Pelvic Congestion Syndrome Treatment

[Isabel Newton]
Let's talk a little bit about pelvic congestion syndrome. It has garnered a lot of attention because it's probably a whole lot more prevalent than it is recognized. You're doing some work now and seeing the ramifications of what this is, and how it may be responsible for a larger swath of problems than we know. Can you speak to that?

[Brooke Spencer]
One thing we have to look at is why the results in gonadal vein embolization and its treatment are less successful in women than they are in men. So the data is better in varicocele than it is in gonadal vein embolization, and I think the reason for that is that the venous system is a complex, intricate, connected system, and the gonads are inside a woman, and in a man, they're outside. So they're an end organ in men, and they aren't in women.

It's the same concept of treating a saphenous vein in the leg without treating the May-Thurner. If you treat the venous reflux and the pelvic varices to some degree without treating an obstructed deep venous system, and you have elevated venous pressures … six months, a year, two years later, those veins will find a way to dilate, recruit blood flow, and be abnormal again. I don't have a complete dataset to tell you that the answer is we're missing May-Thurner all day long, every day in these pelvic congestion patients. That we're only treating their gonadal venous reflux, and we're not treating their underlying venous obstruction … but I truly believe that, and I don't know whether the data will bare that out.

So the next question that we have to ask becomes the same question in the leg. Do you treat the superficial vein or the deep vein first, or do you treat both? And the same question exists with pelvic congestion, but we have to start at least having the conversation.

Is it the May-Thurner that's making these people symptomatic, or is it the gonadal reflux? There are millions of women walking around with dilated gonadal veins after pregnancy, and not all of them are symptomatic, and not all of them are abnormal. There are millions of women walking around with May-Thurner. Not all of them are symptomatic, and not all of them are physiologically significant. So we need to do a lot better data and research on who needs to have their gonadal vein embolized and who needs to have their May-Thurner stented, but I think the next step in that process in figuring this out is to recognize the myriad of symptoms that are exacerbated if not caused by pelvic venous disease.

[Isabel Newton]
Do you think that there's going to be a push towards greater recognition of pelvic congestion syndrome and treatment of it, or do you think that there's a lot more work that has to be done?

[Brooke Spencer]
Well, I think there's a lot more work that has to be done, but I think this is like a billion-dollar industry. I think there are millions of women walking around with this problem who are fairly easily fixed, and think there are going to be a lot of naysayers at first, and I think it's going to take a long time. It's going to take some very good data, which is going to be very expensive and difficult to obtain, but if we can obtain it I think that people will start to believe.

I have a 44-year-old woman who since age 15 has had severe pelvic pain. She had three endometriosis surgeries. The first one, one ovary removed, then endometriosis burn, then her uterus and the other ovary removed. She's had colonoscopies and has been on narcotics. She has been depressed and in horrible chronic pain, and I talked to her about the possibility of May-Thurner because her GYN have started sending a lot of patients to me with chronic pelvic pain that hasn't been explained by other things. She ended up having a 75% stenosis with mild cross-collateral filling.

So I put a stent in her, and I won't say she was pain-free immediately. She had good days and bad days for about a month or a month and a half and then was completely pain-free for three months until she did some weird movement, and then she had a little bit of pain on and off again, and then that's going away.

So she's off all narcotics, off all pain medication, her depression is lifted, she feels like a new person, and it's given her life back. There will be people out there who say that I like to put stents in, right? But I like to put stents in because it's changing people's lives, and I don't think this is a placebo effect. These patients have had colonoscopies, they've had surgeries, they've had many other things that could be considered an intervention that could lead to them saying "I feel better" out of nowhere. So I don't know why placing a stent would be different than those in terms of how much it's changing their life. I mean, they come into the office crying in tears of joy and sobbing, and their life has changed, their relationships with their husband has changed, the dyspareunia gone. All of these things that were severely impacting their lives are improved, so I'm a big believer.