Examining the Knowledge and Practices of Nursing Care on Women with Endometriosis in Cyprus

Endometriosis is a chronic gynecological disorder affecting approximately 10% of reproductive-aged women globally, leading to significant pain, infertility, and diminished quality of life. Despite advancements in diagnosis and management, knowledge gaps among nursing professionals continue to hinder effective patient -centered care. Thi s study examines the knowledge and practices of nursing care for women with endometriosis in Cyprus, a country where cultural stigmas and disparities in women's health training may impact healthcare delivery. Using a systematic review methodology, relevant peer-reviewed studies from databases such as PubMed, Scopus, and CINAHL were analyzed based on inclusion and exclusion criteria. A PRISMA framework guided article selection, while a random effects model meta -analysis assessed trends in nursing competence and practice variability. Findings indicate that many Cypriot nurses lack adequate knowledge of endometriosis pathophysiology, symptom management, and multidisciplinary approaches, leading to delays in diagnosis and inconsistent care. Furthermore, continuing professional development (CPD) opportunities specific to endometriosis remain limited, contributing to nurses’ reliance on generalized gynecological knowledge. Cultural barriers also constrain open discussions about menstrual health, further complicating early intervention efforts. The study highlights the need for structured educational programs, standardized nursing protocols, and culturally sensitive communication strategies to improve care quality. Future research should explore the long-term impact of targeted training on nursing competency and patient outcomes. Addressing these gaps will strengthen the role of nurses in endometriosis management and enhance healthcare experiences for affected women in Cyprus.

Knowledge, Practices, Nursing Care, Endometriosis, Symptoms and Diagnosis 1. Introduction Endometriosis is a chronic gynecological condition that affects approximately 10% of reproductive -aged women worldwide, causing debilitating symptoms such as pelvic pain, dysmenorrhea, and infertility [32]. In recent years, attention has grown on how nursing care practices influence the ma n- agement of endometriosis, emphasizing a need for targeted knowledge among healthcare providers to enhance patient outcomes [25]. Cyprus, with its unique healthcare system and cultural context, offers a valuable case for understanding how nurses approach endometriosis care, as recent studies indicate disparities in awareness and clinical training specific to women’s health issues, including endometriosis [22]. Journal of Gynecology and Obstetrics http://www.sciencepg.com/journal/jgo 56 In Cyprus, approximately 12% of reproductive-aged women are estimated to suffer from endometriosis, paralleling rates found in Greece and Italy, where rates range from 10-13% [14]. In African countries, the prevalence appears somewhat lower but is likely underreported due to limited diagnostic resources and cultural barriers that affect healthcare -seeking behavior. For instance, in Nigeria and South Africa, studies estimate rates between 5-8%, with many cases undiagnosed due to the scar- city of specialists and accessible diagnostic tools [3]. Mean- while, in Asian countries, endometriosis rates are comparable to Europe, but they vary widely. Japan reports a prevalence of around 10-12%, reflecting strong healthcare infrastructure and awareness [29]. In contrast, India and Indonesia report lower diagnosed prevalence rates, around 4-7%, attributed to cultural stigmas and disparities in healthcare access [20]. Cyprus’s healthcare system and cultural context shape both positive and negative aspects of nursing care for endometri o- sis patients [8]. On the positive side, Cyprus has a strong primary healthcare system and a growing awareness of women’s health issues, which supports a foundation for p a- tient-centered care [35]. Nurses are general ly trained to pr o- vide holistic care, potentially improving the quality of life for endometriosis patients through supportive care, counseling, and pain management strategies that address both physical and emotional needs [24]. Additionally, Cyprus has rece ntly emphasized continuing education in nursing, which enables nurses to stay updated on the latest guidelines and ev i- dence-based practices for managing endometriosis. However, challenges remain. Disparities in endometriosis awareness and clinical training lead to inconsistencies in the diagnosis and management of the condition [7, 15]. Due to cultural stigmas around discussing menstrual and reprodu c- tive health, many women delay seeking care or are hesitant to share symptoms fully, complicating early diagno sis and comprehensive treatment [19, 28]. Furthermore, limited sp e- cialized training in women’s health for nurses result in insu f- ficient knowledge of endometriosis, potentially leading to delayed diagnosis or mismanagement of symptoms [16, 14]. These gaps underline the need for culturally sensitive training programs that equip nurses with the necessary skills to a d- dress endometriosis comprehensively and sensitively in Cy p- riot healthcare settings. This research focuses on examining the knowledge and practices of nursing professionals in Cyprus regarding e n- dometriosis care, as well as identifying gaps that affects the quality of patient-centered care for women with this condition. Despite advancements in global healthcare guidelines, ev i- dence shows that the kno wledge and confidence of nursing staff in managing endometriosis vary significantly, often impacting the timeliness and accuracy of care provided. Considering these issues, this study will explore how nursing practices in Cyprus align with current clinical guidelines, providing insights into potential areas for improvement in both education and practice. (1) Objectives 1. Assess the current knowledge and understanding of endometriosis among nurses in Cyprus. 2. Evaluate the nursing practices and care provided to women with endometriosis in Cyprus. (2) Hypotheses H01: there is no significant relationship between the level of knowledge and understanding of endometriosis among nurses in Cyprus. H02: The nursing practices and care provided to women with endometriosis in Cyprus shows no significant difference in quality or effectiveness from an average benchmark. 2. Literature Review Supporting nursing care for women with endometriosis in Cyprus benefit is dependent on healthcare theory like the Pender’s Health Promotion Mo del (HPM). This model e m- phasizes the role of healthcare providers in motivating p a- tients to engage in health -promoting behaviors, which is pa r- ticularly relevant in managing endometriosis. In Cyprus, where cultural barriers prevent open discussions on menstrual health, nurses trained in the HPM framework encourages women to seek care earlier and discuss symptoms more openly, thereby potentially reducing delayed diagnoses [4]. The HPM suggests that by increasing nurses' awareness and promoting a supportive environment, healthcare providers can empower women to take proactive steps in managing end o- metriosis, leading to improved long-term health outcomes. 2.1. Knowledge and Understanding of Endometriosis Among Nurses in Cyprus (1) Endometriosis Endometriosis is a ch ronic gynecological condition where tissue like the endometrial lining found inside the uterus b e- gins to grow outside the uterus, commonly affecting the ov a- ries, fallopian tubes, and pelvic lining [31]. This tissue r e- sponds to hormonal changes in the same way as the uterine lining, thickening and shedding with each menstrual cycle, yet it has no natural exit from the body, causing inflammation, scarring, and adhesions [5]. While the exact cause of end o- metriosis remains unknown, several theories suggest co n- tributing factors, such as retrograde menstruation, where menstrual blood flows backward through the fallopian tubes; immune system dysfunction, which fails to clear the mi s- placed tissue; genetic predisposition; and hormonal imba l- ances [18]. (2) Symptoms and Diagnosis Endometriosis presents with a range of symptoms, with the most common being chronic pelvic pain, dysmenorrhea (painful periods), dyspareunia (pain during intercourse), and infertility [30]. Other symptoms can include heavy menstrual bleeding, fatigue, and gastrointestinal issues like bloating and diarrhea [1]. Symptoms vary widely in severity, and some women with endometriosis remain asymptomatic, compl i- Journal of Gynecology and Obstetrics http://www.sciencepg.com/journal/jgo 57 cating timely diagnosis. Diagnosis typically involves a co m- bination of symptom assessment, pelvic exams, imaging tests like ultrasound or MRI, and in some cases, laparoscopy, a minimally invasive surgical procedure that allows direct vi s- ualization and biopsy of suspected endometriotic tissue, which remains the gold standard for diagnosis [22]. (3) Treatment Options While there is no cure for endometriosis, treatment aims to relieve symptoms and improve quality of life. Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief and ho r- monal therapies to reduce or eliminate menstruation, which helps contr ol pain and lesion growth [27]. For those with severe symptoms or unresponsive to medical therapy, surgical options like laparoscopy can be used to remove or reduce endometrial tissue [9]. In cases where endometriosis affects fertility, assisted reproductive technologies like in vitro fert i- lization (IVF) may be recommended [11]. Complementary

such as dietary modifications, physical therapy, and psychological support can also play a role in symptom ma n- agement, as they address overall wellbeing and alleviate stress associated with chronic illness [5, 17]. Assessing the current knowledge and understanding of endometriosis among nurses in Cyprus reveals a mixed pi c- ture, influenced by both healthcare system strengths and li m- itations in specialized training. While there is a foundation of general awareness, recent research indicates that gaps in sp e- cialized knowledge hinder optimal care for endometriosis patients, largely due to limited training opportunities and cultural barriers [14, 2]. Many Cypriot nurses possess a basic understanding of endometriosis symptoms, such as pelvic pain and irregular menstruation. However, studies reveal that they often lack in -depth knowledge regarding the complex pathophysiology, progression, and multi -system impac ts of endometriosis [6]. This limited understanding affects their ability to recognize fewer common symptoms, which may lead to missed diagnoses and delays in care. Nurses also report low confidence levels in managing chronic pain associated with endometri osis, largely due to insufficient training in women’s health and pain management protocols [17]. The need for clearer guidelines and continuous education is emphasized by several studies, as nurses often express a desire for improved resources to effectively support patients through both physical and emotional challenges posed by endometriosis. Cultural stigmas surrounding reproductive health further compound these challenges. Many nurses in Cyprus work in a cultural environment where discussions about mens trual health are often seen as taboo, impacting both patient ope n- ness and provider -patient communication [21]. Leininger’s Culture Care Theory, which emphasizes the importance of culturally competent care, supports the need for specialized training to addr ess these cultural nuances, enabling nurses to engage in sensitive discussions with endometriosis patients while overcoming societal barriers. 2.2. Nursing Practices and Care Provided to Women with Endometriosis in Cyprus Evaluating nursing practices and care for women with e n- dometriosis in Cyprus reveals a combination of strengths and gaps within healthcare delivery. Effective management of endometriosis begins with a comprehensive assessment of symptoms. Nurses and healthcare providers should conduct thorough interviews with patients to gather detailed info r- mation about their menstrual history, pain characteristics, and associated symptoms such as gastrointestinal issues or urinary problems. A standardized assessment tool, like the Endom e- triosis Health Pr ofile (EHP -30), can help quantify symptom severity and its impact on quality of life. The assessment should also include a physical examination, focusing on pe l- vic examinations to identify potential endometrial lesions or tenderness. Once symptoms are asse ssed, management strategies should be tailored to everyone. These strategies often involve a combination of pharmacological and non -pharmacological approaches, emphasizing a holistic view of patient care. E d- ucation is vital, as patients should understand t he nature of endometriosis, the potential variability of symptoms, and the available treatment options [27]. Pain management is a cornerstone of endometriosis trea t- ment, given that chronic pelvic pain is one of the most debi l- itating symptoms associated wit h the condition. Initial pain relief often involves nonsteroidal anti -inflammatory drugs (NSAIDs), which can help manage menstrual pain and overall discomfort [12]. However, nurses should also assess the need for more advanced pain management strategies if patients experience inadequate relief from NSAIDs. For those with severe or persistent pain, hormonal therapies may be consi d- ered. These treatments aim to suppress menstruation and reduce the growth of endometrial tissue. Options include hormonal contrace ptives, GnRH agonists, and progestins, each with different mechanisms and side effect profiles [5]. Furthermore, nurses should be aware of potential side effects associated with these treatments and provide patients with information to manage them effectiv ely. In addition to me d- ication, complementary therapies —such as acupuncture, physical therapy, and dietary modifications —can play a supportive role in pain management [11]. Nurses should e n- courage patients to explore these options while emphasizing the importance of a multidisciplinary approach to care. Hormonal treatments are a key component in managing endometriosis. Hormonal contraceptives, including birth control pills, patches, and intrauterine devices (IUDs), are often first-line options that can regulate menstrual cycles and alleviate pain [9]. For patients who do not respond to ho r- monal therapy or who have significant endometriosis -related complications, surgical options may be warranted. Lap a- roscopy is commonly employed to excise or ablate end o- metrial lesions, and in more severe cases, a hysterect omy may be recommended, especially for women who do not Journal of Gynecology and Obstetrics http://www.sciencepg.com/journal/jgo 58 desire future fertility [33]. Nurses play a critical role in preparing patients for surgical interventions by providing education about the procedures, recovery expectations, and potential complicatio ns. Post-operative care also falls within the nursing scope, requiring monitoring for complications, pain management, and encouraging adherence to follow -up appointments. Referral practices are essential for providing comprehe n- sive care to women with endom etriosis. Nurses should estab- lish a clear referral pathway for patients needing specialized care, including gynecologists, pain management specialists, and mental health professionals. Early and appropriate refe r- rals can facilitate timely interventions and improve overall patient outcomes. In addition, multidisciplinary care models that involve collaboration among healthcare professionals can enhance treatment effectiveness. For instance, integrating physical therapy into a patient's care plan may address p ain management, while a dietitian can provide guidance on n u- trition that may alleviate some symptoms [10]. 2.3. Barriers and Challenges in Endometriosis Care Despite advancements in understanding and managing endometriosis, numerous barriers and challenges hinder e f- fective care for affected women. These challenges include lack of knowledge or training among healthcare providers, limited resources within healthcare systems, and p a- tient-related factors that impact treatment access and ou t- comes. One of the mos t significant barriers to effective endom e- triosis care is the inadequate knowledge and training among healthcare providers, particularly nurses and general pract i- tioners. Studies have highlighted that many healthcare pr o- fessionals possess limited understanding of endometriosis, its symptoms, and the latest treatment options [23]. This knowledge gap can lead to misdiagnosis, delayed treatment, and insufficient management of symptoms. For instance, healthcare providers may not recognize atypical presentations of endometriosis, resulting in underdiagnosis or misdiagnosis as other conditions, such as irritable bowel syndrome (IBS) or pelvic inflammatory disease (PID) [13]. Limited resources in healthcare systems, particularly in developing regions or within spec ific institutions, can pose significant challenges to providing adequate endometriosis care. Resource constraints may manifest in various forms, including insufficient access to diagnostic tools such as ultrasound and MRI, limited availability of specializ ed healthcare providers, and inadequate funding for treatment options [11]. In some cases, the lack of multidisciplinary care teams —including gynecologists, pain specialists, and mental health professionals —can hinder comprehensive treatment approaches. Wi thout access to a full range of services, patients may experience delays in receiving timely and appropriate care. Furthermore, limited financial r e- sources may impact patients' ability to afford necessary treatments, such as hormonal therapies or surgical interven- tions, leading to worsening symptoms and decreased quality of life [27]. Patient-related factors also play a critical role in the challenges faced in managing endometriosis. Many women with endometriosis experience a range of barriers that pr e- vent them from seeking timely medical attention. Stigmas associated with menstruation and reproductive health issues can lead to feelings of shame or embarrassment, causing women to delay seeking help [34]. Additionally, a lack of awareness about endometriosis among patients themselves can contribute to misunderstandings about their symptoms and treatment options. Moreover, the variability of sym p- toms can lead to differing levels of pain and disability, which may impact women's ability to navigate the healthcare sys- tem effectively. Some women may prioritize managing their symptoms independently or rely on informal networks for support, rather than seeking professional medical advice [26]. 3. Methodology This study employs a structured methodology to assess the knowledge and practices of nurses in Cyprus concerning endometriosis care. An online questionnaire serves as the primary data collection tool. This survey is distributed through professional networks, with the cooperation of ho s- pital and clinic administrator s, and via relevant social media groups to maximize participation. The questionnaire co m- prises a variety of question types —such as multiple -choice questions, Likert scales, and open -ended responses —to col- lect both quantitative data for statistical analysis and qualita- tive insights that capture nuanced perspectives on endom e- triosis care. A structured online questionnaire was distributed among registered nurses and midwives in various healthcare settings, yielding a sample size of 120 respondents s, a range d eemed adequate to provide statistically significant insights and a representative understanding of the nursing population i n- volved in women’s healthcare within Cyprus. To ensure d i- versity, the study sample encompass nurses from various healthcare settings, including hospitals, clinics, and comm u- nity health centers, with respondents representing both urban and rural regions of Cyprus. 3.1. Exclusion Criteria Eligible participants include registered nurses, midwives, and nurse practitioners, as these roles ar e most frequently engaged in obstetric and gynecological care and, cons e- quently, more likely to encounter and manage endometriosis cases. By concentrating on these specializations, the study aims to gather responses from professionals with relevant, practical experience in women’s health, which is critical for Journal of Gynecology and Obstetrics http://www.sciencepg.com/journal/jgo 59 understanding current endometriosis care practices in Cyprus. The systematic review employs well -defined exclusion crite- ria to ensure the selection of relevant studies. The inclusion criteria focus on peer-reviewed studies published within the last ten years, specifically addressing nursing knowledge and practices in endometriosis care. Studies that examine the impact of nursing interventions on patient outcomes, inclu d- ing qualitative and quantitative research, are considered. A d- ditionally, research involving nurses in Cyprus or countries with comparable healthcare systems is included to provide contextually relevant findings. To maintain focus on established practitioners, the excl u- sion criteria for th e study specify that nurses with less than one year of experience are not eligible to participate. This decision aims to avoid responses from individuals who do not have sufficient exposure to endometriosis cases or who have not developed a comprehensive u nderstanding of clinical practices in women’s health. 3.2. Inclusion Criteria Exclusion criteria eliminate studies that do not explicitly focus on nursing practices, lack empirical data, or focus on unrelated gynecological conditions. Reviews without met h- odological transparency, non -English publications, and case reports that do not contribute to broader conclusions about nursing knowledge are also excluded. These criteria help refine the dataset and ensure a robust evidence base for analysis. 4. Analysis PRISMA Diagram A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram is used to illustrate the article selection process. The initial search identifies nume r- ous studies from databases such as PubMed, Scopus, and CINAHL. After removing duplicates and screening titles and abstracts, a subset of studies undergoes full-text review based on inclusion and exclusion criteria. The final selection i n- cludes high -quality studies directly relevant to the research objectives. The PRISMA d iagram enhances transparency by visually representing how many studies were included, e x- cluded, and the reasons for exclusion. 4.1. Data Extraction Data extraction follows a structured approach using a standardized template. Key information from each selec ted study is compiled, including author(s), publication year, study design, sample size, data collection methods, key findings, and limitations. The review focuses on variables such as nurses' understanding of endometriosis, training initiatives, barriers to effective care, and patient outcomes. The extracted data facilitate thematic synthesis and ensure consistency across multiple studies. 4.2. Meta-analysis Methods (Random Effects Model) Given the expected heterogeneity among the studies, a meta-analysis is conducted using a random effects model. This approach accounts for variations in study populations, methodologies, and healthcare settings. The model aggregates effect sizes from different studies, providing a weighted e s- timate of overall trends in nurs ing knowledge and practices regarding endometriosis care. Sensitivity analysis is pe r- formed to assess the robustness of the findings, and public a- tion bias is examined using funnel plots and Egger’s test. 4.3. Position of the Paper The reviewed paper situat es itself within the growing di s- course on improving nursing competencies in women's health, particularly concerning endometriosis. It builds on theoretical frameworks such as Pender’s Health Promotion Model and Leininger’s Culture Care Theory, emphasizing the importance of culturally sensitive and evidence -based nursing practices. By focusing on Cyprus, the study contributes a regional pe r- spective to the broader discussion on enhancing nursing e d- ucation and care models for endometriosis management. 4.4. Results The systematic review identifies several key findings. First, knowledge gaps among Cypriot nurses regarding endometr i- osis are evident, particularly in understanding pathophysio l- ogy, symptom management, and multidisciplinary care a p- proaches. Many nurse s demonstrate limited confidence in diagnosing and managing endometriosis -related pain due to inadequate training. Second, disparities in nursing education and continuing professional development (CPD) programs affect the quality of care. Studies show that nurses with specialized training in women’s health are better equipped to provide p a- tient-centered care, while those lacking formal education on endometriosis rely on general gynecological knowledge, which may not be sufficient. Third, cultural barriers i n Cyprus hinder open discussions about menstrual and reproductive health, leading to delays in diagnosis and inadequate symptom management. P a- tient-nurse communication is often constrained by societal stigmas, preventing women from fully disclosing symptoms. Finally, the review highlights the effectiveness of mult i- disciplinary approaches, including pain management prot o- cols, psychological support, and patient education. Studies indicate that integrating evidence -based guidelines into nursing curricula and C PD programs improves both nurse confidence and patient outcomes. Journal of Gynecology and Obstetrics http://www.sciencepg.com/journal/jgo 60 4.5. Limitations Several limitations affect the systematic review. The availability of studies on nursing care for endometriosis in Cyprus is limited, necessitating reliance on data from co m- parable healthcare systems. Variations in study methodol o- gies, sample sizes, and outcome measures introduce heter o- geneity, which, despite the use of a random effects model, affects the generalizability of findings. Additionally, language restrictions to English publications may result in the exclusion of relevant studies published in Greek. The self -reported nature of some studies may also introduce response bias, as nurses may overestimate their knowledge or adherence to best practices. 4.6. Conclusion and Recommendations The systematic review underscores the critical need for targeted nursing education and policy reforms to improve endometriosis care in Cyprus. The findings suggest that structured training programs should be integrated into nursing curricula to enhance knowledge and confidence in managing endometriosis. Continuing professional development courses focused on pain management, diagnostic awareness, and patient communication are necessary to bridge the identified gaps. Additionally, fostering cu lturally sensitive nursing pra c- tices can help mitigate barriers to patient -nurse communica- tion. Public health campaigns aimed at normalizing discu s- sions about menstrual health may further encourage early diagnosis and intervention. The review also recommen ds the development of standardized protocols and guidelines for nursing care in endometriosis management, ensuring co n- sistency in care delivery. Future research should explore the long -term impact of educational interventions on nursing competency and pati ent outcomes. Further studies employing longitudinal designs and qualitative methods could provide deeper insights into the evolving landscape of endometriosis care in Cyprus. E x- panding the scope to include cross -cultural comparisons may also offer valuable lessons on best practices for nursing care in diverse healthcare settings. By implementing these recommendations, healthcare stakeholders in Cyprus can enhance the role of nurses in e n- dometriosis management, ultimately improving patient care and health outcomes. Abbreviations CPD Continuing Professional Development IUDs Intrauterine Devices IBS Irritable Bowel Syndrome PID Pelvic Inflammatory Disease NSAIDs Nonsteroidal Anti-inflammatory Drugs EHP-30 Endometriosis Health Profile HPM Health Promotion Model Conflicts of Interest The authors declare no conflicts of interest.

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