According to the World Health Organization (WHO) criteria for uterine smooth muscle, tumors have historically been distinct in benign leiomyomas, leiomyomas variants, and malignant leiomyosarcomas based on cytological atypia, mitotic rate, and presence or absence of tumor cell necrosis. Ultrasound, especially new techniques such as three-dimensional (3D)/four-dimensional (4D) ultrasound and 3D/4D color Doppler, is an excellent tool in the hands of ultrasonographers in the detection of atypical myomas and potential malignancy in uterine fibroids. Preoperative detection of malignancy in leiomyoma is a challenge for the ultrasonographer. It is very important to define an atypical leiomyoma by ultrasound examination because of its specificity, this type of leiomyoma can mimic leiomyosarcomas and can be precursors for the development of leiomyosarcoma.