ISUOG Basic Training

Writing the Gynecological Ultrasound Report

Basic Training
 Learning objectives
At the end of the lecture you will be able to:
• Write a clear, concise and accurate gynecology
ultrasound report
• Understanding the importance of writing a good
gynecology ultrasound report
• Understand the basic principles of gynecology
ultrasound reporting

Basic Training
 Key questions
1. What are the key features of a gynecology ultrasound
report?

2. How can I make sure I write a good report?

Basic Training
What is an ultrasound report and why is it important?
• Medico-legal document
• Primary means of communication between sonologist, referring
clinician and patient
• Constitutes a clinical opinion of a specialist’s interpretation of
images
• Aim: to answer the original clinical question and provide
information - patient management
• Should be accurate, clear, concise and logical

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 The imaging examination
• Before the examination
– What is the clinical question?

• During the examination

• After the examination

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 Basic guidelines for writing a report
• Should be written and issued by the sonologist performing
the examination
• Integral part of the entire examination
• Should be written as soon as possible after the examination
is completed
• Sonologist is fully responsible for the accuracy and content
• Sonologists should be aware of their limitations and seek
advice where necessary

Basic Training
 Basic guidelines for writing a report
• Mostly printed
• If handwritten, black ink should be used
• Report must be appropriately dated, signed with reporter’s name
and designation and filed in medical records.
• Use of a pre-existing template/ electronic database
– Is it helps maintain consistency of reporting
– Allows research and audit to take place
– Ensures adherence to local standards

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Basic Training
 Example of reporting database

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 Report style
• Clear and concise
• Use present tense
• Easily understood using standardized terminology
• Avoid technical jargon
• Abbreviations should only be used when standard
• Any actions or recommendations should be clearly reported
• A succinct conclusion should be included
• Report should be conclusive where possible and indicate when the appearances are
consistent with a specific diagnosis
– Where this is not possible, alternative explanations may be offered

Basic Training
 Summary of report contents
• Clinical history
• Structures examined
• Description of findings
• Interpretation of findings
• Conclusion

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 Report contents: clinical and technical details
• Patient details: Name, surname, DOB
• Sonologist details
• Name of chaperone (when present)
• Place of scan
• Type of ultrasound machine used: model, probe features
• Examination method: Transvaginal, transrectal and/or abdominal
• Indication for scan
• Any limitations: Body habitus, overlying bowel gas
• Basic history
- Includes LMP, length of menstrual cycle, pregnant or not, parity
- Menopausal status, contraception or HRT use

Basic Training
 Examination outline: uterus
• Orientation (version/ flexion)
• Position (e.g. axial/ laterodeviated left side/ right side)
• Size (length of the entire uterus, largest anteroposterior diameter of the
corpus of the uterus, largest transverse diameter of the corpus of the uterus)
• General echotexture/echopattern
• Shape (e.g. globular)
• External contour (regular/lobulated)
• Mobility/sliding sign

Basic Training
 Examination outline: endometrium
• Assessment (visible/not visible/assessable/not assessable)  because of
position/version/flexion (e.g. axial)/because of presence of pathologies,
etc.
• Thickness/ appearance (e.g. synchronous with menstrual
period/postmenopausal status/medical treatment? etc.)
• Endometrial-myometrial junction (regular/ irregular/ interrupted/ not
assessable)
• Focal pathology (e.g. fibroid/polyps/other)

Basic Training
 Examination outline: myometrium
• Myometrium:
– Overall myometrial echogenicity (homogeneous/
heterogeneous)
– Presence of diffuse/localised abnormalities (e.g. fibroids,
adenomyosis/ size/ location etc)
• Cervix (if normal, usually not mentioned)
• Any abnormalities noted in endometrium or myometrium
– report using IETA and MUSA terms and definitions

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 Examination outline: adnexa
• Both adnexa must be examined
• Size of both ovaries should be measured in 3 orthogonal planes
• Number and pattern of follicles where present, phase of cycle in
premenopausal
• Mobility: mobile/reduced/fixed (to uterus/bowel/pelvic side wall)
• Tenderness on pressure
• Fallopian tubes if visible: possible hydrosalpinx, haematosalpinx, pyosalpinx
• Any abnormalities noted
– In the case of an adnexal mass this should be reported using IOTA terms and definitions

Basic Training
 Examination outline: free fluid/ ascites
• Comment on presence of free fluid
– Location (Pouch of Douglas, uterovesical fold, adnexal
region)
– Amount
– Ascites
– Appearance: Could represent clear (anechoic) fluid in
keeping with recent ovulation or be echoic/ low level/ with
clots in keeping with blood/ pus

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 Pelvic mass
• If a large pelvic mass is noted, a transabdominal scan must
be performed to fully assess the mass

• If a gynecological malignancy is suspected, it is good practice

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 Conclusion of report
• Conclusion should be succinct
• Report abnormal findings with likely diagnosis or
differential diagnosis
• Could suggest further investigations, management

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 Case example 1
• 37 year old
• P2 (NVD)
• Irregular vaginal bleeding for the last 3 months
• Negative urine pregnancy test

Basic Training
 Ultrasound report
Uterus anteverted. Echogenic focus seen with a feeding
vessel. Normal appearance of both ovaries. No masses or
free fluid seen.

Conclusion:
Ultrasound findings demonstrate an echogenic focus within
the uterus with a feeding vessel.

Basic Training
 Ultrasound checklist
Concise style
No ambiguous terminology
No inappropriate technical language • No measurement given for
Irrelevant information avoided any of the structure
Limitations stated • Does not give a differential
Addresses the clinical question diagnosis

Abbreviations used carefully

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 Case example 2
• 53 year old
• Post-menopausal
• Abdominal pain and bloating
• Previous hysterectomy

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 Ultrasound report
The uterus is absent (hysterectomy noted). Normal left
ovary. The right ovary contains a complex mass. No free
fluid in the pelvis.

Conclusion:
Complex mass in the right ovary
Suggest referral to the gynecology rapid access clinic.

Basic Training
 Ultrasound checklist
Concise style
No ambiguous terminology
No inappropriate technical language
• No measurement given for
Irrelevant information avoided any of the structures
Limitations stated • Does not give a
Addresses the clinical question differential diagnosis
Abbreviations used carefully
Conclusive where possible
Accurate report

Basic Training
 Case example 2

• 53 year old
• Post-menopausal
• Abdominal pain and bloating
• Previous hysterectomy

Basic Training
 Ultrasound report
TV ultrasound performed with verbal consent. Good views obtained. The
uterus is absent (hysterectomy noted). The left ovary is visible, measuring
10 x 15 x 18mm, is mobile and appears quiescent (compatible with age
and postmenopausal status). The right ovary contains a smooth multi-
locular mass (5 locules), measuring 100 x 98 x 125mm, with anechoic
content, no crescent sign visible. The lesion is mobile and non-tender.
IOTA color score 1. No free fluid is seen within the pelvis.

Conclusion:
Smooth and avascular multi-locular mass (5 locules) in the right ovary.
Suggest referral to the gynecology rapid access clinic.

Basic Training
 Ultrasound checklist
Concise style
No ambiguous terminology
No inappropriate technical language
Irrelevant information avoided
Limitations stated
Addresses the clinical question
Abbreviations used carefully
Conclusive where possible
Accurate report

Basic Training
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Basic Training