Slow-flow, high-impact: radiologic features in venous malformations of the female genital tract

Gynaecological venous malformations are rare, congenital slow-flow vascular anomalies arising from early developmental errors. They may occur as isolated lesions or within syndromic contexts (associated with somatic gene variants such as PIK3CA and TEK). They remain poorly documented and frequently misclassified due to persistent outdated terminology and diagnostic challenges-requiring integration of clinical, radiological, and histopathological data. Imaging plays a pivotal role in the diagnosis of gynaecological venous malformations: ultrasound serves as the first-line imaging modality, while Magnetic Resonance Imaging offers superior anatomical detail, confirms the diagnosis, and guides treatment planning and follow-up. However, the lack of standardised protocols and consensual imaging features complicates differentiation from other gynaecological vascular conditions with overlapping radiological appearances. Given diagnostic challenges and concerns regarding fertility, a multidisciplinary approach in specialised vascular anomaly centres combining clinical, radiological, histological, and genetic data is essential. This review aims to provide a complete sonographic and MRI framework aligned with current nomenclature, with key clinical and histopathological insights to support radiologists in their diagnostic process. CRITICAL RELEVANCE STATEMENT: Gynaecological venous malformations are frequently overlooked or misdiagnosed due to shared imaging features and a lack of standardised protocols, making accurate imaging description and multidisciplinary assessment essential for a positive diagnosis and appropriate management in dedicated centres. KEY POINTS: Gynaecological venous malformations are rare and often misdiagnosed congenital anomalies. Diagnostic features include an organ enlargement with a sponge-like appearance and slow-flow.