Ultrasound is the primary imaging modality of the female pelvis which allows adequate evaluation of most adnexal lesions using transvaginal and transabdominal technique. The O-RADS US lexicon uses terms supported in the literature and by the International Ovarian Tumor Analysis (IOTA) group to describe ovarian/adnexal lesions and assign a risk of malignancy. Imaging and clinical management recommendations accompany the risk assessment categories to optimize patient outcomes. An update to the O-RADS US system was made in November 2022 (O-RADS US v2022) and all governing documents (tables, lexicon, governing concepts, etc.) have been modified accordingly.