvic congestion syndrome. Semin Intervent Radiol. 2013;30(4):372–380. https://doi.org/10.1055/s-0033-1359731.
57. Dzhenina OV, Bogachev VYu, Lobanov VN, Bodanskaya AL. Symptomatic therapy for vulvar and perineal varicosities in pregnant women. Russian Bulletin of Obstetrician-Gynecologist. 2018;18(5):82–87. (In Russ.) https://doi.org/10.17116/rosakush20181805182.
58. Grandi G, Feliciello L, Iaccheri M, Melotti C, Anceschi F, Facchinetti F. The effect of a flavonoid mixture containing diosmin, hesperidin and troxerutin in women with congestion syndrome associated to pelvic pain: a color Doppler ultrasonography study. Minerva Obstet Gynecol. 2024;76(3):250–256. https://doi.org/10.23736/S2724-606X.24.05432-0.
59. Lacroix I, Beau AB, Hurault-Delarue C, Bouilhac C, Petiot D, Vayssière C et al. First epidemiological data for venotonics in pregnancy from the EFEMERIS database. Phlebology. 2016;31(5):344–348. https://doi.org/10.1177/0268355515589679.
60. Gavrilov SG, Karalkin AV, Mishakina NY, Grishenkova AS. Hemodynamic and neurobiological factors for the development of chronic pelvic pain in patients with pelvic venous disorder. J Vasc Surg Venous Lymphat Disord. 2023;11(3):610–618.e3. https://doi.org/10.1016/j.jvsv.2023.01.006.
61. Phillips D, Deipolyi AR, Hesketh RL, Midia M, Oklu R. Pelvic congestion syndrome: etiology of pain, diagnosis, and clinical management. J Vasc Interv Radiol. 2014;25(5):725–733. doi:10.1016/j.jvir.2014.01.030.
62. Stupin DA, Kolesnikova LI, Semendyaev AA, Darenskaya MA, Tukhieva DV, Bystrova ES et al. Clinical efficacy of complex antioxidant therapy for pelvic varicose veins in women: A prospective non-randomized controlled study. Gynecology. 2024;26(1):52–58. (In Russ.) https://doi.org/10.26442/20795696.2024.1.202556.
63. Akhmetzyanov RV, Bredikhin RA, Fomina EE. Quality of Life Assessment in Patients with Pelvic Varicose Veins. Flebologiya. 2019;13(2):133–139. (In Russ.) https://doi.org/10.17116/flebo201913021133.
Review
For citations:
Akhmetzianov R.V., Bredikhin R.A. Modern ideas about pharmacotherapy of pelvic congestion syndrome in women. Ambulatornaya khirurgiya = Ambulatory Surgery (Russia). 2024;21(2):94-103. (In Russ.) https://doi.org/10.21518/akh2024-039
Views:
1876
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International.
Email this article 