How to Read Your Pelvic Imaging Report Using O‑RADS

Why might you need a pelvic ultrasound?

Pelvic Ultrasound uses sound waves to create images of the organs and structures in the pelvis, including the ovaries and uterus. Common reasons for undergoing a pelvic ultrasound include:

• Pelvic pain or bloating
• Unusual vaginal bleeding (e.g., irregular or heavy menstrual cycles, or bleeding after menopause)
• Detection of a palpable pelvic mass
• Evaluation of infertility
• Follow up of a known Ovarian Mass
• Screening for ovarian cancer in high-risk individuals, such as those with genetic mutations (e.g., BRCA1 or BRCA2)

Why might you need a pelvic MRI?

A Pelvic MRI is often performed when an ultrasound or CT scan shows a pelvic lesion that requires further evaluation. MRI uses powerful magnets to create detailed images of the ovaries, uterus and other pelvic structures and organs. In some cases, contrast material is injected to improve the visibility of tissues during the exam. For more details about contrast material, please refer to the Contrast Materials Safety page.

What is an ovarian mass?

The ovaries are part of the female reproductive system, located in the pelvis on either side of the uterus. They are responsible for producing ova (eggs). Most ovarian masses are either related to normal physiologic processes or are benign (non-cancerous). Examples include follicles and corpora lutea. Common benign conditions affecting the ovary include endometriomas and hemorrhagic cysts. Benign tumors, such as fibromas, dermoid cysts, and other types of cysts such as cystadenomas, can also occur. While Ovarian Cancer is rare, it often causes no or few symptoms early on, leading to detection at more advanced stages.

What is O-RADS?

O-RADS, which stands for Ovarian and Adnexal Reporting and Data System, is a system that radiologists use to describe and characterize masses in the ovaries and adjacent structures, collectively referred to as the adnexa. ACR O-RADS™ provides:

• Standardized language to describe adnexal masses
• A numeric score assignment from 0 to 5 to estimate the likelihood of cancer based on imaging appearance of a mass
• Management recommendations that may include follow-up ultrasound exam, pelvic MRI, evaluation by a gynecologist, and/or referral to a gynecologic oncologist (a surgeon specializing in treating gynecologic cancers)

It is important to understand that an O-RADS score is not a definitive diagnosis. In some cases, the radiologist can confidently determine that the ovaries are normal or that a finding is almost certainly benign. However, there are instances where the radiologist cannot be entirely certain and will use the scoring system to communicate their level of concern or the estimated risk of ovarian cancer. The management recommendations in the report serve as general guidance. Next steps will depend on your symptoms, personal preferences, and individual risk for ovarian cancer. Your clinician and other specialists will help you decide the best management option for you.

What do O-RADS ultrasound scores mean?

For ultrasound, the O-RADS scores are as follows:

O-RADS 0: The pelvic ultrasound is incomplete or cannot be interpreted due to technical reasons. Additional imaging, such as a repeat ultrasound or, occasionally, an MRI may be recommended.

O-RADS 1: Ovaries are normal with no signs of cancer. Prior to menopause, physiologic cysts such as follicles or corpus luteum may be mentioned in the report. No follow-up or additional imaging is needed.

O-RADS 2: Findings are almost certainly benign and include cysts and benign masses. Given the likelihood of cancer is so low, management recommendations may include no further work-up or a repeat pelvic ultrasound for monitoring. Rarely, if you are postmenopausal, an MRI will be recommended. A gynecologist may be needed for management.

O-RADS 3: Findings are more likely to be benign and the concern for cancer is low. These masses should be managed by a gynecologist. They may refer you to an imaging specialist, order a repeat pelvic ultrasound for monitoring, or get a pelvic MRI. You should talk with your gynecologist to decide the best management option for you.

O-RADS 4: Findings are still more likely to be benign than cancer, but more information is needed. An MRI is commonly recommended and occasionally blood tests may be obtained. You may also be referred by your clinician to see a gynecologic oncologist to discuss next steps (see below).

O-RADS 5: While findings may be benign, there is a higher concern for cancer. Likely, you will be referred to a gynecologic oncologist to discuss next steps (see below).

What do O-RADS MRI scores mean?

For MRI, the O-RADS scores are as follows:

O-RADS 0: The MRI is incomplete or cannot be interpreted due to technical reasons. A repeat MRI or pelvic US may be recommended.

O-RADS 1: The ovaries appear normal, with no signs of cancer. Prior to menopause, physiologic cysts such as a follicle or corpus luteum and small hemorrhagic cysts may be mentioned in the report. No follow-up or additional imaging is needed.

O-RADS 2: Findings are almost certainly benign and include cysts and benign masses. Given the likelihood of cancer is extremely low, management recommendations include no further work-up or a repeat pelvic ultrasound or MRI for monitoring. A gynecologist may be needed for management.

O-RADS 3: Findings are much more likely to be benign than cancer. You should talk with your gynecologist to decide the best management option for you.

O-RADS 4: While findings may be benign, there is a higher concern of cancer. You will likely be referred to a gynecologic oncologist to discuss next steps.

O-RADS 5: Findings are highly concerning for cancer. You will be referred to a gynecologic oncologist to discuss next steps.

Next Steps

It is a good idea to obtain a copy of your images and report. Bring them with you to appointments with your doctor and treatment team. Ask your imaging facility to download a copy of your imaging exam and report.

For more information, see How to Obtain and Share Your Medical Images.

To protect your privacy, only you can grant permission to share your imaging and report with others.

Pelvic Ultrasound and MRI scores of O-RADS 4 and O-RADS-5 likely warrant further management, your next steps might involve your doctor reviewing and discussing your imaging results with you, and then your care team will recommend the most suitable plan for you. This may include:

• Additional tests, such as an MRI (if you have not already had one), blood tests, or a CT scan, to help guide management decisions.
• Scheduling surgical removal of the mass or ovary.
• Referral to a gynecologic oncologist, a surgeon specializing in surgical treatment and management of gynecologic cancers.

It’s important to inform your care team if you have a family history of gynecologic or breast cancer as this information may influence your care plan.

The diagnosis of ovarian cancer cannot be confirmed without removal and review by a pathologist. In many cases, the final pathology may reveal a benign condition rather than cancer.