Vulvar Varicosities: Symptoms, Types, Causes and Treatment

Vulvar varicosities (VV) are a lesser-discussed yet surprisingly common condition affecting women, especially during pregnancy and in those with pelvic or lower limb varicose veins. These dilated veins in the vulva can cause a range of symptoms, sometimes mimicking other health issues, and often raise concerns for both patients and clinicians. This comprehensive guide explores their symptoms, types, causes, and evidence-based treatment options, helping demystify VV and provide clarity for those seeking knowledge or care.

Symptoms of Vulvar Varicosities

Vulvar varicosities can present with a variety of symptoms, ranging from mild discomfort to more pronounced physical findings. Recognizing these symptoms is crucial for timely diagnosis and appropriate management.

Symptom	Description	Common in Pregnancy	Source(s)
Swelling	Bulging veins, visible or palpable mass in vulvar area	Yes	1 2 5 8
Pain	Aching, pressure, or moderate pain, worse with standing or exercise	Yes	1 2 5 7 8
Pruritus	Itching in vulvar region	Sometimes	2
Heaviness	Sensation of fullness or prolapse	Yes	2 5 8
Dyspareunia	Painful intercourse	Sometimes	5 8 9
Symptom Fluctuation	Worse with exertion, standing, menstruation	Yes	1 2 5 8

Table 1: Key Symptoms

Understanding the Symptoms

Vulvar varicosities often make their presence known through visible swelling or a bulging mass in the vulvar area. These masses can be intermittent, becoming more pronounced after exercise, during periods of increased intra-abdominal pressure, or after prolonged standing 1 2 5 8.

Pain and Discomfort

• Many women experience aching or moderate pain, especially when the varicosities are prominent.
• The pain may worsen with physical activity, standing, or sexual intercourse (dyspareunia) 1 2 5 7 8 9.
• Some women may only notice a sensation of heaviness or fullness, rather than outright pain 2 5 8.

Itching and Other Sensations

• Pruritus, or itching, can occur due to local vein distension and skin changes 2.
• A feeling of prolapse or downward pressure is sometimes reported, particularly during pregnancy 2 5 8.

Fluctuating Symptoms

• Symptoms often fluctuate, being more noticeable at certain times (e.g., after exercise, during menstruation, or with increased intra-abdominal pressure) and may disappear with rest or position changes 1 2 5 8.

Recognizing these hallmark features helps differentiate vulvar varicosities from other vulvar masses such as cysts, tumors, or hernias 1.

Types of Vulvar Varicosities

Vulvar varicosities are not all the same—variations exist in their location, associated conditions, and underlying venous origins. Understanding these types is essential for accurate diagnosis and optimal treatment planning.

Type	Description	Association	Source(s)
Isolated VV	Limited to vulva, no pelvic/leg involvement	Rare	8
VV with PCS	Associated with pelvic congestion syndrome (PCS)	Chronic pelvic pain	5 8 9
VV in Pregnancy	Occurs during pregnancy, often resolves postpartum	Pregnancy	2 4 5 8
VV with Leg Varices	Coexists with lower extremity varicose veins	Chronic varicosity	5 8
Atypical Location	Upper thigh, peri-vulvar, or external pudendal vein involvement	Less common	4 8

Table 2: Types of Vulvar Varicosities

Exploring the Different Types

Vulvar varicosities can manifest in several clinical patterns:

Isolated Vulvar Varicosities

• These occur strictly within the vulvar region, without evidence of pelvic or lower extremity vein involvement.
• True isolated VV are rare; most cases have underlying pelvic or leg varicosities 8.

VV Associated with Pelvic Congestion Syndrome (PCS)

• PCS is a chronic pain syndrome caused by varicose veins in the pelvis, often involving the ovarian veins.
• VV associated with PCS are typically accompanied by persistent pelvic pain, sometimes extending to the vulva 5 8 9.

Pregnancy-Related VV

• Up to 4% of pregnant women experience vulvar varicosities, usually appearing in the second or third trimester 2 4 5 8.
• These often resolve spontaneously after childbirth but may be symptomatic during pregnancy.

VV with Leg Varices

• Many women with vulvar varicosities also have varicose veins in their legs, indicating a more widespread venous insufficiency 5 8.
• This association influences treatment choices, as isolated treatment of VV may not be sufficient.

Atypical and Unusual Locations

• Though most VV occur in the vulva, they can occasionally involve the upper thigh or peri-vulvar regions, sometimes originating from less common veins like the external pudendal vein 4 8.

Causes of Vulvar Varicosities

The underlying causes of vulvar varicosities are multifactorial, involving anatomical, hormonal, and lifestyle factors. Identifying these causes is vital for both prevention and treatment.

Cause	Mechanism/Trigger	Common Context	Source(s)
Pregnancy	Increased venous pressure, hormonal changes	Pregnant women	2 4 5 8
Pelvic Venous Insufficiency	Retrograde pelvic blood flow, valvular failure	PCS, non-pregnant	5 8 9
Ovarian Vein Varices	Dilated ovarian veins, reflux	PCS, chronic pain	4 5 8 9
Lower Extremity Varices	Spread of venous insufficiency	Women with leg varices	5 8
Increased Intra-abdominal Pressure	Straining, chronic cough, constipation	Exacerbates VV	1 5 8
Congenital/Anatomic Factors	Venous wall weakness, variant anatomy	Sporadic cases	8

Table 3: Causes of Vulvar Varicosities

Unpacking the Causes

Pregnancy

• Pregnancy is the most common context for VV, due to increased blood volume, hormonal changes that relax vessel walls, and the pressure of the growing uterus on pelvic veins 2 4 5 8.
• These factors together promote venous distension in the vulvar region.

Pelvic Venous Insufficiency and Ovarian Vein Varicosities

• Chronic pelvic venous insufficiency, often due to valvular failure in the ovarian veins, leads to retrograde blood flow and venous engorgement 4 5 8 9.
• PCS is a related condition where pelvic varices, including VV, cause chronic pelvic pain.

Lower Extremity Varicose Veins

• Venous insufficiency in the legs can extend to the vulvar veins, especially when overall venous return is compromised 5 8.
• This creates a broader pattern of varicosities.

Increased Intra-abdominal Pressure

• Activities or conditions that raise intra-abdominal pressure—such as straining, heavy lifting, chronic cough, or constipation—can exacerbate VV symptoms and contribute to their development 1 5 8.

Congenital and Anatomic Factors

• Some women may have an inherent weakness in the vein walls or unique venous anatomy that predisposes them to developing VV 8.

Treatment of Vulvar Varicosities

Treatment for vulvar varicosities is tailored to the individual, considering the severity of symptoms, underlying causes, and patient preferences. Options range from conservative management to minimally invasive interventions.

Treatment Option	Approach/Method	Indications	Source(s)
Conservative	Compression, rest, symptom monitoring	Pregnancy, mild cases	2 5 8
Venoactive Agents	Micronized purified flavonoid fraction	Symptom relief	5
Sclerotherapy	Injection of sclerosing agent	Symptomatic, non-pregnant	2 7 8
Embolization	Radiological vein closure	PCS, persistent VV	4 8 9
Surgical Ligation	Vein tying/removal (rare)	Refractory, complex cases	5 8
Multimodal/Combined	Sclerotherapy + embolization	Complex, extensive disease	8 9

Table 4: Treatment Approaches

Treatment Strategies Explained

Conservative Management

• Most VV during pregnancy are managed conservatively, as they often resolve after delivery 2 5 8.
• Measures include:
  • Rest and elevation of pelvis
  • Avoidance of prolonged standing or heavy lifting
  • Use of supportive garments or compression 2 5 8

Venoactive Agents

• Certain medications, such as micronized purified flavonoid fraction, have shown efficacy in reducing symptoms of VV and improving venous tone 5.

Sclerotherapy

• Injection-compression sclerotherapy uses agents like sodium tetradecyl sulfate to collapse and close off abnormal veins 2 7 8.
• This is effective for symptomatic non-pregnant women and as a preventive measure for women approaching childbirth 2 7.
• Compression is essential after injection to maximize effectiveness 7.

Embolization

• Radiologic embolization is a minimally invasive procedure where abnormal veins are closed using coils or agents delivered via catheter 4 8 9.
• Particularly useful in women with PCS or when VV are associated with pelvic vein insufficiency 4 8 9.
• Embolization may be combined with sclerotherapy for complex cases 8 9.

Surgical Approaches

• Surgical ligation (tying off) or removal of vulvar or ovarian veins is now rarely performed, reserved for refractory or complex cases not responsive to less invasive treatments 5 8.
• Past approaches included hysterectomy or vein ligation, but these have largely been replaced by modern techniques 4 5 8.

Tailored, Multimodal Therapy

• Treatment should be individualized:
  • Simple, isolated VV may respond well to sclerotherapy alone.
  • VV associated with PCS or leg varices often require a combination of therapies and imaging to guide intervention 5 8 9.
  • Imaging (ultrasound, venography) is crucial before treatment to map venous anatomy and avoid recurrence or incomplete therapy 5 8.

Conclusion

Vulvar varicosities are a common yet frequently misunderstood condition, with impactful symptoms and a variety of management options. Awareness and a tailored, evidence-based approach are key to improving outcomes and quality of life.

Key takeaways:

• Symptoms: VV commonly cause vulvar swelling, pain, heaviness, and occasionally itching or dyspareunia; symptoms often fluctuate and may worsen with activity or standing 1 2 5 7 8 9.
• Types: VV can be isolated, associated with PCS, occur during pregnancy, coexist with leg varices, or appear in atypical locations 4 5 8 9.
• Causes: Main contributors include pregnancy, pelvic venous insufficiency, ovarian vein varices, lower extremity varicosities, increased intra-abdominal pressure, and congenital factors 1 2 4 5 8 9.
• Treatment: Options range from conservative management and venoactive agents to sclerotherapy, embolization, and surgery; imaging and individualized care are essential for optimal results 2 4 5 7 8 9.

With greater understanding, both patients and clinicians can recognize vulvar varicosities early and pursue the most appropriate, effective care.