Reference Handbook of Gynecologic Pelvic MRI

Gynecologic pelvic MRI is a crucial imaging modality for problem solving, offering superior soft-tissue contrast and multiplanar capabilities for the detailed evaluation of female patients across a range of indications. Accurate interpretation of gynecologic pelvic MRI depends on using protocols tailored to the clinical indication, reviewing the patient's clinical history (such as age, symptoms, medical and surgical history, and genetic mutations), and considering laboratory data. A comprehensive understanding of the female pelvic anatomy, best visualized on high-resolution multiplanar T2-weighted images, is also essential. A systematic step-by-step approach to lesion evaluation further contributes to accurate interpretation. This process begins with determining lesion origin. Once identified, evaluating lesion tissue composition and assessing solid tissue morphology enables lesion classification into one of the following categories: (a) T1-hyperintense lipid-containing lesions, (b) T1-hyperintense blood-containing lesions without solid tissue, (c) cysts (simple or proteinaceous fluid) without solid tissue, (d) cystic or solid lesions with dark T2/dark diffusion-weighted imaging (DWI) solid tissue, and (e) cystic or solid lesions with non-dark T2/non-dark DWI solid tissue. Based on lesion origin and these categories, the differential diagnosis can be developed and communicated in a structured radiology report, ensuring clear and concise communication with the treatment team. Supplemental material is available for this article. ^©RSNA, 2026 See the invited commentary by Ghafoor and Stocker in this issue.