I am 26. I have long had painful, abnormal periods. Six months ago, I had a week of heavy, clumpy bleeding and severe cramping. Two months later I began having severe pain during intercourse. I was given antibiotics, but the pain continued, so my doctor gave me a laparoscopy two weeks ago. He said he cauterized two spots of endometriosis on my uterus and that I had "pelvic congestion." What exactly is pelvic congestion? I am scared and confused and can't seem to get answers.

A.S.

When it comes to discussing pelvic congestion syndrome, physicians often offer conflicting opinions. The more varied doctors' opinions on a topic, the more likely it means that our knowledge is limited.

Many medical traditions that were once well-accepted approaches to problems have been found to be less acceptable after modern diagnostic and epidemiologic study. Pelvic pain was for a long time attributed to a condition called "pelvic congestion," and hysterectomy was the treatment of choice. Unfortunately, effective means to detect this condition were not available. As such, this diagnosis was often made after hysterectomy revealed no other obvious cause of pelvic pain. Was the condition really present, or just an excuse to perform a hysterectomy? In many cases the latter was obviously the case.

However, newer diagnostic tools, such as transvaginal ultrasound examination or diagnostic laparoscopy, can give today's doctors clues that pelvic congestion may actually be present. By current definitions, pelvic congestion is a dilation of veins on the pelvic side wall. Such veins normally contain blood under low pressure; in fact, there is not really enough pressure present to force the blood back to the heart. But the human body has got this figured out. Small one-way valves at close intervals along the vein enable blood to slowly progress through the vein, eventually finding its way back to the heart.

I am certain you know about varicose veins, and you probably have seen some pretty unsightly ones. Varicose veins result from incompetent or ineffective valves. This can happen with the pelvic veins as well. Without proper valve function, the column of blood from your pelvis to your heart is not separated into small compartments. This means the blood pools in the veins, and the presence of all that blood dilates and stretches the veins. In men, the pressure from incompetent venous valves can result in a varicocele (dilated testicular veins); in women, the dilated veins occur along the pelvic side wall.

On transvaginal ultrasound, the veins will often appear enlarged and will be tender when pressed with the ultrasound probe. At laparoscopy, usually performed while you are asleep, it's a bit harder to confirm that the dilated veins are actually the cause of your pain. Your physician may suggest a pain mapping procedure. This is a "micro-laparoscopy" done for diagnostic purposes, using only local anesthesia and minimal sedation. A small probe is used to touch each pelvic structure so you can identify the source of your pain.

Treating pelvic congestion, for those physicians who believe it is a cause for pelvic pain, is another controversial subject. Nonsteroidal anti-inflammatory agents such as ibuprofen or naproxen sodium may be helpful is reducing pain. Hormonal suppression with birth control pills or Lupron (which induces a temporary menopause) may help avoid surgical treatment. If conservative medical therapy is not effective, physicians will still consider hysterectomy as a treatment of last resort.