The Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) risk stratification and management system was first published by the American College of Radiology in 2020. It provides standardized terminology for evaluation of ovarian and adnexal masses, aids risk stratification, and provides management guidelines for different categories of lesions. This system has been validated by subsequent research and found to be a useful diagnostic and management tool. However, as noted in the system's governing concepts, in some clinical scenarios, such as patients with acute symptoms or with a history of ovarian malignancy, O-RADS US does not apply, or the system's standard management may be adjusted. Additional scenarios, such as an adnexal mass in pregnancy, present challenges in the application of O-RADS US to assist diagnosis and management. The purpose of this article is to highlight 10 clinical scenarios in which O-RADS US version 1 may not apply, may be difficult to apply, or may require modified management. Additional scenarios in which O-RADS US can be appropriately applied are also described.
Keywords: O-RADS; adnexa; implementation challenges; malignancy; ovaries; pregnancy; ultrasound.