Endometriosis breadth - passmed

Question 1

What is endometriosis?

Answer 1

Endometriosis is characterized by the growth of ectopic endometrial tissue outside of the uterine cavity, affecting around 10% of women of reproductive age.

Question 2

What are the clinical features of endometriosis?

Answer 2

Chronic pelvic pain, secondary dysmenorrhea, pain before bleeding, deep dyspareunia, subfertility, and non-gynecological symptoms like urinary issues and dyschezia. Reduced organ mobility and tender nodularity may also be observed on pelvic examination.

Question 3

What is the gold-standard investigation for endometriosis?

Answer 3

Laparoscopy is the gold-standard investigation for diagnosing endometriosis.

Question 4

What is the role of primary care in the investigation of endometriosis?

Answer 4

Primary care has little role in investigating endometriosis; significant symptoms should lead to referral for definitive diagnosis.

Question 5

What are the first-line treatments for endometriosis according to NICE guidelines?

Answer 5

NSAIDs and/or paracetamol for symptomatic relief.

Question 6

What hormonal treatments are used for endometriosis when analgesia is ineffective?

Answer 6

Hormonal treatments like the combined oral contraceptive pill or progestogens (e.g., medroxyprogesterone acetate).

Question 7

When should a patient with endometriosis be referred to secondary care?

Answer 7

If analgesia/hormonal treatment does not improve symptoms, or if fertility is a priority.

Question 8

What is the role of GnRH analogues in managing endometriosis?

Answer 8

GnRH analogues induce a ‘pseudomenopause’ by lowering estrogen levels, but do not significantly impact fertility rates.

Question 9

What surgical options are available for endometriosis?

Answer 9

Laparoscopic excision or ablation of endometriosis, adhesiolysis, and ovarian cystectomy for endometriomas, especially to improve conception chances.

Question 10

A 30-year-old nulliparous woman presents with severe dysmenorrhoea, heavy & irregular bleeding, pain on defecation and dyspareunia - what is diagnsosis

Answer 10

endometriosis

Question 11

A 20-year-old G2P1 woman presents to the emergency department with mild vaginal bleeding and abdominal pain. She had a positive urine pregnancy test 6 weeks ago. Ultrasound shows pelvic free fluid and no identifiable intrauterine pregnancy.

This pregnancy was conceived spontaneously. Her first child was born vaginally. Her medical history includes endometriosis and Hashimoto’s thyroiditis. She has never had an STI. Apart from levothyroxine, she takes no regular medications. She does not smoke but drinks alcohol regularly. Her BMI is 33 kg/m2.

What feature puts her at risk of the likely diagnosis?
Alcohol use
Endometriosis
Her BMI
Levothyroxine use
Multiparity

Answer 11

Endometriosis is a risk factor for ectopic pregnancy

The correct answer is endometriosis. The most likely diagnosis for this patient is an ectopic pregnancy, whereby the blastocyst has been implanted in a location other than the uterine endometrial tissue. Abdominal pain and vaginal bleeding are common features in the presentation of ectopic pregnancy, and the diagnosis is confirmed by the absence of an intrauterine pregnancy on ultrasound. The presence of pelvic free fluid could indicate that her ectopic pregnancy has ruptured, and the patient should be transferred to the operating theatre for surgical management. Endometriosis is a recognised risk factor for ectopic pregnancy. The mechanism for this is not well understood but could be related to the laparoscopic procedure required for diagnosis or the presence of endometrial tissue in abnormal locations.

Alcohol use is incorrect because whilst alcohol use is strongly discouraged in pregnancy due to the potential effects on the developing foetus, it has no known association with ectopic pregnancy. In contrast, smoking is a known risk factor for ectopic pregnancy, especially if the patient smokes around the time of conception. This patient does not smoke and there is no other substance or medication history that would increase her risk. She should be counselled on the risks of alcohol in future pregnancies, but it is unlikely to have caused her current pregnancy complications.

Her BMI is incorrect because while having a high BMI is a risk factor for a number of pregnancy-related complications, it is not associated with ectopic pregnancy. Having a high BMI can increase a patient’s risk of early pregnancy loss, diabetes, pregnancy-induced hypertension, preeclampsia, preterm delivery, post-term pregnancy, multi-foetal pregnancy, congenital anomalies, complicated labour, Caesarean delivery, and other postpartum complications. It does not increase the risk of ectopic pregnancy.

Levothyroxine use is incorrect because this medication has no known association with an increased risk of ectopic pregnancy. It is compatible with pregnancy at all stages as well as breastfeeding; in fact, untreated hypothyroidism is associated with poorer outcomes for the unborn child. Thyroid function should be monitored during pregnancy to ensure adequate treatment. This patient’s ectopic pregnancy is unlikely to be related to her regular medication but is more likely associated with her history of endometriosis.

Multiparity is incorrect. This patient has previously had a completed pregnancy without significant complication, meaning that a blastocyst has been able to implant within the uterus in the past. A previous history of ectopic pregnancy is a significant risk factor for a subsequent ectopic pregnancy, which may be due to continuing underlying risks as well as the treatment required for the first one. Any procedure or inflammatory process that can affect the Fallopian tubes increases the risk of ectopic pregnancy. The fact that this woman has had a child in the past does not increase her risk.

Question 12

A 30-year-old woman presents with ongoing, cyclical pain around the time of her periods. The pain starts several days before the period itself and can last until several days after. She also experiences pain during sexual intercourse, particularly with deep penetration.

Examination demonstrated tender nodularity in the posterior fornix.

The patient has already tried paracetamol and ibuprofen, but these are no longer effective.

What is the next most appropriate step?

Clomifene
Combined oral contraceptive pill
Elagolix
Laparoscopic excision
Leuprorelin

Answer 12

If analgesia doesn’t help endometriosis then the combined oral contraceptive pill or a progestogen should be tried

This patient has endometriosis, as evidenced by her symptoms and findings on examination. First-line treatment involves the use of simple analgesia. As this is no longer effective, the next step is to use either progestogens or the combined oral contraceptive pill. Hormonal treatments are generally effective at controlling endometriosis-related pain.

Clomifene is used to induce ovulation in a number of conditions. While endometriosis can affect fertility and clomifene may be used for this aspect, by an experienced fertility doctor, it would not be the next step in pain management.

Elagolix is a relatively new gonadotropin-releasing hormone antagonist. It is licensed in the USA for endometriosis-related pain. It is not widely used in the UK currently and so the next most appropriate option remains the combined contraceptive pill.

Laparoscopic excision is further down the line, as surgery carries significant risks. The next step, after simple analgesia, is the use of hormonal options.

Leuprorelin is a gonadotropin-releasing hormone agonist. Whilst effective for the control of endometriosis-related pain, it is prescribed by specialists and would not be the next step after simple analgesia.

Question 13

A 32-year-old woman presents with a history of painful, regular periods. Since stopping the combined oral contraceptive pill eight-months ago her periods are more painful and heavy. She is upset because she would like to conceive but the pain is limiting intercourse. She would like to know the cause of her symptoms.

On examination, her abdomen is soft and non-tender with no masses, but a bimanual examination pelvic examination is limited due to pain.

What is the gold standard diagnostic test for this woman?

CT
Laparoscopy
MRI
Transvaginal and pelvic ultrasound
CA125

Answer 13

Laparoscopy is the gold-standard investigation for patients with suspected endometriosis

Laparoscopy is the gold-standard investigation for patients with suspected endometriosis. It allows direct visualisation and biopsies of the endometrial deposits.

A CT scan may be used to show endometrial deposits but they are less specific than MRI scans.

Ultrasound can be helpful to show endometriomas but a normal scan does not exclude endometriosis.

CA125 is not used to diagnose endometriosis. A raised serum CA125 may be consistent with endometriosis but a normal result does not exclude it.

Pelvic MRI scans should not be used as the primary investigation for endometriosis. They can be helpful before laparoscopy to assess the extent of deep endometriosis, but laparoscopy remains the gold-standard investigation.

Question 14

Theme: Pelvic pain

A. Appendicitis
B. Ovarian torsion
C. Subacute bowel obstruction
D. Endometriosis
E. Urinary tract infection
F. Ovarian cyst
G. Chronic interstitial cystitis
H. Uterine fibroids
I. Pelvic inflammatory disease
J. Ectopic pregnancy

For each one of the following scenarios please select the most likely diagnosis:

6. A 31-year-old woman complains of intermittent pain in the left iliac fossa for the past 3 months. The pain is often worse during intercourse. She also reports urinary frequency and feeling bloated. There is no dysuria or change in her menstrual bleeding
   Pelvic inflammatory disease
7. A 23-year-old woman complains of anorexia, vomiting, fever and abdominal pain. The pain was initially periumbilical but is now worse in the lower abdomen.
8. A 28-year-old woman complains of a two year history of bad period pains which are not controlled by NSAIDs or the combined contraceptive pill. She also reports significant pains during intercourse.

Answer 14

6. A 31-year-old woman complains of intermittent pain in the left iliac fossa for the past 3 months. The pain is often worse during intercourse. She also reports urinary frequency and feeling bloated. There is no dysuria or change in her menstrual bleeding
   Pelvic inflammatory disease
   The correct answer is: Ovarian cyst

Large ovarian cysts may lead to abdominal swelling and pressure effects on the bladder.

7. A 23-year-old woman complains of anorexia, vomiting, fever and abdominal pain. The pain was initially periumbilical but is now worse in the lower abdomen.
   Appendicitis
8. A 28-year-old woman complains of a two year history of bad period pains which are not controlled by NSAIDs or the combined contraceptive pill. She also reports significant pains during intercourse.
   Endometriosis

This is a characteristic history of endometriosis.

Question 15

A 28-year-old woman presents with cyclical pelvic pain that is worse around her periods. The pain starts 2 days before the period and lasts until several days after. She has associated dyspareunia and has had some painful bowel movements. Paracetamol and ibuprofen previously helped, however, they no longer do.

An examination reveals generalised tenderness, a fixed and retroverted uterus and uterosacral ligament nodules. Her BMI is 29 kg/m². She would like to start a family next year but does not mind taking contraceptives if she is able to stop and conceive then.

What is the next best step in her management?

Offer combined oral contraceptive pill
Offer medroxyprogesterone acetate
Offer mefenamic acid
Refer for consideration of GnRH analogue
Refer for laparoscopic excision

Answer 15

If analgesia doesn’t help endometriosis then the combined oral contraceptive pill or a progestogen should be tried

Offer combined oral contraceptive pill is correct. This patient has signs and symptoms consistent with endometriosis, characterised by her chronic cyclical pelvic pain, dyspareunia, secondary dysmenorrhoea, and pain with bowel movements. The examination findings support this diagnosis and are commonly seen in people with endometriosis. The first-line option to try in endometriosis is paracetamol with or without an NSAID (usually mefenamic acid or ibuprofen). If these fail, the second-line option is hormonal therapy (e.g. the combined oral contraceptive pill, medroxyprogesterone acetate etc.). Since this patient would like to start a family within the next year, it would be more appropriate to offer the combined oral contraceptive pill, as it is not associated with a delayed return to fertility. Medroxyprogesterone acetate is also known as Depo Provera and provides contraception for up to 12 weeks, but its effects cannot be reversed once given and it is associated with a potential delayed return to fertility (up to 12 months).

Offer medroxyprogesterone acetate is incorrect. Although the combined oral contraceptive pill or a progestogen should be offered if analgesia does not help endometriosis, this patient would like to start a family within the next year, therefore it would be more appropriate to offer the combined oral contraceptive pill, as it is not associated with a delayed return to fertility. Medroxyprogesterone acetate is also known as Depo Provera and provides contraception for up to 12 weeks, but its effects cannot be reversed once given and it is associated with a potential delayed return to fertility (up to 12 months). As well as this, her BMI is 34 kg/m² and a known side effect of the injectable contraceptive is weight gain.

Offer mefenamic acid is incorrect. Analgesia has already been tried without success in this patient. Mefenamic acid is another type of NSAID and would be unlikely to work if ibuprofen is unsuccessful. If analgesia does not help in endometriosis, the combined oral contraceptive pill or a progestogen should be trialled.

Refer for consideration of GnRH analogue is incorrect. This would be considered if hormonal therapy is ineffective. It would be inappropriate to jump to a referral without trialling the combined oral contraceptive pill first.

Refer for laparoscopic excision is incorrect. This would be considered if hormonal therapy and other measures such as GnRH agonists are ineffective. It would be inappropriate to jump to a referral without trialling the combined oral contraceptive pill first, as surgery carries more risks that may not be necessary (e.g. infection and bleeding).

Question 16

A 26-year-old woman is referred to the gynaecology clinic with severe dysmenorrhoea and a clinical history suggestive of endometriosis. She has tried paracetamol and ibuprofen with little benefit. She is not planning to start a family for the next couple of years. What is the recommended first-line management, providing that there are no contraindications?

Laparoscopic adhesiolysis
Copper intrauterine device
Progesterone injection Depo-Provera
Combined oral contraceptive pill (COCP)
Gonadotropin-releasing hormone (GnRH) analogues

Answer 16

Endometriosis is a common disorder, characterised by the deposits of endometrial-like tissue outside the uterus. It is an oestrogen dependent condition, that starts after menarche and regresses following the menopause.

Treatments depend upon whether the patient wishes to conceive or not. If the patient is not planning to conceive then treatments include methods that inhibit ovulation (as endometriosis is an oestrogen dependent condition).

The COCP is the first line option and can be used back-to-back with no pill-free interval. Second line treatments include progesterone only methods, such as POP, implant or injection (again they work by inhibiting ovulation). In addition, the Mirena coil can be used as it will reduce bleeding, resulting in less retrograde menstruation. The copper intrauterine device can make menstrual cycles longer and more painful and would not be a suitable option.

If the above methods fail to improve a patient’s symptoms, then GnRH analogues may be used.

In patients with endometriosis who wish to conceive, then a referral to fertility services is recommended if the couple have not conceived after 6 months of regular unprotected vaginal sexual intercourse. Surgical options such as laparoscopic adhesiolysis may improve fertility rates in patients with mild-moderate disease.

GP notebook. Endometriosis treatments.

Question 17

A 22-year-old lady, nulligravida presents with chronic pelvic and sacral pain with menstruation. Temperature = 37.2 degrees. On examination her posterior vaginal fornix is tender and there is uterine motion tenderness. Pelvic ultrasound is normal. What is the next diagnostic test?

Endometrial biopsy
Laparoscopy
Hysterosalpingography
CA-125
Serial beta-hCG

Answer 17

Laparoscopy is the gold-standard investigation for patients with suspected endometriosis

The correct answer in this case is laparoscopy. This is because the patient’s presentation of chronic pelvic and sacral pain with menstruation, along with tenderness on examination, is suggestive of endometriosis. Laparoscopy is the gold standard diagnostic test for endometriosis, as it allows for direct visualization and biopsy of suspected lesions.

An endometrial biopsy would not be the most appropriate choice in this situation, as it is primarily used to diagnose endometrial hyperplasia or malignancy. While endometriosis involves ectopic endometrial tissue, an endometrial biopsy would not detect its presence outside of the uterine cavity.

Hysterosalpingography is a radiographic procedure used to evaluate the patency of fallopian tubes and assess the uterine cavity, often in cases of infertility or recurrent pregnancy loss. While it may provide information about tubal obstruction related to endometriosis, it does not directly visualize or diagnose endometriotic lesions.

A CA-125 blood test measures the level of cancer antigen 125 in the bloodstream. Elevated levels can be found in various conditions such as ovarian cancer, endometriosis, and pelvic inflammatory disease (PID). However, CA-125 has limited sensitivity and specificity for diagnosing endometriosis and cannot differentiate between these conditions. Therefore, it is not recommended as a primary diagnostic tool for this patient’s presentation.

Finally, serial beta-hCG measurements are used to monitor early pregnancy progression or detect ectopic pregnancy by assessing changes in human chorionic gonadotropin hormone levels. In this case scenario, there is no mention of pregnancy-related symptoms or concerns; thus, serial beta-hCG testing would not be indicated as a diagnostic tool for her pelvic pain.

Question 18

A 26-year-old nulliparous Caucasian woman presents to their GP for a follow-up regarding a 3-month history of intermittent severe cramping abdominal and back pain that occurs during and prior to menstruation, which is regular each month. She complains of menorrhagia, stating that she needs to change her pads every 2-3 hours. She is worried these periods are affecting her fertility, as she has been trying to conceive with her long-term boyfriend for over 2 years. A transvaginal ultrasound is completed and reveals an endometrial thickness of 7mm with no other findings.

What is the most likely diagnosis?

Adenomyosis
Endometriosis
Pelvic inflammatory disease
Uterine fibroids
Von Willebrand’s disease

Answer 18

The classic symptoms of endometriosis are pelvic pain, dysmenorrhoea, dyspareunia and subfertility

Endometriosis is correct, as this woman is presenting with symptoms of menorrhagia, dysmenorrhoea, and subfertility. Furthermore, the absence of any findings seen in the transvaginal ultrasound with a normal endometrial thickness does not rule out endometriosis, as findings are often normal in this condition. Endometriosis is the presence of endometrial deposits outside of the endometrium. These deposits are still oestrogen-responsive and therefore can bleed and cause the patient pain, depending on where they are. Bowel and urinary symptoms can sometimes be seen if there are endometrial deposits in these regions. This patient’s lower abdominal and back pain could potentially be due to endometrial deposits located in the peritoneal cavity. For a definitive diagnosis to be made, the gold standard is laparoscopic surgery to visualise these endometrial deposits.

Adenomyosis is incorrect as this condition is typically seen in multiparous women towards the end of their reproductive years. This woman is nulliparous and 26 and therefore does not fit with the typical age group affected by this condition. Furthermore, the transvaginal ultrasound is normal in this patient. Due to the presence of endometrial deposits in the myometrium, transvaginal USS findings in adenomyosis can include an asymmetrical uterus, abnormal myometrial echo texture and myometrial cysts. This patient’s transvaginal USS is normal and therefore makes adenomyosis less likely, though it does not rule it out.

Pelvic inflammatory disease is incorrect, as while you can see abdominal pain in this condition, it also commonly presents with features such as persistent low-grade fever, dyspareunia, vaginal discharge, and dysuria, none of which the patient has. Furthermore, the patient does not fit the demographic typically seen in patients with pelvic inflammatory disease. It is most commonly caused by sexually transmitted organisms (Chlamydia trachomatis., Neisseria gonorrhoea.) and is, therefore, more commonly seen in patients with multiple previous sexual partners. As this patient has a long-term boyfriend, this makes the diagnosis of pelvic inflammatory disease less likely.

Von Willebrand’s disease is incorrect as this is the most commonly inherited bleeding disorder which typically presents with a history of epistaxis and menorrhagia. The patient is presenting with abdominal pain, which would be unexpected. Furthermore, there is only a 3-month history of menorrhagia, whereas a longer history would be expected in this patient due to a bleeding disorder.

Uterine fibroids are incorrect as these would present as a feature on the transvaginal ultrasound scan, which only shows normal findings and a normal endometrial thickness. Furthermore, uterine fibroids are more common in African and Caribbean populations, whereas this woman is Caucasian.

Question 19

A 25-year-old woman presents to her GP with a continuation of her chronic pelvic pain, which has not been helped with regular paracetamol and ibuprofen use. She continues to suffer from severe pelvic pain before her period, which is irregular. She is not sexually active and does not plan to become pregnant soon. Her main priority is her pain management, and she is open to any treatment. She has a past medical history of migraines with aura, for which she takes sumatriptan and propranolol.

What would be an appropriate next-line treatment?

Bilateral salpingo-oophorectomy with hysterectomy
Combined oral contraceptive pill
GnRH analogue
Oral diclofenac
Progesterone-only pill

Answer 19

If analgesia doesn’t help endometriosis then the combined oral contraceptive pill or a progestogen should be tried

Progesterone-only pill is correct because this woman is presenting with suspected endometriosis, given her severe pelvic pain before the onset of her periods. Her symptoms are not being controlled using regular non-steroidal anti-inflammatory drugs, e.g., ibuprofen and regular paracetamol, therefore, NICE guidelines suggest that if the pain is not controlled with NSAIDs or paracetamol, either the combined oral contraceptive pill (COCP) or a progestogen should be tried. However, this woman has a history of migraines with aura, which means the COCP is contraindicated because of the increased risk of ischaemic stroke in patients who take both COCPs and suffer from migraines with aura. Therefore, because of this contraindication, a progestogen would be the next option for this woman, such as the progesterone-only pill. Other valid progestogen options include the implant, progestogen injectables or a levonorgestrel intrauterine system.

Bilateral salpingo-oophorectomy with hysterectomy is incorrect because this is the last resort for patients with endometriosis and often does not resolve their pain as they can still have endometrial deposits responsive to oestrogen outside of the reproductive tract. This surgery can be offered to patients who have been unresponsive to other therapies as a last resort; however, it would be too early to consider surgery for this patient, who has not tried hormonal options yet.

Combined oral contraceptive pill is incorrect because this is contraindicated in this woman because of her history of migraines with aura.

GnRH analogue is incorrect as this medication can be tried in patients intolerant/unresponsive to first-line hormonal treatment (i.e. progestogen/COCP) or if hormonal treatment is contraindicated. GnRH analogues act to temporarily induce a menopause state and therefore reduce circulating oestrogen levels. Reducing oestrogen levels can cause symptoms to decrease by reducing the response of the ectopic endometrial deposits.

Oral diclofenac is incorrect because analgesia has not worked so far in her management. Diclofenac is another NSAID, and since ibuprofen has already failed to treat this woman’s pain, it is now appropriate to start hormonal treatment. As the COCP is contraindicated for this patient because of her history of migraines with aura, a progestogen, such as the progesterone-only pill, should now be tried.

Question 20

A 30-year-old woman presents to the gynaecology clinic after having been diagnosed with endometriosis 2 years ago following laparoscopic surgery. She experiences chronic pelvic pain, which worsens during her menstrual cycle, as well as deep dyspareunia.

The patient has had unsuccessful trials of ibuprofen, the progestogen-only pill and the combined oral contraceptive pill. She takes no other medication, has no allergies and has no other medical history. The patient is not currently wishing to become pregnant.

What would be an appropriate next step in treatment?

Insert a copper intrauterine device
Prescribe a regular weak opioid
Prescribe amitriptyline
Trial a gonadotrophin-releasing hormone agonist
Trial an androgen

Answer 20

GnRH analogues may be used in endometriosis if NSAIDs/COCP have not controlled symptoms

Gonadotrophin-releasing hormone agonists (GnRH agonists) may be used as second-line medical management in patients with endometriosis if a combination of non-steroidal anti-inflammatories and the combined oral contraceptive pill have not controlled their symptoms. In this first stage of treatment, patients may also be offered progestogen-only contraception (such as the pill, implant or levonorgestrel intrauterine system), as this patient has. GnRH agonists lead to the down-regulation of GnRH receptors, thus reducing oestrogen (and androgen) production. This reduces the symptoms of endometriosis as oestrogen thickens the uterine lining.

The copper intrauterine device is incorrect. This is because the copper intrauterine device does not contain hormones, so will not prevent the build-up of the uterine lining which is what causes symptoms in endometriosis. Instead, the copper intrauterine device can actually make periods heavier and more painful.

Prescribe a regular weak opioid is incorrect. NICE does not recommend opioids in the management of endometriosis, as endometriosis is a chronic condition and hence there is a high risk of adverse effects and addiction.

Prescribe amitriptyline is incorrect. Whilst this is a medication used in the management of chronic pain, currently, the patient has not explored many of the treatment options for endometriosis. It would be appropriate to work through the pathway of medical (and possibly surgical) endometriosis treatments before prescribing amitriptyline, which comes with side effects and is risky in overdose.

Trial an androgen is incorrect as androgens are third-line treatments, that may be tried for medical management if a GnRH agonist has not been successful. Androgens work by suppressing the hypothalamic-pituitary-androgen axis, leading to a low-oestrogen state. Their use is limited by the side effects of androgen excess.

Question 21

A 30-year-old woman is brought into the emergency department in intense pain. She has a past medical history of endometriosis, and it is one week since her last period. On ultrasound scan there is free fluid in the pelvis. What is the cause of her acute abdomen?

Diverticular disease
Ectopic pregnancy
Endometriosis
Ruptured endometrioma
Toxic megacolon

Answer 21

If an endometrioma ruptures, it will cause sudden intense pain

The history of endometriosis, acute abdomen, and the pelvis filled with fluid all point towards a rupture endometrioma. Diverticular disease is rare in this age group and would not give the clinic picture above. Endometriosis pain is unlikely as she is not currently having her period. Toxic megacolon does not fit the picture. Ectopic pregnancy is an extremely important differential to bear in mind, however as she had her period one week ago, it is not very likely, but it would of course need to be ruled out.

Question 22

A 22-year-old woman presents to the emergency department with sudden onset right shoulder tip pain and lower abdominal pain, associated with an episode of vaginal bleeding. Her last menstrual period was 10 weeks ago. She is currently sexually active with a long term partner and uses condoms only as a method of contraception.

Urine hCG is reported as elevated and transvaginal ultrasound identifies a foetal pole at the ampulla of the left fallopian tube.

Given the likely diagnosis, which of the following is likely to act as the greatest risk factor?

A history of endometriosis
Maternal age of 22
Previous miscarriage
Previous use of the combined contraceptive pill
Recurrent urinary tract infections (UTIs)

Answer 22

Endometriosis is a risk factor for ectopic pregnancy

Endometriosis is a risk factor for ectopic pregnancy.

Although increasing maternal age is associated with ectopic pregnancy, this only becomes significant above the age of 35.

Previous miscarriage is not necessarily associated with an increased risk of ectopic pregnancy.

Use of the combined contraceptive pill is not a risk factor for ectopic pregnancy.

Recurrent UTIs are only weakly associated with an increased risk of ectopic pregnancy.

Question 23

A 29-year-old nulliparous female presents to gynaecology clinic with a history of worsening menstrual pain for three years. There is no relief from ibuprofen. She is sexually active with her husband and reports pain during intercourse. Dysuria and urgency in urination are also present. She has been trying to conceive for the past two years, but failed. On examination, her uterus is of normal size. Rectovaginal exam reveals uterosacral nodularity and tenderness.

Which of the following is the most likely diagnosis?

Endometriosis
Fibroid
Interstitial cystitis
Pelvic inflammatory disease
Uterine myoma

Answer 23

The classic symptoms of endometriosis are pelvic pain, dysmenorrhoea, dyspareunia and subfertility
Important for meLess important
This patient has history of menstrual pain (dysmenorrhoea), pain during intercourse (dyspareunia), and subfertility (tried to conceive, but failed). These are classic symptoms of endometriosis. Uterosacral nodularity and tenderness further supports the diagnosis. Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Some patients may also have urinary symptoms due to bladder involvement or adhesions, as seen in this patient.

Uterine leiomyoma (fibroid) is the common pelvic tumor in women. It causes abnormal uterine bleeding, pelvic pressure and pain, and reproductive dysfunction. On examination, there is an enlarged, mobile uterus. Uterosacral nodularity and tenderness on rectal examination is not seen in leiomyoma.

Interstitial cystitis causes urinary frequency and urgency. Patients typically complain of pain with a full bladder that is relieved upon voiding.

The pelvic inflammatory disease presents with fever, nausea, acute pain along with malodorous vaginal discharge, and cervical motion tenderness/adnexal tenderness.

Uterine myoma often presents with heavy and/or irregular menstrual bleeding. A pelvic exam may show an enlarged, nodular pelvic mass that can vary in size and shape.

Question 24

Sally is a 34-year-old woman who comes to see you with a 6 month history of chronic pelvic pain and dysmenorrhoea which is starting to affect her daily life particularly at work. On further questioning, she also describes painful bowel movements which start just before her period and continue throughout it.

You suspect endometriosis and Sally asks you how this can be checked for.

What is the gold-standard investigation that can confirm this diagnosis for Sally?

Laparoscopic visualisation of the pelvis
Pelvic MRI scan
Transabdominal ultrasound
Transvaginal ultrasound
Serum CA125 level

Answer 24

Laparoscopy is the gold-standard investigation for patients with suspected endometriosis

NICE guidelines state:

Diagnosis of endometriosis can only be made definitively by laparoscopic visualization of the pelvis.

Laparoscopy should be considered in women with suspected endometriosis, even if a transvaginal or transabdominal ultrasound is normal.

If a full, systematic laparoscopy is performed and is normal, the woman should be advised that she does not have endometriosis, and alternative management offered.

Question 25

A 32-year-old, G5P3, rhesus-negative woman attends the antenatal clinic for her dating scan. She is worried as she experienced a miscarriage 18 months ago. The patient has previous diagnoses of polycystic ovarian syndrome (PCOS) and endometriosis for which she used the combined oral contraceptive pill throughout most of her adulthood, except when she was trying to conceive.

An ultrasound is reported below.

Transvaginal ultrasound 6mm gestational sac implanted in the left fallopian tube.

What is the strongest risk factor for this patient’s most likely diagnosis?

Combined oral contraceptive pill use
Endometriosis
History of polycystic ovarian syndrome
Intrauterine contraceptive device (IUCD)
Previous miscarriage

Answer 25

Endometriosis is a risk factor for ectopic pregnancy
Important for meLess important
Endometriosis is the correct answer. This scenario describes a case of ectopic pregnancy based on the presentation and the USS findings of a 6mm implanted gestational sac in the left fallopian tube. The fallopian tube is the most common site of extra-uterine implantation in cases of ectopic pregnancy. Endometriosis is a known risk factor for ectopic pregnancy as it can cause scarring and distortion of the fallopian tubes which impedes the normal passage of the fertilised ovum to the uterus. Other risk factors are a history of an ectopic pregnancy, pelvic inflammatory disease, pelvic/tubal surgery, copper intrauterine device, in-vitro fertilisation and the progesterone-only pill.

Combined oral contraceptive pill use is incorrect. While the progesterone-only pill can increase the risk of an ectopic pregnancy, there are some studies linking the use of the combined contraceptive pill with a decreased risk of ectopic pregnancy, making this answer incorrect.

History of polycystic ovarian syndrome is incorrect. A history of polycystic ovarian syndrome often causes difficulties in conceiving but it is not commonly associated with a significant increase in the risk of ectopic pregnancy. Although PCOS can lead to irregular ovulation and menstrual cycles, it does not directly affect tubal function or structure and thus does not increase the risk of an ectopic pregnancy. Since the question is asking for the strongest risk factor for the development of an ectopic pregnancy, endometriosis is a more suitable answer compared to the patient’s history of polycystic ovarian syndrome.

Intrauterine contraceptive device (IUCD) is incorrect. An IUCD is a risk factor for ectopic pregnancies as anything that alters the normal anatomy and physiology of the reproductive system such as surgeries, foreign objects and medical devices can increase the risk of a pregnancy implanting in the wrong location. However, there is no mention of this patient currently having or ever using an intrauterine contraceptive device, therefore this answer is incorrect.

Previous miscarriage is incorrect. Miscarriages can be managed conservatively (expectant management), medically or surgically. This is decided on a case-by-case basis and the gestational age is the main determinant of treatment. A previous miscarriage is not a risk factor in itself, although if the miscarriage had been managed surgically, for example, this could have increased the risk of scarring. Scarring of or around the fallopian tubes can increase the likelihood of an embryo implanting in that area, leading to an ectopic pregnancy. However, there is no mention of this, therefore this is not the correct answer

Question 26

A 27-year-old female presents to the emergency department with right lower quadrant abdominal pain and vaginal bleeding. The pain radiates to her right shoulder, is exacerbated by movement, and has no alleviating factors. She has no associated gastrointestinal symptoms. Her last menstrual period was 7 weeks ago. A urine pregnancy test is positive.

Which of the following is a risk factor for this presentation?

Combined oral contraceptive pill (COCP) use
Emergency hormonal contraception use (‘morning-after pill’)
Endometriosis
Multiparity
Nulliparity

Answer 26

Endometriosis is a risk factor for ectopic pregnancy

The lower abdominal pain that refers to her shoulder, the vaginal bleeding, the lack of gastrointestinal symptoms and the positive pregnancy test all indicate that this woman has an ectopic pregnancy. Implantation of a fertilised ovum outside the uterus results in an ectopic pregnancy. Endometriosis is a risk factor for ectopic pregnancy. This is because endometriosis can result in the formation of scar tissue and adhesions which may prevent zygotes from reaching the uterus.

Combined oral contraceptive pill use does not increase the risk of ectopic pregnancy. NICE guidance states that the rates of ectopic pregnancies in women using the combined oral contraceptive pill are similar to those in the general population.

Emergency hormonal contraception use does not increase the risk of ectopic pregnancy. NICE guidance states that the rates of ectopic pregnancies in women using emergency hormonal contraception are similar to those in the general population.

Multiparity is not associated with an increased risk of ectopic pregnancy. Previous ectopics, however, are.

Nulliparity is not associated with an increased risk of ectopic pregnancy. It is, however, a risk factor for multiple malignancies, including breast, endometrial and ovarian cancer.

Question 27

A 31-year-old woman presents to her GP with severe dysmenorrhoea and deep dyspareunia. She has a regular menstrual cycle. She has no other medical or gynaecological history of note. On examination she has a fixed, retroverted uterus.

What is the most likely diagnosis?

Chlamydia
Ectopic pregnancy
Endometriosis
Ovarian cyst
Pelvic inflammatory disease

Answer 27

The classic symptoms of endometriosis are pelvic pain, dysmenorrhoea, dyspareunia and subfertility

The symptoms described in this scenario suggest intra-pelvic pathology. A fixed, retroverted uterus alongside this patient’s age are classic features of the presentation of endometriosis.

Chlamydia is often asymptomatic; some patients may present with dyspareunia but infection with chlamydia does not cause dysmenorrhoea.

Ovarian cysts can cause lower abdominal pain.

An ectopic pregnancy would typically cause lower abdominal pain. Patients are likely to be amenorrhoeic.

Pelvic inflammatory disease is more common in women under the age of 30, it is unlikely to cause dysmenorrhoea.

Question 28

A 25-year-old woman presents with a 3 year history of dysmenorrhoea and deep dyspareunia. The pain she experiences during her period can be severe and is associated with nausea. She also states that she and her partner have now been trying for a baby for 24 months with no success. What is the likely diagnosis?

Pelvic inflammatory disease
Endometriosis
Bicornuate uterus
Cervical carcinoma
Uterine fibroids

Answer 28

The classic symptoms of endometriosis are pelvic pain, dysmenorrhoea, dyspareunia and subfertility
Important for meLess important
The key signs and symptoms of endometriosis are cyclical abdominal pain and deep dyspareunia. It can be associated with fertility problems.

Pelvic inflammatory disease can also cause sub-fertility, dyspareunia and pelvic pain, but this pain is not typically associated with menstruation.

A bicornuate uterus is an embryological abnormalilty giving the uterus 2 fundi, giving a ‘heart-shaped’ uterus. It is thought to be associated with an increased risk of recurrent miscarriages.

Cervical carcinomas typically cause abnormal bleeding such as post-coital and inter-menstrual bleeding. It is unlikely to have such a long history as 3 years.

Uterine fibroids are more common in women older than this patient, usually presenting between the ages of 30 and 50. They can cause menorrhagia when large and submucosal fibroids can cause infertility. This is usually reversed on removal.

References and Resources:

European Society of Human Reproduction and Embryology: Management of Women with Endometriosis. http://www.eshre.eu/~/media/Files/Guidelines/ESHRE%20guideline%20on%20endometriosis%202013.pdf

Patient UK: Fibroids. http://patient.info/doctor/fibroids-pro

Patient UK: Pelvic Inflammatory Disease. http://patient.info/doctor/pelvic-inflammatory-disease-pro

Question 29

A 39-year-old female with a history of chronic pelvic pain is diagnosed with endometriosis. Which one of the following is not a recognised treatment for this condition?

Dilation and curettage
Gonadotrophin-releasing hormone analogues
Combined oral contraceptive pill
Medroxyprogesterone acetate
Intrauterine system (Mirena)

Answer 29

The correct answer is Dilation and curettage. This procedure involves dilating the cervix and scraping or suctioning tissue from the lining of the uterus. It’s typically used to diagnose or treat conditions such as heavy bleeding or to clear the uterine lining after a miscarriage or abortion. Dilation and curettage isn’t a recognised treatment for endometriosis because this condition involves endometrial-like tissue growing outside the uterus, not within it. Therefore, scraping the inside of the uterus won’t remove these growths.

The other options listed are all recognised treatments for endometriosis.

Gonadotrophin-releasing hormone analogues are drugs that suppress ovarian function by inhibiting the release of gonadotrophins (luteinising hormone and follicle-stimulating hormone) from the pituitary gland. This creates a state similar to menopause, reducing estrogen levels which can shrink endometrial implants and provide pain relief.

Combined oral contraceptive pill is often used in managing endometriosis. The hormones in combined pills can help control menstrual periods, reduce pain associated with endometriosis, and prevent disease progression.

Medroxyprogesterone acetate is a progestogen that works by suppressing ovulation and reducing menstrual flow, which can help manage symptoms of endometriosis.

Finally, an Intrauterine system (Mirena), which releases levonorgestrel (a type of progestogen), is also used in treating endometriosis-related pain. It works by thinning the lining of your uterus which reduces menstrual flow and decreases overall inflammation in your pelvic area.

Question 30

A nulliparous 22-year-old consults her GP with dysmenorrhoea. Her periods were not painful when she started menstruating at age 14. However, they have become increasingly painful over the last 3 years. She has a 29-day cycle and the pain starts days before she starts bleeding. It is bad enough that she needs to take time off work. She has also noted deep pelvic pain during intercourse and, despite trying for 14 months, has been unable to conceive. Her periods are not heavy and she denies abnormal discharge or intermenstrual bleeding.

Given the likely diagnosis, what is the gold-standard diagnostic test?

Diagnostic laparoscopy
MRI
Speculum examination with high swabs
Transabdominal ultrasound scan
Transvaginal ultrasound scan

Answer 30

Laparoscopy is the gold-standard investigation for patients with suspected endometriosis
Important for meLess important
Diagnostic laparoscopy is the gold-standard investigation for suspected endometriosis. Dysmenorrhoea that starts several days before the period and is bad enough to necessitate time off work is a typical history of endometriosis. Deep dyspareunia and subfertility are also common features of endometriosis.

Whilst an MRI may detect endometriosis, it is not as sensitive as direct visualisation of the pelvis during a laparoscopy. An MRI may be more useful in diagnosing adenomyosis. This condition causes similar symptoms to endometriosis but also tends to cause menorrhagia.

A speculum examination with high swabs would be useful in the diagnosis of pelvic inflammatory disease (PID). PID is a differential for endometriosis. Whilst it would be pertinent to screen for infection in this patient, the diagnosis is more likely endometriosis than PID as the patient has no change in vaginal discharge.

A transabdominal ultrasound is rarely useful to diagnose endometriosis. The pelvic structures are better viewed with a transvaginal ultrasound.

A transvaginal ultrasound is often a first-line investigation in suspected endometriosis as it can both identify endometriomas and identify alternative pathologies such as fibroids. However, it is not the gold-standard investigation as it is not as sensitive at diagnosing endometriosis as direct visualisation is.

Question 31

A 23-year-old woman attends a gynaecology clinic with ongoing pain during sexual intercourse. She has previously complained of this and her symptoms have not resolved with NSAIDs or progesterone-only hormonal treatments. She has a past medical history of migraine with aura. On questioning, the pain occurs with deep penetration and is worse during the end of her menstrual cycle, before her period. She also suffers from dysmenorrhoea. On pelvic examination, there is tender nodularity at the posterior vaginal fornix.

What is the most appropriate next step in management given the likely diagnosis?

Combined oral contraceptive pill
GnRH analogues
IM ceftriaxone and PO doxycycline
Intra-uterine device
NSAIDs and codeine

Answer 31

GnRH analogues may be used in endometriosis if NSAIDs/COCP have not controlled symptoms

GnRH analogues are the correct answer. This woman has endometriosis, supported by the symptoms of deep dyspareunia and dysmenorrhoea with tender nodularity on examination in the posterior vaginal fornix. Endometriosis is typically worse for women during the luteal phase of the menstrual cycle as it is caused by ectopic endometrial tissue proliferating in response to rising oestrogen levels. The first-line treatment is paracetamol and NSAIDs, which can help resolve pelvic pain. This has not been helpful in the management of her endometriosis. Since the combined oral contraceptive is contraindicated in this woman due to her migraine with aura and progesterone-only hormonal treatment has been unsuccessful, the next step is a GnRH analogue. These act to induce a menopause state, so the woman must be warned that she will experience the symptoms of menopause as a side effect. These are only started by specialists after careful consideration of the side effect profile.

Combined oral contraceptive pill (COCP) is incorrect. This treatment can be trialled if paracetamol and NSAIDs are unsuccessful at controlling pain; however, this woman has a past medical history of migraine with aura, meaning the COCP is contraindicated. This explains why previously this woman has trialled NSAIDs and progesterone-only hormonal treatments (likely intra-uterine system), rather than the combined oral contraceptive pill.

IM ceftriaxone and PO doxycycline is incorrect. Whilst pelvic inflammatory disease (PID) can present as deep dyspareunia; the examination would show cervical motion tenderness instead of posterior fornix tender nodularity. Furthermore, you would expect the woman to be unwell, and there would be no cycle to her symptoms as hormones do not influence PID.

Intra-uterine device (IUD) is incorrect. This is not recommended as a treatment for endometriosis. The IUD has no hormonal component so will not aid in symptom management for this woman. Furthermore, the IUD can cause increased bleeding and worsening pelvic pain. Therefore, it is not a management step for endometriosis.

NSAIDs and codeine is incorrect. NSAIDs are the only pain relief that is advisable in the management of endometriosis which is the likely diagnosis in this patient. If they cannot suitably treat her endometriosis, hormonal methods should be explored.

Question 32

A 31-year-old woman presents to her GP with progressively worsening menstrual pain that usually commences a few days before her period. She tried to take paracetamol and ibuprofen to alleviate the pain, but they are not effective in doing so. She also describes extreme discomfort when she has penetrative sex.

Digital vaginal examination reveals nodularity and marked tenderness in the posterior fornix of the cervix. Bimanual examination reveals a fixed, retroverted uterus.

Given the likely diagnosis, which of the following investigations is considered the gold standard?

Hysteroscopy
Laparoscopy
MRI pelvis
Transabdominal ultrasound
Transvaginal ultrasound

Answer 32

Laparoscopy is the gold-standard investigation for patients with suspected endometriosis

The diagnosis here, given the description of severe dysmenorrhoea (which does not respond to NSAIDs) and deep dyspareunia, is endometriosis. This condition commonly affects (around 10% of) women of reproductive age. The gold standard for diagnosing this condition is laparoscopy. This investigation can identify areas of ectopic endometrial tissue. Adhesions, peritoneal deposits and endometrial deposits on the ovaries (chocolate cysts) may be visualised during the procedure.

Hysteroscopy would not play a role here, as endometriosis refers to the growth of endometrial tissue outside of the womb. Hysteroscopy would only involve investigation of the womb itself.

MRI pelvis is sometimes used and is useful for imaging the entire abdomen and pelvis, but its specificity and sensitivity varies depending on the location of the disease.

Transabdominal ultrasound is not the gold standard diagnosis for endometriosis. It would not allow for adequate visualisation of the ectopic endometrial tissue.

Although transvaginal ultrasound is often requested in primary care as an initial investigation, it is not adequately reliable or accurate enough to diagnosis endometriosis.

Question 33

A 28-year-old woman presents to the GP complaining of incidences of dyspareunia, as well as dysuria, and dysmenorrhoea.

Bimanual examination reveals generalised tenderness, a fixed, retroverted uterus and uterosacral ligament nodules.

You refer her for laparoscopy to confirm the suspected diagnosis of endometriosis.

What is the most appropriate initial management option?

Codeine
Combined oral contraceptive pill
Ibuprofen
Mirena coil
Progestogen-only pill

Answer 33

NSAIDs and/or paracetamol are the recommended first-line treatments for endometriosis
Important for meLess important
Ibuprofen is the most appropriate option for the initial management of endometriosis, as analgesia is the recommended first-line treatment. NSAIDs such as ibuprofen, or another analgesic such as paracetamol can be trialled initially for symptomatic management. These can then be used in conjunction if the pain is not managed with just one. If this is unsuccessful, consider hormonal treatment.

Codeine is incorrect. The first line analgesia to be trialled includes paracetamol and NSAIDs like ibuprofen. Opiates can be used further down the management line but these wouldn’t typically be considered until hormonal therapies have been trialled.

Combined oral contraceptive pill is incorrect. The first line intervention is analgesia including paracetamol and/ or NSAIDs, and if a combination of these fails to manage the symptoms hormonal treatment should be considered.

Mirena coil is incorrect. The first line intervention is analgesia including paracetamol and/ or NSAIDs, and if a combination of these fails to manage the symptoms hormonal treatment should be considered.

Progestogen-only pill is incorrect. The first line intervention is analgesia including paracetamol and/ or NSAIDs, and if a combination of these fails to manage the symptoms hormonal treatment should be considered.

Question 34

A 23-year-old woman with no past medical history presents to her GP with progressively painful periods over the last two years. The pain starts several days before menstruation begins, is severe enough to necessitate time off work, and is accompanied by painful defecation and deep dyspareunia. She has tried lifestyle interventions such as yoga and hot baths, but these have not provided relief.

On examination, she has a tender, immobile uterus.

She is referred to gynaecology for further evaluation of the presumed diagnosis.

What other management is appropriate?

Trial of goserelin
Trial of mefenamic acid
Trial of the copper intrauterine device
Trial of the progestogen-only pill
Trial of tranexamic acid

Answer 34

Trial of mefenamic acid

NSAIDs and/or paracetamol are the recommended first-line treatments for endometriosis
Important for meLess important
The selection of mefenamic acid, a non-steroidal anti-inflammatory drug (NSAID), is appropriate. The patient exhibits classic symptoms of endometriosis: significant dysmenorrhoea impacting her daily activities, dyschezia, deep dyspareunia, and examination findings of a tender, fixed uterus suggestive of adhesions. A definitive diagnosis necessitates a gynaecology referral for laparoscopic investigation. According to NICE guidelines, initial management of endometriosis should involve simple analgesics such as paracetamol or an NSAID. Given that this patient has only attempted lifestyle modifications to date, commencing treatment with mefenamic acid represents a suitable first step.

Trialling goserelin is not advised at this stage. Goserelin is classified as a gonadotropin-releasing hormone agonist (GnRH agonist), which inhibits oestrogen production and thereby curtails the proliferation of endometrial tissue. However, due to potential adverse effects like menopausal symptoms and decreased bone mineral density, GnRH agonists are not considered first-line therapy for endometriosis. They are generally reserved for use in secondary care when other interventions—such as analgesics and hormonal contraceptives—have proven ineffective and are prescribed only for limited durations.

A trial of the copper intrauterine device (IUD) is incorrect. As a non-hormonal option, the copper IUD does not influence the growth of endometrial tissue nor does it provide any analgesic benefit; indeed, it may be associated with exacerbated menstrual discomfort.

Trialling the progestogen-only pill is not indicated as a primary intervention for this individual who has not yet explored simple analgesic options. Nonetheless, hormonal contraceptives—including both combined oral contraceptives and progestogen-only formulations—are considered second-line treatments for managing endometriosis due to their capacity to suppress endometrial tissue growth.

A trial of tranexamic acid is inappropriate in this context. Tranexamic acid functions as an anti-fibrinolytic agent rather than an analgesic and is typically employed in cases of heavy menstrual bleeding.