Endometriosis — structured SAQ (15 marks)

(a) Symptom profile and severity-vs-extent (3 marks)

One mark per point, maximum three. ^[1][2]

• Classical profile: secondary, progressive dysmenorrhoea; deep dyspareunia; chronic pelvic pain — plus cyclical dyschezia, cyclic dysuria/haematuria, cyclical rectal bleeding, infertility, and fatigue/low mood.
• Cyclical and temporal to menses is the discriminator from non-cyclical pain (IBS, interstitial cystitis, myofascial pain).
• Symptom severity does NOT correlate with disease extent because pain arises from nerve involvement, prostaglandin-mediated inflammation, adhesions, and central sensitisation — not simply from visible lesion volume.^[2]

(b) Diagnostic approach and paradigm shift (4 marks)

One mark per point. ^[1][4]

• Exclude pregnancy first.
• Paradigm shift: ESHRE 2022 explicitly "challenges laparoscopy and histology as gold standard diagnostic tests"; the Australian Living Evidence Guideline operationalises this — clinical diagnosis plus imaging is enough to start treatment.
• TVUS first-line (SpPin for endometrioma: sensitivity 0.93, specificity 0.96); add bowel-prepared TVUS and rectal water contrast for suspected rectosigmoid DIE.
• MRI when TVUS is unavailable, negative, or DIE is suspected; laparoscopy reserved for negative imaging with high suspicion, refractory symptoms, or therapeutic intent. CA-125 is NOT a stand-alone diagnostic test.^[4]

(c) Medical management ladder with dienogest evidence (5 marks)

One mark per rung/evidence point, maximum five. ^[1][5]

• Principle: induce a relative hypo-oestrogenic state with continuous hormonal suppression preferred to cyclic.
• Ladder: (1) simple analgesia (paracetamol, NSAIDs); (2) continuous COCP; (3) progestogen-only — LNG-IUS or oral progestins including dienogest; (4) GnRH analogues with add-back, limited to 6 months without add-back.
• Dienogest evidence: Strowitzki's RCT showed dienogest 2 mg/day was equivalent to depot leuprolide for pain (VAS reduction 47.5 vs 46.0 mm at 24 weeks), with a better bone profile (lumbar BMD +0.25% vs -4.04%).^[5]
• Add non-pharmacological adjuncts: psychological support (CBT), pelvic floor physiotherapy, pain management, multidisciplinary care.
• Frame as a chronic disease: goal is symptom control and fertility preservation, not a single cure; recurrence is the norm.^[1]

(d) Fertility management and the EFI (3 marks)

One mark per point. ^[1][6]

• Medical suppression does NOT improve natural fertility — do not delay the fertility workup to suppress symptoms; treat fertility on its own pathway.
• Avoid ovarian-damaging surgery for an endometrioma unless the cyst is symptomatic, suspicious, or surgery is needed to access oocytes — counsel on AMH impact.
• Use the Endometriosis Fertility Index (EFI) after surgery to guide expectant management vs ART — high EFI (9–10) up to 91% non-ART live birth at 5 years; low EFI (0–2) warrants prompt ART.^[6]