The 2026 update of the ACR Appropriateness Criteria addresses gynaecological causes of acute pelvic pain (under three months) in postmenopausal women, including ovarian torsion, pelvic inflammatory disease and acute fibroid complications.
The panel singles out this age group because presentations are less typical and the chance of an underlying malignancy is higher than in younger women. Ultrasound remains the first imaging test, with MRI or CT reserved for when ultrasound is inconclusive.
For referrers, the practical point is that torsion and infection do occur after menopause and should not be dismissed, and that an adnexal mass found during work-up for pain needs characterisation rather than being assumed benign.
- Request pelvic ultrasound first for acute pelvic pain in postmenopausal women.
- Consider ovarian torsion even after menopause, particularly with an adnexal mass.
- Move to MRI or CT when ultrasound is inconclusive.
- Characterise any adnexal mass found, given the higher malignancy risk in this age group.
Why it matters
Atypical presentations in older women make a clear first test more important, not less.
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