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🩺 OSCE EXAM PREP: ENDOMETRIOSIS — Complete 5-Station Guide

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STATION 1 — HISTORY TAKING

Opening

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Core Symptom Complex (SOCRATES for each)

Extra-pelvic Symptoms (ask if cyclic)

• Chest pain, haemoptysis, pneumothorax symptoms → thoracic endometriosis
• Cyclically painful scar/mass on abdomen → abdominal wall endometriosis

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Gynaecological History

• Menarche age (early menarche = risk factor)
• Cycle regularity, length, duration, heaviness
• Contraceptive use (has OCP been tried? — partial relief suggests endometriosis)
• Previous gynaecological surgery

Obstetric History

• Nulliparity is a risk factor
• Mullerian anomalies (outflow obstruction)

Past Medical / Surgical History

• Prior laparoscopy findings?
• Previous diagnoses: adenomyosis, fibroids, IBS, IC/PBS (common co-morbidities)

Family History

• First-degree relative with endometriosis (genetic predisposition)

Social History

• Impact on quality of life, work/school absenteeism
• Relationship impact (dyspareunia)

Red Flags to Screen

• Weight loss, night sweats, bowel habit change (exclude IBD, malignancy)
• Age of onset, duration of symptoms (average delay in diagnosis = 7–10 years)

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Exam Marking Tip

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STATION 2 — PATIENT EDUCATION

Explain in Simple Language

"Endometriosis is a condition where tissue similar to the lining of your womb grows in places outside the womb — for example, on the ovaries, fallopian tubes, bowel, or bladder. Like the normal womb lining, this tissue responds to your menstrual hormones each cycle — it swells and bleeds but has nowhere to go, causing inflammation, scarring, and pain."

1. Prevalence: Affects approximately 1 in 10 women of reproductive age. It is NOT rare.
2. It is NOT your fault: Not caused by anything you did. Not contagious. Not a form of cancer (though rare malignant transformation can occur with long-standing endometriomas).
3. Symptoms vary: Some women have severe pain; others with extensive disease have none. Pain severity does NOT reflect disease severity.
4. Common sites: Ovaries (endometriomas/"chocolate cysts"), uterosacral ligaments, cul-de-sac (pouch of Douglas), bowel, bladder.
5. Impact on fertility: Endometriosis can affect your ability to fall pregnant naturally. This does not mean you cannot have children — many women with endometriosis conceive, with or without treatment.
6. Chronic condition: Endometriosis tends to return after treatment, especially before menopause. Management is long-term.
7. Treatment options (age-appropriate counselling):
   • Pain medicines (NSAIDs) for symptom relief
   • Hormonal treatments (pill, progestins, injections, IUS) to suppress the tissue
   • Surgery (laparoscopy) to remove lesions — especially for fertility or diagnostic purposes
   • Assisted reproduction (IVF) if natural conception is not achieved
8. Follow-up: Regular gynaecology reviews needed. Symptoms returning or new symptoms should prompt reassessment.
9. Lifestyle: Exercise, physiotherapy and psychological support can improve quality of life. Discuss support groups (e.g., Endometriosis UK/Foundation).

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STATION 3 — DIAGNOSIS

Clinical Diagnosis (Non-Surgical)

• Secondary dysmenorrhea (pain-free cycles then onset of dysmenorrhea)
• Deep dyspareunia
• Cyclic dyschezia
• History of infertility

• Bimanual/rectovaginal exam: uterosacral nodularity, focal tenderness
• Fixed, retroverted uterus or laterally deviated cervix (fibrosis from endometriosis)
• Adnexal mass (endometrioma)
• Localised tenderness in broad ligament / uterosacral area
• Cyclically painful abdominal wall mass → scar endometriosis

Clinical (non-surgical) diagnosis is accurate in approximately 50% of cases

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Investigations

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Laparoscopic Findings

Positive histology confirms the diagnosis; negative histology does NOT exclude it.

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ASRM Staging (rAFS Classification)

⚠️ Important: Stage does NOT correlate with pain severity. A stage I patient can have debilitating pain; stage IV may be pain-free. Stage does correlate with fertility impact.

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STATION 4 — MANAGEMENT

Principles of Treatment

1. The primary complaint — pain vs. infertility vs. both
2. Desire for future fertility
3. Severity and location of disease
4. Age and previous treatments

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A. Medical Management (Pain-focused)

First-line (not trying to conceive)

• NSAIDs (e.g., ibuprofen, mefenamic acid) — symptom relief; do not treat lesions
• Combined oral contraceptive pill (COCP) — continuous regimen preferred over cyclic; reduces dysmenorrhea; lighter, shorter periods
  • Cyclic and continuous OCP equally effective; continuous may better maintain remission after surgery

Second-line

• High-dose progestins — medroxyprogesterone acetate, norethindrone acetate; as effective as GnRH analogues; effective in ~75% of women
• Levonorgestrel IUS (Mirena) — as effective as GnRH depot for chronic pain; good long-term option
• Etonogestrel implant — as effective as DMPA

Third-line / Specialist

• GnRH agonists (e.g., leuprorelin, goserelin) + add-back therapy:
  • Create pseudo-menopause; reduce lesion size and pain
  • Side effects: hot flushes, bone loss, vaginal dryness, mood changes
  • Add-back: norethindrone acetate 2.5–5 mg/day ± low-dose oestrogen to reduce side effects
  • Typically limited to 6–12 months (bone protection); can extend with add-back + bisphosphonate
  • Recurrence after stopping: 36–70% at 5 years
• GnRH antagonists (e.g., elagolix, relugolix) — newer; oral; rapid onset; dose-dependent oestrogen suppression
• Danazol — androgenic; inhibits LH surge and steroidogenesis; anti-inflammatory; significant androgenic side effects (acne, hirsutism, voice changes, weight gain) → less commonly used
• Aromatase inhibitors (e.g., letrozole, anastrozole) — block peripheral oestrogen synthesis; used in refractory cases; always combined with ovarian suppression in premenopausal women

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B. Surgical Management

For Pain

• Laparoscopic ablation or excision of endometriotic lesions + adhesiolysis
  • More effective than diagnostic laparoscopy alone
  • Excision preferred over ablation (lower recurrence rates)
• Endometrioma: laparoscopic cystectomy preferred over drainage + ablation
  • Cystectomy: lower recurrence of pain, lower endometrioma recurrence, better spontaneous pregnancy rates
  • Drain + ablation: reserved for large cysts where excision risks removing significant ovarian tissue
• Deep infiltrating endometriosis: complete surgical excision in a single-step procedure at a specialist centre (multidisciplinary)
• Hysterectomy ± bilateral salpingo-oophorectomy (BSO): for women who have completed childbearing with severe, refractory disease; most definitive treatment

For Infertility

• Surgical excision of minimal/mild endometriosis improves fecundity (more effective than diagnostic laparoscopy alone)
• Suppression of ovulation is NOT effective for improving fertility
• IVF/ART: recommended for moderate-severe disease or failed surgical/medical treatment

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C. Multidisciplinary / Adjunct

• Pelvic floor physiotherapy
• Pain psychology / CBT (especially for central sensitisation / endometriosis-related pain syndrome)
• Treat co-morbidities: IBS, IC/PBS, vulvodynia, anxiety concurrently
• Dietitian (low-FODMAP for bowel symptoms)

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STATION 5 — DIFFERENTIAL DIAGNOSIS

Main Differentials for Endometriosis (by Symptom)

For Dysmenorrhea + Pelvic Pain

For Deep Dyspareunia

• Adenomyosis, PID (chronic), ovarian cyst, pelvic adhesions (any cause), vaginal pathology

For Dyschezia / Bowel Symptoms

For Infertility

• Tubal factor (post-PID), PCOS, male factor, hypothalamic amenorrhoea, uterine anomaly

For Adnexal Mass (Endometrioma vs.)

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Quick-Reference Summary Table

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Sources: Berek & Novak's Gynecology, Chapter 13 (Endometriosis); Robbins & Kumar Basic Pathology; Swanson's Family Medicine Review — all cross-referenced with 2024–2026 ESHRE/ACOG guidelines (PMID 38815122, 41712950).

🩺 HISTORY TAKING STATION — ENDOMETRIOSIS

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🟢 Opening Questions

"What brings you in today?" "Can you describe your pain?" "How long has this been going on?"

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🔍 Pain History — SOCRATES

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🔥 Associated Symptoms — The 4 Ds

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🩸 Gynaecological History

• "How old were you when your periods started?" → Age at menarche (early = risk factor)
• "Are your periods regular?" → Cycle regularity
• "Are your periods heavy?" → Menorrhagia
• "Any bleeding between periods?" → Intermenstrual bleeding
• "Have you or your partner had any difficulty getting pregnant?" 🚨 → Infertility — VERY important, always ask
• "Have you ever been pregnant before?" → Obstetric history (nulliparity = risk factor)

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❤️ Sexual History

• "Do you experience pain during intercourse? Is it deep or superficial?" → Deep dyspareunia = uterosacral/cul-de-sac involvement
• "What contraception are you currently using?" → OCP may have been masking symptoms

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🚽 Bowel & Urinary History

• "Do you have pain when passing a stool, particularly around your period?" → Cyclic dyschezia
• "Have you noticed any change in your bowel habit — constipation or diarrhoea?"
• "Any blood in your stool around your period?" → Rectal endometriosis
• "Any pain or burning when passing urine? Any blood?" → Bladder endometriosis

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🧬 Past Medical & Family History

• "Has anyone in your family — mum, sister — been diagnosed with endometriosis?" → First-degree relative = strong risk factor
• "Have you had any previous pelvic surgery or laparoscopy?" → Previous findings/adhesions
• "Have you ever been told you have fibroids, ovarian cysts, or IBS?" → Common co-morbidities

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💊 Drug History & Allergies

• "Are you currently taking the oral contraceptive pill?" → May suppress/mask symptoms
• "What painkillers do you take, and do they help?" → NSAIDs response gives diagnostic clues
• "Any allergies to medications?"

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🚨 Red Flags — Always Mention

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✅ Closing the History

"Is there anything else you'd like to tell me that you think is important?" "How has this been affecting your daily life, work, and relationships?"

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🧠 Examiner's Checklist — What Scores Marks