62-year-old female correctly diagnosed over 15 years ago with pelvic congestion syndrome (PCS). The patient was offered a hysterectomy which is not the first line of treatment for this condition. She declined. The patient was identified by her chiropractor as have PCS and was referred for treatment. In this patient, the primary cause of PCS was compression of the left renal vein , which is referred to as Nutcracker Phenomena when asymptomatic. In addition, the patient had findings of iliac vein compression. This patient is interesting as the decision-making for the best treatment options is complex.