Category Archives: Pain

Pelvic congestion syndrome as a frequent cause of chronic pelvic pain!

Pelvic congestion syndrome (PCS) is characterized by chronic pelvic discomfort exacerbated by prolonged standing and coitus in women who have periovarian varicosities on imaging studies. The etiology of PCS is unclear and the optimum treatment is uncertain. It primarily affects multiparous women in the reproductive age group and no cases have occurred in menopausal women.

The most commonly made diagnosis in chronic pelvic pain is endometriosis (31%). The majority are undiagnosed or improperly diagnosed.  In the majority of women with no obvious pathological cause for their pain, they may be suffering from pelvic congestion syndrome (PCS) instead. PCS accounts for up to 30% of patients presenting with chronic pelvic pain and is characterized by symptoms of dysmenorrhea, dysuria, and dyspareunia. PCS also carries a psychological burden and is often found in conjunction with increased levels of anxiety, stress, and depression.  It can often be found in conjunction with vulvar and pelvic varices in women and with varicoceles in men. Many patients will present with chronic, dull, lower abdominal pain often accompanied by dyspareunia and bladder irritability and urgency. The pain is typically relieved by lying down and exacerbated by standing up or increased intra-abdominal pressure, such as during pregnancy and the premenstrual period. Pain during intercourse or during the postcoital period is not uncommon.

Differential diagnosis in chronic pelvic pain is lengthy and includes pelvic inflammatory disease, endometriosis, pelvic tumors, interstitial cystitis, and inflammatory bowel disease

It has been found that there is gross dilatation, incompetence, and reflux of the ovarian veins in women with PCS.  Anatomic and hormonal factors lead to venous insufficiency of the ovarian veins and/or internal iliac veins, resulting in periovarian pelvic varicosities, thus producing pelvic venous congestion. Ovarian vein dilatation, stasis, and/or reflux on pelvic venography are common findings in multiparous premenopausal women but only some have symptoms. The use of venoconstrictors or ovarian vein ligation has produced relief of pain in some patients. Studies using Dihydroergotamine during an acute attack demonstrated relief of pain when the veins in the pelvis constrict.  (Lancet. 1987;2(8555):351) Multiparous women (who have had multiple pregnancies) have a higher prevelance of PCS due to the 50% increase in vascular congestion that occurs in pregnancy, leading to venous incompetence and reflux in the non-pregnant state and thus pain.

Extrinsic compression of the left renal vein between the aorta and superior mesenteric artery leads to an increase incidence of PCS on the left side of the pelvis. This results in left flank pain, hematuria, and pelvic congestion. It has been noted that the left ovarian veins have no valves, increasing congestion on the left side as well.

Menopause decreases the incidence of PCS because estrogen acts as a venodilator and of course is no longer present after menopause.

Examination will show tenderness on abdominal examination over the adnexa and history of postcoital aching pain.  Ultrasound may show incompetent and dilated ovarian veins which  are common but nonspecific findings. Also,  dilatation of the left ovarian vein with reversed caudal flow, presence of tortuous and dilated pelvic venous plexuses, and dilated arcuate veins crossing the uterine myometrium are found in PCS with increased diameters of the left ovarian vein at 7.9 mm (usual is 5.4 mm).

Selective ovarian and internal iliac venography through catheterization of the right and left ovarian veins via a percutaneous femoral or jugular approach demonstrate abnormally dilated ovarian veins (>10 mm in diameter), sluggish blood flow, reflux causing retrograde fill and congestion of the ovarian venous plexus in PCS. Up to 80 % of premenopausal women  are found to have pelvic varicosities and venous stasis.

 Computed tomography (CT) and magnetic resonance (MR) imaging identify tortuous, dilated pelvic and ovarian veins, broad ligament vascular congestion, and ovarian varicoceles better than ultrasound imaging. A growing body of data suggests that magnetic resonance venography (MRV) and CT scan are just as useful as pelvic Ultrasound.

Treatment :

Treatment of PCS consists of hormone therapy, embolotherapy, sclerotherapy, and endovascular and open surgery

First options are medical treatment using Goserelin, Medroxyprogesterone acetate, or etongestrel implants to hormonally treat the vascular congestion.

Invasive therapies that are successful include procedures such as embolization or sclerotherapy of the ovarian veins with or without the internal iliac veins. This involves interventional radiology:

Pelvic congestion link

Success rates of ovarian vein embolization range from 89 to 100 percent.  Surgical ligation of the ovarian vein has been associated with improvement in pain in approximately 75 percent.

DIagnosis and treatment of pevic congestion syndrome (1)

Current Concepts of Pelvic Congestion and chronic pelvic pain

Pelvic Congestion Syndrome Diagnosis and treatment

Mast Cell-Mediated Mechanisms of Nociception

Pelvic congestion syndrome
Pelvic congestion syndrome

pelvic congestion 220px-9cmFibroidUS PelvicCongestion-Ex1


Edwards RD, Robertson IR, MacLean AB, Hemingway AP. Case report: pelvic pain syndrome – successful treatment by ovarian vein embolization. Clin Radiol. 1993;47:429-431.

14. Kindgen-Milles D, Arndt JO. Nitric oxide as a chemical link in the generation of pain from veins in humans. Pain. 1996;64:139-142.

13. Stones RW, Thomas DC, Beard RW. Suprasensitivity to calcitonin gene-related peptide but not vasoactive intestinal peptide in women with chronic pelvic pain. Clin Auton Res. 1992;2:343- 348.

12. Stones RW, Vials A, Milner P, Beard RW, Burnstock G. Release of vasoactive agents from the isolated perfused human ovary. Eur J Obstet Gynecol Reprod Biol. 1996;67:191-196.

Beard RW, Reginald PW, Pearce S. Psychological and somatic factors in women with pain due to pelvic congestion. Adv Exp Biol Med. 1988;245:413-421.

Allen WA. Chronic pelvic congestion and pelvic pain. Am J Obstet Gynecol. 1971:109:198-202.

Capasso P, Simons C, Trotteur g, Dondelinger RF, Henroteaux D, Gaspard U. Treatment of symptomatic pelvic varices by ovarian vein embolization. Cardiovasc Intervent Radiol. 1997:20:107-111.

Kim HS, Malhotra AD, Rowe PC, Lee JM, Venbrux AC. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol 2006;17(Pt 1):289-97.

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;16:931-9.

Kim KW, Cho JY, Kim SH, Yoon JH, Kim DS, Chung JW, et al. Diagnostic value of computed tomographic findings of nutcracker syndrome: correlation with renal venography and renocaval pressure gradients. Eur J Radiol 2011;80:648-54.

Malgor RD, Labropoulos N. Diagnosis of venous disease with duplex ultrasound. Phlebology 2013;28(Suppl 1):158-61.

Asciutto G, Asciutto KC, Mumme A, Geier B. Pelvic venous incompetence: reflux patterns and treatment results. Eur J Vasc Endovasc Surg 2009;38:381-6.

Kurklinsky AK, Rooke TW. Nutcracker phenomenon and nutcracker syndrome. Mayo Clin Proc 2010;85:552-9.

Asciutto G, Mumme A, Marpe B, Koster O, Asciutto KC, Geier B. MR venography in the detection of pelvic venous congestion. Eur J Vasc Endovasc Surg 2008;36:491-6.



Chondroiton Sulfate and Glucosamine is effective in moderate-to-severe knee osteoarthritis.

lo res cartilage structure copy GlucosamineCombined chondroitin sulfate and glucosamine on Knee osteoarthritis

The MOVES trial tested whether chondroitin sulfate (CS)  plus glucosamine hydrochloride (GH) has comparable
efficacy to celecoxib after 6 months of treatment in patients
with painful knee osteoarthritis.

MOVES study for Chondroiton Sulfate and GH  < LINK to study

  • The trial tested 606 patients with moderate-to-severe knee osteoarthritis (OA) based on a WOMAC (Western Ontario and McMaster osteoarthritis index) scale >301 (range is 0-500). Treatment with 400 mg of CS and 500 mg GH three times a day was compared with the effects of Celocoxib 200 mg once a day for 6 months.
  • The results: Both treatments were equally effective. For CS/GH Vs.  Celocoxib, both treatments resulted in decreasing pain by 50% as well as joint swelling.
  • In summary: Using either Celocoxib or GH/CS had equal effect in decreasing joint stiffness, pain, functional limitations, and joint swelling after 6 months in the treatment of OA of the knee.
  • Be certain to obtain your GH/CS from a trusted source which can be checked on line at Consumer Lab  or the US Pharmacopeia.
  • Side effects of Glucosamine may be an increase in glucose levels, so be careful if you are diabetic. Also if you have an allergy to shellfish, Glucosamine can be derived from materials in shellfish, so again be careful.
  • Recommended daily doses of Glucosamine is 1,500 mg ans 1,200 mg of chondroiton.
  •  Glucosamine, Chondroitin Sulfate, and the Two in Combination NEJM  GAIT trial < link to gate trial. A prior study in the New Englandd Journal of Medicine had shown results hinting that CS/GH work best in moderate-to-severe disease, but not so much is lesser OA pain.In the study discussion, it was noted:  Analysis of the prespecified subgroup of patients with moderate-to severe pain demonstrated that combination therapy significantly decreased knee pain related to osteoarthritis, as measured by the primary outcome or by the OMERACT–OARSI response rate. We did not identify significant benefits associated with the use of glucosamine or chondroitin sulfate alone. Although the results for glucosamine did not reach significance, the possibility of a positive  effect in the subgroup of patients with moderate-to-severe pain cannot be excluded, since the difference from placebo in the OMERACT–OARSI response rate approached significance in this group. Treatment with chondroitin sulfate was associated with a significant decrease in the incidence of joint swelling, effusion, or both. We did not find an increased risk of ischemic cardiovascular events among patients who received celecoxib or among patients with diabetes who received glucosamine, but this study was not powered to assess these risks… Our finding is that the combination of glucosamine and chondroitin sulfate may have some efficacy in patients with moderate-to-severe symptoms.
  • Be certain to lose weight and exercise.  Obesity places huge stress on knees and ankles and hips. Supplements should complement these steps.


Insane Medicine – Arthritis pain and what to do:

Arthritis Pain:


Arthritis affects millions of individuals, reducing quality of life.  There are multiple facets that can be addressed regarding arthritis pain and what to do, but I will address several points:

  • Exercise added to the daily routine is the best way to help combat arthritis. Unused joint cause increased pain. What type of exercise? Flexibility Exercises, strength training, and aerobic exercises all help combat joint pain. They also help an individual lose weight as well, which increases mobility.
  • Range of motion exercises can help with stiffness and can improve mobility. Flexibility  exercises allow one to do this. Tai chi and yoga are examples.
  • Preserve your muscle mass with strength training at least three times a week. This also allows one to lose weight and helps maintain mobility. Muscle training helps support the joint structure and function, such as the knees. This decreases joint stress.
  • Aerobic exercises also add a lot to overall health and diminish joint pain. Swimming is low impact. Walking is another option.

Options to help arthritis pain:

  • Heat application: Relaxes the muscles and increases blood flow to affected areas, helping provide nutrients and oxygen. This is useful in multiple areas such as knee, neck, and back pain.
  • Cold Applications: Cold packs can be used acutely after exercise to decrease inflammation, muscle spasms, and pain, especially in the first 72 hours, after which, use heat.
  • Emotional support: Remember that a large challenge to arthritis is the emotional impact. Cognitive behavioral therapy is an option to help one cope with the pain of arthritis. Remember to keep busy and keep moving. Meditation can help overcome the negative emotions that can actually increase your pain. Pain can increase your anxiety and depression. Insomnia can result from arthritis pain, so the emotional impact is huge as arthritis affects so many facets in one’s life.
  • Acupuncture: This may be an option in some individuals. Consider going online to find a certified acupuncture specialist near you.
  • Spinal Manipulation Therapy (SMT): Look at the entire body and evaluate the triggers that aggravate arthritis. SMT can reduce stiffness and help with joint movement.  These changes in joint mobility have a local effect on the chemical factors that cause inflammation and pain. The joint may be the culprit in causing stiffness or the muscles surrounding the joint may be inflamed or spastic, resulting in lower mobility and pain.
  • Physical Therapy: Consult your physician for a PT referral., which can help you find ways to promote strength and flexibility.
  • Quit Smoking: Smoking lowers bone density.

Remember that muscles support your bones, and it is important to increase your muscle mass as it provides numerous benefits in addition to supporting your joints and your back. The back, in particular, with it’s discs and small facets, is affected over time by pressure, which can be unloaded by stretching and strengthening the spinal muscles through basic exercises like:

  1. Pelvic tilt exercises:

    Pelvic tilt
    Pelvic tilt
  2. One -legged wind releasing

    one legged wind releasing
    one legged wind releasing
  3. trunk lift
    trunk lift
    trunk lift

    You need core muscle strength and flexibility to help preserve your back. The hip muscles need to have flexibility maintained as well for better back health. Consider doing this through the 4.hammerstring stretch:

    hammerstring stretch
    hammerstring stretch


  4. hamstring-stretch-seated
    hamstring-stretch-seated< link to stretching blog – and alternative therapies.


Insane Medicine – Passion fruit peel has some efficacy for arthritis pain.

Insane Medicine - Passion fruit for arthritis pain
Passion fruit for arthritis pain.
  • Passiflora edulis has shown to reduce joint pain and stiffness by close to 20% when the passion fruit peel (150 mg a day) was taken for two months.
  • Passion fruit has flavonoids with anti-oxidant and anti-inflammatory ability. It may also be helpful in reducing blood pressure and asthma.
  • You can add this fruit to your well-rounded diet. It comes in many forms including puree, concentrate, or as the fresh fruit itself.
  • In addition to passion fruit for your pains, incorporate other avenues of treatment including appropriate exercise and stretching exercises. Increase your vegetable intake for the anti-inflammatory component, as well as spices such as tumeric and ginger, for their inflammation-fighting abilities. Don’t forget the omega-3 fatty acids found in fish and walnuts, which can help reduce your pain as well!


Insane Medicine – Chronic pain and it’s emotional component

  • Chronic pain affects both cognitive and emotional circuits in the brain as both mood and cognition are affected. Basically, an injury causes changes in the body’s chemistry and function which results in a change in the brain’s circuitry on how we perceive pain. Normal emotional processing is damaged.
  • Initially, acute pain is perceived in brain regions involved with pain reception, but as it transitions to chronic pain, it is perceived in centers of the brain that are involved with the mediation of emotions. Chronic pain involves abnormal stress responses, in which patients with chronic pain have higher cortisol stress hormone released to a painful stimulus. They also have smaller hippocampus areas of the brain that are involved in memory, learning, and emotions, This area of the brain begins to process pain signals poorly while areas of the brain that are involved in anticipatory anxiety and associative learning have over activity. There appears to be connectivity problems between brain areas involved in mood and cognitive function. This results not on ly in the sensation of pain, but also mood disorders such as anxiety and problems with decision-making.
  • Significant factors leading to chronic pain include non-restorative sleep, anxiety, memory impairment, and poor quality of life.
  • Things that help: Get regular exercise at least 30 minutes a day for 5 days a week. Ensure healthful sleep with good sleep hygiene. Be certain to sleep in a quiet, comfortable environment and avoid caffeine and strenuous activities before bedtime. Become more active in Lifesocialize more and get involved with hobby or helping others.
  • Other options for treatment include vagal-nerve stimulation to interfere with pain perception and transcranial magnetic stimulation, in which a magnet is used to alter nerve circuits in the brain that are involved with pain. Cognitive behavioral therapy, acupuncture, and meditation are also means of combating chronic pain.