Leiomyomas are the most common uterine tumor and the most common cause of uterine enlargement in the nonpregnant patient. Sonography is the imaging modality of choice for the initial diagnosis and imaging workup of uterine leiomyomas and is also extremely helpful in determining the etiology of a broad range of pelvic symptoms in the female patient. Although the classic sonographic appearance of uterine leiomyomas is well established and easily recognizable, other pelvic masses may occasionally be confused with uterine leiomyomas, and the ability to distinguish between these entities is crucial in optimizing appropriate patient care. This article will review pelvic abnormalities that can be confused on ultrasound with uterine leiomyomas and potential methods that can be used to avoid these pitfalls.