Acute pelvic pain, defined as pain in the lower abdomen or pelvis lasting <3 months, is a common presenting symptom in women of all ages. This document will focus on gynecologic causes of acute pelvic pain in the postmenopausal age group, an age group that deserve special consideration, as these etiologies may be more challenging to diagnose, may present with atypical symptoms, and have higher potential for malignancy than causes of acute pain in premenopausal women. Etiologies considered include ovarian torsion, pelvic inflammatory disease, and acute complications of uterine fibroids. Ultrasound is the initial imaging modality of choice, with MRI and CT used in cases where sonographic findings are inconclusive. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.