Laudário Report templates Transvaginal pelvic

Transvaginal pelvic ultrasound report template (normal)

The most requested gynecologic ultrasound. The template below follows the structure uterus, endometrium, ovaries and cul-de-sac, with the clinical data that changes the interpretation: the phase of the cycle.

Normal template

TRANSVAGINAL PELVIC ULTRASOUND

FINDINGS:

Last menstrual period: [dd/mm/yyyy].

Anteverted, anteflexed uterus with regular contours and homogeneous myometrial echotexture.

Uterine dimensions: [x] x [x] x [x] cm. Volume: [x] cm³.

Endometrium of [x] mm, [trilaminar/homogeneous] in appearance, consistent with the phase of the cycle.

Right ovary: [x] x [x] x [x] cm, volume of [x] cm³, normal in appearance.

Left ovary: [x] x [x] x [x] cm, volume of [x] cm³, normal in appearance.

No adnexal masses.

No free fluid in the cul-de-sac.

IMPRESSION:

Normal transvaginal pelvic ultrasound.

Example: submucosal fibroid

FINDINGS:

Hypoechoic myometrial nodule with regular contours in the posterior wall of the uterine body, measuring 2,3 x 2,1 x 2,0 cm, with less than 50% intramural extension (FIGO 1). Myometrial-free margin to the serosa of 0,8 cm.

IMPRESSION:

Submucosal fibroid (FIGO 1).

Fields in brackets are filled in from the exam. The template is a starting point: the report must reflect what was seen and your practice's guidelines.

Frequently asked questions

What is the normal endometrial thickness?

It depends on the phase: about 4 mm after menstruation up to 14 mm or more in the secretory phase. In postmenopausal bleeding, the cutoff is 4 mm.

How should ovarian cysts be described?

Classic lesions (simple cyst, hemorrhagic cyst, endometrioma, teratoma) by name; the others by the lexicon and the O-RADS category.

Other report templates

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