Normal Pelvic Ultrasound Report Template (Transabdominal / Transvaginal)
Normal gynecologic pelvic ultrasound report template: uterus with measurements, endometrial stripe, ovaries with volumes, free fluid — transabdominal and transvaginal wording.
EXAMINATION: Pelvic ultrasound, transabdominal and transvaginal. CLINICAL HISTORY: [indication] COMPARISON: None available. TECHNIQUE: Real-time grayscale and color Doppler transabdominal and transvaginal imaging of the pelvis. FINDINGS: Uterus: Anteverted, measuring [x] x [x] x [x] cm. Normal myometrial echotexture. No fibroid. Endometrium: Homogeneous endometrial stripe measuring [x] mm. Right ovary: [x] x [x] x [x] cm. Normal follicular pattern. Normal Doppler flow. Left ovary: [x] x [x] x [x] cm. Normal follicular pattern. Normal Doppler flow. Adnexa: No adnexal mass. Cul-de-sac: No free fluid. IMPRESSION: 1. Normal pelvic ultrasound.
Dictation notes
- Endometrial thickness drives management in postmenopausal bleeding — give the number and the measurement technique.
- An incidental adnexal cyst gets O-RADS wording, not “simple cyst, likely benign”.
Related references
Frequently asked questions
What measurements belong in a pelvic ultrasound report?
A gynecologic pelvic ultrasound report records the uterine dimensions in three planes with version and myometrial echotexture, the endometrial stripe thickness in millimeters, each ovary's three-plane dimensions with follicular pattern and Doppler flow, the adnexa, and the cul-de-sac for free fluid. Both transabdominal and transvaginal techniques are named when performed. The normal impression is 'Normal pelvic ultrasound.'
Why does endometrial thickness matter in postmenopausal bleeding?
In postmenopausal bleeding, the endometrial stripe measurement drives management: a thin, homogeneous endometrium — commonly thresholded at 4 mm or less — carries a very low risk of carcinoma, while a thicker or heterogeneous endometrium prompts tissue sampling. The report should therefore give the number and the measurement technique, since management hinges on that value rather than on a qualitative description.
How should an incidental adnexal cyst on ultrasound be described?
An incidental adnexal cyst should receive O-RADS wording — the lesion's morphology, size and color score mapped to an O-RADS ultrasound category — rather than informal phrases like 'simple cyst, likely benign.' The O-RADS category carries a defined malignancy risk and a management pathway, and it distinguishes physiologic findings (a follicle or corpus luteum up to 3 cm in a premenopausal patient) from lesions that need follow-up or referral.
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