· Multiparametric MRI plays a pivotal role in the assessment of female pelvic masses.

· A multiparametric MRI protocol of the female pelvis should include T2- and T1-weighted, as well as additional diffusion-weighted imaging or contrast-enhanced sequences, according to the indication.

· MRI allows the characterization of female pelvic masses based on compartment or organ of origin, lesion shape, signal intensities, and clinical history.

· A practical step-by-step approach to MRI for the evaluation of female pelvic masses enables a short, meaningful differential diagnosis or, often, a definitive diagnosis.

· MRI provides valuable information for diagnosis, treatment selection, treatment planning, and follow-up of both benign and malignant gynecologic conditions.

Pelvic masses in female patients include a broad spectrum of differential diagnoses comprising both benign and malignant neoplasms, as well as non-neoplastic diseases. Pelvic masses can often be a diagnostic challenge, because of their proximity to a variety of pelvic structures and the overlap of specific imaging features between different diagnoses. Ultrasound is usually the first-line imaging modality for the assessment of female pelvic masses. However, ultrasound is limited by poor acoustic windows and the depth of penetration, which often prevents a definite characterization of some masses. Computed tomography of the pelvis is limited by a lack of soft-tissue contrast, and, therefore, a confident differentiation of decompressed bowel from adnexal structures can be problematic. Advances in magnetic resonance imaging (MRI), such as an increased field strength, the development of imaging techniques such as parallel imaging, and the use of novel methods of rapid data acquisition, have markedly improved image quality in body MRI applications. MRI provides excellent contrast resolution, resulting in accurate tissue characterization and excellent anatomic delineation. With these advances, there are also new challenges, as the endpoint of MRI of the female pelvis is no longer to simply detect an abnormality but rather to play a pivotal role in diagnosis, treatment selection, treatment planning, and follow-up of both benign and malignant gynecologic conditions. However, by applying a systematic approach to complex female pelvic masses, one that integrates the patient’s clinical and surgical history as well as multiparametric MRI findings, a short, meaningful differential diagnosis, or often, even a denitive diagnosis is facilitated.Female pelvic imaging is performed with the patient in the supine position using pelvic surface-array, multi-channel coils. A standard MRI protocol includes a localizer sequence, multiplanar, high-resolution, T2-weighted sequences, and native T1-weighted seqences with and without fat-saturation. Slice orientation depends on indication and is perpendicular to the uterine cavity (coronal to the patient, axial oblique of an anteverted uterus) for endometriosis, endometrial cancer staging, benign uterine conditions, and when determining the origin of a uterine mass. Slice orientation is perpendicular to the endocervix for cervical cancer staging, perpendicular to the long axis of the vagina for the evaluation of vaginal pathologies, and strict axial, coronal, or sagittal in patients with a hysterectomy. Additional sequences based on the indiciation include diffusion-weighted imaging (DWI) for adnexal mass characterization, and endometrial, as well as ovarian cancer staging. Contrast-enhanced sequences are perfomed for endometrial cancer staging, the evaluation of cystic/solid adnexal masses, and if there is a doubt about whether bladder, rectal, or vaginal wall pathology is endometriosis or cancer. Contrast-enhanced sequences should be 3D, with fat-saturation covering the entire pelvis and with optimized k-space sampling, depending on the indication. Female pelvic masses can be characterized using a systematic approach. The determination of the compartment or organ of origin significantly narrows the differential diagnosis of a female pelvic mass and it varies with different organs (urinary bladder, urethra, vagina, uterus, cervix, ovaries, fallopian tubes, and rectum) and spaces (peritoneal, mesorectal, rectorectal, presacral, extraperitoneal space and pelvic sidewall). When attempting to place a mass into one of the spaces or spaces of the pelvis, it is important to evaluate how the mass displaces the normal anatomic structures. Identifying the blood supply and drainage of a pelvic mass also provides valuable information. Once the anatomic origin and shape of a mass have been determined, it is essential to assess the composition of the mass based on its signal intensity in T1 and T2-weighting, its tissue diffusivity and enhancment/-pattern. Finally, it is necessary to put the mass in a clinical context (patient age and history, clinical signs and symptoms and laboratory results). This presentation will describe the role of MRI of the female pelvis and will provide a practical step-by-step practical approach for the evaluation of female pelvic masses based on compartment or organ of origin, lesion shape, signal intensities, and clinical history to generate a limited differential diagnosis, which can often even be reduced to a single definitive diagnosis. The MRI features of common benign and malignant uterine, ovarian and adnexal pathologies will be reviewed.