Conservative treatment of pelvic venous disease

Pelvic venous incompetence (PVI), although usually asymptomatic, may cause pelvic venous disease (PeVD), which may clinically manifest through pelvic symptoms, particularly chronic pelvic pain (CPP). There is no standard approach to manage PeVD and, therefore, the treatment should be individualized based on symptoms and the patient"s needs. To date, many treatment methods have been proposed, including conservative treatment, pelvic vein embolization, and reparative surgery. Medical treatment of CPP due to PVI includes non-steroidal anti-inflammatory drugs (NSAIDs), medical suppression of ovarian function, venoprotective agents, vasoconstrictor drugs, and psychotropic agents. The NSAIDs have a short-term efficacy and, due to side effects after longer use, they should be avoided as a long-term solution. Pharmacological suppression of ovarian function may result in CPP relief and may be achieved using medroxyprogesterone acetate, gonadotropin-releasing hormone (GnRH) agonist, long-acting reversible contraceptives, and danazol. They have been proven to be effective in the treatment of pelvic symptoms of PeVD. Venoactive drugs (VADs), particularly micronized purified flavonoid fraction (MPFF) and psychotropic agents, also provide an improvement in CPP related to PVI. A conservative approach represents the first-line treatment modality. It is reasonable to offer such treatment initially, reserving more invasive approaches for resistant cases and patients who present with side effects to the conservative management.