from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import ListFlowable, ListItem

OUTPUT = "/home/daytona/workspace/gynae-studyguide/Gynaecology_StudyGuide_NEETPG.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=1.8*cm,
    leftMargin=1.8*cm,
    topMargin=2*cm,
    bottomMargin=2*cm,
)

styles = getSampleStyleSheet()

# Custom styles
TITLE = ParagraphStyle("TITLE", parent=styles["Title"], fontSize=22, textColor=colors.HexColor("#1a237e"),
                        spaceAfter=6, spaceBefore=0, alignment=TA_CENTER, fontName="Helvetica-Bold")
SUBTITLE = ParagraphStyle("SUBTITLE", parent=styles["Normal"], fontSize=11, textColor=colors.HexColor("#37474f"),
                           spaceAfter=14, alignment=TA_CENTER, fontName="Helvetica-Oblique")
H1 = ParagraphStyle("H1", parent=styles["Heading1"], fontSize=14, textColor=colors.white,
                     backColor=colors.HexColor("#1a237e"), spaceBefore=14, spaceAfter=4,
                     leftIndent=-4, rightIndent=-4, fontName="Helvetica-Bold",
                     borderPadding=(4,6,4,6))
H2 = ParagraphStyle("H2", parent=styles["Heading2"], fontSize=12, textColor=colors.HexColor("#1a237e"),
                     spaceBefore=10, spaceAfter=3, fontName="Helvetica-Bold",
                     borderWidth=0, leftIndent=0)
H3 = ParagraphStyle("H3", parent=styles["Heading3"], fontSize=10.5, textColor=colors.HexColor("#880e4f"),
                     spaceBefore=7, spaceAfter=2, fontName="Helvetica-Bold")
BODY = ParagraphStyle("BODY", parent=styles["Normal"], fontSize=9.5, leading=14,
                       spaceAfter=3, fontName="Helvetica", alignment=TA_JUSTIFY)
BULLET = ParagraphStyle("BULLET", parent=styles["Normal"], fontSize=9.5, leading=13,
                          leftIndent=12, firstLineIndent=-10, spaceAfter=2,
                          fontName="Helvetica")
BULLET2 = ParagraphStyle("BULLET2", parent=styles["Normal"], fontSize=9.2, leading=13,
                           leftIndent=22, firstLineIndent=-10, spaceAfter=2,
                           fontName="Helvetica", textColor=colors.HexColor("#37474f"))
HIGHLIGHT = ParagraphStyle("HIGHLIGHT", parent=styles["Normal"], fontSize=9.5, leading=13,
                             backColor=colors.HexColor("#fff9c4"), leftIndent=6,
                             borderPadding=3, spaceAfter=4, fontName="Helvetica-Bold")
NOTE = ParagraphStyle("NOTE", parent=styles["Normal"], fontSize=9, leading=13,
                       backColor=colors.HexColor("#e3f2fd"), leftIndent=6,
                       borderPadding=3, spaceAfter=4, fontName="Helvetica-Oblique",
                       textColor=colors.HexColor("#0d47a1"))
FOOTER_NOTE = ParagraphStyle("FOOTER_NOTE", parent=styles["Normal"], fontSize=8,
                               textColor=colors.HexColor("#607d8b"), alignment=TA_CENTER,
                               fontName="Helvetica-Oblique", spaceBefore=4)

def b(text): return f"<b>{text}</b>"
def i(text): return f"<i>{text}</i>"
def bi(text): return f"<b><i>{text}</i></b>"
def u(text): return f"<u>{text}</u>"

def bullet(text, level=1):
    sym = "•" if level == 1 else "–"
    st = BULLET if level == 1 else BULLET2
    return Paragraph(f"{sym}  {text}", st)

def h1(text): return Paragraph(text, H1)
def h2(text): return Paragraph(text, H2)
def h3(text): return Paragraph(text, H3)
def p(text): return Paragraph(text, BODY)
def hl(text): return Paragraph(f"★  {text}", HIGHLIGHT)
def note(text): return Paragraph(f"📝  {text}", NOTE)
def sp(h=4): return Spacer(1, h)
def hr(): return HRFlowable(width="100%", thickness=0.5, color=colors.HexColor("#90a4ae"), spaceAfter=4, spaceBefore=4)

def two_col_table(left_items, right_items, col_header_l="", col_header_r=""):
    tdata = []
    if col_header_l or col_header_r:
        tdata.append([Paragraph(b(col_header_l), BODY), Paragraph(b(col_header_r), BODY)])
    max_rows = max(len(left_items), len(right_items))
    for i in range(max_rows):
        l = Paragraph(f"• {left_items[i]}", BODY) if i < len(left_items) else Paragraph("", BODY)
        r = Paragraph(f"• {right_items[i]}", BODY) if i < len(right_items) else Paragraph("", BODY)
        tdata.append([l, r])
    t = Table(tdata, colWidths=[8.5*cm, 8.5*cm])
    t.setStyle(TableStyle([
        ("VALIGN", (0,0), (-1,-1), "TOP"),
        ("GRID", (0,0), (-1,-1), 0.3, colors.HexColor("#cfd8dc")),
        ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#e3f2fd")),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [colors.white, colors.HexColor("#f5f5f5")]),
        ("FONTSIZE", (0,0), (-1,-1), 9),
        ("TOPPADDING", (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ]))
    return t

def simple_table(headers, rows, col_widths=None):
    tdata = [[Paragraph(b(h), BODY) for h in headers]]
    for row in rows:
        tdata.append([Paragraph(str(c), BODY) for c in row])
    if not col_widths:
        w = 17.0 / len(headers)
        col_widths = [w*cm] * len(headers)
    t = Table(tdata, colWidths=col_widths)
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#1a237e")),
        ("TEXTCOLOR", (0,0), (-1,0), colors.white),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [colors.white, colors.HexColor("#e8eaf6")]),
        ("GRID", (0,0), (-1,-1), 0.4, colors.HexColor("#9fa8da")),
        ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
        ("FONTSIZE", (0,0), (-1,-1), 9),
        ("TOPPADDING", (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ]))
    return t

# ============================================================
# CONTENT
# ============================================================
story = []

# COVER
story += [
    sp(30),
    Paragraph("GYNAECOLOGY", TITLE),
    Paragraph("Concise Study Guide for University Exams &amp; NEET PG", SUBTITLE),
    sp(6),
    Paragraph("Based on: Sheila Balakrishnan | Lakshmi Seshadri (Essentials of Gynaecology 3e)", SUBTITLE),
    Paragraph("Supplemented with Berek &amp; Novak's Gynecology | Updated FIGO 2018/2023 | ACOG | RCOG Guidelines", SUBTITLE),
    sp(10),
    HRFlowable(width="80%", thickness=2, color=colors.HexColor("#1a237e"), spaceAfter=8),
    Paragraph("NEET PG 2026 | ~19 Questions from OBG | 49% Case-Based", SUBTITLE),
    sp(60),
    Paragraph("Compiled: July 2026", FOOTER_NOTE),
    PageBreak(),
]

# ============================================================
# SECTION 1: MENSTRUAL DISORDERS
# ============================================================
story += [h1("1. MENSTRUAL DISORDERS & ABNORMAL UTERINE BLEEDING"), sp(4)]

story += [h2("1.1 Normal Menstrual Parameters"), sp(2)]
story += [simple_table(
    ["Parameter", "Normal Range"],
    [
        ["Cycle length", "21–35 days"],
        ["Duration of bleeding", "2–7 days"],
        ["Blood loss", "20–80 mL per cycle"],
        ["Menarche", "11–13 years (mean 12.5)"],
        ["Menopause", "45–55 years (mean 51)"],
    ],
    [8*cm, 9*cm]
), sp(6)]

story += [h2("1.2 PALM-COEIN Classification (FIGO 2011, updated)"), sp(2)]
story += [p("The FIGO PALM-COEIN system replaced the old term DUB (Dysfunctional Uterine Bleeding):")]
story += [
    bullet(b("PALM") + " – Structural causes (detectable by imaging/biopsy)"),
    bullet("P – Polyp", 2), bullet("A – Adenomyosis", 2),
    bullet("L – Leiomyoma (FIGO type 0-8)", 2), bullet("M – Malignancy / hyperplasia", 2),
    bullet(b("COEIN") + " – Non-structural causes"),
    bullet("C – Coagulopathy", 2), bullet("O – Ovulatory dysfunction (includes PCOS)", 2),
    bullet("E – Endometrial", 2), bullet("I – Iatrogenic", 2), bullet("N – Not yet classified", 2),
    sp(4),
]

story += [h2("1.3 Leiomyoma (Fibroids) – FIGO Classification"), sp(2)]
story += [p("FIGO classifies fibroids (leiomyomas) by location (Types 0–8):")]
story += [simple_table(
    ["Type", "Location", "Clinical Relevance"],
    [
        ["0", "Pedunculated intracavitary (submucosal)", "Causes AUB, infertility; treat by hysteroscopy"],
        ["1", "Submucosal <50% intramural", "AUB; hysteroscopic resection"],
        ["2", "Submucosal ≥50% intramural", "AUB; hysteroscopy or myomectomy"],
        ["3", "Contacts endometrium; 100% intramural", "AUB; medical/surgical"],
        ["4", "Intramural (no endometrial/serosal contact)", "Bulk symptoms, pressure"],
        ["5-6", "Subserosal (≥50% / <50% intramural)", "Mostly asymptomatic or bulk"],
        ["7", "Subserosal pedunculated", "Torsion risk"],
        ["8", "Cervical / parasitic / broad ligament", "Special management"],
    ],
    [1.5*cm, 5.5*cm, 7*cm]
), sp(4)]
story += [hl("NEET PG Key: Type 0 fibroid = entirely intracavitary pedunculated. Type 2-5 = hybrid transmural (written as e.g., 2-5)."), sp(4)]

story += [h2("1.4 Dysmenorrhoea"), sp(2)]
story += [
    bullet(b("Primary:") + " No organic cause; prostaglandin excess; onset 6–12 months after menarche; Rx: NSAIDs (first-line), COCPs"),
    bullet(b("Secondary:") + " Organic cause (endometriosis, adenomyosis, fibroids, PID); starts after pain-free cycles; treat underlying cause"),
    sp(4),
]

story += [h2("1.5 Premenstrual Syndrome (PMS) / PMDD"), sp(2)]
story += [
    bullet("Symptoms in luteal phase, resolving after menstruation"),
    bullet("PMDD (severe form): diagnosed by DSM-5 criteria"),
    bullet("Rx: SSRIs (first-line for PMDD), COCPs (drospirenone-containing preferred), vitamin B6"),
    sp(4),
]

story += [h2("1.6 Amenorrhoea"), sp(2)]
story += [
    bullet(b("Primary amenorrhoea:") + " No menses by age 15 with secondary sexual characters, OR age 13 without any secondary sexual characters"),
    bullet(b("Secondary amenorrhoea:") + " Cessation of menses for 3 months in previously regular cycles, OR 6 months in irregular cycles"),
    sp(2),
]
story += [p(b("Causes (Berek & Novak):") + " Most common causes with normal secondary sexual chars = Pregnancy (always exclude first), PCOS, Hyperprolactinemia, Thyroid disease, Premature Ovarian Insufficiency (POI), Hypothalamic dysfunction.")]
story += [
    bullet("Outflow obstruction: Imperforate hymen, transverse vaginal septum, Asherman syndrome"),
    bullet("Müllerian anomalies: MRKH syndrome (46,XX, absent uterus/vagina, normal ovaries)"),
    bullet("Gonadal dysgenesis: Turner (45,X) – most common cause of primary amenorrhoea"),
    bullet("Androgen insensitivity syndrome (AIS): 46,XY, absent uterus, blind vagina, female phenotype"),
    sp(2),
]
story += [hl("NEET PG: Turner syndrome – shield chest, webbed neck, short stature, coarctation of aorta, gonadal streaks. FSH/LH elevated (hypergonadotropic hypogonadism)."), sp(4)]

# ============================================================
# SECTION 2: PCOS
# ============================================================
story += [PageBreak(), h1("2. POLYCYSTIC OVARY SYNDROME (PCOS)"), sp(4)]
story += [hl("NEET PG 2025/2026: Most asked reproductive endocrinology topic. Rotterdam criteria = must know."), sp(4)]

story += [h2("2.1 Diagnostic Criteria"), sp(2)]
story += [p(b("Rotterdam 2003 criteria") + " (endorsed by NIH 2012, ESHRE/ASRM): Diagnosis requires " + b("2 of 3:") )]
story += [
    bullet("1. Oligo- or anovulation (irregular/absent cycles)"),
    bullet("2. Clinical or biochemical hyperandrogenism (hirsutism, acne, elevated testosterone)"),
    bullet("3. Polycystic ovaries on ultrasound (≥20 follicles 2–9 mm per ovary, or ovarian volume >10 mL on either ovary – " + i("updated 2018 threshold") + ")"),
    bullet(b("Exclusions:") + " Elevated prolactin, thyroid dysfunction, adult-onset CAH, androgen-secreting tumors"),
    sp(4),
]

story += [h2("2.2 Pathophysiology"), sp(2)]
story += [
    bullet("Elevated LH:FSH ratio (typically >2:1) → increased androgen production by theca cells"),
    bullet("Insulin resistance (IR) + hyperinsulinemia → amplifies androgen excess (independent of gonadotropins)"),
    bullet("Peripheral conversion of androgens to estrone → chronic estrogen stimulation → endometrial hyperplasia risk"),
    bullet("Obesity (>50%) is associated but NOT part of diagnostic criteria"),
    sp(4),
]

story += [h2("2.3 Clinical Features"), sp(2)]
story += [two_col_table(
    ["Menstrual irregularity (oligo/amenorrhoea)", "Hirsutism (Ferriman-Gallwey score >8)", "Acne, alopecia", "Obesity (central/android)", "Infertility (anovulation)", "Acanthosis nigricans (IR marker)"],
    ["Elevated LH, normal/low FSH", "Elevated total/free testosterone", "Low SHBG", "Elevated AMH (>5 ng/mL)", "Glucose intolerance / T2DM risk", "Cardiovascular risk (dyslipidaemia)"],
    "Clinical", "Lab / Metabolic"
), sp(4)]

story += [h2("2.4 Management"), sp(2)]
story += [
    bullet(b("Lifestyle modification:") + " First-line; 5–10% weight loss restores ovulation in obese PCOS"),
    bullet(b("Menstrual regulation:") + " COCP (drospirenone-containing preferred); progestogen cyclical therapy"),
    bullet(b("Hirsutism:") + " COCP + spironolactone; finasteride; eflornithine (topical)"),
    bullet(b("Ovulation induction:") + " Letrozole (first-line per ESHRE 2023 – surpassed clomiphene); Clomiphene citrate; Metformin; Gonadotrophins; Laparoscopic ovarian drilling (LOD)"),
    bullet(b("Endometrial protection:") + " Progestogen 12–14 days/cycle or levonorgestrel IUS if not wanting COCP"),
    bullet(b("Metabolic:") + " Metformin (reduces IR, restores ovulation, prevents T2DM); screen for impaired glucose tolerance"),
    sp(2),
]
story += [note("2026 Update: ESHRE/ASRM 2023 PCOS International Guideline now recommends LETROZOLE as first-line ovulation induction over clomiphene. AMH threshold updated. The term PMOS (polyendocrine metabolic ovarian syndrome) proposed in May 2026 but PCOS still widely used in exams."), sp(4)]

# ============================================================
# SECTION 3: ENDOMETRIOSIS
# ============================================================
story += [h1("3. ENDOMETRIOSIS & ADENOMYOSIS"), sp(4)]

story += [h2("3.1 Endometriosis"), sp(2)]
story += [p("Presence of endometrial glands and stroma " + b("outside") + " the uterus. Affects 10% of reproductive-age women; 30–50% with infertility.")]
story += [
    bullet(b("Classic triad:") + " Dysmenorrhoea, dyspareunia (deep), infertility (3 D's)"),
    bullet(b("Sites:") + " Ovaries (most common → chocolate cysts/endometriomas), pouch of Douglas, uterosacral ligaments, bowel, bladder"),
    bullet(b("Theories:") + " Sampson's retrograde menstruation (most accepted); coelomic metaplasia; lymphatic/vascular spread"),
    bullet(b("Staging:") + " rASRM Stage I–IV (minimal, mild, moderate, severe); based on laparoscopic findings"),
    bullet(b("Gold standard diagnosis:") + " Laparoscopy with histological confirmation (biopsy)"),
    bullet(b("CA-125:") + " Elevated in moderate-severe endometriosis; non-specific marker"),
    sp(2),
]
story += [h3("Management:"), sp(2)]
story += [
    bullet(b("Medical:") + " NSAIDs (pain); COCPs (continuous); Progestogens (lynestrenol, norethisterone); LNG-IUS; GnRH agonists (add-back HRT); Dienogest (highly selective progestogen)"),
    bullet(b("Surgical:") + " Laparoscopic ablation/excision of lesions; cystectomy (endometrioma); hysterectomy + BSO (definitive for adenomyosis/severe endo)"),
    bullet(b("Infertility + endometriosis:") + " Laparoscopic surgery improves spontaneous pregnancy rates in mild-moderate disease; IVF for severe or failed surgical treatment"),
    sp(2),
]
story += [note("ACOG 2026 New Guidance: Presumptive clinical diagnosis of endometriosis (based on clinical features + imaging) is now acceptable to start treatment, without mandatory surgical confirmation in all cases."), sp(4)]

story += [h2("3.2 Adenomyosis"), sp(2)]
story += [
    bullet("Endometrial glands/stroma within the " + b("myometrium") + " → uterine enlargement"),
    bullet(b("Classic patient:") + " Multiparous woman >35 years with menorrhagia, dysmenorrhoea, globally enlarged uterus ('boggy uterus')"),
    bullet(b("Diagnosis:") + " MRI (gold standard); Transvaginal ultrasound (junctional zone >12 mm); definitive = histology post-hysterectomy"),
    bullet(b("Rx:") + " LNG-IUS (first-line medical); GnRH agonists; hysterectomy (definitive)"),
    sp(4),
]

# ============================================================
# SECTION 4: INFERTILITY
# ============================================================
story += [PageBreak(), h1("4. INFERTILITY"), sp(4)]
story += [
    bullet(b("Definition:") + " Failure to conceive after 12 months of regular unprotected intercourse (6 months if female age >35)"),
    bullet(b("Primary:") + " Never conceived previously; " + b("Secondary:") + " Previous conception"),
    bullet(b("Prevalence:") + " ~15% of couples"),
    sp(4),
]

story += [h2("4.1 Causes"), sp(2)]
story += [simple_table(
    ["Factor", "Contribution (%)", "Key Investigation"],
    [
        ["Male factor", "30–40%", "Semen analysis (WHO 2021 criteria)"],
        ["Ovulatory dysfunction", "25–30%", "Mid-luteal progesterone, Day 2 FSH/LH/AFC"],
        ["Tubal/peritoneal", "20–30%", "HSG, laparoscopy, HyCoSy"],
        ["Uterine/cervical", "10%", "Hysteroscopy, saline sonography"],
        ["Unexplained", "10–15%", "All normal investigations"],
    ],
    [4.5*cm, 3.5*cm, 8*cm]
), sp(4)]

story += [h2("4.2 Male Factor – WHO 2021 Normal Semen Parameters"), sp(2)]
story += [simple_table(
    ["Parameter", "Lower Reference Limit (5th percentile)"],
    [
        ["Volume", "≥1.4 mL"],
        ["Total sperm number", "≥39 million per ejaculate"],
        ["Sperm concentration", "≥16 million/mL"],
        ["Total motility (PR+NP)", "≥42%"],
        ["Progressive motility (PR)", "≥30%"],
        ["Morphology (Kruger strict)", "≥4% normal forms"],
    ],
    [7*cm, 10*cm]
), sp(4)]

story += [h2("4.3 Ovulation Induction Agents"), sp(2)]
story += [
    bullet(b("Letrozole:") + " Aromatase inhibitor; 2.5–7.5 mg Day 3–7; First-line (ESHRE 2023); better live birth rate than clomiphene in PCOS"),
    bullet(b("Clomiphene citrate:") + " Anti-estrogen; 50–150 mg Day 2–6; max 6 cycles; OHSS risk lower than gonadotrophins"),
    bullet(b("Metformin:") + " Improves IR; restores ovulation in PCOS; prevents OHSS in high-risk"),
    bullet(b("Gonadotrophins (FSH/LH):") + " Used for hypogonadotropic hypogonadism or clomiphene-resistant PCOS; highest OHSS risk"),
    bullet(b("Laparoscopic Ovarian Drilling (LOD):") + " 4 punctures per ovary; surgical alternative in clomiphene-resistant PCOS; reduces LH and testosterone"),
    sp(4),
]

story += [h2("4.4 Assisted Reproductive Technology (ART)"), sp(2)]
story += [
    bullet(b("IUI:") + " Intrauterine insemination; indicated in unexplained infertility, mild male factor, donor sperm"),
    bullet(b("IVF:") + " Indicated in tubal factor, severe male factor (ICSI), endometriosis, failed OI; stimulation → retrieval → fertilization → transfer"),
    bullet(b("ICSI:") + " Intracytoplasmic sperm injection; for severe oligoasthenoteratospermia, obstructive azoospermia"),
    bullet(b("Preimplantation Genetic Testing (PGT):") + " For chromosomal disorders, single gene defects, recurrent implantation failure"),
    sp(4),
]

# ============================================================
# SECTION 5: ECTOPIC PREGNANCY
# ============================================================
story += [h1("5. ECTOPIC PREGNANCY"), sp(4)]
story += [hl("NEET PG: Frequently asked as clinical vignette – triad, beta-hCG discrimination zone, management algorithm."), sp(4)]

story += [
    bullet(b("Definition:") + " Implantation outside uterine cavity; 95–98% in fallopian tube (ampullary most common)"),
    bullet(b("Incidence:") + " ~1–2% of pregnancies; 2.7% of all maternal deaths"),
    sp(2),
]
story += [h2("5.1 Risk Factors"), sp(2)]
story += [
    bullet(b("Strongest:") + " Prior ectopic pregnancy (recurrence 10–15% after 1st; 30% after 2nd)"),
    bullet("Previous tubal surgery (ligation, salpingostomy), PID, STI (Chlamydia)"),
    bullet("Endometriosis, salpingitis isthmica nodosa, assisted reproduction (IVF)"),
    bullet("IUD failure → if pregnancy occurs, more likely ectopic"),
    sp(2),
]
story += [h2("5.2 Diagnosis"), sp(2)]
story += [
    bullet(b("Symptoms:") + " Amenorrhoea + lower abdominal pain + vaginal bleeding (Acute triad)"),
    bullet(b("β-hCG:") + " Serial measurements; if not doubling in 48 hours (normal IUP rises >66% in 48h) → suspect ectopic/non-viable"),
    bullet(b("Discriminatory zone:") + " β-hCG >1500–2000 IU/L → IUP should be visible on TVUS; if empty uterus at this level → ectopic until proven otherwise"),
    bullet(b("TVUS:") + " Adnexal ring (tubal ring sign) + absence of IUP; free fluid in POD"),
    bullet("Haemoperitoneum (ruptured ectopic) → surgical emergency"),
    sp(2),
]
story += [h2("5.3 Management"), sp(2)]
story += [simple_table(
    ["Option", "Criteria", "Details"],
    [
        ["Expectant", "β-hCG <1000 IU/L, falling, small ectopic, asymptomatic", "Serial β-hCG monitoring every 48h"],
        ["Medical – Methotrexate (MTX)", "β-hCG <5000 IU/L, no fetal heartbeat, no rupture, haemodynamically stable, no contraindications", "Single dose 50 mg/m² IM; Serial β-hCG Day 4 & 7; must fall >15% Day 4–7"],
        ["Surgical – Salpingostomy", "Haemodynamically stable, contralateral tube damaged, wish to preserve fertility", "Conservative; risk of persistent trophoblast (5%); follow β-hCG"],
        ["Surgical – Salpingectomy", "Haemodynamically unstable (ruptured), completed family, diseased tube", "Definitive; preferred if contralateral tube healthy"],
    ],
    [3*cm, 6*cm, 7*cm]
), sp(4)]
story += [note("Contraindications to MTX: breastfeeding, immunodeficiency, liver/renal disease, blood dyscrasias, intrauterine sac >3.5 cm, fetal cardiac activity."), sp(4)]

# ============================================================
# SECTION 6: OVARIAN TUMORS
# ============================================================
story += [PageBreak(), h1("6. OVARIAN TUMORS"), sp(4)]

story += [h2("6.1 Classification"), sp(2)]
story += [simple_table(
    ["Category", "Types", "Tumour Markers"],
    [
        ["Epithelial (65–70%)", "Serous (most common – 75%), Mucinous, Endometrioid, Clear cell, Brenner, Mixed", "CA-125 (serous); CEA (mucinous)"],
        ["Germ Cell (15–20%)", "Dysgerminoma, Teratoma (mature cystic – most common benign), Yolk sac, Choriocarcinoma, Embryonal", "AFP (yolk sac); β-hCG (choriocarcinoma); LDH (dysgerminoma)"],
        ["Sex Cord-Stromal (5–8%)", "Granulosa cell (most common malignant SCST), Sertoli-Leydig, Thecoma, Fibroma", "Inhibin B (granulosa); testosterone (Sertoli-Leydig)"],
        ["Metastatic", "Krukenberg (from stomach/colon), Brenner-like", "CEA, CA19-9"],
    ],
    [3.5*cm, 7.5*cm, 5*cm]
), sp(4)]

story += [h2("6.2 Key High-Yield Points"), sp(2)]
story += [
    bullet(b("Mature cystic teratoma (dermoid cyst):") + " Most common ovarian tumour in reproductive age; contains hair, teeth, sebum; risk of torsion; malignant transformation <2%"),
    bullet(b("Dysgerminoma:") + " Most common malignant GCT; highly radiosensitive and chemosensitive; LDH marker; occurs in young women"),
    bullet(b("Granulosa cell tumour:") + " Sex cord-stromal; produces estrogen → feminizing effects → precocious puberty in children, endometrial hyperplasia/carcinoma in adults; " + b("Call-Exner bodies") + " on histology; marker: Inhibin B"),
    bullet(b("Yolk sac tumour (endodermal sinus tumour):") + " AFP marker; most common malignant GCT in children; Schiller-Duval bodies on histology"),
    bullet(b("Pseudomyxoma peritonei:") + " Complication of mucinous borderline tumour/carcinoma; jelly-belly appearance"),
    bullet(b("Meigs syndrome:") + " Ovarian fibroma + ascites + pleural effusion; CA-125 may be elevated; resolves after tumour removal"),
    bullet(b("Origin of serous ovarian cancer:") + " Now known to originate from STIC (serous tubal intraepithelial carcinoma) in the fallopian tube, NOT the ovarian surface – important recent paradigm shift"),
    sp(4),
]

story += [h2("6.3 BRCA & Hereditary Ovarian Cancer"), sp(2)]
story += [
    bullet("BRCA1 mutation: lifetime risk of ovarian cancer ~40–50%"),
    bullet("BRCA2 mutation: lifetime risk ~15–25%"),
    bullet("Lynch syndrome (MMR gene mutations): Endometrial cancer #1, Ovarian cancer #3"),
    bullet("Risk-reducing salpingo-oophorectomy (RRSO) recommended after childbearing complete: BRCA1 – age 35–40; BRCA2 – age 40–45"),
    sp(4),
]

story += [h2("6.4 Management of Epithelial Ovarian Cancer"), sp(2)]
story += [
    bullet(b("Primary cytoreductive (debulking) surgery:") + " Optimal = residual disease <1 cm; TAH+BSO+omentectomy+LN sampling+peritoneal biopsies"),
    bullet(b("Chemotherapy:") + " Carboplatin + Paclitaxel (first-line); 6 cycles IV"),
    bullet(b("PARP inhibitors (maintenance):") + " Olaparib (BRCA-mutated); Niraparib, Bevacizumab (angiogenesis inhibitor)"),
    bullet(b("NACT:") + " Neoadjuvant chemo (3 cycles) → interval debulking surgery → 3 more cycles; for patients unfit for primary surgery"),
    sp(4),
]

# ============================================================
# SECTION 7: CERVICAL CANCER
# ============================================================
story += [h1("7. CERVICAL CANCER"), sp(4)]
story += [hl("NEET PG: Most asked gynae malignancy. FIGO 2018 staging changes = must know."), sp(4)]

story += [h2("7.1 Epidemiology & Etiology"), sp(2)]
story += [
    bullet("Most common gynae cancer in developing countries; second most common worldwide"),
    bullet(b("HPV 16 & 18:") + " Cause 70% of cervical cancers; HPV 16 > squamous cell; HPV 18 > adenocarcinoma"),
    bullet("Squamous cell carcinoma = 75–80%; Adenocarcinoma = 15–20%"),
    bullet("Transformation zone (T-zone / squamocolumnar junction) = site of origin"),
    bullet(b("CIN:") + " CIN I (low grade; usually regresses), CIN II–III (high grade; treat)"),
    sp(2),
]
story += [h2("7.2 Screening"), sp(2)]
story += [
    bullet(b("Pap smear (cytology):") + " From age 21; every 3 years (21–29); co-test with HPV every 5 years (30–65)"),
    bullet(b("HPV DNA testing:") + " Primary screening (preferred from age 25–30 in updated guidelines); more sensitive than cytology"),
    bullet(b("VIA (Visual Inspection with Acetic acid):") + " Used in low-resource settings; screen and treat approach"),
    bullet(b("Colposcopy:") + " Indicated for abnormal Pap/HPV; directed biopsy from aceto-white areas"),
    sp(2),
]
story += [h2("7.3 FIGO 2018 Staging – NEET PG MUST KNOW"), sp(2)]
story += [p("Major changes in FIGO 2018: Imaging (CT/MRI/PET) and pathological findings may now be used for staging. Stage IB split into 3 sub-stages. New IIIC for lymph node involvement.")]
story += [simple_table(
    ["Stage", "Description"],
    [
        ["IA1", "Stromal invasion <3 mm depth"],
        ["IA2", "Stromal invasion ≥3 mm and <5 mm"],
        ["IB1", "≥5 mm depth, lesion <2 cm (fertility-sparing possible)"],
        ["IB2", "2–4 cm"],
        ["IB3", "≥4 cm"],
        ["IIA1", "Upper 2/3 vagina involved, <4 cm"],
        ["IIA2", "Upper 2/3 vagina, ≥4 cm"],
        ["IIB", "Parametrial involvement (not to pelvic wall)"],
        ["IIIA", "Lower 1/3 vagina"],
        ["IIIB", "Pelvic wall / hydronephrosis"],
        ["IIIC1", "Pelvic lymph node metastasis (r = radiological; p = pathological)"],
        ["IIIC2", "Para-aortic lymph node metastasis"],
        ["IVA", "Bladder / rectal mucosa invasion"],
        ["IVB", "Distant metastasis"],
    ],
    [3*cm, 14*cm]
), sp(4)]

story += [h2("7.4 Treatment"), sp(2)]
story += [
    bullet(b("IA1 (no LVSI):") + " Cone biopsy (fertility desired) OR simple hysterectomy"),
    bullet(b("IA1 (LVSI+) / IA2:") + " Modified radical hysterectomy (MRH) + pelvic LN sampling OR trachelectomy (fertility)"),
    bullet(b("IB1 / IIA1 (<4cm):") + " Radical hysterectomy (Wertheim) + pelvic LND OR CCRT"),
    bullet(b("IB3 / IIA2 / IIB and above:") + " Concurrent chemoradiotherapy (CCRT) with " + b("Cisplatin") + " (first-line radiosensitiser)"),
    bullet(b("IVB / Recurrent:") + " Cisplatin-based chemotherapy; pembrolizumab (PD-L1+) – recent approval"),
    sp(4),
]
story += [hl("Memory: Stage IIB onwards = no surgery; CCRT is standard. IIB = parametrial involvement = beyond surgical range."), sp(4)]

# ============================================================
# SECTION 8: ENDOMETRIAL CANCER
# ============================================================
story += [h1("8. ENDOMETRIAL CARCINOMA"), sp(4)]

story += [h2("8.1 Risk Factors & Classification"), sp(2)]
story += [
    bullet(b("Type I (Endometrioid, Grade 1–2):") + " Estrogen-driven; 80%; associated with obesity, PCOS, nulliparity, tamoxifen, unopposed estrogen; PTEN mutation; better prognosis"),
    bullet(b("Type II (Serous, Clear cell, Grade 3):") + " Non-estrogen driven; <10% cases; >50% of all deaths; p53 mutation; aggressive"),
    bullet(b("Presentation:") + " Postmenopausal bleeding (PMB) – ectopic pregnancy of the postmenopausal woman (always investigate)"),
    bullet(b("Investigation:") + " TVUS (endometrial thickness ≥4–5 mm in PMB → biopsy); Office endometrial biopsy (Pipelle) = first-line investigation"),
    sp(2),
]
story += [h2("8.2 FIGO 2023 Staging (Updated – NEET PG!)"), sp(2)]
story += [p("FIGO 2023 integrates " + b("molecular classification") + " (POLE, MMR, p53, NSMP) into staging – major departure from purely anatomical 2009 staging:")]
story += [simple_table(
    ["Stage", "2023 Description (Key Changes)"],
    [
        ["IA1", "Non-aggressive histotype, no/superficial myometrial invasion (<50%), no/focal LVSI"],
        ["IA2", "Non-aggressive histotype, no/superficial invasion, substantial LVSI"],
        ["IA3", "Low-grade endometrioid + synchronous low-grade ovarian endometrioid (good prognosis group – new substage)"],
        ["IB", "Non-aggressive, deep invasion (≥50%)"],
        ["IC", "Aggressive histotype (serous, clear cell, NEEC, carcinosarcoma) – any myometrial invasion"],
        ["IIA", "Cervical stromal invasion (non-aggressive type)"],
        ["IIB", "Substantial LVSI (non-aggressive type)"],
        ["IIC", "Aggressive type with any myometrial invasion"],
        ["IIIA–C", "Same as before but with molecular stratification"],
        ["IVA", "Bladder/bowel mucosa"],
        ["IVB", "Distant metastasis including inguinal LN"],
    ],
    [2.5*cm, 14.5*cm]
), sp(4)]
story += [note("Molecular classification: POLEmut = ultra-low risk (excellent prognosis regardless of stage); MMRd = intermediate; p53abn = high risk; NSMP = variable."), sp(4)]

story += [h2("8.3 Treatment"), sp(2)]
story += [
    bullet(b("Surgical:") + " TAH + BSO + peritoneal cytology; lymph node assessment (pelvic ± para-aortic)"),
    bullet(b("Adjuvant:") + " Low risk = observation; Intermediate = vaginal brachytherapy; High risk = EBRT + chemotherapy (carboplatin/paclitaxel)"),
    bullet(b("Fertility-sparing:") + " Stage IA, grade 1 endometrioid + PTEN/mismatch repair testing → progestins (MPA or levonorgestrel IUS); requires close follow-up"),
    sp(4),
]

# ============================================================
# SECTION 9: GTD
# ============================================================
story += [PageBreak(), h1("9. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)"), sp(4)]
story += [hl("NEET PG favourite. β-hCG is THE marker. Complete vs partial mole distinctions are frequently tested."), sp(4)]

story += [h2("9.1 Classification"), sp(2)]
story += [simple_table(
    ["Condition", "Karyotype", "Origin", "β-hCG", "Malignant Potential"],
    [
        ["Complete Hydatidiform Mole", "46,XX (diploid) – all paternal", "2 sperm + enucleate oocyte", "Very high (>100,000)", "15–20% → GTN"],
        ["Partial Hydatidiform Mole", "69,XXX or 69,XXY (triploid)", "2 sperm + normal oocyte", "Mildly elevated", "1–5% → GTN"],
        ["Invasive Mole", "Variable", "Mole invades myometrium", "Elevated", "Locally invasive"],
        ["Choriocarcinoma", "Variable", "Any pregnancy (50% mole)", "Very high", "Highly malignant; metastasizes"],
        ["PSTT", "Variable", "Intermediate trophoblast", "Low β-hCG; high hPL", "Chemoresistant"],
        ["ETT", "Variable", "Chorionic type IT", "Mildly elevated", "Rare"],
    ],
    [3.5*cm, 3*cm, 3*cm, 2.5*cm, 4*cm]
), sp(4)]

story += [h2("9.2 Complete vs Partial Mole"), sp(2)]
story += [two_col_table(
    ["46,XX diploid (all paternal)", "No fetal tissue", "Snowstorm appearance on USG (classic)", "Uterus large for dates", "Theca lutein cysts (bilateral)", "β-hCG very high", "Higher risk of malignant transformation"],
    ["69,XXX or 69,XXY triploid", "Fetal/embryonic tissue present", "Swiss cheese placenta on USG", "Uterus normal or small for dates", "Theca lutein cysts rare", "β-hCG mildly elevated", "Lower malignant risk"],
    "Complete Mole", "Partial Mole"
), sp(4)]

story += [h2("9.3 Diagnosis & Treatment"), sp(2)]
story += [
    bullet(b("Diagnosis:") + " USG (snowstorm); β-hCG (markedly elevated); Chest X-ray (pulmonary metastases); exclude other pregnancy complications"),
    bullet(b("Treatment of Mole:") + " Suction evacuation (curettage) under oxytocin cover; Rh prophylaxis if Rh-negative"),
    bullet(b("Contraception:") + " Avoid pregnancy for 6–12 months post-evacuation (COCP preferred; IUD contraindicated until β-hCG normal)"),
    bullet(b("β-hCG follow-up:") + " Weekly until normal × 3, then monthly × 12 months"),
    sp(2),
]
story += [h2("9.4 GTN – WHO Prognostic Scoring (FIGO)"), sp(2)]
story += [p("Score 0–6 = " + b("Low risk") + " (single-agent chemo); Score ≥7 = " + b("High risk") + " (combination chemo)")]
story += [simple_table(
    ["Prognostic Factor", "Score 0", "Score 1", "Score 2", "Score 4"],
    [
        ["Age", "<40", "≥40", "–", "–"],
        ["Antecedent pregnancy", "Mole", "Abortion", "Term", "–"],
        ["Interval from index pregnancy", "<4 months", "4–6 months", "7–12 months", ">12 months"],
        ["Pre-treatment β-hCG (IU/L)", "<1,000", "1,000–10,000", "10,000–100,000", ">100,000"],
        ["Largest tumour (cm)", "<3", "3–5", ">5", "–"],
        ["Site of metastasis", "Lung/vagina", "Spleen/kidney", "GI tract", "Brain/liver"],
        ["Number of metastases", "0", "1–4", "5–8", ">8"],
        ["Prior failed chemo", "None", "Single drug", "≥2 drugs", "–"],
    ],
    [5*cm, 2.5*cm, 2.5*cm, 2.5*cm, 4.5*cm]
), sp(4)]
story += [
    bullet(b("Low-risk chemo:") + " Methotrexate (MTX) ± folinic acid (1st line); Actinomycin-D (2nd line)"),
    bullet(b("High-risk chemo:") + " EMA-CO (Etoposide, MTX, Actinomycin D, Cyclophosphamide, Vincristine) – first-line"),
    bullet(b("Key point:") + " GTN is one of the few cancers curable even with widespread metastasis. Normal subsequent pregnancy is possible after chemotherapy."),
    sp(4),
]

# ============================================================
# SECTION 10: CONTRACEPTION
# ============================================================
story += [h1("10. CONTRACEPTION"), sp(4)]

story += [h2("10.1 Efficacy – Pearl Index"), sp(2)]
story += [simple_table(
    ["Method", "Pearl Index (failure/100 WY)", "Notes"],
    [
        ["Copper IUD (T380A)", "0.6–0.8", "Best non-hormonal reversible; also emergency contraception"],
        ["LNG-IUS (Mirena)", "0.1–0.2", "Best for menorrhagia + contraception"],
        ["Implant (Implanon/Nexplanon)", "0.05", "Most effective reversible contraceptive"],
        ["Combined OCP", "0.3 (perfect use)", "Failure 8% typical use"],
        ["Male condom", "2–3 (perfect)", "Only STI protection"],
        ["Diaphragm + spermicide", "6", "Requires fitting"],
        ["Progestogen-only pill (POP)", "0.3–1.1", "Suitable in lactation"],
        ["Tubal ligation", "0.5", "Permanent"],
        ["Vasectomy", "0.1", "Most effective permanent"],
    ],
    [4.5*cm, 4*cm, 8.5*cm]
), sp(4)]

story += [h2("10.2 Emergency Contraception"), sp(2)]
story += [
    bullet(b("Levonorgestrel 1.5 mg:") + " Within 72 hours of UPSI; failure rate ~1–2%; inhibits/delays ovulation; no effect on implanted embryo"),
    bullet(b("Ulipristal acetate (Ella/EllaOne):") + " Within 120 hours; more effective than LNG, especially days 72–120"),
    bullet(b("Copper IUD:") + " Within 5 days (or up to 5 days after earliest likely ovulation); most effective emergency contraception (>99%); ongoing contraception"),
    bullet(b("Mifepristone 10 mg:") + " Used in China; highly effective"),
    sp(2),
]
story += [h2("10.3 Contraception in Special Situations"), sp(2)]
story += [
    bullet(b("Breastfeeding:") + " Progestogen-only methods (POP, implant, DMPA, LNG-IUS); Cu-IUD; COCP contraindicated <6 weeks postpartum"),
    bullet(b("PCOS:") + " COCP (drospirenone/cyproterone-containing) – regulates cycles, treats hirsutism, protects endometrium"),
    bullet(b("Migraine with aura:") + " COCP absolutely contraindicated (WHO MEC 4); use POP or non-hormonal"),
    bullet(b("Hypertension / CVD:") + " COCP contraindicated; use POP, implant, IUD"),
    bullet(b("Diabetes:") + " All methods generally safe; avoid COCP in women with vascular disease"),
    bullet(b("Postpartum:") + " IUD can be inserted within 48h or after 4 weeks; DMPA within 6 weeks"),
    sp(4),
]

# ============================================================
# SECTION 11: MENOPAUSE
# ============================================================
story += [PageBreak(), h1("11. MENOPAUSE"), sp(4)]
story += [
    bullet(b("Definition:") + " Cessation of menstruation for 12 months; average age 51 years (range 45–55)"),
    bullet(b("Premature Ovarian Insufficiency (POI):") + " Menopause <40 years; affects 1% women; FSH >25 IU/L on 2 occasions 4 weeks apart; requires HRT until natural menopause age"),
    bullet(b("Perimenopause:") + " Menopausal transition; irregular cycles + symptoms, may last 4–8 years"),
    sp(2),
]
story += [h2("11.1 Symptoms"), sp(2)]
story += [two_col_table(
    ["Vasomotor: hot flushes, night sweats", "Genitourinary: vaginal dryness, dyspareunia, UTI", "Psychological: mood changes, insomnia", "Musculoskeletal: joint pain, myalgia"],
    ["Long-term: Osteoporosis (bone loss 2–3%/year in early menopause)", "Cardiovascular disease risk increases", "Cognitive changes", "Skin changes"],
    "Short-term", "Long-term"
), sp(4)]

story += [h2("11.2 Hormone Replacement Therapy (HRT)"), sp(2)]
story += [
    bullet(b("Indications:") + " Bothersome vasomotor symptoms, prevention/treatment of osteoporosis, premature menopause"),
    bullet(b("Types:") + " Estrogen alone (if hysterectomy); Combined E+P (if intact uterus – progestogen needed to prevent endometrial cancer)"),
    bullet(b("Routes:") + " Oral, transdermal (patch/gel – lower VTE risk than oral), vaginal (local genitourinary symptoms)"),
    bullet(b("Benefits:") + " Reduces vasomotor symptoms, prevents bone loss, reduces fractures, improves mood/quality of life"),
    bullet(b("Risks:") + " VTE (lower with transdermal), breast cancer (combination HRT after 5 years), stroke"),
    bullet(b("Contraindications:") + " Estrogen-dependent cancers (breast, endometrial), active VTE, liver disease, uncontrolled HTN"),
    sp(2),
]
story += [note("Current guidance (NICE 2023, RCOG): Benefits of HRT outweigh risks for symptomatic women <60 years or within 10 years of menopause (the 'timing hypothesis' / window of opportunity)."), sp(4)]

story += [h2("11.3 Osteoporosis in Menopause"), sp(2)]
story += [
    bullet(b("Diagnosis:") + " DXA scan; T-score: Normal ≥-1; Osteopenia -1 to -2.5; Osteoporosis ≤-2.5"),
    bullet(b("Treatment:") + " HRT (first-line if symptomatic); Bisphosphonates (alendronate, zoledronate); Denosumab; Raloxifene (SERM)"),
    bullet(b("Supplementation:") + " Calcium 1200 mg/day + Vitamin D 800–1000 IU/day"),
    sp(4),
]

# ============================================================
# SECTION 12: PELVIC FLOOR & PROLAPSE
# ============================================================
story += [h1("12. PELVIC ORGAN PROLAPSE (POP)"), sp(4)]
story += [
    bullet(b("Definition:") + " Descent of pelvic organs into or through the vaginal canal"),
    bullet(b("Types:") + " Cystocoele (anterior wall prolapse), Rectocoele (posterior wall), Enterocoele (small bowel), Uterovaginal prolapse, Vault prolapse (post-hysterectomy)"),
    bullet(b("Risk factors:") + " Multiparity, instrumental delivery, obesity, chronic straining, menopause, connective tissue disorders"),
    sp(2),
]
story += [h2("12.1 POP-Q Staging (IUGA/ICS)"), sp(2)]
story += [simple_table(
    ["Stage", "Description"],
    [
        ["Stage 0", "No prolapse"],
        ["Stage I", "Most distal point >1 cm above hymen"],
        ["Stage II", "Most distal point between 1 cm above and 1 cm below hymen"],
        ["Stage III", "Most distal point >1 cm below hymen but not complete eversion"],
        ["Stage IV", "Complete eversion of vagina"],
    ],
    [3*cm, 14*cm]
), sp(4)]

story += [h2("12.2 Management"), sp(2)]
story += [
    bullet(b("Conservative:") + " Pelvic floor exercises (Kegel); pessary (ring pessary for Stage I–III); lifestyle changes"),
    bullet(b("Surgical:") + " Anterior repair (cystocoele), posterior repair (rectocoele), Manchester operation (amputation of cervix + anterior colporrhaphy – for uterovaginal prolapse in younger women), Fothergill's operation, sacrocolpopexy, Le Fort colpocleisis (elderly, unfit)"),
    bullet(b("Stress urinary incontinence:") + " Midurethral sling (TVT/TOT) – most common surgical procedure"),
    sp(4),
]

# ============================================================
# SECTION 13: STIs & PID
# ============================================================
story += [h1("13. SEXUALLY TRANSMITTED INFECTIONS & PID"), sp(4)]

story += [h2("13.1 Key STIs in Gynaecology"), sp(2)]
story += [simple_table(
    ["STI", "Organism", "Key Features", "Treatment"],
    [
        ["Gonorrhoea", "N. gonorrhoeae", "Thick yellow-green discharge; cervicitis; risk of PID; gram-negative diplococcus", "Ceftriaxone 500 mg IM stat (dual therapy with azithromycin 1g increasingly recommended)"],
        ["Chlamydia", "C. trachomatis", "Most common STI; often asymptomatic; mucopurulent cervicitis; major cause of PID/tubal infertility", "Azithromycin 1g stat OR Doxycycline 100 mg × 7 days"],
        ["Syphilis", "T. pallidum", "Painless chancre (1°); condylomata lata (2°); Hutchinson triad (congenital)", "Benzathine penicillin"],
        ["Trichomonas", "T. vaginalis", "Frothy green-yellow discharge; strawberry cervix; motile flagellates on wet prep", "Metronidazole 2g stat (treat partner)"],
        ["HSV-2", "Herpes simplex virus", "Painful vesicles/ulcers; recurrent; Tzanck smear shows multinucleated giant cells", "Aciclovir/Valaciclovir"],
        ["HPV", "Human papillomavirus", "Condylomata acuminata (types 6, 11); cervical cancer (types 16, 18)", "Podophyllin; ablation; LEEP for CIN"],
    ],
    [2.5*cm, 2.5*cm, 5.5*cm, 6.5*cm]
), sp(4)]

story += [h2("13.2 Pelvic Inflammatory Disease (PID)"), sp(2)]
story += [
    bullet(b("Definition:") + " Ascending infection from lower genital tract to upper genital tract (endometritis, salpingitis, oophoritis, peritonitis)"),
    bullet(b("Common organisms:") + " Chlamydia, Gonorrhoea, Anaerobes, Mycoplasma genitalium"),
    bullet(b("Clinical:") + " Pelvic/lower abdominal pain, adnexal tenderness, cervical motion tenderness (CMT/chandelier sign), fever"),
    bullet(b("Diagnosis:") + " Clinical; TVUS (tubo-ovarian abscess); laparoscopy (gold standard)"),
    bullet(b("Complications:") + " Tubo-ovarian abscess (TOA), Fitz-Hugh-Curtis syndrome (perihepatitis), infertility, ectopic pregnancy, chronic pelvic pain"),
    bullet(b("Treatment:") + " Outpatient: Ceftriaxone 500mg IM + Doxycycline 100mg BD × 14 days + Metronidazole 400mg BD × 14 days; Inpatient (TOA): IV Cefoxitin + Doxycycline; Clindamycin + Gentamicin"),
    sp(4),
]

# ============================================================
# SECTION 14: VULVAR CONDITIONS
# ============================================================
story += [h1("14. VULVAR CONDITIONS & VAGINAL DISCHARGE"), sp(4)]

story += [h2("14.1 Vaginal Discharge – Differential"), sp(2)]
story += [simple_table(
    ["Condition", "Discharge", "pH", "Whiff Test", "Microscopy"],
    [
        ["Normal physiological", "Clear/white, no odour", "<4.5", "Negative", "Lactobacilli predominant"],
        ["Bacterial Vaginosis (BV)", "Grey-white, fishy odour", ">4.5", "Positive", "Clue cells (>20%); Amsel criteria (3/4)"],
        ["Candida", "White curdy, no odour", "<4.5", "Negative", "Pseudohyphae + budding yeast"],
        ["Trichomonas", "Frothy green-yellow", ">4.5", "Positive", "Motile trichomonads"],
    ],
    [3.5*cm, 3.5*cm, 1.5*cm, 2.5*cm, 6*cm]
), sp(4)]
story += [p(b("BV Amsel Criteria (3 of 4):") + " Grey discharge, pH >4.5, clue cells, positive whiff test. Treatment: Metronidazole 400 mg BD × 7 days or 2g stat.")]
story += [p(b("Recurrent Vulvovaginal Candidiasis:") + " ≥4 episodes/year; oral fluconazole 150 mg weekly × 6 months maintenance.")]
story += [sp(4)]

story += [h2("14.2 Vulvar Skin Conditions"), sp(2)]
story += [
    bullet(b("Lichen sclerosus:") + " White atrophic patches; figure-of-8 distribution around vulva and perianal; intense pruritus; risk of malignant change to SCC (5%); Rx: ultrapotent topical steroids (clobetasol)"),
    bullet(b("Lichen planus:") + " Wickham's striae; erosive form causes scarring; Rx: steroids"),
    bullet(b("Vulvar intraepithelial neoplasia (VIN):") + " HPV-related (usual type) or non-HPV (differentiated type – higher malignancy risk); treat with excision or imiquimod"),
    bullet(b("Vulvar cancer:") + " Mainly SCC; >60 years; bimodal: young (HPV-related VIN) + old (lichen sclerosus/VIN differentiated); staging FIGO (surgery-based)"),
    sp(4),
]

# ============================================================
# SECTION 15: QUICK REVISION & NEET PG MNEMONICS
# ============================================================
story += [PageBreak(), h1("15. QUICK REVISION – HIGH-YIELD POINTS & MNEMONICS"), sp(4)]

story += [h2("Tumour Markers – Must Know"), sp(2)]
story += [simple_table(
    ["Marker", "Tumour"],
    [
        ["CA-125", "Epithelial ovarian cancer (serous); also endometriosis"],
        ["AFP (alpha-fetoprotein)", "Yolk sac tumour (endodermal sinus tumour)"],
        ["β-hCG", "Choriocarcinoma, GTD"],
        ["Inhibin B", "Granulosa cell tumour"],
        ["hPL + low hCG", "Placental site trophoblastic tumour (PSTT)"],
        ["CEA + CA19-9", "Mucinous ovarian tumour, Krukenberg tumour"],
        ["LDH", "Dysgerminoma"],
        ["SCC antigen", "Squamous cell carcinoma of cervix"],
        ["CA-19-9", "Fallopian tube carcinoma"],
        ["Testosterone", "Sertoli-Leydig cell tumour"],
    ],
    [5*cm, 12*cm]
), sp(4)]

story += [h2("Key Histological Findings"), sp(2)]
story += [
    bullet(b("Call-Exner bodies:") + " Granulosa cell tumour (rosette pattern of cells around eosinophilic material)"),
    bullet(b("Schiller-Duval bodies:") + " Yolk sac tumour (glomerulus-like structures)"),
    bullet(b("Psammoma bodies:") + " Serous cystadenocarcinoma ovary; also papillary thyroid carcinoma, meningioma"),
    bullet(b("Rokitansky protuberance (dermoid plug):") + " Mature cystic teratoma"),
    bullet(b("Reinke crystals:") + " Leydig cell tumour"),
    bullet(b("Coffee-bean nuclei:") + " Brenner tumour (transitional cell type)"),
    bullet(b("Arias-Stella reaction:") + " Endometrial change in ectopic pregnancy (hypersecretory endometrium, no chorionic villi)"),
    sp(4),
]

story += [h2("Staging Systems Summary"), sp(2)]
story += [
    bullet(b("Cervical cancer:") + " Clinical staging (2018 FIGO: imaging/pathology now allowed)"),
    bullet(b("Endometrial cancer:") + " Surgical staging (2023 FIGO: includes molecular classification)"),
    bullet(b("Ovarian cancer:") + " Surgical staging (FIGO 2014: Stage IIIC = positive retroperitoneal LN)"),
    bullet(b("Vulvar cancer:") + " Surgical staging"),
    bullet(b("Vaginal cancer:") + " Clinical staging (only purely clinical FIGO system remaining alongside cervix)"),
    bullet(b("GTN:") + " FIGO staging + WHO prognostic score"),
    sp(4),
]

story += [h2("NEET PG 2025/2026 – Highest Yield Gynaecology Topics"), sp(2)]
story += [
    bullet("1. Cervical cancer: FIGO 2018 staging + IB1/2/3 cutoffs + CCRT vs surgery"),
    bullet("2. PCOS: Rotterdam criteria + letrozole (new first-line) + insulin resistance"),
    bullet("3. GTD: Complete vs partial mole + WHO scoring + EMA-CO"),
    bullet("4. Ectopic pregnancy: Discriminatory zone + MTX criteria + salpingectomy vs salpingostomy"),
    bullet("5. Endometrial cancer: FIGO 2023 molecular staging + Type I vs II"),
    bullet("6. Ovarian cancer: Tumour markers + CA-125 + fallopian tube origin of HGSOC"),
    bullet("7. PALM-COEIN + fibroid FIGO types"),
    bullet("8. Contraception: Pearl index + EC methods + WHO MEC contraindications"),
    bullet("9. Menopause: HRT window hypothesis + POI + DXA T-score"),
    bullet("10. Endometriosis: Classification + ACOG 2026 presumptive diagnosis guideline"),
    sp(4),
]

story += [h2("Key Drugs in Gynaecology"), sp(2)]
story += [simple_table(
    ["Drug", "Uses in Gynaecology", "Key Point"],
    [
        ["Methotrexate", "Ectopic pregnancy, low-risk GTN", "Folinic acid rescue; avoid in renal failure, liver disease"],
        ["Carboplatin + Paclitaxel", "Ovarian cancer chemotherapy", "First-line; alopecia, neuropathy SEs"],
        ["EMA-CO", "High-risk GTN", "Etoposide, MTX, ActD, Cyclophosphamide, Vincristine"],
        ["Cisplatin", "Cervical cancer CCRT", "Radiosensitiser; nephrotoxicity"],
        ["GnRH agonists", "Endometriosis, fibroids, PCOS", "Initial flare; hypo-estrogenic state; add-back HRT"],
        ["Letrozole", "Ovulation induction (PCOS)", "Aromatase inhibitor; now first-line over clomiphene (ESHRE 2023)"],
        ["Mifepristone", "Medical abortion, fibroids", "Progesterone receptor modulator"],
        ["Misoprostol", "Medical abortion, cervical priming", "PGE1 analogue; DO NOT use in prior uterine scar without caution"],
        ["LNG-IUS (Mirena)", "Menorrhagia, endometriosis, contraception", "Reduces blood loss by 90%; local progestogen"],
        ["Dienogest", "Endometriosis", "Highly selective progestogen; comparable to GnRH analogues"],
        ["Pembrolizumab", "Recurrent cervical cancer (PD-L1+)", "Immune checkpoint inhibitor – recent NICE/FDA approval"],
        ["Olaparib", "BRCA-mutated ovarian cancer maintenance", "PARP inhibitor; significant PFS benefit"],
    ],
    [3.5*cm, 5.5*cm, 8*cm]
), sp(4)]

# Final note
story += [
    hr(),
    Paragraph(
        "Sources: Berek & Novak's Gynecology (16e) · Essentials of Gynaecology – Lakshmi Seshadri (3e) · "
        "Sheila Balakrishnan Textbook of Obstetrics (3e) · FIGO 2018/2023 Staging · ESHRE PCOS Guideline 2023 · "
        "ACOG 2026 Endometriosis Guidance · RCOG Green-top Guidelines · NEET PG 2025/2026 Analysis",
        FOOTER_NOTE
    ),
    Paragraph("Compiled by Orris AI Medical Assistant | July 2026 | For Educational Purposes Only", FOOTER_NOTE),
]

doc.build(story)
print(f"PDF generated: {OUTPUT}")