Endometriosis — structured oral station (12 minutes)

Opening prompt — "What is your working diagnosis and why?"

Model response — the symptom profile: ^[1][2]

• "Her pattern is the classical endometriosis profile: progressive secondary dysmenorrhoea, deep dyspareunia, and crucially cyclical dyschezia — pain on defecation around her menses. The cyclical and temporal relationship to her cycle is the discriminator from IBS."
• "I would also screen directly for cyclic dysuria/haematuria, fatigue, and the impact on her relationships and work. And I would note that symptom severity does NOT correlate with disease extent — her pain is real regardless of what I find on imaging."^[2]

Probe 1 — "How will you investigate her?"

• "I exclude pregnancy first. Then the paradigm shift matters: ESHRE 2022 explicitly challenges laparoscopy as the gold standard, and the Australian Living Evidence Guideline says clinical diagnosis plus imaging is enough to start treatment. So I arrange a transvaginal ultrasound — it is a SpPin test for an endometrioma (sensitivity 0.93, specificity 0.96) — and add bowel-prepared TVUS or rectal water contrast for her rectosigmoid symptoms."^[1][3]
• "I reserve MRI for DIE when TVUS is unavailable or equivocal, and I do NOT use CA-125 as a stand-alone diagnostic test."^[3]

Probe 2 — "Her TVUS shows a 4 cm right ovarian endometrioma with ground-glass content. What now?"

• "I start empirical hormonal treatment on the clinical syndrome — I do not wait for a laparoscopy. I frame endometriosis as a chronic disease with the goal of symptom control and fertility preservation."^[1]
• "I walk the medical ladder: simple analgesia, then a continuous combined pill, then a progestogen-only option. For her, given the severity, I would discuss dienogest 2 mg/day — Strowitzki's RCT showed it is equivalent to depot leuprolide for pain with a better bone profile."^[4]

Probe 3 — "She asks whether she will be able to have children. What do you say?"

• "I address her fertility intentions directly and do not delay the fertility workup to suppress symptoms. Hormonal suppression treats pain, not fertility."^[1][5]
• "I would avoid ovarian-damaging surgery for the endometrioma unless it is symptomatic, suspicious, or surgery is needed to access oocytes — cystectomy may harm AMH. If she does have surgery, I use the Endometriosis Fertility Index to guide expectant vs ART — a high EFI supports a trial of timed intercourse."^[5]

Probe 4 — "She is frightened this means she will never be pain-free. What do you say?"

This is a scored communication domain — demonstrate it out loud: ^[1]

• Move to her eye level, use her name, acknowledge the fear and the years of being dismissed: "You have been let down by a system that took years to listen. Endometriosis is chronic, but it is treatable — we have a clear ladder of options, we will find what works for you, and your fertility is something we plan around, not against. I am not going to send you away to cope alone."^[1]

Probe 5 — "How would your approach differ if she were 15?"

• "In an adolescent, anovulation is the commonest cause of dysmenorrhoea but endometriosis is in the differential when NSAIDs and the COCP fail. I favour non-invasive diagnosis and medical suppression, and I limit surgery to refractory disease. The bar to operate is much higher than in a 27-year-old."^[1]