 Subacute or chronic pelvic pain is a broad clinical presentation common to a variety of gynecologic, urinary, gastrointestinal, and musculoskeletal disorders. There are specific ACR Appropriateness Criteria documents pertaining to many of these diagnoses, which are detailed in Appendix 1. In particular, we emphasize the importance of both vaginal bleeding and suspected adnexal mass in postmenopausal women because of the prevalence of endometrial and ovarian neoplasia in this age group. These clinical features, if present, should take precedence over the general complaint of pelvic pain in directing the management algorithm. Patients with acute pain, suspected pelvic floor dysfunction, or urinary complaints may be managed in accordance with the respective algorithms for those conditions. Imaging evaluation for suspected endometriosis is not considered here as endometriosis is estrogen dependent and usually regresses after menopause [3]. If a postmenopausal woman is experiencing pain from endometriosis, it is likely secondary to scarring or reactivation that is due to postmenopausal hormonal therapy. In cases of persistent endometriosis-related symptoms after menopause, readers are referred to ACR Appropriateness Criteria guidance for the premenopausal age group (see Appendix 1). Finally, like other types of chronic pain, pelvic pain is a complex process with incompletely mapped cognitive and neurologic contributors. As such, there is a growing body of literature regarding potential use of neurologic imaging in patients with chronic pelvic pain [4-7]. However, central nervous system functional imaging remains in the research domain for evaluation of chronic pelvic pain at this time, so we will not consider it formally among the discussed imaging procedures. When all of these aspects of subacute and chronic pelvic pain in postmenopausal women are excluded from direct consideration, a handful of clinically significant conditions remain.
Postmenopausal Subacute or Chronic Pelvic Pain.  Subacute or chronic pelvic pain is a broad clinical presentation common to a variety of gynecologic, urinary, gastrointestinal, and musculoskeletal disorders. There are specific ACR Appropriateness Criteria documents pertaining to many of these diagnoses, which are detailed in Appendix 1. In particular, we emphasize the importance of both vaginal bleeding and suspected adnexal mass in postmenopausal women because of the prevalence of endometrial and ovarian neoplasia in this age group. These clinical features, if present, should take precedence over the general complaint of pelvic pain in directing the management algorithm. Patients with acute pain, suspected pelvic floor dysfunction, or urinary complaints may be managed in accordance with the respective algorithms for those conditions. Imaging evaluation for suspected endometriosis is not considered here as endometriosis is estrogen dependent and usually regresses after menopause [3]. If a postmenopausal woman is experiencing pain from endometriosis, it is likely secondary to scarring or reactivation that is due to postmenopausal hormonal therapy. In cases of persistent endometriosis-related symptoms after menopause, readers are referred to ACR Appropriateness Criteria guidance for the premenopausal age group (see Appendix 1). Finally, like other types of chronic pain, pelvic pain is a complex process with incompletely mapped cognitive and neurologic contributors. As such, there is a growing body of literature regarding potential use of neurologic imaging in patients with chronic pelvic pain [4-7]. However, central nervous system functional imaging remains in the research domain for evaluation of chronic pelvic pain at this time, so we will not consider it formally among the discussed imaging procedures. When all of these aspects of subacute and chronic pelvic pain in postmenopausal women are excluded from direct consideration, a handful of clinically significant conditions remain.