A High-Yield UKMLA/PLAB Scenario (February 2025 Exam Question) - Chronic Pelvic Pain and Infertility 🩺
Essential Insights for Medical Licensing Exams: Diagnosing Endometriosis and Endometrioma
This article highlights a real-world clinical scenario from the February 2025 PLAB 1 exam, focusing on a classic presentation of endometrioma — a crucial topic for UKMLA, PLAB, and other medical licensing exams.
📚 PLAB 1 Exam Case Scenario
A 30-year-old woman visits her GP surgery with progressive lower abdominal pain over the past 9 months. Her pain worsens just before and during her periods and is occasionally associated with deep dyspareunia. She has been trying to conceive for 1 year without success. She has no history of pelvic inflammatory disease and no changes in her bowel or urinary habits.
A transvaginal ultrasound reveals a 5 cm left ovarian cyst with homogeneous ground-glass echogenicity.
What is the most likely diagnosis?
A) Functional ovarian cyst
B) Endometrioma
C) Mature cystic teratoma (dermoid cyst)
D) Polycystic ovary syndrome (PCOS)
E) Ovarian epithelial carcinoma
Answer with an explanation is provided below.
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✅ Correct Answer: B) Endometrioma (Chocolate Cyst)
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Clinical Reasoning and Explanation
🔎 Key Diagnosis – Endometrioma Linked to Endometriosis
This patient’s symptoms — progressive pelvic pain, dysmenorrhoea, deep dyspareunia, and subfertility — form a classic presentation of endometriosis, a chronic inflammatory condition where endometrial-like tissue grows outside the uterus.
The ultrasound finding of a 5 cm cyst with homogeneous "ground-glass" echogenicity is highly characteristic of an endometrioma, a blood-filled ovarian cyst (chocolate cyst) caused by ovarian endometriosis.
🔬 Hallmark Clinical Features of Endometriosis
Chronic pelvic pain: Cyclical or constant, worsens premenstrually and during periods
Dysmenorrhoea: Severe period pain, often starting before menstruation
Deep dyspareunia: Pain with deep penetration
Subfertility: A common complication
Cyclical bowel or bladder symptoms: May occur if lesions affect the bowel or bladder
🖥️ Interpreting the Ultrasound Findings – Ground-Glass Cyst
Ground-glass echogenicity refers to a cyst filled with thick, old blood, which is highly suggestive of an endometrioma.
Functional cysts tend to be simple and thin-walled, without internal echoes.
Dermoid cysts typically have mixed echogenicity due to fat, hair, and calcification.
PCOS presents with multiple small follicles (string of pearls) rather than a single cyst.
Ovarian carcinoma would more likely show solid areas, septations, and vascularity on Doppler.
❌ Why the Other Options Are Incorrect
A) Functional ovarian cyst
Functional cysts (follicular or corpus luteum cysts) are simple, thin-walled, and usually asymptomatic or cause mild pain, not chronic pelvic pain with dysmenorrhoea.
C) Mature cystic teratoma (dermoid cyst)
Typically shows heterogeneous echogenicity, often with fat-fluid levels and calcifications. Not linked with chronic pelvic pain or dysmenorrhoea.
D) Polycystic ovary syndrome (PCOS)
Characterised by multiple small follicles (2-9 mm) and ovarian volume >10 mL, not a solitary cyst. PCOS does not cause severe dysmenorrhoea.
E) Ovarian epithelial carcinoma
Ovarian cancer in a 30-year-old woman would be rare and typically presents with complex solid-cystic masses, not isolated ground-glass cysts.
Management
✅ Refer to gynaecology for further assessment.
✅ Laparoscopy is the gold standard for diagnosing and treating endometriosis.
✅ Consider management options including:
Analgesia (NSAIDs)
Hormonal suppression (combined oral contraceptive pill, progestogens, GnRH analogues)
Surgical excision for severe disease or fertility preservation.
Key Learning Points for PLAB 1 / UKMLA:
Endometriosis is a chronic inflammatory condition where endometrial-like tissue is found outside the uterus.
Symptoms typically start in the reproductive years.
The most common sites include the ovaries, pelvic peritoneum, uterosacral ligaments, and rectovaginal septum.
Endometriomas (chocolate cysts) are ovarian cysts filled with old, altered blood, giving the characteristic ground-glass appearance.
Endometriosis is a leading cause of chronic pelvic pain and subfertility.
This topic was tested in the February 2025 exam.
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