Sonographic images rely upon the transmission and degree of reflection of ultrasound sound waves that are converted digitally into an image, generally based on a "grey" scale of reflected intensity.  Basic ultrasound generally refers to 2-dimensional techniques, although systems are increasingly available that allow the acquisition of 3-dimensional images.  For the uterus, transvaginal ultrasound (TVUS) is generally provides the best images but there are circumstances where TVUS is not feasible (most adolescent and virginal women), or when a uterus is so large that much or most of its volume is actually in the abdomen. If ultrasound equipment is available, clinicians should be encouraged to perform ultrasound evaluations themselves, even if there is to be a referral to a radiologist for a "formal" study.

The instillation of sonolucent contrast into the uterus allows for more accurate depiction of the intracavitary anatomy. The procedure is readily done by placing a catheter transcervically into the endometrial cavity, while contrast is instilled under transvaginal ultrasonic direction. This is a highly useful if not essential component of evaluation of the  uterus for structural anomalies such as polyps and leiomyomas. The contrast is typically saline, where the procedure is called saline infusion sonography (SIS), but gel can also be used (gel infusion sonography or GIS). If an ultrasound unit is available to the gynecologist, SHG is a fairly simple procedure as passing a catheter into the uterus is as simple as intrauterine insemination, and less painful than endometrial biopsy or IUD insertion. A number of studies have shown that SHG has similar sensitivity to cavity architecture as hysteroscopy and it provides additional information or clarity regarding the myometrium, including the involvement of leiomyomas.

The newest imaging technology that may have utility in the evaluation of women with leiomyomas is ultrasound or MRI based elastography. Elastography basically provides an evaluation of the "stiffness" of tissue - essentially a quantitative "palpation" of the uterus.  It is likely that the greatest role for elastography will be in the evaluation of the impact of adenomyosis on the uterus.

In many instances, MRI will provide the most granular depiction of leiomyoma phenotype. It is understood that access to MRI will be limited in many jurisdictions, but there are a number of circumstances where it may be the optimal method of assessment. One is when transvaginal ultrasound is not feasible (for example virginal women) and the patient's body habitus is such that transabdominal ultrasound is insufficient. Another situation occurs when older pre and early postmenopausal women are identified with growing leiomyomas; while imperfect, MRI with contrast can provide some indication of the risk of malignancy. MRI may also be useful when it is important to understand whether or not adenomyosis is also present, either along side of leiomyomas, or if the leiomyoma is actually an adenomyoma.