GCC Gynaecology Nursing Guide

Dysmenorrhoea

Primary Dysmenorrhoea

• No pelvic pathology; prostaglandin-mediated uterine cramping
• Onset: 6-12 months after menarche
• Management: NSAIDs (first-line), COCP, heat therapy

Secondary Dysmenorrhoea — Endometriosis

• Endometriotic tissue outside uterus — retrograde menstruation theory
• Triad: dysmenorrhoea, dyspareunia, dyschezia
• Average diagnosis delay: 7-10 years
• Laparoscopy: gold standard diagnosis
• Medical: NSAIDs, COCP, progestogens, GnRH analogues (Zoladex)
• Surgical: excision/ablation, oophorectomy in severe cases

Amenorrhoea

Primary (no menses by age 16)

• Imperforate hymen, Turner syndrome (45X), Mullerian agenesis

Secondary (6+ months absent menses)

• FIRST: exclude pregnancy
• Causes: hypothalamic (stress, exercise, weight loss), hyperprolactinaemia, thyroid, PCOS, premature ovarian insufficiency (POI)
• Investigations: beta-hCG, FSH, LH, oestradiol, prolactin, TSH, USS pelvis

Menorrhagia (Heavy Menstrual Bleeding)

Assessment

• Pictorial blood assessment chart (PBAC score)
• FBC (anaemia), coagulation screen, thyroid function, USS pelvis
• PALM-COEIN framework for cause

Management Ladder

Rotterdam Criteria (2 of 3)

• Oligo/anovulation (irregular cycles, <8 per year)
• Clinical/biochemical hyperandrogenism (hirsutism, acne, elevated testosterone)
• Polycystic ovarian morphology on USS (≥12 follicles per ovary or ovarian volume >10mL)

Investigations

• FSH, LH (LH:FSH ratio >2 suggestive but not diagnostic)
• Total/free testosterone, SHBG, FAI
• Fasting glucose, HbA1c, fasting insulin, lipid profile
• USS pelvis (polycystic morphology)
• Thyroid, prolactin (exclude differentials)

Management

Lifestyle (First-Line)

• 5-10% weight loss restores ovulation in majority
• Low GI diet, regular exercise — culturally adapted advice in GCC

Medical

• Metformin: insulin sensitiser — improves cycle regularity, reduces androgen levels, weight loss
• COCP: cycle regulation, anti-androgen (Yasmin/Dianette)
• Clomiphene/Letrozole: ovulation induction for fertility
• Inositol: emerging evidence for insulin resistance

Long-term Risks (Nurse Education)

• Type 2 diabetes, metabolic syndrome
• Endometrial hyperplasia/cancer (unopposed oestrogen)
• Subfertility
• Psychological impact — body image, hair growth

Uterine Fibroids

• Benign smooth muscle tumours — most common gynaecological tumour
• Types: submucosal (AUB), intramural (bulk symptoms), subserosal (pressure)
• Symptoms: HMB, pelvic pain, urinary frequency, subfertility

Management

• Medical: GnRH analogues (pre-op shrinkage), UPA (ulipristal), tranexamic acid, LNG-IUS (submucosal unsuitable)
• Uterine Artery Embolisation (UAE): interventional radiology — uterine-preserving; post-procedure: pain management (post-embolisation syndrome), monitor for infection
• Myomectomy: open/laparoscopic/hysteroscopic — fertility-preserving
• Hysterectomy: definitive — vaginal/laparoscopic/open

Ovarian Cysts

Benign Features (RMI)

• Unilocular, thin-walled, no solid areas, bilateral, premenopausal, normal CA-125
• Functional cysts: resolve spontaneously — reassure, repeat USS in 6-8 weeks
• Dermoid/teratoma: fat, hair, teeth — risk of torsion
• Endometrioma: "chocolate cyst" — homogeneous low-level echoes

Malignant Risk Assessment

• CA-125 + HE4 → ROMA score (Risk of Ovarian Malignancy Algorithm)
• RMI (Risk of Malignancy Index) = USS score × menopausal status × CA-125
• RMI >200 → refer to gynaecological oncology MDT
• Suspicious features: solid components, multilocular, ascites, bilateral, papillary projections

Prevention & Screening

• Caused by persistent high-risk HPV (HR-HPV) — types 16, 18 responsible for 70%
• GCC vaccination: national programmes exist but uptake variable — cultural barriers, awareness gaps in expat communities
• Gardasil-9: protects against HPV 6, 11, 16, 18, 31, 33, 45, 52, 58
• Screening: primary HPV testing replacing cytology; colposcopy referral if HPV+

Colposcopy Nursing

• Acetic acid (5%) applied — acetowhite changes indicate CIN
• Lugol's iodine (Schiller's test) — normal epithelium stains brown
• Biopsy taken from most abnormal area
• Post-colposcopy: no intercourse/tampons 4 weeks, brown discharge normal

LLETZ (Large Loop Excision of Transformation Zone)

• Under local anaesthetic (LA infiltration) — reassure patient re: sounds/sensations
• Post-LLETZ: watery discharge 2-4 weeks, avoid intercourse 4 weeks
• Warn: primary/secondary haemorrhage (return immediately if soaking pad in 1 hour)

Cervical Cancer Treatment Nursing

FIGO Staging

• Stage I: confined to cervix
• Stage II: beyond uterus, not pelvic wall/lower vagina
• Stage III: extends to pelvic wall/lower vagina/hydronephrosis
• Stage IV: bladder/rectum/distant metastasis

Treatment Modalities

• Stage IA1: LLETZ/cone biopsy (fertility-sparing)
• Stage IB-IIA: radical hysterectomy or chemoradiation
• Stage IIB+: concurrent chemoradiotherapy (cisplatin weekly + EBRT)

Brachytherapy Nursing

• Bladder filling protocol: 180mL for IGRT planning consistency
• Vaginal dilator use post-treatment: starts 6-8 weeks post-RT to prevent stenosis
• Psychosexual support referral

Diagnosis Pathway

• TVUS: endometrial thickness >5mm in postmenopausal woman → biopsy required
• Pipelle endometrial biopsy: outpatient, 90% sensitivity for endometrial cancer
• Hysteroscopy + directed biopsy: gold standard if pipelle insufficient/inconclusive
• MRI pelvis: staging, myometrial invasion depth, cervical involvement
• CT chest/abdomen/pelvis: lymph node and distant metastasis assessment

Risk Factors (Nurse Education)

• Unopposed oestrogen (obesity, PCOS, nulliparity, late menopause)
• Type 2 diabetes, hypertension
• Tamoxifen use (breast cancer patients)
• Lynch syndrome (hereditary)

Surgical Treatment Nursing

• Total hysterectomy + bilateral salpingo-oophorectomy (TH+BSO)
• Laparoscopic or robotic-assisted preferred (faster recovery)
• Pelvic/para-aortic lymph node assessment/sentinel node biopsy

Pre-operative Nursing

• VTE prophylaxis: TED stockings + LMWH (high risk due to obesity/cancer)
• Bowel prep as per surgeon preference
• Enhanced recovery: carbohydrate loading, early mobilisation plan

Post-operative Nursing

• Monitor: wound, urinary output, PCA/epidural analgesia
• Drain management: Jackson-Pratt, document output
• Early mobilisation (4-6h post-op), physiotherapy
• Lymphoedema prevention if lymph node dissection performed

Diagnosis & Staging

• CA-125 elevated in 80% epithelial ovarian cancer (but non-specific)
• HE4 + CA-125 → ROMA score (pre/postmenopausal algorithms)
• CT chest/abdomen/pelvis: peritoneal disease, omental cake, ascites
• USS-guided ascites drainage: symptom relief + cytology
• Diagnostic laparoscopy/laparotomy: confirm diagnosis, assess resectability

BRCA1/2 Testing — GCC Context

• BRCA1/2 mutations: lifetime ovarian cancer risk 40-60% (BRCA1), 15-20% (BRCA2)
• GCC BRCA prevalence: founder mutations described in Lebanese, Iranian, Ashkenazi Jewish populations in region
• PARP inhibitors (olaparib) for BRCA-mutated recurrent disease
• Referral to genetic counselling — family implications

Treatment Nursing

Primary Debulking Surgery

• Goal: complete cytoreduction (no residual disease >1cm)
• Includes: TH+BSO, omentectomy, peritoneal stripping, bowel resection if needed
• Intensive ITU/HDU care post-operatively

Chemotherapy Nursing

• Carboplatin + paclitaxel: standard first-line combination
• IP (intraperitoneal) chemotherapy: requires Tenckhoff catheter care
• Paclitaxel hypersensitivity: pre-medicate with dexamethasone + antihistamine
• Carboplatin toxicity: thrombocytopenia, nephrotoxicity — monitor FBC + renal function
• Alopecia counselling: wig referral, cold cap discussion
• Bevacizumab (Avastin): anti-VEGF — monitor BP, wound healing, thrombosis

Pre-operative Nursing

• Consent: include possibility of laparotomy conversion (patient must accept this)
• Bowel prep: surgically dependent — document and administer as prescribed
• NBM: 6h solid food, 2h clear fluids (ERAS protocol)
• VTE prophylaxis: TED stockings, LMWH as prescribed
• Abdominal shave/skin prep per local policy
• Consent to remove uterus/ovaries only if pre-discussed (document clearly)
• Jewellery/nail varnish removal; ID band checked
• Allergies documented; anaesthetic review completed

Post-operative Nursing

Immediate Recovery

• ABCDE assessment; oxygen until fully awake
• Pain: paracetamol + NSAIDs + opioid PRN; PCA if major case
• PONV: ondansetron/cyclizine — common post-laparoscopy

Specific Concerns

• Port site care: small wounds, check for bleeding/hernia, sutures/Steri-strips
• Urinary output: >0.5mL/kg/h; Foley catheter removal as per surgical plan
• Bloating/distension: expected; passage of flatus indicates bowel function returning
• Discharge: same-day or next day for diagnostic; longer for operative

Complications to Monitor

• Bowel/bladder injury (rare): abdominal pain, pyrexia, haematuria
• Vascular injury: haemodynamic instability — emergency laparotomy
• Port site hernia: bulge/pain at incision site

Procedure Overview

• Distension media: glycine (monopolar) or saline (bipolar/NovaSure)
• Indications: AUB investigation, polyp removal, submucous fibroid resection, endometrial ablation, lost IUD, uterine septum resection
• Outpatient hysteroscopy: vaginoscopic approach — misoprostol pre-treatment for cervical priming

Fluid Deficit Monitoring — Critical Nursing Role

• Record input (bags used) and output (tubing collection) in real-time
• Document deficit on theatre board every 10 minutes
• If deficit exceeded: inform surgeon immediately, request serum sodium/osmolality

Complications

Uterine Perforation

Post-procedure Nursing

• Recovery: vital signs q15min until stable, pain assessment
• Vaginal bleeding: pad check — light spotting expected; heavy bleeding → surgical review
• Urinary retention: post-operative retention risk — in/out catheter if needed
• Discharge criteria: voided, pain controlled, tolerating oral fluids
• Patient information: cramping/discharge 1-2 weeks; no intercourse 2 weeks

Endometrial Ablation Post-care

• Watery discharge 2-4 weeks — use sanitary pads, not tampons
• Contraception still required (pregnancy after ablation is high risk)
• Haematometra: severe cramping months later — retained blood above synechiae

Vaginal Hysterectomy

Immediate Post-operative

• Vital signs: haemorrhage monitoring — check vaginal loss q1h initially
• Urinary catheter: usually 24-48h; monitor output hourly
• Pelvic drain: document output; remove as per surgical preference
• Analgesic: multimodal — paracetamol, diclofenac, morphine PRN

Complications

• Vault haemorrhage: vaginal bleeding >soaking pad in 30 minutes → immediate surgical review; may require examination under anaesthetic and vault suture
• Urinary retention: after catheter removal — trial of void; re-catheterise if fails; voiding diary
• Pelvic floor: physiotherapy referral for pelvic floor exercises post-hysterectomy
• VTE: LMWH 28 days post-major gynaecological oncology surgery

LLETZ Post-procedure Instructions

• Performed under local anaesthetic (LA) in colposcopy clinic
• Patient may feel pressure/smell of burning but no pain if LA adequate

Discharge Instructions (nurse-led)

• Watery/blood-stained discharge: expected for 2-4 weeks
• Avoid intercourse, tampons, swimming: 4 weeks
• No heavy lifting/strenuous exercise: 2 weeks

Follow-up

• Histology result: 3-4 weeks — discuss margins (clear vs involved)
• If involved margins: re-LLETZ or surveillance
• HPV testing at 6 months (test of cure)
• Cervical length concerns: document for future pregnancy surveillance (risk of preterm birth)

Diagnosis

• Clinical diagnosis: 12 consecutive months amenorrhoea in woman >45
• FSH >30 IU/L (measured twice, 4-6 weeks apart) — useful in women <45 or on HRT
• Average age: 51 years (UK/GCC similar)
• Premature Ovarian Insufficiency (POI): menopause before age 40 — FSH >25 IU/L twice, 4 weeks apart
• Perimenopause: irregular cycles + symptoms; FSH may be variable

Vasomotor Symptoms

• Hot flushes: affect 75% of menopausal women; can last 5-10 years
• Night sweats: sleep disruption → fatigue, mood changes
• Palpitations, dizziness

Non-HRT Options for Hot Flushes

• Cooling strategies: fan, loose cotton clothing, cool environment
• CBT: effective as HRT for vasomotor symptom distress
• SSRIs/SNRIs: paroxetine, venlafaxine — caution in breast cancer (tamoxifen interaction with paroxetine)
• Clonidine: modest benefit
• Fezolinetant (NK3 receptor antagonist): new non-hormonal option
• Isoflavones: weak evidence; avoid in oestrogen-sensitive cancers

Genitourinary Syndrome of Menopause (GSM)

• Vaginal dryness, atrophy, dyspareunia, recurrent UTI, urinary urgency
• Affects 50-60% of postmenopausal women — underreported (cultural barriers in GCC)

Products

• Vagifem/Vagirux pessaries: low-dose oestradiol 10mcg inserted nightly × 2 weeks, then twice weekly
• Ovestin cream: 0.1% oestriol cream
• Intrarosa (prasterone/DHEA): non-oestrogen option for dyspareunia
• Ospemifene: SERM — oral tablet for GSM (no vaginal insertion needed)
• Lubricants (water-based) and moisturisers: non-hormonal support

Bone Protection

• Oestrogen prevents osteoporosis — continued risk after stopping HRT
• DEXA scan indicated: POI, early menopause, steroid use, fracture history
• Calcium (1200mg/day) + Vitamin D (800-1000 IU/day) — deficiency common in GCC (cultural dress, indoor lifestyle)
• Bisphosphonates (alendronate): if T-score ≤ -2.5

Types of HRT

Routes

• Transdermal (patches/gel): preferred — bypasses hepatic first-pass → lower VTE risk, better lipid profile
• Oral: convenient but higher VTE risk
• Progestogen: micronised progesterone (Utrogestan) — safer breast profile than synthetic progestogens (MPA)

Timing Hypothesis (CVD)

• HRT started within 10 years of menopause / before age 60 → cardiovascular benefit
• Started >10 years post-menopause → no benefit, possible harm

HRT Risks — Evidence-Based Nuance

Breast Cancer (WHI Study Context)

• WHI 2002: increased risk with combined HRT — widely misinterpreted; absolute risk small
• Oestrogen-only HRT: does NOT increase breast cancer risk (post-hysterectomy)
• Risk depends on: duration, type of progestogen (MPA > micronised progesterone), route
• Transdermal + micronised progesterone = lowest breast risk profile

VTE

• Oral HRT: 2-3× increased VTE risk
• Transdermal oestrogen + progesterone: NO increased VTE risk
• Prescribe transdermal in women with obesity, previous VTE (with haematology advice)

Absolute Contraindications to HRT

• Active/recent breast cancer, oestrogen-receptor positive cancer
• Active thromboembolic disease
• Unexplained vaginal bleeding (investigate first)
• Active liver disease
• Pregnancy
• Endometrial cancer (relative — oncologist-led decision)

Burden in South Asian Expats

• South Asian expat women (Indian, Bangladeshi, Pakistani) have high cervical cancer incidence in home countries — screening access limited in GCC for this group
• Barriers: language, awareness, cultural modesty, lack of female healthcare providers in some settings
• Many women present with advanced disease having never had a smear
• Nurse's role: opportunistic cervical cancer screening education; facilitate referral to dedicated women's health clinics

HPV Vaccination in GCC

• UAE: Gardasil-9 available; school-based programme for girls
• Saudi Arabia: National programme introduced for adolescent girls
• Qatar, Bahrain, Kuwait: programmes in varying stages of implementation
• Coverage lower in expat communities — access, cultural acceptance, misinformation barriers
• Nurse role: HPV vaccine counselling — address misconceptions re: sexual activity; vaccine works best pre-exposure

Leading Gynaecology Centres in GCC

Female Doctor Preference

• Strong cultural and religious norm in GCC: female gynaecologist preferred or required
• Many Muslim women refuse examination by male practitioner — this must be respected
• Nurse role: advocate for female examiner; facilitate same-gender chaperone; sensitively document patient preference in notes
• For emergencies where female doctor unavailable: explain necessity with compassion; female nurse chaperone mandatory

Teenage Marriage & Early Pregnancy

• Legal in some GCC jurisdictions with family/judicial consent
• Risks: obstetric fistula, perinatal mortality, preterm birth, anaemia, mental health impact
• Nursing: non-judgmental care; assess safeguarding concerns (escalate per hospital policy); advocate for adolescent health services

Consanguinity & Genetic Conditions

• First-cousin marriages: 25-60% in parts of GCC — high rates of autosomal recessive conditions
• Gynaecological relevance: Turner syndrome, congenital uterine anomalies, premature ovarian failure with genetic basis
• BRCA2 founder mutations in certain Gulf populations
• Nurse role: facilitate genetic counselling referral; support antenatal genetic testing discussions

Female Genital Mutilation/Cutting (FGM/C)

WHO Classification

• Type I: clitoridectomy (partial/total)
• Type II: clitoridectomy + labia minora excision
• Type III (infibulation): narrowing of vaginal opening — most severe
• Type IV: other procedures (pricking, cauterisation)

Gynaecological Complications

• Recurrent UTI/ascending infection (Type III — obstructed outflow)
• Scar tissue dyspareunia — pain on intercourse, superficial scarring
• Haematocolpos, haematometra (if introital obstruction)
• Obstetric complications: perineal tears, prolonged second stage
• Deinfibulation: surgical opening of infibulated scar — performed antepartum or during labour by trained practitioner

Nursing Response

• Mandatory reporting where legally required (UAE, UK)
• Non-judgmental, trauma-informed care
• Refer to specialist FGM clinic (available at Latifa, Corniche, KFSH)
• Psychosocial support; child safeguarding if daughters at risk

Fertility & Islamic Ethics in GCC

• IVF permissible within marriage using husband's sperm and wife's eggs — fatwa widely accepted in GCC
• Donor gametes: complex — generally not permitted in Sunni Islam; some Shia scholars permit donor eggs
• Surrogacy: generally not permitted in GCC
• Embryo storage, PGD for genetic disease: permissible in many GCC regulations
• Nurse role: facilitate discussion between patient, family, and religious advisors; liaise with hospital chaplaincy/ethics committee