The 2026 update of the ACR Appropriateness Criteria addresses gynaecological causes of acute pelvic pain, lasting less than three months, in postmenopausal women. The causes covered include ovarian torsion, pelvic inflammatory disease and acute complications of fibroids.
Ultrasound remains the first imaging test. MRI and CT are reserved for cases where ultrasound does not answer the question.
The panel singles this age group out because causes are harder to diagnose, present with atypical symptoms and are more likely than in younger women to be associated with malignancy. A torsed ovary in a postmenopausal woman may be twisting around a tumour; a tubo-ovarian abscess may coexist with cancer.
The practical change is in mindset rather than test order. Pelvic pain after menopause should not be treated as the same problem as in a younger woman, and an adnexal finding needs characterising with malignancy in mind and clear follow-up advice.
- Start with pelvic ultrasound, transvaginal where possible, for acute pelvic pain after menopause.
- Use MRI or CT when ultrasound is inconclusive.
- Characterise any adnexal mass with malignancy in mind.
- Consider an underlying tumour when torsion or abscess is found in an older woman.
- Give explicit follow-up recommendations for indeterminate findings.
Why it matters
The same symptom carries a different list of causes after menopause, and the scan report needs to reflect that.
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