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While endometriosis is highly associated with chronic pelvic pain, some women may actually have a different primary or maybe a coexisting secondary etiology, like pelvic vascular congestion called vascular origin chronic pelvic pain or void CPP for short. Although it is controversial as an entity, there have been diagnostic algorithms and we're going to cover some of them in this episode, which have been published both on pelvic ultrasound, MRI and of course venography to help establish the presence of this issue. About 10 to 40% of chronic pelvic pain cases may be attributed to pelvic vascular congestion, a term that has been now replaced by pelvic venous disorder, otherwise known as pevd. That's pelvic venous disorder. Now, even though the estimates vary based on which study you look at, and even though different studies have different ways of diagnosing this, the prevalence seems to be higher in premenopausal women than in postmenopausal women. One study found that 8% of all premenopausal women had documented chronic pelvic pain of unclear etiology and were actually found to have dilated ovarian or pelvic veins on imaging. Now here's one of the issues though. Even though that's a pretty high number, this can also be found in asymptomatic women. So it remains a little bit of a dilemma and an enigma. Therapies for this have been limited, but flavonoids have been in the press lately as a potential low risk and high yield therapeutic intervention. Now, taking a flavonoid pill seems to be much better as a treatment option for care than something like embolization, which obviously carries additional risks. Now, interestingly enough, outside of the field of ob gyn, other researchers in other areas of medicine are also taking a look at this, namely interventional radiologists. So I'm very thankful that in medicine, guys, as you all know, we have a lot of watershed areas. We have a lot of watershed areas with perinatology, neonatology, and of course even with radiology radio. Remember that it was the ACR who gave us the new scheme of how to characterize ovarian masses. And we talked about that called basically an ovarian rad or RADS system, a birad system, like there is from mammography. There exists one also for ovarian masses, and we've covered that in previous episodes. That's all through the American College of Radiology. So I'm very thankful that not just ob gyns are examining this issue of chronic pelvic pain, but even radiologists have a vested interest in this, especially interventional radiologists, because they're the ones who get called on to embolize these things potentially. Now, guys, potentially, there's something else on the table that's less invasive and may help, even though, let me say right now in the intro, even though we obviously need better large scale RCTs on the subject. However, the door has been open to this discussion as of December 23, 2025, when a new systematic review was published in the journal Phlebology. Now that's just a ripping title, isn't it? I mean, phlebology, the study of veins, hey, thank goodness for it. But this new systematic review actually is very special to me for two reasons. Number one, as a gynecologist, I'm always looking for new ways to treat chronic pelvic pain, even though my focus is on obstetrics. Hey, we still see a fair amount of gynecology, especially with the residency. And this is an issue here. As we all know, chronic pelvic pain kind of is the thorn in all of our flesh because it's just so non satisfying, unsatisfying to take care of these patients when we can't really fit a good therapy in a lot of cases. All right, now let me be very clear. I'm not saying that every patient with chronic pelvic pain has this issue of pelvic venous disease or vascular disease or insufficiency. I'm just saying that it definitely is an issue. And I'm going to tell you some more stats here when we get out of the intro. But this whole idea of pelvic venous disorder, PE VD is a real thing. Pelvic venous disorder, otherwise known as pelvic congestion syndrome. Now, so that's the first reason it's important to me, as it should be important to all of us, because chronic pelvic pain, these poor patients that are suffering with this, if we think that this is an issue, and remember, we gotta go through the whole algorithm here, make sure it's not endo. Is it a Degenerating fibroid. Is it an adeno? We gotta go through the typical structure of evaluation. I've got a previous podcast on this to look for a cause of chronic pelvic pain. That's number one, including a detailed history. However, in those patients where an ultrasound with Doppler suggest dilated pelvic vasculature, especially in the broad ligament, may be maybe this is something to consider. Even though we need more data, it definitely is a low risk, potentially high yield intervention. And we're going to get into that in this episode because this new systematic review also comes peripherally from one of our podcast family members. Now, it's not our podcast family member is a physician, is an ob GYN in New York, but her husband is actually an interventional radiologist who is actually the lead author on this new study. So that's the kind of world, how small the world that we live in is and the kind of community that we have built here. So to our podcast family member, thank you for sharing that podcast on chronic pelvic pain with your husband who is the lead author of this new publication which we are covering. And so kudos to that team to getting this published. So all to say, we're going to cover a brand new systematic review, not a meta analysis, just a Systematic Review. On December 23, 2025 when this went live, ahead print in the journal Phlebology that takes a look at a potential therapy for vascular origin chronic pelvic pain. That's vocpp, vascular origin cpp, otherwise known as pelvic venous disorder. You and I learned this likely as pelvic congestion syndrome. However, the brand new expert panel out of radiology back in 2023 changed that to pelvic venous disorder because it was much more appropriate than pelvic congestion. Anyway, it's fascinating. We're going to cover some of this. We'll give you the reference for that 2023 expert panel narrative review actually out from the College of Radiology. So not even obgyn, it's radiologists and their expert panel published in the American Journal of Radiology. And I'll post that link that reference in our show notes. So all to say, let's get into the new data on vascular origin CPP, otherwise known as therapy for PEVD, that's pelvic venous disorder out of New York from December 23, 2025. Here we. This is Dr. Chapa's obgyn no spin podcast.
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I really do love this whole idea of interventional radiologists taking a look at this thing. I mean, ACOG has of course, their guidance on chronic pelvic pain, but they don't really say a lot about pelvic congestion syndrome. But I love how, you know, we just do the referrals, right? Hey, I don't know, it's a vascular thing. Go see, I don't know, go see interventional radiology. So they finally picked up the ball and they're like, well, why don't we come up with something here that we can all agree with. So we're going to publish an expert review here that was published in November of 2023 and good for them. Again, this was out of AJR, American Journal of Radiology. And I know it's actually American Journal of rolo, but I'm not going to say that just American Journal of Radiology. That was their expert panel narrative review on this very issue. It was the diagnosis and management of pelvic venous disorders. Y' all get that, guys? Not venous disorders in general or like in the leg pelvic venous disorders where we get the PE VD that has replaced, replaced pelvic congestion syndrome. At least it has in the world of radiology. So I love that. That's the way it should be. Nothing, nothing is owned by a discipline. I mean, this can very well be done by, by interventional radiologists. It could be done by vascular surgeons. Why not? Whoever has interest with this. That's how, you know, medicine gets greedy and covers it and gets very territorial and then nobody wins. So good for this group of researchers, again mainly out of New York, that are looking into this. It's phenomenal. We've got to do this to find better care for these patients. And again, I know it's controversial. I understand that not every patient with pelvic pain has vascular congestion, now called pelvic vascular disorder or venous disorder. But it's possible, and it may be either primary as its only issue, or it could be a comorbid condition. In other words, just because you have endo doesn't mean you can't have anything else. Endo typically is primary parallel with adenomyosis, just like endo also has a high frequency of comorbidity and coexistence with interstitial cystitis or painful bladder syndrome. There's things that kind of share pathology and it's very easy for us as clinicians to give somebody a diagnosis. Hey, here's your label. Thank you very much. Keep going. There's your label. And then we stop looking for things. Or in patients that you can't find anything and don't have classic endometriosis symptoms, maybe they don't have all of the D's involved with endometriosis. And then perhaps this is a possibility. Now, there's been a variety of different schemes here that have been looked at to try to diagnose this. And I mentioned this in the intro. Pelvic ultrasound with Doppler mri. And of course, venography would be the gold standard, but of course that's the invasive option. Most choose something that's non invasive in addition to looking for all the other things and once everything else is excluded, having the possibility of this issue being in existence in a patient with pelvic pain. Okay, now just to do this due diligence because I do want to give, you know, kudos to who actually helped with this. As we talked about medicine being a collaborative sport and different specialties looking into different conditions that nobody owns a disease. This whole publication is a collaborative piece. So we have somebody from the Department of Intraomedicine and Vascular Center. This is out of the Mayo Clinic in Rochester, Minnesota. We've got a VASA LLC out of Scottsdale. We of course have Weill Cornell in New York and even University of North Carolina, Chapel Hill. The lead author and the person I've been communicating with about this is actually out of the division of internal. Internal, sorry, interventional radiology. I guess it is internal radiology, isn't it? Could there be an external radiology? Oh, good Lord. So division of Interventional Radiology. I guess all radiology is internal. Oh, my gosh. Division of Interventional Radiology at Weill Cornell and also at a New York Presby. So Neil, thank you for sharing this good systematic review with us and our podcast team. We're happy to put this out again, out of sage publication, out of the journal Phlebology. Not a sponsor. All right, good for you, Dr. Kalnani, in getting this work done. It is a systematic review, not a meta analysis. And they explain why that's the case in this paper towards the end. And I'll explain that here in a little bit. So. I love it, I love it, I love it. Anything that puts a possible therapy out there in the appropriate patient. Hey, you got chronic pelvic pain check. Sucks, but okay. At least you got a diagnosis. Then you go through the usual eval and work up and you're like, well, I don't really find anything. But on Doppler Boyish, you do have these kind of big varicosities around the broad ligament. Potentially this is an issue. Maybe try this therapy. And now I'll be very clear because I don't want to overstep the bounds of the data. We need more evidence. We definitely larger RCTs, as I mentioned in the intro. However, as these authors say, themselves this easy to adopt non invasive, very well tolerated therapy. Why not? I mean, it's flavonoids, for heaven's sakes. Now, this doesn't mean that patients can drink green tea until they're, you know, green themselves to help this better. It's a specific kind of flavonoids because flavonoids is a big group and not all flavonoids are the same. So, yes, there's flavonoids in a lot of citrus fruits. There's a lot of flavonoids in some fruits, like apples, grapes, onions, kale. Kale and broccoli have some flavonoid family, of course, green tea, cocoa. Cocoa has some flavonoids in it. Red wine, big source of flavonoids, and soybeans. However, it's a specific type of mixture of flavonoids in the right combination that might could help these patients with vascular origin cpp. All right, vascular origin cpp. Now, before we go any further, let me go over a couple of things as to again why we're doing this. Number one, as already mentioned, anything can help a patient that's well tolerated and potentially can help. I'm in. Two, it covers something that has to do with gynecology. That's us. Three, we want to be true to our mission, which is covering stuff that's relatively new in press. And this just came out at the end of December 2025. So again, very timely to get this out. And we promised, you know, Neil and his team that we would get the word out because they should be recognized for this even though of course we need more data. Now notice this is a group of radiologists and vascular folks. So they're not gynecology. And so they're not proposing a type of surgical intervention. They're proposing a type of easy adopt medication that is a non medicine to begin with. Right. It's non pharmacological. It's kind of a supplement. It's a flavonoid therapy. And I'll get into that in just a minute. But this is not necessarily new flavonoids in addition to being antioxidant over the last really three decades, even though it goes back more than that. But for at least three decades, we're finding out more and more that slavonoids aren't just antioxidants. They have a lot of vascular stabilization issues, they help with endothelial function, they decrease weird permeability stuff. They work as a kind of vessel regulatory modulator. Okay. And, and I am not saying that flavor is going to cure all. Like let's be real. Okay, that's not the case. But as my wife's family would say, if it might, could, if it might, could help, why not? So I'm going to get into that in this episode as we break down their publication in a very quick way, although I think it's already gotten a little lengthy. All right. Short of it is non invasive imaging for this. It all starts with history, starts with physical exam look for things. And yes, the radiology peeps, very thankful for them. They've given us nice ways to characterize this either with Doppler on ultrasound, which includes mainly transvaginal, although there is some trans abdominal approaches that have looked at this and it has to do with venous dilation, especially of the left ovarian vein and also how Doppler shows that blood flow. So especially if there's some reversed caudal flow in the ovarian vein, if there's some pelvic varicosities, these things have very high specificity that the vascular system, the venous system in the uterus, AKA the broad ligament and even that draining the ovaries could be leaky and or backfiring. All right, now it's very well known that varicose veins in the leg hurt. It's very well known that varicose veins in your booty hurt. Also that's called the hemorrhoid because of the pressure and the sensitivity that they cause. So dilated pelvic congestion, which was the old term pelvic congestion syndrome, or this new pelvic venous or vascular disorder, has the real biological possibility of causing discomfort. That's something, again, that we've covered in our previous episode on chronic pelvic pain. Go back and listen to that. Because, yes, it is possible that some vasoactive substances can help specifically when this is found. I'm not saying if they're totally full of endo and they don't have vascular congestion on Doppler ultrasound, that this is necessarily gonna help them. Even though taking flavonoids is low risk and it's an antioxidant and it may help, but that's not really for them. Treat the disease process. You find. If you find vascular congestion, possibly, maybe consider this as an alternative. Again, not mainstream, but the data is growing like this brand new systematic review that slavonoids in a specific combination may possibly help. Okay, so. And I'll give you that combination here in a little bit, but flavonoids. Looking into this specifically, a specific kind called mpff. Mpff. That's called micronized purified flavonoid fraction. Okay. Micronized purified flavonoid fraction. Micronized purified flavonoid fraction. MPFF in a specific combination has data. Now, some of these studies, and this is a systematic review, so I like it. It's not looking at one study. They actually looked at 11. They started with more, but they whittled it down to 11 because some of that wasn't exactly what they were looking for. But it actually ended up with a total n of about 748 women with vascular origin CPP. So this isn't chronic pelvic pain with big degenerating fibroid, suspected adeno, known endo. This is when those who've gone through the workup and go, hey, I think there's vascular issue here. We're looking at an N of 748. So not thousands of patients. We gotta start somewhere. And so I applaud Neil and his team for at least bringing this to the table for discussion. So take this to your journal club and your OBGYN residency and talk amongst yourselves and see what you think about this. Even though, again, we still need more data. It's a good conversation starter and potentially a therapy that we can offer to patients. My goodness, I'm all wound up and I don't know why. Michael, what's going on? Where Did I lost my place? Okay, thank you. All right, so. So let's go back to mpff. So this micronized purified flavonoid fraction, what they're specifically looking for, it's not like you can go to the store and just say, oh, I'm looking for MPFF. You got to find a specific mixture. It's 90% Diosmin, 10% Hesperidin. Okay. You're like, what? Don't worry about it. MPFF. Just remember that and know that there's data in the flavonoid family looking at treatment for this. It's a pretty high dose. It's like 1000mg or up to 2000mg daily for at least one or two months. Most treatments have carried this out. Most of the studies take this from like, as short as a month to about six months. And I'm gonna show you the data that this seems to help, but it seems to help as you're taking it. This is not a cure. Okay? This is a treatment for vascular origin cpp. Once they stop, there seems to be a regression, a return. The regression of the symptoms goes away to a now, to a progression or a renewal of symptomatology because it seems to be that the therapeutic benefit is only as the patients are on the MP FF therapy. Okay.
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So again, they chose a systematic review to look at this ended up with 11 studies. Hey, I'll take what I can get. Again, this is relatively novel, so there's not a lot of data on this. And the primary endpoint, what are we trying to do here? It's not for fertility. We're not helping them with their menstrual cycle. What do you think that the main outcome is for these studies? Come on, guys. We're talking about chronic pelvic pain. Hello. So it's pain assessment that typically this is done with a VAS score. And I get it, VAS score is a little subjective. I get that. But even when they have looked at these kind of treatments with. With radiology follow up, like, hey, there's Less backload. Hey, there's. There's less dilation of the vessels, there's more vascular stability. That has been done, adding to the credence that this thing may work. Okay, so the primary outcome of these 11 studies, which three, by the way, were RCTs, the other eight were prospective studies, and that's where you get the 11. So eight open label prospective studies, three were RCTs. These were all, of course, reproductive age patients with a diagnosis of vascular origin CPP diagnosed either by imaging or by laparoscopy, with the treatment being studied being the MPFF. All right. With a pain score decrease in VAs as the primary result. Short answer is yeah, I mean, it worked. So based on not just the VAS score, but also the clinical severity score and also a pelvic varicose vein questionnaire, all of these had improvement in values with improved symptoms and quality of life. So here's my thing, guys. Even if this is a placebo, now remember, this included some RCTs, but even if this was a placebo effect, if they're feeling better and nobody died from the treatment, meaning it's relatively safe. And this was, barring some headache, maybe some GI issues, like, like nausea and diarrhea, this is pretty well tolerated. It's flavonoids, and it's not hormonal. Just to throw it out there as an option here for treatment for vocpp. Okay, now, guys, we're being true to our podcast mission. Letting you know it's relatively fresh in print, letting you know things that not just in the obstetrics world, which is my first love, but also in gynecology, and to do our due diligence, to not just look within ourselves, but to reach across the aisle, look at radiologists, and thank them for the great work that they're doing on our behalf. Okay, so a short answer is yes, based on this systematic review. Even though. And let me say it right here, even though there's some biases in this that are hard to take into account, and even though some of the study metrics, some of the studies that were done were kind of low quality, it's something to start the discussion in an active way with patients. Okay, so these are. Sometimes there's got some issues here in both and how they treat it based on the dose of the Flavano and in their diagnostic patterns. However, even though these may be of low quality studies, there is a trend here towards benefit with high acceptability, high tolerability, and otherwise low risk. Okay, so let me read you the chief sentence here from the discussion. I'll read you their conclusion, we'll wrap this up and I'm going to tell you why they stopped at a systematic review and didn't continue on with a meta analysis, which I would have loved. But it is what it is and they're very clear and very transparent about why they did not quote. Although many studies were deemed to be of low quality. So they say it okay, it's an issue. They go on quote. The evaluation of VAS pain scores as endpoints for assessing the impact of flavonoids on vascular origin. CPP consistently showed a reduction in VAS scores across all the reviewed studies. So that's good. Now they keep going. Additional endpoints that were evaluated also demonstrated benefit and included the pelvic venous Symptom Questionnaire, the pelvic venous clinical severity score and various objective measures. Did y' all get that, guys? Various objective measures like pelvic vein diameter and congestion scores assessed using spect. That's pretty cool. So again, thankfully they included something that was more objective. When I was first reading this, I'm like, oh man, please tell me we didn't stop at VAS scores because super, super subjective. But now if you say, oh no, we included objective measures and these things got better. Now I'm in. So when I was communicating with Neil, I'm like, hey doc, this is good, I love it. Good design. Boom. We're going to put this on our to cover in our show and it bumped something else that we were supposed to cover. So yes, even though say what it is, some of these are low quality because there's a lot of heterogeneity, especially in the trials. When you put this in as a systematic review, there seems to be a trend there. Now that's all I'm asking for is if there's a trend of efficacy and safety, then I'll take it. The authors also describe why they were not able to do a meta analysis. So let me read it directly and we'll start wrapping this up and I'll give you some real world applications. Our systematic review highlighted consistent pain reduction with MPFF in vocpp. But here it is, guys. Heterogeneity and steady design, precluded meta analytic data based conclusions, end quote. It's fine. And that's one of the issues. Just because you do a systematic review doesn't lend itself always to a meta analysis. If the scatter in the design and patient population and or in dosing and intervention is too whack it's hard to bring that all back into one corral. Okay. But nonetheless, I think this is worth discussing. I think it's a great journal club. Again, the title of this review article out of the journal Phlebology, not a sponsor, is Venoactive Drugs for Venous Origin Chronic Pelvic Pain in Women A Systematic Review. Very proud of this team. Again, good collaboration from among different sites. Neo, Dr. Kalnani, good for you and your team for looking into this on our behalf. As gynecologists in women's health, I'll take any help that we get. So this discussion of specific combination of flavonoids potentially can help with vascular origin pelvic pain. Why not? So can green tea help? Sure, maybe. But it's a specific combination of 90% diosmin, 10% hesperidin fraction in this micronized purified flavonoid fraction that ideally. Guys, here's what I wish, okay? If we can't, I'm not gonna go embolize everybody with pelvic congestion pevd with this because, you know, fertility is gonna be an issue. You can embolize. You know, things get necrotic if too much embolize, embolization happens or goes the wrong way. What I would love to see is we have a well designed RCT on this reproducible where MPFF is commercially available as. As a set product. Phenomenal. Phenomenal. So even though, even though we need more data to confirm these things, as these authors say, quote, Future well designated RCTs are needed to confirm these findings. But in the meantime. Here it is, guys. In the meantime, flavonoids should be considered a therapeutic option for symptomatic patients with PEVD who are not qualified for not wishing or who are awaiting some other intervention, end quote. In other words, they're like, hey, I'm not doing hormones, I'm not having surgery, I don't want embolization. Hey, there's this study out of New York and some other places that said maybe a specific combination of MPFF could help. Knowing of course, that there's limitations to the data. But this is definitely a door and game changer, at least to begin this discussion. So thank you, new for bringing this to my attention. Thank you for being part of our extended podcast family. And now podcast family, we're recording this. So, you know, at the end of December 2025. I don't know if we're gonna put this out before the new year or right after 2026. I have no idea. Wait, what so Michael, our producer, is saying maybe before due to 28th. So that's. When is that coming out? Maybe. Maybe on January 1st. I don't know. The point is it's coming out soon. That's why we wanted to knock this out, because I'm actually on call this week. Michael, he's going to have a week off of his regular job. This is his side gig. So thank you for hanging in there with Michael as well. And to everybody on our podcast, thank you for supporting us throughout the year. Look at this community that we've built, guys. Somebody in New York said, hey, we're part of the podcast family. You covered something called pelvic. Pelvic pain, Chronic pelvic pain on previous episode. I'm working on this and here's what I found and it's published. That's how we do this. We want to share and build each other up. Neil, thank you so much. Keep up the good work. And I think I've done what I'm supposed to do. Let's get out of here. Podcast family, we're grateful for you. We're thankful for you. And now that we've done all that, Michael, let's take it home. This has been Dr. Chapa Zobichyn, no Spin Podcast, Podcast family. Thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin Podcast.