REVIEWS AND COMMENTARY • STATEMENTS AND GUIDELINES

O-RADS US v2022: An Update from the American

College of Radiology’s Ovarian-Adnexal Reporting and
Data System US Committee
Lori M. Strachowski, MD • Priyanka Jha, MBBS • Catherine H. Phillips, MD • Misty M. Blanchette Porter, MD •
Wouter Froyman, MD • Phyllis Glanc, MD, FACR • Yang Guo, MD • Maitray D. Patel, MD, FACR •
Caroline Reinhold, MD • Elizabeth J. Suh-Burgmann, MD • Dirk Timmerman, MD • Rochelle F. Andreotti, MD
From the Department of Radiology and Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San
Francisco, 1001 Potrero Ave, 1X57, San Francisco, CA 94110 (L.M.S.); Department of Radiology, Stanford University School of Medicine, Palo Alto, Calif (P.J.); De-
partment of Radiology and Radiologic Sciences, Vanderbilt University Medical Center, Nashville, Tenn (C.H.P.); Department of Obstetrics, Gynecology, and Reproductive
Sciences, Larner College of Medicine at the University of Vermont, Burlington, Vt (M.M.B.P.); Department of Obstetrics and Gynecology, University Hospitals and Depart-
ment of Development and Regeneration, KU Leuven, Leuven, Belgium (W.F., D.T.); Department of Medical Imaging, Sunnybrook Health Science Centre, University of
Toronto, Toronto, Canada (P.G.); Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass (Y.G.); Department of Radiology, Mayo
Clinic Arizona, Phoenix, Ariz (M.D.P.); Department of Radiology, McGill University Health Centre, Montreal, Canada (C.R.); Department of Gynecologic Oncology, Kaiser
Permanente Northern California, Walnut Creek, Calif (E.J.S.B.); and Department of Radiology and Radiological Sciences and Department of Obstetrics and Gynecology,
Vanderbilt University College of Medicine, Nashville, Tenn (R.F.A.). Received March 17, 2023; revision requested April 10; final revision received July 6; accepted July 14.
Address correspondence to L.M.S. (email: lori.strachowski@ucsf.edu).

Conflicts of interest are listed at the end of this article.

Radiology 2023; 308(3):e230685 • https://doi.org/10.1148/radiol.230685 • Content codes:

First published in 2019, the Ovarian-Adnexal Reporting and Data System (O-RADS) US provides a standardized lexicon for ovarian
and adnexal lesions, enables stratification of these lesions with use of a numeric score based on morphologic features to indicate the
risk of malignancy, and offers management guidance. This risk stratification system has subsequently been validated in retrospective
studies and has yielded good interreader concordance, even with users of different levels of expertise. As use of the system increased, it
was recognized that an update was needed to address certain clinical challenges, clarify recommendations, and incorporate emerging
data from validation studies. Additional morphologic features that favor benignity, such as the bilocular feature for cysts without solid
components and shadowing for solid lesions with smooth contours, were added to O-RADS US for optimal risk-appropriate scoring.
As O-RADS US 4 has been shown to be an appropriate cutoff for malignancy, it is now recommended that lower-risk O-RADS US
3 lesions be followed with US if not excised. For solid lesions and cystic lesions with solid components, further characterization with
MRI is now emphasized as a supplemental evaluation method, as MRI may provide higher specificity. This statement summarizes the
updates to the governing concepts, lexicon terminology and assessment categories, and management recommendations found in the
2022 version of O-RADS US.
© RSNA, 2023

T he first-line imaging modality for evaluation of the ova-

ries and adnexa is US. The Ovarian-Adnexal Report-
ing and Data System (O-RADS) US was introduced in a
2018 American College of Radiology white paper outlin-
ing an evidence-based lexicon for ovarian and adnexal le-
sions. In 2019, the O-RADS US risk stratification system
based on sonographic morphologic features to predict
malignancy followed and included guidance on manage-
ment (1,2). Since its introduction, multiple retrospective
studies in both selected and nonselected populations have
demonstrated that O-RADS US has high sensitivity and
specificity for detection of both benign and malignant
lesions (3–9). These data confirmed that an O-RADS
US 2 score conferred a near 100% chance of benignity,
while the diagnostic performance of an O-RADS US 4
score was the optimal cutoff for malignancy character-
ization. Additionally, reproducibility studies have shown
that the O-RADS US system performs well even in the
hands of nonexperienced reviewers and trainee radiolo-
gists, with high interreader concordance (10–14). While
the use of O-RADS US has been validated in multiple
studies, others have raised concerns regarding the appar-
ent complexity of the system, omission of features such as
shadowing for solid adnexal lesions, lack of congruence
This copy is for personal use only. To order copies, contact reprints@rsna.org
with the Society of Radiologists in Ultrasound (SRU)
Consensus Guidelines for Adnexal Cysts, and areas of
discrepancy with the O-RADS MRI risk stratification
system (15–22).
In addition to these concerns, two recent developments
prompted consideration of an O-RADS US update. In
2021, the Centers for Medicare and Medicaid Services ap-
proved use of the O-RADS US management scheme as a
quality assurance tool (23). This resulted in an increased
interest in incorporating O-RADS in all pelvic US reports
and raised questions regarding applicability to the nor-
mal, nonvisualized, and surgically absent ovary. In 2022,
the International Ovarian Tumor Analysis (IOTA) group
published a retrospective study using 2-year interim data
from IOTA phase 5, an ongoing international multicenter
prospective observational cohort study, to evaluate the di-
agnostic performance of O-RADS US and the IOTA two-
step strategy in patients with an adnexal lesion who either
underwent surgical resection or were followed up clinically
(23). This study found a lower risk of malignancy for some
solid smooth lesions with shadowing and smooth cysts
with a single septation, permitting statistical support for
an O-RADS US update. As its major objective, this study
also confirmed that both the O-RADS US lexicon and the
O-RADS US v2022: An Update from the American College of Radiology
Abbreviations
IOTA = International Ovarian Tumor Analysis, O-RADS = Ovarian-
Adnexal Reporting and Data System, SRU = Society of Radiologists in
Ultrasound
Summary
The Ovarian-Adnexal Reporting and Data System (O-RADS) US
v2022 update provides additional user clarity, improves specificity, bet-
ter aligns with existing consensus statements, and offers more directed
management recommendations.
Essentials
■ The 2022 update of the Ovarian-Adnexal Reporting and Data
System (O-RADS) US provides new lexicon descriptors to im-
prove diagnostic specificity of lower-risk lesions, including the
terms bilocular for cystic and shadowing for smooth solid lesions,
as well as additional descriptors for classic benign lesions.
■ Emerging data validate that the risk of malignancy for adnexal
lesions categorized as O-RADS US 3 is low; O-RADS US manage-
ment guidelines have thus been updated to allow short-term US fol-
low-up, although MRI should still be considered for solid O-RADS
US 3 lesions.
■ To better align with existing consensus statements, the calculation
of average linear dimension (sum of length, width, and height
divided by 3) is now encouraged for growth assessment, and the
time and duration of surveillance for lower-risk lesions has been
updated.
IOTA two-step strategy can be used to assess malignancy risk of
ovarian lesions.
To address user concerns, promote increased applicability,
and incorporate emerging data, the American College of Radiol-
ogy convened a multidisciplinary committee in January 2022 to
update O-RADS US. The panel, comprised of eight radiologists
(including one representative each from the SRU Consensus on
Adnexal Cysts and O-RADS MRI Committee), three gynecolo-
gists (including two representatives from IOTA), and one gy-
necologic oncologist, used a modified Delphi process to reach
consensus (≥80% agreement). The result, titled O-RADS US
v2022 (Fig 1), was released in November 2022 and is consensus-
based, relies on both scientific data and expert opinion, and
addresses many of the issues brought forward. Specifically, the
update provides additional guidance and clarification for everyday
application of the system, addresses discrepancies with O-RADS
MRI and the SRU Consensus on Adnexal Cysts, and enables the
application of O-RADS US to all pelvic US reports. In addition,
O-RADS US v2022 improves specificity of certain lower-risk
lesions and strengthens management recommendations to better
align with validation studies and clinical protocols (24). Update
details are described in this statement, organized by governing
concepts, lexicon terminology and assessment categories, and
management recommendations.
Updates to Governing Concepts
The governing concepts provide guidance on when and how to
use O-RADS US, technical considerations, and relevant defini-
tions. In O-RADS US v2022, these concepts have been updated
to provide additional clarity and fall into three major categories:
applicability criteria, definitions and technique, and rules for
2 radiology.rsna.org
system use as they relate to the lexicon, assessment categories,
and management (Table 1).
Applicability Criteria (Governing Concepts 1–3)
The first governing concept in O-RADS US v2022 emphasizes
that the intent of O-RADS US is for categorizing ovarian and
adnexal lesions by their risk of malignancy when it is relevant
for management. This important principle helps users identify
scenarios in which the system would not apply. For instance,
O‑RADS US would not apply to adnexal findings related to
mani­festations of conditions unrelated to malignancy (such as
pelvic inflammatory disease, ectopic pregnancy, and ovarian tor-
sion when no ovarian lesion is identified). While atypical pre-
sentations of these processes may result in misinterpretation
that leads to the inclusion of these lesions in O-RADS US, the
committee agreed that most of these would be corrected as the
patient moves through the management process. O-RADS US
would also not apply when a nonovarian or nontubal cause is
suspected, or when a uterine origin is clearly identified (such as
exophytic and subserosal myomas) (Fig 2). Recognizing that in
some scenarios the origin of a lesion remains uncertain on US
images, guidance was added to consider alternate imaging with
CT or MRI.
To enable incorporation of O-RADS US within all pelvic
US examination reports (including templates) and reconcile
with O-RADS MRI, applicability to the normal ovary with-
out a focal observation has been added, which is assigned an
O-RADS US 1 score (Figs 1, 3) (20,25). When an ovary is not
seen or absent and no adnexal lesions are identified, O-RADS
US is not applicable in most cases (Fig 1). Common scenarios
of ovarian nonvisualization include the postmenopausal pa-
tient with atrophic ovaries or obscuration of the ovaries by
bowel gas. An exception where O-RADS US may be applicable
to the nonvisualized ovary is when the examination intent is
ovarian detection and visualization is expected (eg, premeno-
pausal patient with genetic predisposition for ovarian cancer).
In this scenario, O-RADS US 0 (technically inadequate) may
be considered with recommendation for repeat US or MRI.
The option of O-RADS 0 for ovarian nonvisualization may
also be appropriate when US is requested for follow-up of a
previously identified lesion or to further evaluate a finding seen
at another imaging modality.
When multiple or bilateral adnexal lesions are encountered,
the recommendation is to provide a separate O-RADS US score
for each lesion. In most cases, management is guided by the high-
est score. In scenarios when lesions may be managed differently,
such as surgical management of one lesion and US surveillance
of another, it may be prudent to provide separate management
recommendations along with individual scores to allow optimal
longitudinal follow-up and management. As such, a modifica-
tion to provide separate management recommendations for
bilateral and multiple lesions as indicated has been added.
Definitions and Technique (Governing Concepts 4–7)
O-RADS US v2022 further clarifies definitions and sono-
graphic technique (18). For instance, in the original version of
O-RADS US, menopause was established as amenorrhea for
■ Radiology: Volume 308: Number 3—September 2023
 Strachowski et al

Figure 1: The American College of Radiology Ovarian-Adnexal Reporting and Data System (O-RADS) US v2022 governing concepts and
tables for assessment categories and classic benign lesions. (A) The governing concepts have been expanded to better clarify O-RADS US use. These
have been reordered in a practical fashion starting with criteria of when to use O-RADS US and concluding with principles related to management.
H = height, L = length, W = width (Fig 1 continues).

1 year or longer; however, this did not address patients with prior following menopause) or late (5 years or more since meno-
hysterectomy or uncertain menopausal status. In addition, for pause) (21). In O-RADS US v2022, guidance is provided to
assessing hemorrhagic cysts, the SRU Consensus on Adnexal determine menopausal status that is unknown or cannot be de-
Cysts classifies menopause as either early (less than 5 years termined by using a patient age of 50 years or older. To manage

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O-RADS US v2022: An Update from the American College of Radiology

Figure 1 (continued): (B) O-RADS US v2022 assessment categories are organized per the American College of Radiology color-coded
schema with columns exhibiting (a) risk assessment score (0–5), (b) corresponding nomenclature and numeric risk range of malignancy, (c) lexicon
descriptors, and (d) management recommendations. Below the main table, a glossary containing definitions, abbreviations, and guidance as well as
verbiage explaining the asterisks displayed in the management recommendations column have been added. IOTA = International Ovarian Tumor
Analysis, N/A = not applicable (Fig 1 continues).

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 Strachowski et al

Figure 1 (continued): (C) Classic benign lesions include the ovarian categories of hemorrhagic cyst, dermoid cyst, and endometrioma and the
extraovarian categories of paraovarian cyst, peritoneal inclusion cyst, and hydrosalpinx. Lexicon descriptors and definitions for the typical appear-
ance of classic benign lesions are outlined in the second column. Specific management recommendations for classic benign lesions categorized as
O-RADS US 2 are included in the third column. Ovarian classic benign lesions measuring 10 cm or more are scored as O-RADS US 3 and should
be managed following the recommendations described in the (B) assessment categories table. Reprinted, with permission, from the American
College of Radiology.

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O-RADS US v2022: An Update from the American College of Radiology

a hemorrhagic cyst, early and late menopause are applied in
O-RADS US v2022 as defined in the SRU consensus (21).
Similarly, when menopausal status is uncertain or the uterus
is absent, a hemorrhagic cyst may be managed per the early
postmenopausal category when the patient is older than 50 years
Table 1: Summary of Major Updates to the Governing
Concepts for O-RADS US v2022
Applicability criteria
May apply to normal ovaries (previously only lesions)
Does not apply to PID, EP, nonvisualized or absent ovary, etc
When lesion origin is uncertain, may consider CT or MRI
Definitions and technique
When menopausal status is uncertain or uterus absent, use
age ≥50 years to manage per the postmenopausal category
Early and late menopause apply to management of
hemorrhagic cysts
US specialist definition expanded to emphasize the
importance of experience and involvement
TAS may suffice when adequate and TVS is limited;
orthogonal cine clips are strongly encouraged
Interval change over serial exams should be assessed using
average linear dimension ([L + W + H]/3)
Rules for system use
Lexicon and scoring apply to most lesions regardless of patient
risk or symptoms
When features are mixed or variable, use those resulting in a
higher score to optimize sensitivity
Management modifiable by risk, symptoms, clinical factors,
and professional judgment; recommendations are not strict
requirements
Note.—EP = ectopic pregnancy, H = height, L = length,
O-RADS = Ovarian-Adnexal Reporting and Data System, PID =
pelvic inflammatory disease, TAS = transabdominal sonography,
TVS = transvaginal sonography, W = width.
but younger than 55 years of age, and per the late menopausal
category when the patient’s age is 55 years or older.
Feedback requesting that specific criteria be used to define
ultrasound specialist proved difficult to satisfy given the large
regional differences in training and requirements for creden-
tials. Therefore, emphasis is now placed on the importance
of experience in the accurate assessment of adnexal lesions
(14,18). Experiential qualifications might include involve-
ment in quality assurance activities and specialty conferences
(such as routine participation in multidisciplinary and qual-
ity assurance conferences or gynecologic oncology tumor
boards), which typically denote a user with improved ability
to achieve radiology-pathology correlation.
With respect to US technique, transvaginal imaging is rec-
ommended for evaluation of the ovaries and adnexa in O-RADS
US. In the original version of O-RADS US, transabdominal and
transrectal sonographic approaches were included for their pos-
sible value in providing additional lesion characterization. As the
proximity of the transducer in transvaginal imaging often leads
to improved resolution of adnexal lesions for optimal charac-
terization, some users questioned if an examination needs to be
categorized as technically inadequate (O-RADS US 0) in the
absence of transvaginal technique. O-RADS US v2022 clarifies
that transabdominal technique may suffice when transvaginal
imaging is not feasible or inadequate. The transrectal approach
has been removed given its infrequent use in North America.
When feasible, acquisition of cine clips through the entirety of
a lesion in orthogonal planes is now encouraged. This will be
most helpful when real-time scanning is not performed by the
examination interpreter (4).
The largest single dimension of a lesion is used for O-RADS
US risk stratification (scoring) and management, regardless of
the plane in which that occurs. In the O-RADS US v2022 up-
date, growth parameters have been added to help guide manage-
ment when serial examinations are performed. As differences in
measurement technique and probe pressure (which may deform

Figure 2: Exophytic myoma simulating a solid adnexal lesion. (A) Gray-scale US image in a 38-year-old premenopausal patient
presenting with a palpable left pelvic mass shows a left adnexal solid mass (calipers) with smooth outer contour and broad shadowing
(arrows). (B) Color Doppler US image shows bridging vessels (arrows) connecting this lesion to the uterus (arrowhead) and confirming the
diagnosis of a subserosal exophytic myoma. When a solid adnexal lesion is seen, identifying separate ovaries helps exclude an ovarian origin
and prompts consideration of an exophytic or broad-ligament myoma. Interrogating with color Doppler US to demonstrate bridging vessels
confirms the lesion to be of uterine origin; this is particularly helpful when bilateral ovaries are not identified.

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 Strachowski et al

Figure 3: The American College of Radiology Ovarian-Adnexal Reporting and Data System (O-RADS) US v2022 assessment categories algorithm. A user-friendly al-
gorithm has been created to quickly reach an O-RADS risk assessment score (colored boxes). Solid lines indicate the major categories of normal ovary, classic benign lesions,
and other cystic and solid lesions (that do not meet criteria for either a physiologic cyst or classic benign lesion). Dotted lines indicate the variable imaging features, which are
relevant for malignancy risk assessment. When imaging features are mixed (eg, mostly smooth but slightly irregular outer contour, inner walls, or septations), the features leading
to the highest O-RADS score should be used to optimize sensitivity. Reprinted, with permission, from the American College of Radiology.

lesions) limit the use of the largest single dimension for growth,
calculation of the average linear dimension (sum of length,
width, and height divided by 3) is encouraged for growth assess-
ment in congruence with the SRU consensus (21). Accordingly,
including all three measurements in imaging reports will allow
user assessment of interval change across serial examinations, es-
pecially when images are unavailable for direct comparison (21).
Rules for System Use (Governing Concepts 8 and 9)
Clinical implementation of the first version of O-RADS US
raised questions regarding its use in patients with risk factors for
ovarian cancer or acute symptoms (16,19). The IOTA 1–3 and
5 trials, on which the O-RADS US risk assessment categories
are based, included ovarian and adnexal lesions in patients with
and without risk factors for cancer as well as with and without
acute symptoms. As there is currently no evidence to suggest
that the US features used to predict malignancy risk differ based
on symptoms or cancer risk factors, it is emphasized in v2022
that the O-RADS US lexicon and risk assessment scores can be
applied to most lesions regardless of patient risk or symptoms;
it is only the management that may differ in these scenarios
(2,24,26,27).
For lesions with mixed benign and suspicious imaging fea-
tures leading to user uncertainty about feature selection, it is
recommended that the higher-risk features be used to optimize
sensitivity (28). Last, the update re-emphasizes that O-RADS
US provides recommendations for management, not strict re-
quirements. Management may be modified based on factors
including, but not limited to, genetic predisposition, acute
symptoms, professional judgment, and clinical circumstances
(such as pursuing immediate surgery for suspected torsion or
using shorter surveillance intervals to accommodate for patient
anxiety, ongoing infertility treatment, or existent pregnancy).
Updates to Lexicon Terminology and Assessment
Categories
O-RADS US v2022 maintains the six risk assessment categories
(O-RADS US 0–5) with increasing predicted risk of malignancy
from O-RADS US 1 to 5 (Table 2), but now definitions have
been clarified and terminology added to improve specificity for
some low-risk lesions (Table 3).
Importantly, the mainstay of O-RADS US scoring is an
algorithmic approach based on relevant morphologic assess-
ments using lexicon terminology (Fig 3). The smartphone app

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O-RADS US v2022: An Update from the American College of Radiology

for iOS and Android has been updated, providing a convenient O-RADS US 1 assessment category.—To allow users to apply
and efficient tool to quickly obtain an O-RADS US score and O-RADS US in all pelvic US reports and align with O-RADS
management recommendations (29). The complete lexicon for MRI (19), the normal ovary with or without a physiologic find-
O-RADS US v2022 can be found on the American College of ing or lesion is added to the O-RADS US 1 category (Fig 4).
Radiology’s O-RADS website (30). Follicle and corpus luteum remain in O-RADS 1 and are catego-
rized as physiologic cysts.
Definitions For corpus luteum, a discriminatory size cutoff of 3 cm is
now suggested but not required. A morphologically typical cor-
O-RADS US 0 assessment category.—A definition for O-RADS pus luteum (Fig 5) slightly above this size threshold can be clas-
US 0 (technically inadequate examination) was added to sified as O-RADS US 1, and wording for size has been revised
emphasize using this score when technical factors, including large as “typically” ≤3 cm.
lesion size, limit evaluation of features relevant for risk stratifi-
cation and not for uncertain lesion characterization. O-RADS Lexicon Terms
US 0 may also be considered when an ovary is not seen, as
outlined in governing concept 2 (Fig 1A). Bilocular.—O-RADS US previously limited the characteriza-
tion of cyst locularity to two options: unilocular (no complete
septation) and multilocular (one or more complete septations).
Table 2: O-RADS US v2022 Risk Assessment Categories In the SRU Consensus on Adnexal Cysts, based on expert
and Risk of Malignancy
opinion, the management of a cyst with a single thin septa-
tion (which may represent two adjacent simple cysts) is the
Assessment Category Risk of Malignancy (%)
same as that for a simple unilocular cyst (21). To better align
0: Technically inadequate NA
these systems, the 2-year interim data from the IOTA 5 trial
1: Normal ovary 0
was analyzed and supported a change in risk stratification of
2: Almost certainly benign <1
multilocular cysts <10 cm with a smooth inner wall and less
3: Low risk 1 to <10
than very strong flow when they were stratified by number of
4: Intermediate risk 10 to <50
5: High risk ≥50
cyst locules. Cysts with more than two locules had a 2.3% risk
of malignancy, while cysts with a single smooth septation (bi-
Note.—NA = not applicable, O-RADS = Ovarian-Adnexal locular) had a 0.7% risk of malignancy (24). In the original
Reporting and Data System.
O-RADS US, all of these were considered multilocular cysts

Table 3: Summary of Major Updates to Lexicon Terminology and Assessment Category Definitions in O-RADS US v2022

Category or Lesion Updates Comments

Assessment category
O-RADS 0 “Lesion features relevant for risk stratification Emphasizes O-RADS 0 is not for user uncertainty regarding
cannot be accurately assessed due to technical factors” lesion characterization
O-RADS 1 “No ovarian lesion” Allows use of O-RADS 1 for an ovary without a focal
observation
Corpus luteum size “typically” ≤3 cm Emphasizes morphologic characteristics over size
Lesion type
Cystic lesions “Bilocular” (2 locules) Multilocular redefined as ≥3 locules
Solid lesions “Shadowing” (diffuse or broad) Relevant for smooth outer contour; must differentiate
refractive artifact
Classic benign “For any atypical features on initial or follow-up Typical features are those listed in the Classic Benign Lesions
lesions exam, use other lexicon descriptors (e.g. unilocular, table (Fig 1C)
multilocular, solid, etc.)”
Hemorrhagic cyst “Unilocular, no internal vascularity” Reticular pattern should not be confused with septations;
may have peripheral blood flow
Dermoid cyst “≤3 locules, no internal vascularity” Excludes blood flow in walls or intervening septations
Hyperechoic component(s) “(diffuse or regional)” Entire lesion may be hyperechoic without apparent
with shadowing surrounding fluid
Endometrioma “≤3 locules, no internal vascularity” Excludes blood flow in walls or intervening septations
May have “peripheral punctate echogenic foci” Optional feature; uncommon, but specific
Hydrosalpinx “Anechoic fluid-filled tubular structure” No internal echoes; optional features: incomplete septation(s)
and endosalpingeal folds
Note.—Words in italics and within quotation marks reflect updated wording in the Ovarian-Adnexal Reporting and Data System
(O-RADS) US v2022 Assessment Categories and Classic Benign Lesions tables (Fig 1B, 1C).

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 Strachowski et al

Figure 4: Ovary without a focal observation. (A) Gray-scale US image shows a normal ovary in a 52-year-old postmenopausal woman. In the
original version of the Ovarian-Adnexal Reporting and Data System (O-RADS) US, the “normal ovary” category (O-RADS US 1) listed the physiologic
findings of follicle (simple cyst ≤3 cm) and corpus luteum. To clarify that the O-RADS US 1 category would also apply to the normal ovary without any
focal observations, the entry of “no ovarian lesion” has been added in O-RADS US v2022. (B) Gray-scale US image of a normal ovary in a 60-year-
old postmenopausal woman shows a few internal nonshadowing punctate echogenic foci (arrow). These foci are believed to represent sequela of
prior ovulation-related hemorrhage and may be of value in identifying small normal postmenopausal ovaries, which are often challenging to see due
to absence of physiologic cysts.

Figure 5: Typical corpus luteum. (A–C) Gray-scale US images show the typical appearance of a corpus luteum with corresponding (D–F) color Doppler US images
of each shown below. Typical corpora lutea are thick-walled cysts with (A, D) smooth or (B, E) crenulated inner walls (dotted arrows) and (D–F) peripheral flow. (A, D)
Internal echoes (solid arrows) representing blood products are an optional feature of a typical corpus luteum. (C, F) Another typical appearance of a corpus luteum is (C)
“solid-appearing” (arrowheads). This occurs when the thickened walls are opposed and central fluid is not apparent. (F) Peripheral vascularity is particularly helpful with a
solid-appearing corpus luteum to help determine the diagnosis; internal vascularity should always be absent.

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O-RADS US v2022: An Update from the American College of Radiology

Figure 6: Types of cyst locularity included in Ovarian-Adnexal Reporting and Data System (O-RADS) US v2022. Schematic representa-
tions and corresponding patient US images demonstrate the three terms used to describe cyst locularity in O-RADS US v2022: unilocular,
bilocular, and multilocular. The term bilocular has been introduced in v2022 to differentiate a cyst with a single, smooth, thin, complete septation
from a multilocular cyst, with the intent of improving the specificity of low-risk cystic lesions without solid components. The term multilocular, which
previously was defined as a cystic lesion with one or more complete septations, is redefined as a cyst with two or more complete septations
resulting in three or more locules. Incomplete septations do not contribute to the nomenclature for cyst locularity.

and categorized as low risk, category 3 (1% to <10% risk of
malignancy). However, the malignancy risk of the bilocular
cyst reported by Timmerman et al (24) falls within the risk
of malignancy designated to the almost certainly benign
category, O-RADS US 2 (<1% risk of malignancy), thus
warranting their downgrade from category 3. Hence, the term
bilocular has been added in O-RADS US v2022 and is defined
as a cyst with two locules (with or without internal echoes),
while the term multilocular is now reserved for those cysts
containing three or more locules (Fig 6).
Shadowing.—In the original O-RADS US lexicon white paper,
the term shadowing, defined as hypoechogenicity posterior to a
lesion due to attenuation of the acoustic beam, was included as
a descriptor for the typical appearance of dermoid cysts (“hyper-
echoic component with shadowing”) and was also mentioned

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Table 4: Color Score Adopted from the International
Ovarian Tumor Analysis Group
Color Score Degree of Internal Blood Flow*
1 No flow
2 Minimal flow
3 Moderate flow
4 Very strong flow
* Subjective assessment of internal vascularity at color Doppler
US imaging.
with fibromatous lesions (1). For simplicity, this descriptor
was not included as a feature of solid lesions in the original
O-RADS US risk stratification system (2,15). However, concerns
were raised that omission of shadowing in the characterization
of solid lesions may lead to an increased O-RADS US score for
some benign solid lesions and potentially result in unnecessary
surgery (15).
Shadowing was therefore analyzed in the 2-year interim
data from IOTA 5, with results showing that solid lesions with
a smooth outer contour and acoustic shadowing had a <10%
risk of malignancy when the internal vascularity assessed with
color Doppler imaging was categorized as anything less than
very strong (color score <4) (Table 4) (24). Given this evidence,
smooth solid lesions with shadowing and minimal or moderate
blood flow (color score 2–3) may now be classified as O-RADS
US 3 (1% to <10% risk of malignancy), in distinction to prior
scoring as O-RADS US 4 (10% to <50% risk of malignancy)
when shadowing was not an algorithmic feature (24). To avoid
the mischaracterization of refractive artifact as evidence of shad-
owing, the observed shadowing must be diffuse or broad to qual-
ify (Fig 7). Presence of shadowing does not change the risk of
malignancy for solid lesions with an irregular contour, which is
always a worrisome feature warranting an O-RADS US 5 score.
Lexicon Phrases
Classic benign ovarian lesions: locularity and no internal
vascularity.—The strength of the O-RADS US system relies on
accurate characterization of “classic benign lesions” based on the
presence of typical features without any atypical features. As this
is fundamental to accurate scoring, it is now emphasized that a
lesion with features of a classic benign lesion that has any atypical
features should be reassessed using other lexicon descriptors. To
improve specificity of classic benign lesions that arise from the
ovary (eg, hemorrhagic cyst, dermoid cyst, and endometrioma),
additional descriptors of their typical appearance have been
added in v2022, including the number of allowed locules and
absence of internal vascularity.
A typical hemorrhagic cyst is unilocular, with internal blood
products manifesting as retractile clot or a reticular pattern (fine
intersecting lines), which differ from septations, which are con-
tinuous. No internal vascularity should be detected with color
Doppler imaging. However, peripheral flow may be seen in the
surrounding ovarian parenchyma or within its walls, as many
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Strachowski et al
hemorrhagic cysts arise from a corpus luteum where peripheral
flow is common (Fig 8).
On the other hand, dermoid cysts and endometriomas may
appear multilocular. The observed risk of malignancy in a der-
moid cyst or endometrioma with more than three locules is
higher than for those with one to three locules, making three or
fewer locules an appropriate cutoff to qualify as a typical appear-
ance (24,31). A typical dermoid cyst or endometrioma has no
internal vascularity, except within its walls and intervening sep-
tations, which may represent surrounding ovarian parenchyma
around adjacent lesions (24,31) (Fig 9).
Dermoid cyst: hyperechoic component (diffuse or focal) with
shadowing.—A dermoid cyst commonly contains shadowing
hyperechoic components representing fat or calcium within car-
tilage or bone. In the original O-RADS US, the term component
suggested to some that it was a requirement to see the anechoic
appearance of surrounding fluid. This phrase has been modified
as “hyperechoic component (diffuse or focal) with shadowing” to
clarify that recognizable fluid is not always demonstrated at US
and the entire lesion may be hyperechoic with associated acous-
tic shadowing (Fig 10).
Endometrioma: peripheral punctate echogenic foci.—An endo-
metrioma is a blood-filled cyst lined by endometrial cells typi-
cally showing internal homogeneous low-level or ground-glass
echoes. The presence of peripheral punctate echogenic foci (Fig 11),
thought to represent cholesterol deposits related to byproducts
of hemosiderin due to prior hemorrhage, increases the specificity
of an endometrioma diagnosis and has thus been added as an
optional feature of a typical endometrioma (32).
Hydrosalpinx: anechoic, fluid-filled tubular structure.—In the
first version of O-RADS US, there were three descriptors for
hydrosalpinx: tubular, incomplete septation(s), and endosalp-
ingeal folds. Typically, hydrosalpinges are anechoic (no internal
echoes), and the omission of this descriptor did not allow for
distinction from hematosalpinges. This led to incongruence
with O-RADS MRI, which notes an association of hematosal-
pinx with serous tubal intraepithelial carcinoma in the absence
of other causes (such as endometriosis). Therefore, to qualify as
a typical hydrosalpinx at US, the appearance is better described
as an anechoic, fluid-filled tubular structure (Fig 12). Incomplete
septations (representing folds) and endosalpingeal folds (which ap-
pear as short round projections around the inner walls of a fluid-
filled tube) are considered optional features (Fig 12).
Updates to Management Recommendations
The management recommendations in the original O-RADS
US included a mix of imaging and clinical recommendations.
In O-RADS US v2022, management is organized by imaging
and clinical recommendations for all assessment categories (Ta-
ble 5). Follow-up recommendations are better aligned with the
SRU Consensus on Adnexal Cysts, specifically as they relate to
timing and duration for surveillance of lower-risk lesions and
growth parameters.
11
O-RADS US v2022: An Update from the American College of Radiology

Figure 7: Types of shadowing included in the Ovarian-Adnexal Reporting and Data System (O-RADS) US v2022. Schematic representa-
tions and corresponding patient US images demonstrate the two types of shadowing in O-RADS US v2022: diffuse and broad. Including this
feature in the risk stratification system for solid lesions aims to improve specificity of low-risk solid lesions. It is important to differentiate shadowing
due to sound beam attenuation by fibromatous elements from refractive artifact (arrows). Refractive artifact results when sound travels through
adjacent tissues with different acoustic impedance. It is most common at the edge of a lesion, although it may occur from within a lesion where
there are acoustic property differences in tissue components. To qualify as true shadowing in O-RADS US, the shadow should emanate from
the lesion in a diffuse or broad manner. For solid lesions, shadowing is only relevant when the outer contour is smooth; an irregular outer contour
is always suspicious, warranting an O-RADS US 5 score.

Management options for surgically unexcised low-risk le-
sions now includes consideration of short-interval US follow-up
rather than further characterization with MRI. This approach is
supported by validation trials demonstrating low risk of malig-
nancy of O-RADS US 3 lesions and reflects concerns regarding
the limited availability and added value of MRI when evaluating
low-risk cystic lesions without solid components (3,4,6,24,31).
When MRI is performed for O-RADS US 3 solid lesions and
O-RADS US 4 and 5 lesions, the use of O-RADS MRI protocol
and the associated scoring system is strongly recommended.
O-RADS US 0 (Technically Inadequate) Assessment Category
The original O-RADS US recommended alternate imaging man-
agement for the technically inadequate examination. This has

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 Strachowski et al

Figure 8: Typical hemorrhagic cyst. (A, B) Color Doppler US images show the typical appearance of a hemorrhagic cyst as a unilocular
cyst with no internal blood flow but with flow within its walls (arrowheads). Other features of a typical hemorrhagic cyst are seen, including
(A) an internal reticular pattern of fine intersecting lines and (B) retractile clot (arrow) appearing as avascular tissue with angular or straight
margins. It is important for accurate scoring that blood products are correctly characterized and not assessed as solid components in the
Ovarian-Adnexal Reporting and Data System US v2022.

Figure 9: Typical endometrioma with vascularity in walls and intervening septations. (A, B) Color Doppler US images show (A) a
unilocular cystic lesion with homogeneous low-level echoes and punctate echogenic focus (dotted arrow) at the periphery. No internal
vascularity is seen. Surrounding blood flow is apparent (arrows) and may be in the walls of the lesion or the adjacent ovarian parenchyma,
which are typical features of an endometrioma. (B) When an endometrioma is multilocular, vascularity may also be seen within interven-
ing septations (arrowheads), which may represent intervening ovarian parenchyma. Endometriomas are considered typical when three or
fewer locules (two or fewer septations) are seen. Those with more than three locules can have a higher risk of malignancy and should be
characterized using other lexicon descriptors.

been modified to reflect that a repeat US examination may be who may elect continued screening as outlined in governing
attempted if the technical issues limiting assessment are variable; concept number 9 (Fig 1A).
otherwise, MRI evaluation may be considered. Clinical manage-
ment is not applicable for inadequate sonographic evaluation be- O-RADS US 2 (Almost Certainly Benign)
fore risk stratification assessment with other imaging options. Assessment Category

O-RADS US 1 (Normal Ovary) Assessment Category
Imaging and clinical.—As no imaging or clinical follow-up is
typically required for this category, which includes physiologic
cysts and the ovary without any focal observations (Fig 13), no
changes were made to the management recommendations for
O-RADS US 1. One exception, however, is the high-risk patient
Imaging.—The O-RADS US 2 category includes variations of
the unilocular and bilocular cyst as well as classic benign le-
sions, which require special considerations (Figs 14, 15). Due
to the very low risk of malignancy of simple cysts, follow-up
US in 12 months is recommended for cysts >5 cm in premeno-
pausal women and those >3 cm in postmenopausal women.
When a simple cyst is ≥10 cm, a shorter 6-month follow-up

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O-RADS US v2022: An Update from the American College of Radiology

Figure 10: Typical dermoid cyst with shadowing hyperechoic components. (A, B) Gray-scale US images each show a typical dermoid
cyst demonstrating a hyperechoic component (solid arrows) with shadowing (dotted arrows). A hyperechoic component may appear
(A) regional when cystic fluid is seen or (B) diffuse when the cystic fluid is not apparent. To score dermoid cysts accurately with the Ovarian-
Adnexal Reporting and Data System US v2022, dermoid contents are not considered solid components, and posterior shadowing is a key
feature to assist in diagnosis. Another typical feature of a dermoid cyst is (A) hyperechoic lines and dots (arrowhead) representing coiled hair.

Figure 11: Typical endometrioma with peripheral punctate echogenic foci. (A) Gray-scale US image shows a unilocular cyst with
homogeneous low-level echoes and peripheral punctate echogenic foci (arrows). Features are typical for an endometrioma. (B) Gray-scale
US image of another endometrioma shows some coarse internal echoes. Peripheral punctate echogenic foci (arrows) have high specificity for
endometrioma and help confirm the diagnosis.

with US is advised if it is decided that the cyst need not be
surgically excised. Similarly, the risk of malignancy is very
low for postmenopausal women with small <3 cm unilocular
nonsimple cysts that have smooth inner walls but contain in-
ternal echoes or incomplete septations; 12-month follow-up
US is appropriate for such lesions. The follow-up interval is
decreased to 6 months for unilocular nonsimple smooth cysts
>3 cm but <10 cm as well as for bilocular smooth cysts (with or
without internal echoes) in that size range, regardless of meno-
pausal status. For any of the aforementioned lesions, shorter
follow-up may be considered based on certain patient clinical
factors, such as patient anxiety, increased genetic risk, existing
pregnancy, or ongoing fertility treatment.
To better direct management recommendations, criteria
for assessing growth were added. In alignment with the SRU
Consensus on Adnexal Cysts, O-RADS US v2022 includes
an average linear dimension threshold of 10%–15% for in-
dicating size changes and suggests that the end point for sur-
veillance be shortened from 5 to 2 years. In general, lesions
with an average linear dimension that has decreased by at
least 10%–15% at first follow-up are considered benign and
no further imaging is necessary. Lesions that are stable at first
follow-up examination undergo an additional follow-up US
at 24 months from the initial examination to achieve 2-year
stability. Lesions that have grown in average linear dimension
by at least 10%–15% warrant follow-up US at 12 and 24
months from initial examination. If the lesion continues to
grow, clinical management per gynecology is recommended.
Any interval changes in morphologic characteristics man-
dates lesion reassessment using lexicon descriptors.

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Figure 12: Typical hydrosalpinx. (A) Gray-scale longitudinal US image shows a tubular-shaped, fluid-filled structure with no internal
echoes (anechoic). An incomplete septation (arrow) representing a fold is seen, another feature of a typical hydrosalpinx. (B) In a correspond-
ing gray-scale US image in the orthogonal transverse plane, endosalpingeal folds (arrowheads) are seen as short round projections along
the inner margin of the lower fluid-filled component. When the fluid within apparent cystic compartments is not clearly contiguous to suggest its
tubal origin, the presence of endosalpingeal folds can help appropriately diagnose a typical hydrosalpinx and differentiate it from a septated
ovarian cystic lesion with irregular inner walls or papillary projections.
Table 5: Summary of Major Updates to Management
Recommendations in O-RADS US v2022
Category Management Recommendation Updates
O-RADS 0 “Repeat US study or MRI”
O-RADS 1 No change
O-RADS 2 Less follow-up for simple cysts
Use average linear dimension ([L + W + H]/3) for
interval change
Surveillance limited to 24 months; then as clinically
indicated
Classic benign lesions: “If features are only suggestive,
and overall assessment is uncertain, consider follow-
up US within 3 months”
Gynecology as needed for clinical issues
O-RADS 3 “If not surgically excised, consider follow-up US within
6 months”
MRI evaluation remains an option for solid lesions
O-RADS 4 New imaging option: “per gyn-oncologist protocol”
O-RADS 5 “Imaging: per gyn-oncologist protocol”
Note.—Words in italics and within quotation marks reflect
updated wording in the Ovarian-Adnexal Reporting and Data
System (O-RADS) US v2022 Assessment Categories and Classic
Benign Lesions tables (Fig 1B, 1C). Gyn-oncologist = gynecologic
oncologist, H = height, L = length, W = width.
Special Consideration: Classic Benign Lesions
Classic benign ovarian lesions smaller than 10 cm in maximum
dimension and all extraovarian lesions are categorized as O-
RADS US 2. Classic benign ovarian lesions measuring 10 cm
or larger are categorized as O-RADS US 3.
Imaging.—For all classic benign lesions, when sonographic
features are only suggestive and overall assessment is uncer-
tain, follow-up US within 3 months is recommended to assess
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Strachowski et al
stability and allow a second opportunity for morphologic
evaluation. A patient’s menopausal status is now only relevant
for hormonally influenced lesions, such as endometriomas and
hemorrhagic cysts, and no longer relevant for dermoid cysts.
Hemorrhagic cyst.—In alignment with the definitions of early
and late menopause laid out in the SRU Consensus on Adnexal
Cysts, imaging follow-up options for a hemorrhagic cyst <10
cm in early menopause (<5 years) include repeat US in 2–3
months, re-evaluation by a US specialist (if available), or an
MRI examination (with O-RADS MRI score) to confirm the
diagnosis. Hemorrhagic cysts should not occur in late post-
menopausal patients (≥5 years) and must be reassessed using
other lexicon descriptors.
Endometrioma.—Initial detection of an endometrioma in post-
menopausal patients is uncommon, and its appearance overlaps
with neoplasia. Additionally, there is an increased incidence of
endometriosis-associated malignancy after menopause (33).
Therefore, when a suspected endometrioma of ≤10 cm is first
detected after menopause, follow-up options include repeat US
in 2–3 months, re-evaluation by a US specialist (if available), or
an MRI examination (with O-RADS MRI score) to confirm the
diagnosis. If the lesion is not surgically excised, follow-up US is
recommended in 12 and 24 months from initial US examina-
tion to assess for change and document 2-year stability. Subse-
quent imaging should be dictated by clinical necessity.
Dermoid cyst.—Management of a dermoid cyst is no longer
dependent on menopausal status. Follow-up of small typical
dermoid cysts ≤3 cm is now optional. Lesions >3 cm but <10
cm can be surgically excised or can undergo follow-up US in
12 and 24 months from initial US. After 2-year stability is
established, clinical management can be used to determine if
there is a need for subsequent imaging.
15
O-RADS US v2022: An Update from the American College of Radiology

Figure 13: Ovarian-Adnexal Reporting and Data System (O-RADS) US v2022 assessment category 1. Schematic representations and corresponding
gray-scale and color Doppler US images demonstrate features that should lead to categorization as O-RADS US 1. The blue and red shading on the schematic
images indicates blood flow at color Doppler US imaging, which can also be seen on the corresponding color Doppler US images. All ovaries in the normal
category do not contain any lesions. Follicles and corpora lutea are physiologic cysts commonly observed in premenopausal patients and are not considered
lesions. Typical corpora lutea are thick-walled cysts with or without internal echoes or crenulated inner walls or may be “solid-appearing” when fluid is not
apparent centrally. The O-RADS US 1 assessment category has no association with malignancy.

Clinical.—O-RADS US 2 lesions may need management by a
gynecologist, as some may be symptomatic or have other clini-
cal implications.
O-RADS US 3 (Low Risk) Assessment Category
Imaging.—Given that O-RADS US 3 lesions (Fig 16) ap-
pear to be at the lower end of the risk of malignancy range
in validation studies, these lesions may now be followed
with US within 6 months if not surgically excised. If the
lesion is stable, repeat US imaging is recommended at 12
and 24 months from the initial US examination, with the
decision to perform subsequent imaging to be determined
by the referring clinician. For solid O-RADS US 3 lesions,
further characterization by a US specialist or using MRI
(with O-RADS MRI score) may provide higher specificity
(14,20,25,34). Clinical factors, such as patient anxiety, in-
creased genetic risk, or ongoing fertility treatment, may also
necessitate further characterization of O-RADS US 3 lesions
with MRI.
Clinical.—O-RADS US 3 lesions may be managed by gynecol-
ogy without the need for a gynecologic oncologist. Lesions that
are particularly large or symptomatic will often be excised. When
the lesion is not removed, imaging follow-up is recommended,
as detailed in the previous subsection.

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Figure 14: Ovarian-Adnexal Reporting and Data System (O-RADS) US v2022 assessment category 2. Schematic representations and cor-
responding color Doppler US images demonstrate features that should lead to categorization as O-RADS US 2. This category is defined as almost
certainly benign with a very low risk of malignancy of less than 1%. Simple, nonsimple, and bilocular smooth cysts <10 cm are included in O-RADS
US 2. Classic benign lesions that have a typical appearance (see Figs 1C, 15) are also included in this category, with the exception of ovarian classic
benign lesions ≥10 cm, which are upgraded to the O-RADS US 3 category. There is no discriminatory size limit for extraovarian classic benign lesions.

O-RADS US 4 (Intermediate Risk) Assessment Category
Imaging.—For lesions in the intermediate risk category (Fig
17), supplemental assessment continues to include re-eval-
uation by a US specialist or using MRI, with MRI being
most useful for solid lesions and cystic lesions with solid
components due to its higher specificity (9,20,25). Modi-
fications in O-RADS US v2022 include the management
option of allowing the gynecologic oncologist to decide the
next imaging modality and need for additional imaging for
lesion characterization (such as MRI when fertility-sparing
surgery is desired).
Clinical.—Outcomes for patients with ovarian cancer are
improved when the initial surgery is performed by a gyne-
cologic oncologist (35–39). Multiple validation studies have
shown a score of O-RADS US 4 as the appropriate cutoff for
malignancy. Therefore, there is no change in the O-RADS

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O-RADS US v2022: An Update from the American College of Radiology

Figure 15: Ovarian-Adnexal Reporting and Data System (O-RADS) US v2022 classic benign lesions. Schematic representations and corresponding patient images
demonstrate typical features of classic benign lesions. There are three types of classic benign lesions that arise from the ovary (OV): hemorrhagic cyst, dermoid cyst, and
endometrioma. The typical features for each of these are as follows: (a) hemorrhagic cyst: avascular unilocular cyst with internal reticular pattern or retractile clot; (b)
dermoid cyst: avascular cystic lesion with three or fewer locules and hyperechoic lines and dots, diffuse or regional hyperechoic component with shadowing or floating
echogenic spherical structures; and (c) endometrioma: avascular cystic lesion with three or fewer locules, smooth inner walls, and homogeneous low-level or ground-
glass echoes, which may have peripheral punctate echogenic foci. There are three types of classic benign lesions that are considered extraovarian: paraovarian cyst,
peritoneal inclusion cyst, and hydrosalpinx. The typical features for each of these are as follows: (a) paraovarian cyst: simple cyst separate from the ovary; (b) peritoneal
inclusion cyst: fluid collection with an ovary either at the margin or suspended within that conforms to adjacent pelvic organs, which may have internal septations repre-
senting adhesions; and (c) hydrosalpinx: anechoic, fluid-filled tubular structure that may have internal incomplete septations representing folds and endosalpingeal folds,
which appear as short round projections around the inner walls. When typical features for a classic benign lesion are seen along with any atypical features, it is prudent
to characterize using other available lesion lexicon descriptors (eg, unilocular or multilocular with or without solid components, solid lesion, etc).

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 Strachowski et al

Figure 16: Ovarian-Adnexal Reporting and Data System (O-RADS) US v2022 assessment category 3. Schematic representations and corre-
sponding US images demonstrate features that should lead to categorization as O-RADS US 3. The blue and red shading on the schematic images
indicates blood flow at color Doppler US imaging, which can also be seen on the corresponding color Doppler US images. Lesions in the low-risk
category have a risk of malignancy of 1% to <10%. Typical ovarian classic benign lesions as well as simple and bilocular smooth cysts ≥10 cm are
in this category due to their large size. Cysts with slightly worrisome features, such as an irregular inner wall (if unilocular), or relatively small (<10 cm)
multilocular cysts with smooth septations and internal vascularity assessed at color Doppler US imaging that is less than very strong (color score <4) are
also considered low risk. Solid lesions in the low-risk category must have a smooth outer contour and either (a) demonstrate shadowing and a color
score less than 4 or (b) demonstrate no shadowing and have no demonstrable internal blood flow (color score 1).

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O-RADS US v2022: An Update from the American College of Radiology

Figure 17: Ovarian-

Adnexal Reporting and
Data System (O-RADS)
US v2022 assessment
category 4. Schematic
representations and cor-
responding US images
demonstrate features that
should lead to categoriza-
tion as O-RADS US 4. The
blue and red shading on the
schematic images indicates
blood flow at color Dop-
pler US imaging, which can
also be seen on the cor-
responding color Doppler
US images. Lesions in the
intermediate risk category
have a risk of malignancy
of 10% to <50%. Bilocular
and multilocular cysts in this
category have one or more
suspicious features, includ-
ing irregular inner walls,
large size (≥10 cm), and
greater degrees of internal
vascularity as assessed at
color Doppler US imaging.
Some cystic lesions contain-
ing solid components are in
this category; however, dif-
ferent features are relevant
for stratifying cysts with solid
components as O-RADS
US 4 versus O-RADS US 5.
For unilocular cysts, the num-
ber of papillary projections
is relevant (fewer than four
papillary projections should
be categorized as O-RADS
US 4, whereas four or
more papillary projections
should be categorized as
O-RADS 5). For cysts with
septations, the color score
is relevant (a color score of
1–2 should be categorized
as O-RADS US 4, whereas
a color score of 3–4 should
be categorized as O-RADS
5). Solid smooth lesions
demonstrating nonshadow-
ing and minimal or moder-
ate blood flow (color score
2–3) are also in the interme-
diate risk category.

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 Strachowski et al

Figure 18: Ovarian-Adnexal Reporting and Data System (O-RADS) US v2022 assessment category 5. Schematic representations and corre-
sponding US images demonstrate features that should lead to categorization as O-RADS US 5. The blue and red shading on the schematic images
indicates blood flow at color Doppler US imaging, which can also be seen on the corresponding color Doppler US images. The high-risk category
is associated with a risk of malignancy of ≥50% and includes lesions with the most worrisome features. These include cysts with numerous papillary
projections (four or more), both septations and solid components with greater internal vascularity (color score 3–4) at color Doppler US imaging, and
all solid lesions with an irregular contour. The presence of ascites (solid arrows) not attributable to another cause (eg, cirrhosis, volume overload) with
a coexistent O-RADS US 3–5 lesion is suspicious for malignancy, warranting an O-RADS US 5 score. Similarly, peritoneal nodules (dotted arrows),
which are best appreciated when ascites is present, are also highly concerning. When either ascites or peritoneal nodules are seen with an O-RADS
US 1 or 2 lesion, other causes must be considered. UT = uterus.

US 4 recommendation for management by the gynecologist
in consultation with a gynecologic oncologist or referral to a
gynecologic oncologist who may solely manage the patient.
If MRI is being considered for further assessment, clinical
referral may occur after supplemental imaging or in parallel,
with an effort to minimize delays in patient care.
O-RADS US 5 (High Risk) Assessment Category
Imaging.—In the original O-RADS US, patients with lesions in
the high-risk category (Fig 18) were referred to a gynecologic on-
cologist, with next steps (such as imaging or laboratory tests) being
under their purview. Some radiologists expressed concern that this

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O-RADS US v2022: An Update from the American College of Radiology
wording resulted in confusion as to whether they could make rec-
ommendations for specific additional imaging when standard in-
stitutional preferences for such imaging were known. In O-RADS
US v2022, it is now clearly stated that imaging should be per-
formed per gynecologic oncology protocol, which may consist of
MRI for additional characterization and/or CT for staging.
Clinical.—There is no change in the recommendation for referral
to a gynecologic oncologist.
Future Directions and Conclusions
While the O-RADS US committee believes the changes made
in O-RADS US v2022 will lead to improved performance,
future modifications will likely be necessary to further iden-
tify specific O-RADS US 3 and 4 patterns that justify down-
grading of risk assessment and further articulate best practices
for pursuing MRI, given its superior specificity. Validation
in large-scale prospective studies with unselected average-risk
populations as well as reproducibility studies will prove essen-
tial to additional system refinement and widespread adoption,
which will also rely on ease of use and reporting. Educational
material and resources, including a link to reporting tools, will
be posted on the American College of Radiology’s O-RADS
website as they become available.
In conclusion, the 2022 update of the Ovarian-Adnexal Re-
porting and Data System (O-RADS) US risk stratification sys-
tem provides additional guidance and clarification for everyday
application of the system, addresses discrepancies with O-RADS
MRI and the Society of Radiologists in Ultrasound’s Consensus
on Adnexal Cysts, and enables the application of O‑RADS US
to all pelvic US reports. While optimization of sensitivity for
identification of ovarian malignancy and appropriate referral to
gynecologic oncology remains a high priority of the system, the
recent changes made to O-RADS US are expected to improve
specificity of lower-risk lesions. In particular, the addition of the
descriptors bilocular for cystic lesions (allowing for differentia-
tion from multilocular lesions) and shadowing for solid smooth
lesions, as well as the expanded lexicon descriptors for the typical
appearance of some classic benign lesions could aid in reducing
unnecessary surgery. The committee anticipates that O-RADS
US v2022 will facilitate more standardized interpretation of
ovarian and adnexal imaging, accurate risk assessment of lesions
in the more benign categories, and appropriate patient manage-
ment and will enable the widespread adoption of this system in
daily clinical practice.
Author contributions: Guarantors of integrity of entire study, L.M.S., P.J.,
M.M.B.P., R.F.A.; study concepts/study design or data acquisition or data analysis/
interpretation, all authors; manuscript drafting or manuscript revision for important
intellectual content, all authors; approval of final version of submitted manuscript,
all authors; agrees to ensure any questions related to the work are appropriately
resolved, all authors; literature research, L.M.S., P.J., C.H.P., M.M.B.P., P.C., Y.G.,
M.D.P., C.R., R.F.A.; clinical studies, L.M.S., P.J., M.M.B.P., D.T.; experimental
studies, M.M.B.P.; statistical analysis, P.J.; and manuscript editing, all authors
Disclosures of conflicts of interest: L.M.S. Royalties from Elsevier for book chap-
ters in Diagnostic Imaging: Breast. P.J. Honoraria for lectures from CME Science and
UC Davis CME. C.H.P. No relevant relationships. M.M.B.P. No relevant relation-
ships. W.F. Honoraria for lectures from Intuitive Surgical and GE Healthcare. P.G.
No relevant relationships. Y.G. No relevant relationships. M.D.P. Royalties from
22
UpToDate; member of the executive council of the Society of Radiologists in Ul-
trasound. C.R. No relevant relationships. E.J.S.B. No relevant relationships. D.T.
Trustee of the International Society of Ultrasound in Obstetrics and Gynecology.
R.F.A. Honoraria for lectures from Philips Healthcare, World Class CME, American
College of Obstetrics and Gynecology, and New England Roentgen Ray Society.
References
1. Andreotti RF, Timmerman D, Benacerraf BR, et al. Ovarian-Adnexal
Reporting Lexicon for Ultrasound: a white paper of the ACR Ovarian-
Adnexal Reporting and Data System Committee. J Am Coll Radiol
2018;15(10):1415–1429. [Published correction appears in J Am Coll
Radiol 2019;16(3):403–406.]
2. Andreotti RF, Timmerman D, Strachowski LM, et al. O-RADS US Risk
Stratification and Management System: a consensus guideline from the
ACR Ovarian-Adnexal Reporting and Data System Committee. Radiol-
ogy 2020;294(1):168–185.
3. Hack K, Gandhi N, Bouchard-Fortier G, et al. External validation of
O-RADS US Risk Stratification and Management System. Radiology
2022;304(1):114–120.
4. Jha P, Gupta A, Baran TM, et al. Diagnostic performance of the Ovarian-
Adnexal Reporting and Data System (O-RADS) Ultrasound Risk Score in
women in the United States. JAMA Netw Open 2022;5(6):e2216370.
5. Basha MAA, Metwally MI, Gamil SA, et al. Comparison of O-RADS, GI-
RADS, and IOTA simple rules regarding malignancy rate, validity, and re-
liability for diagnosis of adnexal masses. Eur Radiol 2021;31(2):674–684.
6. Cao L, Wei M, Liu Y, et al. Validation of American College of Radiology
Ovarian-Adnexal Reporting and Data System Ultrasound (O-RADS US):
analysis on 1054 adnexal masses. Gynecol Oncol 2021;162(1):107–112.
7. Guo Y, Zhao B, Zhou S, et al. A comparison of the diagnostic perfor-
mance of the O-RADS, RMI4, IOTA LR2, and IOTA SR systems by
senior and junior doctors. Ultrasonography 2022;41(3):511–518.
8. Vara J, Manzour N, Chacón E, et al. Ovarian Adnexal Reporting Data
System (O-RADS) for classifying adnexal masses: a systematic review and
meta-analysis. Cancers (Basel) 2022;14(13):3151.
9. Zhang Q, Dai X, Li W. Systematic review and meta-analysis of O-RADS
Ultrasound and O-RADS MRI for risk assessment of ovarian and adnexal
lesions. AJR Am J Roentgenol 2023;221(1):21–33.
10. Guo Y, Phillips CH, Suarez-Weiss K, et al. Interreader agreement and inter-
modality concordance of O-RADS US and MRI for assessing large, com-
plex ovarian-adnexal cysts. Radiol Imaging Cancer 2022;4(5):e220064.
11. Katlariwala P, Wilson MP, Pi Y, et al. Reliability of ultrasound ovarian-
adnexal reporting and data system amongst less experienced readers before
and after training. World J Radiol 2022;14(9):319–328.
12. Pi Y, Wilson MP, Katlariwala P, et al. Diagnostic accuracy and inter-
observer reliability of the O-RADS scoring system among staff radiolo-
gists in a North American academic clinical setting. Abdom Radiol (NY)
2021;46(10):4967–4973.
13. Antil N, Raghu PR, Shen L, et al. Interobserver agreement between eight
observers using IOTA simple rules and O-RADS lexicon descriptors for
adnexal masses. Abdom Radiol (NY) 2022;47(9):3318–3326.
14. Wu M, Zhang M, Cao J, et al. Predictive accuracy and reproducibility of
the O-RADS US scoring system among sonologists with different training
levels. Arch Gynecol Obstet 2023;308(2):631–637.
15. Wilson MP, Katlariwala P, Low G. Solid hypoechoic adnexal lesions
with acoustic shadowing warrant an MRI recommendation in the
O-RADS Risk Stratification and Management System. Radiology
2020;296(1):E11–E13.
16. Zhou S, Guo Y, Wen L, Zhao B, Liu M. The learning curve and difficult
points of the O-RADS ultrasound risk stratification system in 54 trainees.
Ultrasonography 2022;41(2):365–372.
17. Mohamadian A, Bayani L, Shakki Katouli F. A simplified approach to
ovarian lesions based on the O-RADS US risk stratification and manage-
ment system. Ultrasonography 2023;42(1):165–171.
18. Phillips CH, Guo Y, Strachowski LM, Jha P, Reinhold C, Andreotti RF.
The Ovarian/Adnexal Reporting and Data System for Ultrasound: from
standardized terminology to optimal risk assessment and management.
Can Assoc Radiol J 2023;74(1):44–57.
19. Gargan ML, Frates MC, Benson CB, Guo Y. O-RADS Ultrasound ver-
sion 1: a scenario-based review of implementation challenges. AJR Am J
Roentgenol 2022;219(6):916–927.
20. Thomassin-Naggara I, Poncelet E, Jalaguier-Coudray A, et al. Ovarian-
Adnexal Reporting Data System Magnetic Resonance Imaging (O-RADS
MRI) score for risk stratification of sonographically indeterminate adnexal
masses. JAMA Netw Open 2020;3(1):e1919896.
radiology.rsna.org ■ Radiology: Volume 308: Number 3—September 2023

21. Levine D, Patel MD, Suh-Burgmann EJ, et al. Simple adnexal cysts: SRU
Consensus Conference update on follow-up and reporting. Radiology
2019;293(2):359–371.
22. Levine D. O-RADS US: a retrospective assessment of prediction of malig-
nancy in a high-risk setting. Radiology 2022;304(1):121–122.
23. Stempniak M. CMS approves 5 new Merit-Based Incentive Payment Sys-
tem measures, relieving radiology’s quality crunch. Radiology Business.
https://radiologybusiness.com/topics/healthcare-policy/cms-approves-
new-mips-measures-radiology-quality. Published January 6, 2021. Accessed
May 9, 2023.
24. Timmerman S, Valentin L, Ceusters J, et al. External validation of the
Ovarian-Adnexal Reporting and Data System (O-RADS) Lexicon and the
International Ovarian Tumor Analysis 2-step strategy to stratify ovarian
tumors into O-RADS risk groups. JAMA Oncol 2023;9(2):225–233.
25. Sadowski EA, Stein EB, Thomassin-Naggara I, et al. O-RADS MRI after
initial ultrasound for adnexal lesions: AJR expert panel narrative review. AJR
Am J Roentgenol 2023;220(1):6–15.
26. Timmerman D, Ameye L, Fischerova D, et al. Simple ultrasound rules to
distinguish between benign and malignant adnexal masses before surgery:
prospective validation by IOTA group. BMJ 2010;341:c6839.
27. Landolfo C, Bourne T, Froyman W, et al. Benign descriptors and ADNEX
in two-step strategy to estimate risk of malignancy in ovarian tumors: ret-
rospective validation in IOTA5 multicenter cohort. Ultrasound Obstet
Gynecol 2023;61(2):231–242.
28. Strachowski LM, Jha P, Chawla TP, et al. O-RADS for Ultrasound: a user’s
guide, from the AJR Special Series on Radiology Reporting and Data Sys-
tems. AJR Am J Roentgenol 2021;216(5):1150–1165.
29. ACR Guidance App for iOS and Android. American College of Radi-
ology. Ovarian-Adnexal Reporting & Data System (O-RADS). https://
www.acr.org/-/media/ACR/Files/RADS/O-RADS/ACR-Guidance-App.
pdf. Published April 2023. Accessed May 9, 2023.
Radiology: Volume 308: Number 3—September 2023 ■ radiology.rsna.org
Strachowski et al
30. ACR O-RADS US updated lexicon terms. American College of Radi-
ology. Ovarian-Adnexal Reporting & Data System (O-RADS). https://
www.acr.org/-/media/ACR/Files/RADS/O-RADS/O-RADS_US-
Lexicon-Key-Terms.pdf. Revised January 2023. Accessed May 9, 2023
31. Heremans R, Valentin L, Sladkevicius P, et al. Imaging in gynecological
disease (24): clinical and ultrasound characteristics of ovarian mature cys-
tic teratomas. Ultrasound Obstet Gynecol 2022;60(4):549–558.
32. Patel MD, Feldstein VA, Chen DC, Lipson SD, Filly RA. Endometriomas:
diagnostic performance of US. Radiology 1999;210(3):739–745.
33. Giannella L, Marconi C, Di Giuseppe J, et al. Malignant transformation
of postmenopausal endometriosis: a systematic review of the literature.
Cancers (Basel) 2021;13(16):4026.
34. Kaijser J. Towards an evidence-based approach for diagnosis and man-
agement of adnexal masses: findings of the International Ovarian Tumour
Analysis (IOTA) studies. Facts Views Vis ObGyn 2015;7(1):42–59.
35. Chan JK, Kapp DS, Shin JY, et al. Influence of the gynecologic on-
cologist on the survival of ovarian cancer patients. Obstet Gynecol
2007;109(6):1342–1350.
36. Mercado C, Zingmond D, Karlan BY, et al. Quality of care in advanced
ovarian cancer: the importance of provider specialty. Gynecol Oncol
2010;117(1):18–22.
37. Earle CC, Schrag D, Neville BA, et al. Effect of surgeon specialty on pro-
cesses of care and outcomes for ovarian cancer patients. J Natl Cancer Inst
2006;98(3):172–180.
38. Engelen MJA, Kos HE, Willemse PHB, et al. Surgery by consultant gy-
necologic oncologists improves survival in patients with ovarian carcinoma.
Cancer 2006;106(3):589–598.
39. Salvador S, Scott S, Glanc P, et al. Guideline no. 403: initial investi-
gation and management of adnexal masses. J Obstet Gynaecol Can
2020;42(8):1021–1029.e3.
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