Pelvic Congestion Syndrome vs. Endometriosis: Getting the Right Diagnosis

Chronic pelvic pain has more than one possible cause. Here’s how pelvic congestion syndrome and endometriosis differ — and why getting the right diagnosis matters.

Chronic pelvic pain is frustratingly common, and frustratingly hard to diagnose. Two of the most common underlying causes — pelvic congestion syndrome (PCS) and endometriosis — can produce overlapping symptoms, which is part of why so many women go years without a clear answer. Understanding the differences can help you have a more productive conversation with your care team.

What Endometriosis Is

Endometriosis occurs when tissue similar to the lining of the uterus grows outside the uterus — on the ovaries, fallopian tubes, or other pelvic structures. This tissue responds to hormonal cycles the same way the uterine lining does, causing inflammation, scarring, and pain, often concentrated around menstruation.

What Pelvic Congestion Syndrome Is

PCS is a vascular condition — it occurs when the valves in the pelvic veins (most often the gonadal veins) stop functioning properly, allowing blood to pool rather than drain efficiently. This creates a dull, aching pressure that’s characteristically worse by the end of the day or after prolonged standing.

Where the Symptoms Overlap

Both conditions can cause:

• Chronic pelvic pain lasting more than six months
• Pain that worsens around the menstrual cycle
• Pain during or after intercourse
• Pain that’s difficult to pinpoint to one exact cause

Key Differences to Watch For

A few patterns can help distinguish the two, though a proper evaluation is always the most reliable path:

• Timing of pain: Endometriosis pain often peaks around menstruation. PCS pain typically builds throughout the day, worsening with standing, and may improve when lying down.
• Visible veins: PCS is sometimes accompanied by visible varicose veins on the buttocks, thighs, or vulva — a sign not typically associated with endometriosis.
• Response to hormonal treatment: Endometriosis symptoms often respond, at least partially, to hormonal suppression therapy. PCS, being a vascular rather than hormonal condition, generally does not.

Why the Distinction Matters

Because these conditions have entirely different underlying causes, they require entirely different treatments. Endometriosis is typically managed with hormonal therapy or surgical excision of the abnormal tissue. PCS is treated with gonadal vein embolization, a minimally invasive procedure that closes off the malfunctioning veins. Treating one condition while the other goes unaddressed — or being treated for the wrong one entirely — can leave a woman with ongoing pain and no clear answers.

It’s Also Possible to Have Both

Importantly, these conditions aren’t mutually exclusive — some women have both endometriosis and pelvic congestion syndrome contributing to their symptoms simultaneously, which is part of why a thorough evaluation matters more than assuming a single diagnosis explains everything.

Getting a Proper Diagnosis

Diagnosing PCS specifically typically involves imaging — ultrasound, CT, or MRI — to evaluate the pelvic veins, with a venogram considered the gold-standard confirmatory test. If you’ve been diagnosed with (or are being evaluated for) endometriosis but your treatment hasn’t fully resolved your pain, it’s worth asking whether PCS could be a contributing factor.

Learn more on our Pelvic Congestion Syndrome page, or read what pelvic congestion syndrome is.