"polycystic ovary syndrome" AND "PMOS" OR "new nomenclature"

PMOS polycystic ovary metabolic syndrome new name PCOD 2024 2025

"polycystic ovary syndrome" AND "renaming" OR "new name" OR "PMOS"

PMID: 42119588

PMID: 40687737

"polycystic ovary syndrome" AND management treatment guidelines

"polycystic ovary syndrome" AND "cardiovascular risk" OR "mental health" OR "quality of life"

polycystic ovary syndrome PCOS ultrasound pathophysiology diagram

mkdir -p /home/daytona/workspace/PMOS-presentation && ls /home/daytona/workspace…

~/PMOS-presentation/create_pmos.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = 'LAYOUT_16x9';
pres.author = 'PMOS/PCOS Presentation';
pres.title = 'PMOS – Polyendocrine Metabolic Ovarian Syndrome';

// ─── COLOUR PALETTE ────────────────────────────────────────────────────────
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  darkText   : "1C1235",
  lightText  : "EDE8F7",
  gold       : "F5C842",
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// ─── HELPERS ───────────────────────────────────────────────────────────────
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// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 1 — TITLE SLIDE                                                  ║
// ╚══════════════════════════════════════════════════════════════════════════╝
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  s.addShape(pres.ShapeType.ellipse, { x: -0.8, y: 3.5, w: 3, h: 3, fill: { color: C.midPurple }, line: { color: C.midPurple } });

  s.addText("PMOS", {
    x: 0.5, y: 0.6, w: 9, h: 1.4,
    fontSize: 72, bold: true, color: C.gold, fontFace: "Calibri",
    align: "center", charSpacing: 10,
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  s.addText("Polyendocrine Metabolic Ovarian Syndrome", {
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    fontSize: 22, color: C.lightText, fontFace: "Calibri", align: "center", bold: true,
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  s.addText("The New Name for PCOD / PCOS", {
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  // Divider
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  s.addText("Based on Lancet 2026 · 2023 International Evidence-Based PCOS Guidelines · Berek & Novak's Gynecology · Harrison's 22e", {
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  s.addText("Teede HJ et al., Lancet 2026; DOI: 10.1016/S0140-6736(26)00717-8", {
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    fontSize: 10, color: C.lilac, fontFace: "Calibri", align: "center", italic: true,
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  s.addText("May 2026", {
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    fontSize: 11, color: C.lilac, fontFace: "Calibri", align: "center",
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}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 2 — AGENDA / OVERVIEW                                            ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Overview", "A comprehensive journey through the evolution of PCOS → PMOS");
  const topics = [
    "1. History of PCOS – from Stein-Leventhal to today",
    "2. Why 'PCOS' is a misnomer – the case for change",
    "3. The PMOS nomenclature – Lancet 2026 Global Consensus",
    "4. Epidemiology & global burden",
    "5. Pathophysiology & endocrine mechanisms",
    "6. Clinical features & phenotypes",
    "7. Diagnostic criteria (NIH 1990 → Rotterdam 2003 → AES 2006 → 2023 Guidelines)",
    "8. Metabolic & cardiometabolic risks",
    "9. Reproductive implications",
    "10. Psychological & quality-of-life impact",
    "11. Management – lifestyle, pharmacological, surgical",
    "12. Emerging therapies",
    "13. Implementation strategy for PMOS",
    "14. Key take-home messages & references",
  ];
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}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 3 — HISTORICAL BACKGROUND                                        ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Historical Background", "From Stein & Leventhal (1935) to a Global Consensus");
  addBullets(s, [
    { text: "1935 – Stein & Leventhal: First description of bilateral polycystic ovaries with amenorrhea and obesity", bold: true, color: C.deepPurple },
    "1990 – NIH consensus: Defined PCOS as hyperandrogenism + chronic anovulation (exclusion of other causes)",
    "2003 – Rotterdam ESHRE/ASRM Criteria: Broadened to 2 of 3 features (HA, oligo/anovulation, PCO morphology)",
    "2006 – Androgen Excess Society (AES): Emphasised hyperandrogenism as central feature",
    "2012 – NIH expert workshop: Endorsed Rotterdam criteria; noted 4 distinct phenotypes",
    "2013 – Endocrine Society Clinical Practice Guideline ratified Rotterdam criteria for adults",
    "2018 – International Evidence-based PCOS Guideline (NHMRC-funded) published",
    "2023 – Updated international evidence-based guideline: Most comprehensive recommendations to date",
    { text: "2026 – Lancet: PCOS renamed PMOS (Polyendocrine Metabolic Ovarian Syndrome)", bold: true, color: C.coral },
  ], { y: 1.3, h: 4.1, fontSize: 14.5 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 4 — WHY RENAME? THE CASE FOR CHANGE                              ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Why Rename PCOS to PMOS?", "The name 'polycystic ovary syndrome' is a misnomer — Lancet 2026");

  // Two-column boxes
  accentBox(s, 0.25, 1.35, 4.6, 3.9, "❌  Problems with 'PCOS'", 
    "• Implies pathological cysts — misleading; these are follicles\n• Ovaries need NOT be polycystic to diagnose PCOS\n• Obscures diverse endocrine & metabolic features\n• Causes patient confusion & stigma\n• Delays diagnosis by ≥2 years on average\n• Fragments care across specialties\n• Curtails research funding & policy visibility\n• Underrepresents breadth: cardiac, hepatic, psychological",
    "FFF0F3", C.coral);

  accentBox(s, 5.15, 1.35, 4.6, 3.9, "✅  Benefits of 'PMOS'",
    "• Accurate: captures polyendocrine + metabolic + ovarian dysfunction\n• Reduces confusion and stigma\n• Promotes holistic multi-disciplinary care\n• Aligns with international disease classification systems\n• Encourages broader research framing\n• Endorsed by 56 leading global academic, clinical & patient organisations\n• Supported by 14,360 people with PCOS in global surveys\n• 85.6% of patients & 76.1% of HPs favoured name change",
    "F0FFF8", C.teal);
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 5 — THE LANCET 2026 CONSENSUS PROCESS                           ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "The PMOS Consensus Process", "Teede HJ et al. Lancet 2026 — An unprecedented multistep global process");
  addBullets(s, [
    { text: "CITATION: Teede HJ et al. Lancet 2026; DOI:10.1016/S0140-6736(26)00717-8", bold: true, color: C.coral },
    "Funded governance established with engagement of 56 leading academic, clinical & patient organisations",
    "Global surveys: 14,360 responses from people with PCOS and multidisciplinary health professionals across all world regions",
    "Methods: Iterative surveys, Modified Delphi, Nominal Group Technique workshops, Marketing & implementation analyses",
    "Principles prioritised: scientific accuracy, clarity, stigma avoidance, cultural appropriateness, implementation feasibility",
    "An ACCURATE new name was prioritised over retaining the 'PCOS' acronym or a generic name",
    { text: "Preferred terms: 'polyendocrine', 'metabolic', 'ovarian' → reflecting multisystem pathophysiology", bold: true, color: C.midPurple },
    "Implementation: Evolution not transformation — transition period, education, alignment with health systems & ICD classification",
  ], { y: 1.35, h: 4.0, fontSize: 14.5 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 6 — EPIDEMIOLOGY                                                 ║
// ╚══════════════════════════════════════════════════════════════════════════╝
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  addHeaderBar(s, "Epidemiology", "PMOS affects 1 in 8 women globally — Lancet 2026");

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    { x: 0.3,  y: 1.4,  w: 3.0, h: 1.3, title: "Global Prevalence", body: "~10–13% of women\n(~1 in 8 worldwide)\nReproductive-age women 5–15%", bg: "EDE6FF", tx: C.deepPurple },
    { x: 3.55, y: 1.4,  w: 3.0, h: 1.3, title: "Most Common Endocrine Disorder", body: "Most common endocrine disorder in women of reproductive age\n(Kaplan & Sadock 2024)", bg: "E6F4FF", tx: C.deepPurple },
    { x: 6.8,  y: 1.4,  w: 2.9, h: 1.3, title: "Familial Trait", body: "Complex polygenic inheritance\nMultifactorial aetiology\n(Berek & Novak)", bg: "FFF6E6", tx: C.deepPurple },
    { x: 0.3,  y: 2.9,  w: 3.0, h: 1.3, title: "Geographic Variation", body: "Obesity in PCOS:\nSpain 20%, China 43%,\nItaly 38%, USA 69%", bg: "FFE6F0", tx: C.deepPurple },
    { x: 3.55, y: 2.9,  w: 3.0, h: 1.3, title: "Insulin Resistance", body: "50–80% of women with PMOS have insulin resistance (Harrison's 22e)", bg: "E6FFF8", tx: C.deepPurple },
    { x: 6.8,  y: 2.9,  w: 2.9, h: 1.3, title: "Hirsutism Rate", body: "~70% in USA, only 10–20% in Japan (due to 5α-reductase polymorphisms)", bg: "FFF0E6", tx: C.deepPurple },
  ];
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  s.addText("PCO morphology present in ~23% of women of reproductive age; only 5–10% have full PMOS (Berek & Novak 2023)", {
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    fontSize: 12, color: C.midPurple, fontFace: "Calibri", italic: true,
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}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 7 — PATHOPHYSIOLOGY OVERVIEW                                     ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Pathophysiology of PMOS", "A complex interplay of neuroendocrine, metabolic & genetic factors");
  addBullets(s, [
    { text: "Neuroendocrine Axis Dysregulation", bold: true, color: C.deepPurple, size: 16 },
    "Increased GnRH pulse frequency → elevated LH, relatively suppressed FSH",
    "Elevated LH/FSH ratio (often >2:1) stimulates theca cells → excess androgen production",
    { text: "Hyperandrogenism Mechanism", bold: true, color: C.deepPurple, size: 16 },
    "Theca cells overproduce testosterone, 17α-OH progesterone, androstenedione",
    "CYP17, CYP11A, 3β-HSD2 genes overexpressed → autonomous steroidogenesis",
    { text: "Insulin Resistance & Hyperinsulinism", bold: true, color: C.deepPurple, size: 16 },
    "Hyperinsulinaemia amplifies LH-driven androgen synthesis; reduces SHBG → more free androgens",
    "Inositol paradox: peripheral MI→DCI conversion blocked; ovarian DCI overproduced",
    { text: "Folliculogenesis Arrest", bold: true, color: C.deepPurple, size: 16 },
    "FSH insufficiency → arrest of antral follicles at 5–9 mm ('string of pearls')",
  ], { y: 1.3, h: 4.1, fontSize: 13.5 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 8 — GENETIC BASIS                                                ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Genetic Architecture of PMOS", "Polygenic & multifactorial — Berek & Novak, Harrison's 22e");
  addBullets(s, [
    { text: "GWAS-identified susceptibility loci:", bold: true, color: C.deepPurple },
    "11q22.1 (YAP1) · 2p21 (THADA) · 11p14.1 (FSHB) · 2q34 (ERBB4) · 12q21.2 (KRR1) · 5q31.1 (RAD50)",
    "Confirmed in both European and Han Chinese cohorts",
    { text: "Candidate gene categories (Berek & Novak, 2023):", bold: true, color: C.deepPurple },
    "① Insulin resistance-related genes: insulin receptor, IRS-1, IRS-2, TCF7L2",
    "② Androgen biosynthesis genes: CYP11A, CYP17, 3β-HSD2, STAR, SHBG",
    "③ Inflammatory cytokine genes: IL-6 and related loci",
    "④ Other: FSH receptor, GABA-A receptors, endocytosis genes, FBN3 (19p13.3)",
    { text: "NOT associated with PMOS: GDF9, BMP15, AMH, AMHR2 polymorphisms (no susceptibility link)", bold: false, color: C.teal },
    "Epigenetic modifications and fetal programming (androgen exposure in utero) also contribute",
  ], { y: 1.3, h: 4.1, fontSize: 14 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 9 — CLINICAL FEATURES & PHENOTYPES                               ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Clinical Features & Rotterdam Phenotypes", "Berek & Novak's Gynecology 2023 · 2023 International Guidelines");

  // Phenotype boxes
  const pheno = [
    { x: 0.25, y: 1.35, label: "Phenotype A", desc: "HA + Ovarian\ndysfunction + PCO morphology\n(Classic PMOS)", bg: "E8DEFF" },
    { x: 2.7,  y: 1.35, label: "Phenotype B", desc: "HA + Ovarian\ndysfunction\n(No PCO morphology)", bg: "D4EDFF" },
    { x: 5.15, y: 1.35, label: "Phenotype C", desc: "HA + PCO\nmorphology\n(Ovulatory PMOS)", bg: "FFDCE8" },
    { x: 7.6,  y: 1.35, label: "Phenotype D", desc: "Ovarian dysfunction\n+ PCO morphology\n(Normoandrogenic)", bg: "DCFFEE" },
  ];
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      { text: p.label + "\n", options: { bold: true, fontSize: 13, breakLine: true } },
      { text: p.desc, options: { fontSize: 12 } },
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  s.addText("Key Clinical Manifestations:", { x: 0.35, y: 3.25, w: 9.3, h: 0.35, fontSize: 15, bold: true, color: C.deepPurple, fontFace: "Calibri" });
  addBullets(s, [
    "Menstrual dysfunction: oligomenorrhoea (cycles >35 days) or amenorrhoea; regular menses in 21% may still be anovulatory",
    "Hyperandrogenism: Hirsutism (Ferriman-Gallwey ≥4–6) in ~70% USA, acne, androgenic alopecia",
    "PCO morphology: ≥20 follicles (2–9 mm) per ovary and/or ovarian volume >10 mL on ultrasound",
    "Obesity: >50% patients; central/android distribution (higher waist:hip ratio); ethnicity-variable",
    "Elevated LH:FSH ratio (often >2), elevated total/free testosterone, low SHBG, mild hyperprolactinaemia (~25%)",
  ], { y: 3.55, h: 2.0, fontSize: 13 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 10 — DIAGNOSTIC CRITERIA EVOLUTION                               ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Diagnostic Criteria — Evolution Over Time", "From NIH 1990 to 2023 International Guidelines");

  const rows = [
    ["Criteria Set", "Year", "Requirements", "Authority"],
    ["NIH / Oligo-HA Criteria", "1990", "Chronic anovulation + HA (exclusion of other causes)", "NIH Consensus"],
    ["Rotterdam Criteria", "2003", "2 of 3: Oligo/anovulation · Clinical/biochemical HA · PCO morphology", "ESHRE/ASRM"],
    ["AES Criteria", "2006", "HA + ovarian dysfunction (± PCO morphology)", "Androgen Excess Society"],
    ["NIH Expert Panel", "2012", "Endorsed Rotterdam; recognised 4 phenotypes", "NIH Workshop"],
    ["Endocrine Society CPG", "2013", "Rotterdam criteria for adults; stricter criteria for adolescents", "Endocrine Society"],
    ["2023 International\nEvidence-Based Guideline", "2023", "Rotterdam remains current; AMH as emerging biomarker; focus on cardiometabolic screening", "Teede HJ et al., JCEM/Fertil Steril"],
  ];

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  const colX = [0.2, 2.55, 3.4, 7.75];
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        x: colX[ci], y: rowY, w: colW[ci], h: rowH,
        fill: { color: isHeader ? C.midPurple : (ri % 2 === 0 ? "F5F0FF" : C.white) },
        line: { color: "CCBBEE", width: 0.5 },
      });
      s.addText(cell, {
        x: colX[ci] + 0.05, y: rowY + 0.04, w: colW[ci] - 0.1, h: rowH - 0.08,
        fontSize: isHeader ? 12 : 10.5,
        bold: isHeader,
        color: isHeader ? C.white : C.darkText,
        fontFace: "Calibri",
        valign: "middle",
        wrap: true,
      });
    });
  });
  s.addText("Source: Berek & Novak's Gynecology 2023; Teede HJ et al., Fertil Steril 2023 (PMID 37589624)", {
    x: 0.2, y: 5.15, w: 9.6, h: 0.3, fontSize: 10, italic: true, color: C.midPurple, fontFace: "Calibri",
  });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 11 — DIAGNOSTIC ALGORITHM                                        ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Diagnostic Algorithm for PMOS", "Adapted from Berek & Novak 2023 Fig. 35-4");
  addBullets(s, [
    { text: "Step 1 — Clinical evaluation:", bold: true, color: C.deepPurple },
    "Menstrual history · Hirsutism (mFG score) · BMI + waist circumference · Acne / androgenic alopecia",
    { text: "Step 2 — Biochemical workup:", bold: true, color: C.deepPurple },
    "Testosterone (total & free) · DHEA-S · LH/FSH ratio · SHBG · 17-OHP (basal follicular phase) · Prolactin · TSH · Fasting glucose + insulin · HbA1c · Fasting lipid profile",
    { text: "Step 3 — Imaging:", bold: true, color: C.deepPurple },
    "Transvaginal ultrasound: ≥20 follicles (2–9 mm) OR ovarian volume >10 mL (single ovary sufficient)",
    "AMH level: emerging biomarker correlating with antral follicle count",
    { text: "Step 4 — Exclusion of mimics:", bold: true, color: C.deepPurple },
    "Thyroid disease · Hyperprolactinaemia · Non-classic CAH (↑17-OHP) · Cushing's syndrome · Androgen-secreting tumour · Hypo/hypergonadotropic disorders",
  ], { y: 1.3, h: 4.1, fontSize: 14 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 12 — ULTRASOUND CRITERIA & AMH                                   ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Ultrasound Criteria & AMH in PMOS", "Sonographic definition & emerging biomarkers");
  addBullets(s, [
    { text: "Current TVUS Diagnostic Threshold (Rotterdam 2023 update):", bold: true, color: C.deepPurple },
    "≥20 antral follicles (2–9 mm diameter) in EITHER ovary, OR ovarian volume >10 mL",
    "A single ovary meeting criteria is sufficient to define PCO morphology",
    "3D power Doppler: highlights increased stromal vascularity characteristic of PMOS",
    { text: "AMH (Anti-Müllerian Hormone):", bold: true, color: C.deepPurple },
    "AMH is a reliable predictor of antral follicle count (AFC) independent of PCOS phenotype",
    "Elevated AMH reflects arrested folliculogenesis; useful in cycles where TVUS is not definitive",
    "2023 International Guideline supports AMH as alternative/complementary to ultrasound",
    { text: "Key pitfall:", bold: true, color: C.coral },
    "PCO morphology alone (without HA or menstrual irregularity) does NOT diagnose PMOS",
    "PCO appearance found in ~23% of reproductive-age women; PMOS occurs in only 5–15%",
  ], { y: 1.3, h: 4.15, fontSize: 14 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 13 — METABOLIC COMORBIDITIES                                     ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Metabolic Comorbidities in PMOS", "Harrison's 22e · Berek & Novak · 2023 Guidelines");

  const items = [
    { x: 0.25, y: 1.35, w: 4.65, h: 1.35, t: "Type 2 Diabetes & Pre-diabetes",
      d: "Obese PMOS: ~1/3 have IGT, 7.5–10% T2DM\nRisk elevated even in non-obese PMOS (10% vs 2%)\n→ Screen all at diagnosis & every 3–5 years (OGTT)", bg: "FFE8E8" },
    { x: 5.1,  y: 1.35, w: 4.65, h: 1.35, t: "Dyslipidaemia",
      d: "↑Triglycerides · ↓HDL · ↑LDL\nAssociated with elevated cardiovascular risk\nFasting lipid profile at diagnosis in all overweight/obese women", bg: "E8EEFF" },
    { x: 0.25, y: 2.85, w: 4.65, h: 1.35, t: "Metabolic Syndrome & CVD Risk",
      d: "Insulin resistance → hyperinsulinaemia → endothelial dysfunction\nMetS prevalence markedly elevated (50–80% IR)\nHigher waist:hip ratio = increased CV & T2DM risk", bg: "E8FFE8" },
    { x: 5.1,  y: 2.85, w: 4.65, h: 1.35, t: "Non-Alcoholic Fatty Liver Disease",
      d: "NAFLD prevalence elevated in PMOS\n≥20% patients and/or HPs unaware of association\nLiver enzymes & hepatic ultrasound warranted if suspected", bg: "FFF3E8" },
  ];
  items.forEach(i => accentBox(s, i.x, i.y, i.w, i.h, i.t, i.d, i.bg, C.darkText));

  s.addText("Hypertension · Obstructive sleep apnoea · Endometrial cancer risk (from chronic anovulation) — screen at diagnosis", {
    x: 0.25, y: 4.3, w: 9.5, h: 0.5,
    fontSize: 13, color: C.midPurple, fontFace: "Calibri", bold: true,
  });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 14 — REPRODUCTIVE HEALTH                                         ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Reproductive Health in PMOS", "Infertility, pregnancy complications & obstetric risks");
  addBullets(s, [
    { text: "Most common cause of anovulatory infertility in developed countries (Berek & Novak 2023)", bold: true, color: C.deepPurple },
    "Chronic oligo/anovulation prevents normal follicular maturation and corpus luteum formation",
    { text: "Pregnancy complications (Harrison's 22e):", bold: true, color: C.deepPurple },
    "↑ Early miscarriage risk · ↑ Gestational diabetes · ↑ Gestational hypertension",
    "↑ Preeclampsia · ↑ Preterm birth",
    { text: "Ovulation Induction — 2023 Guideline Hierarchy:", bold: true, color: C.midPurple },
    "1st line: Letrozole (aromatase inhibitor) — superior live-birth rates vs clomiphene",
    "2nd line: Clomiphene citrate ± metformin",
    "3rd line: Injectable gonadotropins (by experienced practitioners — OHSS risk in PMOS)",
    "4th line: Laparoscopic ovarian drilling (LOD) — reduces androgen levels long-term",
    { text: "IVF: consider if above options fail; GnRH antagonist protocols preferred to reduce OHSS", bold: false, color: C.teal },
    "Prepregnancy counselling & lifestyle optimisation advised in all PMOS women seeking pregnancy",
  ], { y: 1.3, h: 4.1, fontSize: 13.5 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 15 — PSYCHOLOGICAL & QoL IMPACT                                 ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Psychological & Quality-of-Life Impact", "Teede HJ et al., EClinicalMedicine 2025 (PMID 40687737)");
  addBullets(s, [
    { text: "Psychological comorbidities are highly prevalent in PMOS:", bold: true, color: C.deepPurple },
    "Depression: 2–3× higher prevalence vs age-matched controls",
    "Anxiety disorders: significantly elevated; body-image distress from hirsutism, acne, weight",
    "Eating disorders: disordered eating patterns common in PMOS",
    { text: "Impact of the name 'PCOS':", bold: true, color: C.coral },
    "The word 'cysts' causes unnecessary alarm and misconceptions about infertility",
    "Delayed diagnosis (mean ≥2 years) leads to frustration, self-blame & reduced healthcare engagement",
    "Stigma associated with obesity and visible androgens affects social and sexual wellbeing",
    { text: "2023 Guideline Recommendations for psychological care:", bold: true, color: C.midPurple },
    "Screen for depression & anxiety at diagnosis and periodically",
    "CBT, mindfulness and psychosocial support should be offered",
    "Multidisciplinary team including psychologist/psychiatrist should be part of PMOS care",
  ], { y: 1.3, h: 4.1, fontSize: 14 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 16 — LIFESTYLE MANAGEMENT                                        ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Lifestyle Management", "Recommended for ALL women with PMOS — 2023 International Guidelines");
  addBullets(s, [
    { text: "Recommended in ALL women with PMOS regardless of BMI (Harrison's 22e; 2023 Guideline)", bold: true, color: C.deepPurple },
    { text: "Weight loss (≥5–10% of body weight in overweight):", bold: true, color: C.midPurple },
    "Reduces androgens, insulin resistance, improves menstrual regularity and fertility",
    "Dietary Modification (Shang Y et al., Front Endocrinol 2021 — Meta-analysis PMID 34790167):",
    "Low-glycaemic index, Mediterranean, low-calorie diets all beneficial for hormonal outcomes",
    "Low-calorie ketogenic diet (LCKD) reduces androgen levels, LH/FSH ratio and improves ovarian function in adolescents",
    { text: "Physical activity:", bold: true, color: C.midPurple },
    "At least 150 min/week moderate aerobic + resistance training",
    "Reduces insulin resistance, adiposity, depression and anxiety",
    { text: "Probiotics/prebiotics/synbiotics (Meta-analysis 2024, PMID 39599701):", bold: true, color: C.teal },
    "Emerging evidence: improve insulin resistance and hormonal balance in PMOS",
  ], { y: 1.3, h: 4.1, fontSize: 14 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 17 — PHARMACOLOGICAL MANAGEMENT — HORMONAL                      ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Pharmacological Management — Hormonal", "Harrison's 22e · Berek & Novak · 2023 Guideline");
  addBullets(s, [
    { text: "Combined Hormonal Contraceptives (CHC) — First-Line for non-pregnant PMOS:", bold: true, color: C.deepPurple },
    "Increases SHBG → reduces free androgens · Regulates menstrual cycles",
    "Lowest effective oestrogen dose; cyclic or continuous",
    "Androgens decrease within 2–3 months; hirsutism/acne may take 6–12 months to improve",
    { text: "Anti-androgens (if CHC inadequate after 6 months):", bold: true, color: C.midPurple },
    "Spironolactone 50–200 mg/day: aldosterone antagonist + androgen receptor blocker",
    "Flutamide (hepatotoxicity risk — use cautiously)",
    "Combined with CHC (mandatory contraception — teratogenic risk)",
    { text: "Progestins for endometrial protection:", bold: true, color: C.midPurple },
    "MPA 10 mg × 10–14 days every 3 months, OR progesterone 200 mg/day, OR LNG-IUD",
    "Prevents endometrial hyperplasia from unopposed oestrogen in anovulatory PMOS",
    { text: "Melin J et al., J Clin Endocrinol Metab 2024 — Meta-analysis (PMID 37554096):", bold: false, color: C.teal },
    "Metformin + OCP superior to OCP alone for hyperandrogenism and metabolic outcomes",
  ], { y: 1.3, h: 4.1, fontSize: 13.5 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 18 — PHARMACOLOGICAL MANAGEMENT — METABOLIC                     ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Pharmacological Management — Metabolic", "Insulin sensitizers, GLP-1 agonists & emerging agents");
  addBullets(s, [
    { text: "Metformin (Biguanide — Insulin Sensitizer):", bold: true, color: C.deepPurple },
    "Adjunct to lifestyle for overweight/obese PMOS and for IGT/T2DM",
    "Reduces hepatic glucose production, improves peripheral insulin sensitivity",
    "Not recommended as sole agent for: HA symptoms, infertility, pregnancy loss, gestational diabetes prevention",
    "Inositol supplementation (Myo-inositol ± D-chiro-inositol):",
    { text: "Fitz V et al., J Clin Endocrinol Metab 2024 — Systematic Review (PMID 38163998):", bold: true, color: C.teal },
    "Myo-inositol improves insulin resistance, androgen levels and menstrual regularity (2023 PCOS Guideline endorsed)",
    { text: "Emerging Therapies:", bold: true, color: C.midPurple },
    "GLP-1 receptor agonists (semaglutide, liraglutide): promising for weight loss, IR and hormonal improvement",
    "SGLT-2 inhibitors: emerging evidence for cardiometabolic benefit in PMOS",
    "Thiazolidinediones (pioglitazone): second-line insulin sensitizer; weight gain concern",
    "Statins: dyslipidaemia management; also reduce androgens",
  ], { y: 1.3, h: 4.1, fontSize: 13.5 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 19 — SURGICAL MANAGEMENT                                         ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Surgical Management of PMOS", "When medical therapy fails for ovulation induction");
  addBullets(s, [
    { text: "Laparoscopic Ovarian Drilling (LOD):", bold: true, color: C.deepPurple },
    "Electrosurgery or laser: 4–10 punctures per ovary",
    "Mechanism: reduces androgen-secreting stromal tissue → LH and testosterone fall → FSH normalises",
    "Induces ovulation in 50–80%; effective for clomiphene-resistant cases",
    "Avoids multiple pregnancy risk; no OHSS risk (unlike gonadotropins)",
    "Effects can last 12–18 months; may not be durable in severely obese women",
    { text: "Bariatric Surgery:", bold: true, color: C.midPurple },
    "For morbidly obese women with PMOS (BMI ≥35–40 with comorbidities)",
    "Dramatic improvement in insulin resistance, menstrual regularity, androgen levels, fertility",
    "Resolution of metabolic syndrome in majority",
    { text: "Ovarian wedge resection (historical):", bold: true, color: C.teal },
    "Original Stein-Leventhal procedure — replaced by LOD due to adhesion risk",
  ], { y: 1.3, h: 4.1, fontSize: 14 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 20 — ADOLESCENTS & SPECIAL POPULATIONS                          ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Adolescents & Special Populations", "Stricter diagnostic criteria — 2023 International Guideline");
  addBullets(s, [
    { text: "Diagnosis in Adolescents (2023 Guideline):", bold: true, color: C.deepPurple },
    "Requires BOTH: persistent anovulation (irregular cycles >2 years post-menarche) AND clinical/biochemical HA",
    "PCO morphology alone is insufficient — normal in early puberty",
    "AMH and ultrasound should be used with caution until ≥8 years post-menarche",
    { text: "Diagnosis in Perimenopause:", bold: true, color: C.deepPurple },
    "More complex — menstrual irregularity is normal; rely on prior history, HA, biochemistry",
    { text: "Lean/Non-obese PMOS:", bold: true, color: C.midPurple },
    "Still at elevated risk of IR and metabolic complications (though lower than obese PMOS)",
    "Metabolic screening mandatory regardless of BMI",
    { text: "Ethnicity considerations:", bold: true, color: C.teal },
    "South Asian women: higher IR at lower BMI; more severe metabolic phenotype",
    "East Asian women: lower hirsutism rates due to reduced 5α-reductase activity",
    "Consider lower BMI thresholds for metabolic risk screening in Asian populations",
  ], { y: 1.3, h: 4.1, fontSize: 14 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 21 — 2023 INTERNATIONAL EVIDENCE-BASED GUIDELINE                ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "2023 International Evidence-Based PCOS Guideline", "Teede HJ et al., Fertil Steril 2023 (PMID 37589624) & Eur J Endocrinol 2023 (PMID 37580861)");
  addBullets(s, [
    { text: "The most comprehensive global guideline for PCOS/PMOS to date:", bold: true, color: C.deepPurple },
    "Joint: Monash University, ESHRE, ASRM, Endocrine Society, AES, ACOG and 11 other societies",
    { text: "Key Recommendations:", bold: true, color: C.midPurple },
    "Rotterdam criteria remain the diagnostic standard for adults",
    "AMH endorsed as an emerging biomarker for PCO morphology assessment",
    "Letrozole is the FIRST-LINE agent for ovulation induction (over clomiphene)",
    "Lifestyle intervention recommended for ALL regardless of weight",
    "Screen for depression, anxiety & eating disorders at diagnosis",
    "Annual metabolic screening (glucose, lipids, BP) for all PMOS women",
    "TVUS threshold updated: ≥20 follicles per ovary (from prior threshold of ≥12)",
    { text: "2023 Guideline quality assessment (Al Wattar BH et al., JCEM 2021 — Systematic Review PMID 33839790):", bold: false, color: C.teal },
    "Only high-quality CPGs endorsed Rotterdam criteria; significant variation in minor guideline recommendations",
  ], { y: 1.3, h: 4.1, fontSize: 13.5 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 22 — IMPLEMENTING THE NAME CHANGE: PMOS                         ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Implementing PMOS — The Transition Strategy", "Lancet 2026 — Global implementation plan");
  addBullets(s, [
    { text: "Co-designed global implementation strategy (Lancet 2026):", bold: true, color: C.deepPurple },
    "Transition period: PCOS and PMOS will co-exist in documentation initially",
    "Education campaigns for patients, healthcare providers and medical educators",
    "Alignment with ICD and disease classification systems (WHO collaboration)",
    { text: "What PMOS captures that PCOS does not:", bold: true, color: C.coral },
    "POLY-endocrine → multiple endocrine disruptions (LH, FSH, androgens, insulin, AMH, cortisol)",
    "METABOLIC → insulin resistance, T2DM risk, dyslipidaemia, NAFLD, cardiovascular risk",
    "OVARIAN → preserved to acknowledge primary site of dysfunction",
    "SYNDROME → retained to reflect the heterogeneous multisystem nature",
    { text: "Stakeholder survey findings (EClinicalMedicine 2025, PMID 40687737):", bold: true, color: C.teal },
    "85.6% patients + 76.1% health professionals support name change",
    "'Endocrine' and 'metabolic' received highest support in both 2015 and 2023 surveys",
  ], { y: 1.3, h: 4.1, fontSize: 14 });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 23 — LONG-TERM HEALTH RISKS & SURVEILLANCE                      ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "Long-Term Health Risks & Surveillance", "Comprehensive screening protocol for PMOS");

  const risks = [
    { label: "Type 2 Diabetes", freq: "At diagnosis; every 1–3 years", test: "OGTT / HbA1c" },
    { label: "Cardiovascular Disease", freq: "Annual", test: "BP, fasting lipids, BMI/waist" },
    { label: "Endometrial Carcinoma", freq: "If >3 months without period", test: "Endometrial biopsy / TVUS" },
    { label: "Obstructive Sleep Apnoea", freq: "At diagnosis (screen)", test: "Epworth Sleepiness Scale → polysomnography" },
    { label: "Depression/Anxiety", freq: "At diagnosis; periodic", test: "PHQ-9, GAD-7, DASS-21" },
    { label: "NAFLD", freq: "Periodically in high-risk", test: "LFTs, hepatic ultrasound" },
  ];

  const hdrY = 1.3;
  ["Condition", "Frequency", "Assessment Tool"].forEach((h, ci) => {
    const xs = [0.2, 3.4, 6.5];
    const ws = [3.1, 3.0, 3.25];
    s.addShape(pres.ShapeType.rect, { x: xs[ci], y: hdrY, w: ws[ci], h: 0.45, fill: { color: C.midPurple }, line: { color: C.midPurple } });
    s.addText(h, { x: xs[ci]+0.05, y: hdrY+0.04, w: ws[ci]-0.1, h: 0.37, fontSize: 13, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
  });
  risks.forEach((r, ri) => {
    const rowY = 1.75 + ri * 0.54;
    const bg = ri % 2 === 0 ? "F5F0FF" : C.white;
    [[r.label, 0.2, 3.1], [r.freq, 3.4, 3.0], [r.test, 6.5, 3.25]].forEach(([text, x, w]) => {
      s.addShape(pres.ShapeType.rect, { x, y: rowY, w, h: 0.5, fill: { color: bg }, line: { color: "CCBBEE", width: 0.5 } });
      s.addText(text, { x: x+0.05, y: rowY+0.05, w: w-0.1, h: 0.4, fontSize: 11.5, color: C.darkText, fontFace: "Calibri", valign: "middle" });
    });
  });
  s.addText("Source: Harrison's 22e, 2023 International PCOS Guideline, Berek & Novak 2023", {
    x: 0.2, y: 5.2, w: 9.6, h: 0.28, fontSize: 10, italic: true, color: C.midPurple, fontFace: "Calibri",
  });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 24 — KEY TAKE-HOME MESSAGES                                      ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.deepPurple);
  s.addShape(pres.ShapeType.ellipse, { x: 7.8, y: -0.5, w: 3.5, h: 3.5, fill: { color: C.midPurple }, line: { color: C.midPurple } });

  s.addText("Key Take-Home Messages", {
    x: 0.3, y: 0.15, w: 9.4, h: 0.65,
    fontSize: 28, bold: true, color: C.gold, fontFace: "Calibri",
  });

  const messages = [
    { num: "01", msg: "PCOS has been renamed PMOS — Polyendocrine Metabolic Ovarian Syndrome (Lancet 2026)", col: C.gold },
    { num: "02", msg: "PMOS affects 1 in 8 women; it is NOT about cysts — it is a multisystem endocrine-metabolic disorder", col: C.lilac },
    { num: "03", msg: "Rotterdam criteria (2 of 3: HA, oligo/anovulation, PCO morphology) remain the diagnostic standard", col: C.teal },
    { num: "04", msg: "Screen ALL women for metabolic, psychological and reproductive comorbidities at diagnosis", col: C.coral },
    { num: "05", msg: "Letrozole is first-line for ovulation induction; lifestyle is mandatory for all women with PMOS", col: C.gold },
    { num: "06", msg: "The name change is backed by global consensus: 14,360 patients + 56 organisations", col: C.lilac },
  ];

  messages.forEach((m, i) => {
    const col = i < 3 ? 0 : 1;
    const row = i % 3;
    const x = col === 0 ? 0.3 : 5.1;
    const y = 0.95 + row * 1.47;
    s.addShape(pres.ShapeType.roundRect, { x, y, w: 4.65, h: 1.35, rectRadius: 0.1,
      fill: { color: "2D1050" }, line: { color: m.col, width: 1.5 } });
    s.addText([
      { text: m.num + "  ", options: { bold: true, fontSize: 20, color: m.col } },
      { text: m.msg, options: { fontSize: 12, color: C.lightText } },
    ], { x: x+0.12, y: y+0.1, w: 4.41, h: 1.15, fontFace: "Calibri", valign: "top" });
  });
}

// ╔══════════════════════════════════════════════════════════════════════════╗
// ║  SLIDE 25 — REFERENCES                                                  ║
// ╚══════════════════════════════════════════════════════════════════════════╝
{
  const s = pres.addSlide();
  addBG(s, C.offWhite);
  addHeaderBar(s, "References & Sources", "Standard textbooks · OBG journals · PubMed evidence");
  const refs = [
    "1. Teede HJ et al. Polyendocrine metabolic ovarian syndrome, the new name for polycystic ovary syndrome: a multistep global consensus process. Lancet. 2026. DOI:10.1016/S0140-6736(26)00717-8 [PMID: 42119588]",
    "2. Teede HJ et al. Recommendations from the 2023 International Evidence-based Guideline for PCOS. Fertil Steril. 2023;120(4):767-793 [PMID: 37589624]",
    "3. Teede HJ et al. Recommendations from the 2023 International Evidence-based Guideline for PCOS. Eur J Endocrinol. 2023 [PMID: 37580861]",
    "4. Teede HJ, Moran LJ et al. PCOS: perspectives from patients and health professionals on renaming. EClinicalMedicine. 2025 [PMID: 40687737]",
    "5. Melin J et al. Metformin and COC pills in PCOS: Systematic Review & Meta-analysis. JCEM. 2024 [PMID: 37554096]",
    "6. Fitz V et al. Inositol for PCOS: Systematic Review & Meta-analysis. JCEM. 2024 [PMID: 38163998]",
    "7. Shang Y et al. Dietary Modification for Reproductive Health in PCOS: Meta-Analysis. Front Endocrinol. 2021 [PMID: 34790167]",
    "8. Al Wattar BH et al. Clinical Practice Guidelines on PCOS: Systematic Review. JCEM. 2021 [PMID: 33839790]",
    "9. Berek JS et al. Berek & Novak's Gynecology. 16th ed. Wolters Kluwer, 2023. Chapter 35.",
    "10. Goldman L, Cooney KA. Goldman-Cecil Medicine. 27th ed. Elsevier, 2024.",
    "11. Loscalzo J et al. Harrison's Principles of Internal Medicine. 22nd ed. McGraw-Hill, 2025. Chapter 404.",
    "12. Martinez Guevara D et al. Probiotics/Prebiotics in PCOS: Systematic Review. Nutrients. 2024 [PMID: 39599701]",
  ];
  const arr = refs.map((r, i) => ({
    text: r,
    options: { bullet: false, fontSize: 10.5, color: i % 2 === 0 ? C.darkText : C.midPurple, breakLine: i < refs.length - 1 },
  }));
  s.addText(arr, { x: 0.3, y: 1.3, w: 9.4, h: 4.2, fontFace: "Calibri", valign: "top" });
}

// ─── WRITE FILE ────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/PMOS-presentation/PMOS_Polyendocrine_Metabolic_Ovarian_Syndrome.pptx" })
  .then(() => console.log("✅  Presentation saved successfully!"))
  .catch(e => { console.error("❌  Error:", e); process.exit(1); });

cd /home/daytona/workspace/PMOS-presentation && node create_pmos.js