Pelvic Ultrasound Report Template: Transabdominal and Transvaginal Examples

A pelvic ultrasound report should show not only uterine and ovarian measurements, but which structures were assessed by which approach. Transabdominal and transvaginal imaging provide different acoustic windows. State when an approach was not performed or a target structure could not be seen. These examples address the non-obstetric adult pelvis and do not replace an obstetric ultrasound report.

Editable complete report framework

Examination: Pelvic ultrasound.
Indication: [Pain / abnormal bleeding / mass / follow-up / other].
Clinical context: [Last menstrual period, cycle day, menopausal status, relevant pregnancy or surgical history, when available].
Comparison: [Study and date / none].

Technique: [Transabdominal and/or transvaginal; transrectal/transperineal if appropriate]. [Bladder status and technical limitations.]

Findings:
Uterus: [Presence, orientation, three dimensions, myometrium, focal lesions].
Endometrium: [Double-layer AP thickness, appearance, intracavitary fluid or focal lesion]. [If fluid is present, measure the layers separately.]
Cervix: [Visible findings].
Right ovary: [Visibility, three dimensions, parenchyma and follicles/mass].
Left ovary: [Visibility, three dimensions, parenchyma and follicles/mass].
Adnexa and cul-de-sac: [Mass, free fluid].
Other: [Findings relevant to the indication].

Impression:
1. [Direct answer to the clinical question].
2. [Important finding and any limitation].

Document the approach and clinical context

Transabdominal imaging provides a broad pelvic overview. The bladder should be distended when needed to move bowel and provide an acoustic window. If overdistention compromises the examination, imaging after partial emptying may help. The bladder is preferably empty for transvaginal imaging. Select the approach according to consent, patient preference, the clinical question, and local policy; if transvaginal imaging is not appropriate, another approach may be considered within local practice and operator expertise.

When relevant, include last menstrual period/cycle day, menopausal status, abnormal bleeding, pregnancy possibility, prior surgery, and comparison studies. Measure the endometrium as a double layer in a true sagittal plane. If there is intracavitary fluid, assess the two endometrial layers separately. Endometrial thickness varies across the premenopausal cycle, so do not apply one cutoff to every clinical question. Interpret the measurement with bleeding, menopausal status, and clinical context.

Record whether each ovary is seen, its three dimensions and appearance, the side and origin of an adnexal mass, and free fluid. Add Doppler according to the finding and clinical question; normal flow alone does not exclude torsion. Do not use “not visualized” as a synonym for “absent.”

Fictional complete report examples

Patient details and measurements below are fictional.

Normal transabdominal and transvaginal examination

Examination: Transabdominal and transvaginal pelvic ultrasound.
Indication: Mild cyclic pelvic pain in a 34-year-old on cycle day 7.
Comparison: None.

Technique: Transabdominal imaging was performed with a full bladder, followed by transvaginal imaging after voiding. Diagnostic image quality.

Findings: The uterus is anteverted and measures 7.6 × 3.9 × 4.2 cm. The myometrium is homogeneous without a focal mass. The endometrium measures 6 mm as a double layer and is smooth, without a focal lesion. The visualized cervix is unremarkable. The right ovary measures 3.1 × 2.0 × 1.8 cm and the left 2.8 × 1.9 × 1.7 cm; physiologic follicles are present without a solid mass. No adnexal mass or free fluid in the cul-de-sac.

Impression: No significant structural abnormality identified on pelvic ultrasound.

This example does not make 6 mm a universal normal threshold; interpret the measurement in relation to cycle day and indication.

Intramural leiomyoma without cavity distortion

Examination: Transabdominal and transvaginal pelvic ultrasound.
Indication: Evaluation of prolonged menstrual bleeding.
Clinical context: Premenopausal; last menstrual period 2026-10-21.
Comparison: Ultrasound dated 2025-08-14.

Technique: Transabdominal imaging with a full bladder and transvaginal imaging after voiding. Diagnostic examination.

Findings: The uterus is anteverted and measures 8.4 × 4.6 × 5.1 cm. A 2.6 cm posterior intramural solid lesion does not distort the endometrial cavity; it measured approximately 2.4 cm on the prior examination. The endometrium measures 9 mm as a double layer and has a smooth appearance without a focal intracavitary lesion. The cervix is unremarkable. Both ovaries have normal morphology without a mass. No free fluid.

Impression: 2.6 cm posterior intramural leiomyoma without cavity distortion, not significantly changed in size. Interpret the endometrium in relation to the bleeding pattern and cycle context.

Limited transabdominal examination

If transvaginal imaging is not performed, state this and the reason, the limits of the transabdominal window, and which structures could not be seen. For example: “Transabdominal examination is limited by prominent bowel gas. The uterus is partly assessed; the ovaries are not visualized. No adnexal mass is identified, although nonvisualization of the ovaries does not exclude a small lesion.” If the clinical question remains unanswered, recommend suitable additional evaluation.

Checklist and pitfalls

• Transabdominal/transvaginal approach and limitations are stated.
• Relevant cycle, menopause, and bleeding context is included.
• Uterus is measured in three dimensions; endometrium is measured as a double layer in the sagittal plane.
• Visibility and dimensions of both ovaries, adnexa, and cul-de-sac are addressed.
• A nonvisualized ovary is not reported as normal or absent.
• One endometrial thickness cutoff is not generalized to every patient.
• When an adnexal lesion requires O-RADS assessment, report the complete examination and justify the category with the relevant classification guidance.

See the O-RADS US v2022 guide for adnexal lesions for lesion classification.

References

• American College of Radiology, ACOG, AIUM, SPR, and SRU. Practice Parameter for the Performance of Ultrasound of the Female Pelvis, revised 2024. ACR practice parameter (PDF) (opens in a new tab)
• American Institute of Ultrasound in Medicine. AIUM Practice Parameter for the Performance of Ultrasound of the Female Pelvis, 2024 Revision. J Ultrasound Med. 2024;43(11):E56–E64. doi:10.1002/jum.16556. PubMed (opens in a new tab)

Clinical note: This educational framework does not replace independent image review or clinical judgment. Adapt each example to the actual patient, examination approach, and indication.