postmenopausal bleeding diagnosis

2025 postmenopausal bleeding evaluation guideline endometrial cancer molecular classification ESGO

postmenopausal bleeding endometrial biopsy hysteroscopy

endometrial cancer molecular classification

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postmenopausal bleeding endometrial sampling diagnostic accuracy

transvaginal ultrasound endometrial thickness postmenopausal bleeding

https://www.acog.org/news/news-releases/2026/04/acog-publish…

mkdir -p "/tmp/workspace/pmb_presentation/src" "/tmp/workspace/pmb_presentation/output" && cat > "/tmp/workspace/pmb_presentation/src/create_pmb_presentation.py" <<'PY' from pptx import Presentation from pptx.util import Inches, Pt from pptx.dml.color import RGBColor from pptx.enum.text import PP_ALIGN, MSO_ANCHOR from pptx.enum.shapes import MSO_SHAPE from pptx.enum.dml import MSO_THEME_COLOR from pptx.chart.data import CategoryChartData from pptx.enum.chart import XL_CHART_TYPE, XL_LEGEND_POSITION from pptx.enum.text import MSO_AUTO_SIZE OUT='/tmp/workspace/pmb_presentation/output/Postmenopausal_Bleeding_25_Slides.pptx' prs=Presentation(); prs.slide_width=Inches(13.333); prs.slide_height=Inches(7.5) blank=prs.slide_layouts[6] # light plain palette NAVY=RGBColor(36,65,89); TEAL=RGBColor(67,137,137); BLUE=RGBColor(89,139,178) INK=RGBColor(48,58,66); MUTED=RGBColor(100,113,123); BG=RGBColor(249,251,249) PALE=RGBColor(232,243,241); PALE2=RGBColor(239,245,250); RED=RGBColor(171,72,72); GOLD=RGBColor(191,139,55) def rect(sl,x,y,w,h,fill,line=None): sh=sl.shapes.add_shape(MSO_SHAPE.RECTANGLE, Inches(x), Inches(y), Inches(w), Inches(h)) sh.fill.solid(); sh.fill.fore_color.rgb=fill sh.line.color.rgb=line or fill return sh def text(sl,txt,x,y,w,h,size=20,color=INK,bold=False,align=None,bullet=False): tb=sl.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h)); tf=tb.text_frame tf.clear(); tf.word_wrap=True; tf.margin_left=tf.margin_right=tf.margin_top=tf.margin_bottom=0 p=tf.paragraphs[0]; p.text=txt; p.font.name='Aptos'; p.font.size=Pt(size); p.font.bold=bold; p.font.color.rgb=color if align: p.alignment=align if bullet: p.level=0; p.text='• '+txt return tb def rich_lines(sl, lines, x,y,w,h, size=19, gap=5): tb=sl.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h)); tf=tb.text_frame; tf.clear(); tf.word_wrap=True tf.margin_left=tf.margin_right=tf.margin_top=tf.margin_bottom=0 for i,(s,b,c) in enumerate(lines): p=tf.paragraphs[0] if i==0 else tf.add_paragraph(); p.text=s; p.font.name='Aptos'; p.font.size=Pt(size); p.font.bold=b; p.font.color.rgb=c; p.space_after=Pt(gap) return tb def base(title, subtitle=None, n=None): sl=prs.slides.add_slide(blank); rect(sl,0,0,13.333,7.5,BG); rect(sl,.55,.58,.12,.7,TEAL) text(sl,title,.86,.54,11.8,.55,27,NAVY,True) if subtitle: text(sl,subtitle,.87,1.13,11.7,.32,11,MUTED) rect(sl,.55,7.08,12.2,.015,RGBColor(205,220,220)) if n: text(sl,f'{n:02d}',12.15,7.15,.55,.2,9,MUTED,False,PP_ALIGN.RIGHT) return sl def bullets(sl, items, x=.92,y=1.7,w=11.4,h=4.8,size=19): lines=[] for item in items: if isinstance(item,tuple): s=item[0] else:s=item lines.append(('• '+s,False,INK)) return rich_lines(sl,lines,x,y,w,h,size,11) def mini_source(sl,s): text(sl,s,.86,6.7,11.7,.22,8,MUTED) def accent_label(sl,label,x=.9,y=1.45,w=2.4): sh=rect(sl,x,y,w,.3,PALE); text(sl,label,x+.12,y+.06,w-.2,.15,9,TEAL,True) # 1 sl=prs.slides.add_slide(blank); rect(sl,0,0,13.333,7.5,BG); rect(sl,.78,.8,.14,4.6,TEAL) text(sl,'Postmenopausal\nBleeding',1.25,1.15,8.2,1.55,37,NAVY,True) text(sl,'A practical, case-based approach to diagnosis, risk stratification and individualized management',1.28,3.0,8.5,.7,19,INK) text(sl,'Includes modern endometrial cancer molecular classification and HPV-independent cervical cancer',1.28,4.0,8.6,.5,13,MUTED) text(sl,'25-slide teaching deck | Updated literature through 2026',1.28,5.2,7,.3,11,TEAL,True) # 2 sl=base('Learning objectives','What this presentation will enable you to do',2) bullets(sl,['Define PMB and identify clinically important sources of bleeding.','Select investigations based on pre-test risk, feasibility and diagnostic limitations.','Interpret test performance without treating a negative test as a universal “rule-out”.','Manage benign disease, EIN/atypical hyperplasia and malignancy in individualized cases.','Apply TCGA/ProMisE molecular groups to endometrial cancer; recognize HPV-independent cervical adenocarcinoma.'],size=18) #3 sl=base('What is postmenopausal bleeding?','A symptom, not a diagnosis',3) accent_label(sl,'DEFINITION') bullets(sl,['Bleeding from the genital tract occurring ≥12 months after the final menstrual period.','May be vaginal, cervical, uterine, vulvar, urinary or rectal in origin: confirm the source before labeling it uterine.','Always warrants timely assessment, even after a single small episode.','The clinical priority is exclusion of endometrial and cervical malignancy while treating common benign causes.'],y=1.9,size=20) mini_source(sl,'Berek & Novak’s Gynecology, “Diagnosis of Postmenopausal Abnormal Bleeding”, p. 480-481.') #4 sl=base('Why PMB matters','Cancer is uncommon, but the consequence of a miss is high',4) # key metrics for x,num,lab,col in [(1.0,'~9%','Pooled risk of\nendometrial cancer in women\nwith PMB',TEAL),(4.8,'~90%','Of women diagnosed with\nendometrial cancer report\nPMB',BLUE),(8.6,'~10%','Endometrial or cervical\nmalignancy in one textbook\nseries',GOLD)]: text(sl,num,x,2.0,2.4,.7,34,col,True,PP_ALIGN.CENTER); text(sl,lab,x,2.9,2.4,1.25,15,INK,False,PP_ALIGN.CENTER) text(sl,'Risk rises with recurrent bleeding, obesity, diabetes, unopposed estrogen exposure, tamoxifen, Lynch syndrome and abnormal examination.',1.1,5.0,10.9,.55,18,NAVY,True,PP_ALIGN.CENTER) mini_source(sl,'Clarke et al. JAMA Intern Med 2018; Berek & Novak’s Gynecology, p. 480.') #5 sl=base('Causes and clinical presentation','Start with anatomy and pattern recognition',5) left=['Genitourinary syndrome of menopause: dryness, dyspareunia, fissuring, scant spotting.','Endometrial polyp: intermittent bleeding; focal lesion or cystic endometrium.','Hyperplasia / EIN: irregular bleeding, often obesity or estrogen excess.','Endometrial cancer: recurrent watery, pink or frank bleeding; may have discharge or anemia.'] right=['Cervical cancer: postcoital/contact bleeding, offensive discharge, visible/friable cervix.','Vaginal/vulvar lesion: bleeding with ulcer, pruritus, trauma or mass.','Drug-related: menopausal hormone therapy, tamoxifen, anticoagulants - but never assume causality without assessment.','Non-gynecologic: urethral caruncle, hematuria, rectal bleeding.'] text(sl,'Uterine causes',.9,1.7,4,.3,17,TEAL,True); bullets(sl,left,.9,2.15,5.5,3.9,16) text(sl,'Other sources',7.0,1.7,4,.3,17,TEAL,True); bullets(sl,right,7.0,2.15,5.5,3.9,16) mini_source(sl,'Berek & Novak’s Gynecology, p. 480-481; Robbins Pathology, cervical carcinoma chapter.') #6 sl=base('Initial clinical assessment','The examination directs the pathway',6) bullets(sl,['History: timing, quantity, recurrence, postcoital bleeding, pain, discharge, medications and prior cervical screening.','Risk profile: BMI, diabetes, hypertension, nulliparity, age at menopause, estrogen exposure, tamoxifen, hereditary cancer history.','Speculum examination: atrophy, lacerations, polyp, vaginitis, cervical lesion, source of blood.','Bimanual examination: uterine size, adnexal mass, parametrial disease; assess nodes when cancer is suspected.','Cervical cytology/HPV testing is screening, not a substitute for biopsy of a suspicious cervix.'],size=18) mini_source(sl,'Berek & Novak’s Gynecology, p. 480-481.') #7 sl=base('Diagnostic pathway','Do not delay tissue diagnosis when risk or persistence is present',7) # arrows simplified steps=[('1','Confirm source\nHistory + speculum'),('2','Risk assessment\nLow vs higher risk'),('3','TVUS ± sampling\nInitial tests'),('4','Cavity assessment\nSIS / hysteroscopy'),('5','Histology & staging\nMDT management')] for i,(no,lab) in enumerate(steps): x=.8+i*2.5; rect(sl,x,2.3,2.02,1.25,PALE if i<3 else PALE2); text(sl,no,x+.12,2.55,.25,.28,18,TEAL,True); text(sl,lab,x+.48,2.53,1.38,.55,15,INK,False,PP_ALIGN.CENTER) if i<4:text(sl,'→',x+2.08,2.72,.35,.25,21,TEAL,True) text(sl,'Escalate directly to endometrial sampling if recurrent PMB, high-risk profile, abnormal/indeterminate ultrasound, or a lesion is seen.',1.1,4.5,11,.5,19,NAVY,True,PP_ALIGN.CENTER) mini_source(sl,'ACOG Clinical Practice Update news release, Apr 2026; Berek & Novak’s Gynecology, p. 480-481.') #8 sl=base('Transvaginal ultrasound (TVUS)','Fast triage, but it assesses thickness better than focal pathology',8) bullets(sl,['Measure the double-layer endometrial echo in the sagittal plane; describe focal lesions, fluid and adnexa.','Historically, ET ≤4 mm in an initial episode has a very high negative predictive value for endometrial cancer. Textbooks also cite <5 mm as low risk.','A thin stripe does not override persistent/recurrent bleeding, high-risk context, poor visualization, or concern for type II histology.','Technical limitations: obesity, fibroids, adenomyosis, axial uterus, intrauterine fluid, tamoxifen-related cystic change.'],size=18) mini_source(sl,'Berek & Novak’s Gynecology, p. 480-481; Long et al. Gynecol Oncol 2020, PMID 32008795; ACOG update 2026.') #9 metrics sl=base('Diagnostic test performance','Explain “success” and “failure” before choosing a test',9) rows=[('TVUS, ET cut-off 4 mm','Very high NPV for cancer in initial PMB; performance depends on cut-off and study population','Risk of missed cancer rises with recurrent PMB or non-measurable stripe'),('Blind office sampling','Cancer sensitivity ≈ 90-95% in meta-analyses; excellent specificity','Insufficient tissue and focal lesions reduce yield'),('Hysteroscopy + directed biopsy','Highest diagnostic yield for focal polyps/submucosal lesions; visual target','Small procedural burden; pathology still required'),('SIS','Strong focal lesion delineation; useful after equivocal TVUS','Does not replace histology when malignancy possible')] text(sl,'Test',.8,1.55,2.55,.3,14,TEAL,True);text(sl,'Diagnostic success',3.55,1.55,4.3,.3,14,TEAL,True);text(sl,'Failure mode / caveat',8.15,1.55,4.4,.3,14,TEAL,True) for i,(a,b,c) in enumerate(rows): y=2.02+i*1.05; rect(sl,.75,y,11.9,.83,RGBColor(244,248,248) if i%2==0 else BG); text(sl,a,.88,y+.12,2.45,.55,14,NAVY,True); text(sl,b,3.55,y+.12,4.25,.6,13,INK); text(sl,c,8.15,y+.12,4.25,.6,13,INK) mini_source(sl,'van Hanegem et al. Eur J Obstet Gynecol Reprod Biol 2016, PMID 26748390; Sakna et al. BMJ Open 2023, PMID 37355271.') #10 sl=base('Endometrial sampling and “insufficient” results','An inadequate sample is a result that needs clinical context',10) bullets(sl,['Office Pipelle is convenient and highly specific when diagnostic tissue is obtained.','Failure/insufficient sample is more likely with cervical stenosis, atrophy and a thin endometrium. A benign or insufficient blind sample may miss a focal polyp or localized carcinoma.','If the sample is insufficient AND bleeding persists/recurred, ET is thick/indeterminate, or risk is high: proceed to hysteroscopy with directed biopsy ± curettage.','A negative blind sample does not end evaluation of ongoing PMB.'],size=19) mini_source(sl,'van Hanegem et al. 2016, PMID 26748390; Berek & Novak’s Gynecology, p. 480-481.') #11 sl=base('Hysteroscopy, SIS and D&C','Choose the tool that answers the unresolved question',11) text(sl,'Hysteroscopy + directed biopsy',.95,1.75,3.4,.3,17,TEAL,True); bullets(sl,['Best when focal lesion suspected','Direct visualization + targeted histology','Polypectomy can be therapeutic'],.95,2.18,3.45,2.7,17) text(sl,'Saline infusion sonography',4.9,1.75,3.4,.3,17,TEAL,True); bullets(sl,['Clarifies intracavitary contour','Useful after equivocal TVUS','No tissue diagnosis'],4.9,2.18,3.4,2.7,17) text(sl,'D&C',8.85,1.75,2.5,.3,17,TEAL,True); bullets(sl,['Not a routine “blind” default','Use with hysteroscopy if needed','Sampling can still be incomplete'],8.85,2.18,3.3,2.7,17) text(sl,'Principle: focal disease needs focal visualization; suspected cancer needs tissue.',1.0,5.5,11.2,.45,20,NAVY,True,PP_ALIGN.CENTER) mini_source(sl,'Bailey & Love’s Short Practice of Surgery, 28e, gynaecological chapter; Berek & Novak’s Gynecology.') #12 sl=base('Case 1: scant spotting and severe atrophy','Individualized management: low-risk presentation, but diagnosis first',12) rich_lines(sl,[('Presentation',True,TEAL),('67 years, 8 years postmenopause, one episode after intercourse; vulvovaginal dryness, fissuring; normal cervix; no obesity, diabetes or tamoxifen.',False,INK),('Work-up',True,TEAL),('Confirm vaginal source. TVUS shows a thin, fully visualized endometrium; no recurrent bleeding.',False,INK),('Management',True,TEAL),('Treat genitourinary syndrome of menopause: moisturizers/lubricants; consider low-dose vaginal estrogen after malignancy is reasonably excluded and contraindications are reviewed. Safety-net for any recurrence.',False,INK)],.95,1.65,11.3,4.7,18,8) mini_source(sl,'Berek & Novak’s Gynecology, p. 481: atrophic vaginitis management after exclusion of other causes.') #13 sl=base('Case 2: recurrent PMB despite thin stripe','Individualized management: do not stop at a reassuring measurement',13) rich_lines(sl,[('Presentation',True,TEAL),('73 years, BMI 38 kg/m² and diabetes; three episodes of watery/pink discharge. ET 3 mm, but visualization suboptimal.',False,INK),('Interpretation',True,TEAL),('Thin ET lowers risk but does not exclude malignancy in recurrent PMB or an inadequately visualized cavity; non-endometrioid cancers can have less obvious thickening.',False,INK),('Management',True,TEAL),('Endometrial sampling. If insufficient or benign but bleeding continues, hysteroscopy with directed biopsy. Inspect cervix and vagina; stage and refer if cancer confirmed.',False,INK)],.95,1.65,11.35,4.7,18,8) mini_source(sl,'ACOG Clinical Practice Update 2026; Long et al. 2020, PMID 32008795.') #14 sl=base('Case 3: focal lesion on ultrasound','Individualized management: treat focal pathology as focal pathology',14) rich_lines(sl,[('Presentation',True,TEAL),('62 years, intermittent PMB. TVUS: 11-mm heterogeneous endometrium with a 16-mm focal echogenic lesion.',False,INK),('Likely differential',True,TEAL),('Endometrial polyp, submucosal fibroid, focal hyperplasia/EIN, carcinoma.',False,INK),('Management',True,TEAL),('Outpatient hysteroscopy with complete polypectomy and directed endometrial biopsy. Send all tissue for histology. Do not accept a benign blind biopsy alone if the lesion remains.',False,INK)],.95,1.65,11.35,4.7,18,8) mini_source(sl,'Berek & Novak’s Gynecology: polyps and PMB; Vroom et al. Ultrasound Obstet Gynecol 2019, PMID 30693579.') #15 sl=base('Case 4: EIN / atypical hyperplasia','Individualized management: account for concurrent carcinoma risk and fitness',15) bullets(sl,['63 years, PMB; biopsy reports EIN/atypical hyperplasia. Review pathology and evaluate for coexistent carcinoma, preferably with hysteroscopic assessment if uncertainty/focal lesion.','Definitive management for postmenopausal women who are fit for surgery: total hysterectomy, usually with bilateral salpingo-oophorectomy. Avoid morcellation.','If medically inoperable or surgery declined: continuous progestin therapy, often levonorgestrel intrauterine system, with close histologic surveillance.','Counsel that persistence/progression or occult cancer requires escalation.'],size=18) mini_source(sl,'Robbins Basic Pathology: EIN and hysterectomy; ACOG Clinical Consensus on EIN/AEH (2023).') #16 sl=base('Case 5: suspected cervical primary','Individualized management: a visible lesion requires biopsy, not reassurance from cytology',16) rich_lines(sl,[('Presentation',True,TEAL),('58 years, postcoital bleeding and malodorous watery discharge; irregular, friable cervical lesion. Pap test 2 years earlier was negative.',False,INK),('Work-up',True,TEAL),('Colposcopy and biopsy of lesion. Pelvic examination and appropriate imaging after histologic confirmation. PMB work-up still includes endometrial assessment if bleeding source remains uncertain.',False,INK),('Management',True,TEAL),('Refer to gynecologic oncology. Stage-directed treatment: surgery for selected early disease; chemoradiation for locally advanced disease. Cytology can be falsely negative in invasive cancer.',False,INK)],.95,1.65,11.35,4.7,18,8) mini_source(sl,'Berek & Novak’s Gynecology, p. 480; Robbins, Cotran & Kumar Pathologic Basis of Disease, cervical carcinoma chapter.') #17 sl=base('Endometrial cancer: contemporary framework','Histology, stage and molecular class work together',17) bullets(sl,['Traditional “type I vs type II” is clinically useful but incomplete. Type I is commonly endometrioid, estrogen-associated and often PTEN/MMR altered. Type II includes serous/other high-grade histologies with frequent TP53 abnormality.','Current practice incorporates histology, FIGO stage, grade, lymphovascular space invasion, molecular class and patient factors.','Obtain molecular testing early enough to inform risk grouping and adjuvant treatment discussions.'],size=19) mini_source(sl,'Goldman-Cecil Medicine, Endometrial cancer chapter; ESGO-ESTRO-ESP Endometrial Cancer Guidelines Update, 2025.') #18 sl=base('TCGA / ProMisE molecular classification','Four clinically useful endometrial cancer groups',18) items=[('POLEmut','Pathogenic POLE exonuclease-domain mutation','Excellent prognosis; may support de-escalation in appropriate stage/risk setting',TEAL),('MMRd','Loss of MMR proteins / MSI-high','Intermediate prognosis; assess Lynch syndrome pathway; immunotherapy relevance',BLUE),('p53abn','Abnormal p53 IHC / copy-number high','Poorer prognosis; often high-grade or serous-like; treatment intensification often considered',RED),('NSMP','No specific molecular profile','Heterogeneous/intermediate; refine with stage, grade, LVSI, ER and other clinicopathologic factors',GOLD)] for i,(a,b,c,col) in enumerate(items): y=1.65+i*1.16; rect(sl,.78,y,1.6,.77,PALE); text(sl,a,.9,y+.23,1.35,.25,16,col,True,PP_ALIGN.CENTER); text(sl,2.65,y+.12,3.3,.5,14,INK,True); # overwrite below # Need correct different text text(sl,b,2.65,y+.12,3.1,.5,14,INK) text(sl,c,6.0,y+.12,6.1,.5,14,INK) mini_source(sl,'Goldman-Cecil Medicine, Endometrial cancer chapter; ESGO-ESTRO-ESP Endometrial Cancer Guidelines Update, 2025.') #19 sl=base('Practical molecular testing algorithm','A pragmatic surrogate for TCGA',19) steps=[('1. MMR IHC','MLH1, PMS2, MSH2, MSH6 loss → MMRd. If MLH1/PMS2 loss, test MLH1 promoter methylation to triage sporadic vs Lynch pathway.'),('2. p53 IHC','Aberrant overexpression, null or cytoplasmic pattern supports p53abn. Interpret with morphology and sequencing when needed.'),('3. POLE sequencing','Pathogenic exonuclease-domain mutation identifies POLEmut.'),('4. Assign hierarchy','POLEmut generally takes precedence; otherwise MMRd; otherwise p53abn; remaining tumors are NSMP.')] for i,(a,b) in enumerate(steps): y=1.6+i*1.15; text(sl,a,.92,y,2.0,.28,16,TEAL,True); text(sl,b,3.15,y,8.95,.68,16,INK) mini_source(sl,'Goldman-Cecil Medicine, Endometrial cancer chapter; 2025 ESGO-ESTRO-ESP guideline update.') #20 sl=base('Endometrial cancer management by individualized risk','Core treatment is surgery, but adjuvant therapy is risk adapted',20) bullets(sl,['Apparent uterine-confined, operable disease: total hysterectomy + bilateral salpingo-oophorectomy; sentinel lymph-node mapping is preferred nodal staging in many settings.','Low risk: surgery alone is often appropriate. High-intermediate/high risk: consider vaginal brachytherapy, external-beam radiotherapy and/or chemotherapy according to stage, LVSI, histology and molecular class.','Advanced/recurrent disease: cytoreductive surgery only when feasible; systemic therapy may include carboplatin-paclitaxel, immunotherapy for MMRd/MSI-H disease, and selected targeted/hormonal options.','Frailty, comorbidity, performance status, access, values and goals of care modify the plan. Use an MDT.'],size=17) mini_source(sl,'ESGO-ESTRO-ESP Endometrial Cancer Guidelines Update, 2025; PMID 42242033 (2026 molecular subtype meta-analysis).') #21 sl=base('HPV-independent cervical cancer','Rare, easily overlooked, clinically important',21) bullets(sl,['Most cervical cancers are HPV-associated. A rare, aggressive HPV-independent cervical adenocarcinoma often shows gastric-type differentiation.','Clinical presentation: watery/mucoid discharge, PMB or postcoital bleeding; cervical enlargement may be subtle and cytology/HPV testing may be less sensitive.','Pathology: p16 often negative or patchy, HPV negative; frequent TP53 and STK11 alterations. Peutz-Jeghers syndrome may be associated with STK11 germline variants.','Management is stage-directed in a gynecologic oncology unit; prognosis is poorer than usual HPV-associated adenocarcinoma.'],size=18) mini_source(sl,'Robbins, Cotran & Kumar Pathologic Basis of Disease, cervical carcinoma chapter.') #22 sl=base('Red flags and safety-netting','The safest pathway is one that anticipates false reassurance',22) bullets(sl,['Recurrent or persistent PMB after a negative TVUS or blind sample.','Inadequate/insufficient endometrial sample with ongoing symptoms or abnormal imaging.','Endometrium not visualized, focal lesion, intracavitary fluid with abnormal endometrium, or ET above local threshold.','Postcoital bleeding, visible cervical/vaginal/vulvar lesion, purulent/watery discharge, pelvic mass, anemia or constitutional symptoms.','Document a return plan: any further bleeding requires reassessment.'],size=20) mini_source(sl,'ACOG update 2026; Berek & Novak’s Gynecology, p. 480-481.') #23 sl=base('Key take-home messages','A disciplined approach prevents missed cancer',23) for i,s in enumerate(['PMB is abnormal until a source is identified and serious disease is excluded.','TVUS is valuable, but a thin stripe is not a universal endpoint: persistence and risk override reassurance.','Tissue diagnosis is central; hysteroscopy closes the gap for focal disease and inadequate/discordant tests.','EIN usually warrants hysterectomy in postmenopausal patients who are surgical candidates.','Endometrial cancer management now integrates molecular class. Keep HPV-independent cervical adenocarcinoma in mind when symptoms and exam disagree with screening.']): text(sl,str(i+1),1.05,1.6+i*.87,.35,.28,18,TEAL,True); text(sl,s,1.65,1.57+i*.87,10.4,.43,18,INK) #24 refs sl=base('Selected references: standard texts and guidelines','Use local protocols alongside these sources',24) refs=['Berek & Novak’s Gynecology. 16th ed. Postmenopausal abnormal bleeding, pp. 480-481.','Goldman-Cecil Medicine. 27th ed. Endometrial cancer: pathobiology and TCGA groups.','Robbins, Cotran & Kumar Pathologic Basis of Disease. 11th ed. Cervical carcinoma chapter.','ACOG. Clinical Practice Update: Evaluation of Postmenopausal Bleeding. 2026.','Concin N, et al. ESGO-ESTRO-ESP Endometrial Cancer Guidelines Update. Lancet Oncol. 2025.','ACOG. Clinical Consensus: Management of Endometrial Intraepithelial Neoplasia or Atypical Endometrial Hyperplasia. 2023.'] bullets(sl,refs,y=1.65,size=16) #25 sl=base('Selected evidence for diagnostic performance','Numbers vary with threshold, population and reference standard',25) refs=['Clarke MA, et al. Association of Endometrial Cancer Risk With Postmenopausal Bleeding. JAMA Intern Med. 2018. PMID 30083701.','Long B, et al. Ultrasound detection of endometrial cancer in women with PMB: systematic review/meta-analysis. Gynecol Oncol. 2020. PMID 32008795.','van Hanegem N, et al. Accuracy of endometrial sampling in PMB: systematic review/meta-analysis. 2016. PMID 26748390.','Sakna NA, et al. Diagnostic accuracy of endometrial sampling tests for detecting endometrial cancer: systematic review/meta-analysis. BMJ Open. 2023. PMID 37355271.','Chee RKW, et al. Re-evaluating endometrial thickness in symptomatic postmenopausal patients: systematic review/meta-analysis. JACR. 2025. PMID 39566874.','Pereira RA, et al. Molecular subtypes and lymph-node metastasis in endometrial cancer: systematic review/meta-analysis. Surg Oncol. 2026. PMID 42242033.'] bullets(sl,refs,y=1.65,size=15) text(sl,'Educational material. Management must follow local pathways, full clinical context and specialist input.',.88,6.2,11.8,.32,11,RED,True,PP_ALIGN.CENTER) # add speaker notes impossible cleanly without XML; document source in slides assert len(prs.slides)==25, len(prs.slides) prs.save(OUT) print(OUT) PY python "/tmp/workspace/pmb_presentation/src/create_pmb_presentation.py" python - <<'PY' from pptx import Presentation p='/tmp/workspace/pmb_presentation/output/Postmenopausal_Bleeding_25_Slides.pptx' prs=Presentation(p) print('slides',len(prs.slides)) for i,s in enumerate(prs.slides,1): txt=' '.join(sh.text for sh in s.shapes if getattr(sh,'has_text_frame',False)) print(i, len(txt), txt[:70].replace('\n',' | ')) PY

~/pmb_presentation/src/create_pmb_presentation.py

python "/tmp/workspace/pmb_presentation/src/create_pmb_presentation.py" && python - <<'PY' from pptx import Presentation p='/tmp/workspace/pmb_presentation/output/Postmenopausal_Bleeding_25_Slides.pptx' prs=Presentation(p) print('slides:',len(prs.slides)) for i,s in enumerate(prs.slides,1): txt=' '.join(sh.text for sh in s.shapes if getattr(sh,'has_text_frame',False)) print(f'{i:02d}: {len(txt)} chars | {txt[:55].replace(chr(10)," / ")}') PY ls -lh "/tmp/workspace/pmb_presentation/output/Postmenopausal_Bleeding_25_Slides.pptx"

~/

~/pmb_presentation/output

python - <<'PY' import shutil, os src='/tmp/workspace/pmb_presentation/output/Postmenopausal_Bleeding_25_Slides.pptx' dst='/tmp/workspace/Postmenopausal_Bleeding_25_Slides.pptx' shutil.copy2(src,dst) print(os.path.getsize(dst)) PY cd "/tmp/workspace" && zip -j "Postmenopausal_Bleeding_25_Slides.zip" "Postmenopausal_Bleeding_25_Slides.pptx" && ls -lh "/tmp/workspace/Postmenopausal_Bleeding_25_Slides.pptx" "/tmp/workspace/Postmenopausal_Bleeding_25_Slides.zip"