polycystic ovary syndrome "polyendocrine metabolic" new nomenclature

polycystic ovary syndrome PCOS Lancet review 2024 2025

polycystic ovary syndrome PCOS review pathophysiology treatment

PCOS "polyendocrine metabolic ovarian syndrome" new name Lancet 2024 2025

PMID: 35934017

PMID: 38637590

polycystic ovary syndrome PCOS pathophysiology diagram

PCOS renaming terminology endocrine metabolic ovarian syndrome

PCOS renamed "polyendocrine metabolic ovarian syndrome" 2024 2025 proposal

mkdir -p /home/daytona/workspace/pcos-ppt && ls /home/daytona/workspace/pcos-ppt…

~/pcos-ppt/build.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "Medical Education";
pres.title = "Polyendocrine Metabolic Ovarian Syndrome (PCOS) - Comprehensive Review";

// ── COLOUR PALETTE ──────────────────────────────────────────────────────────
const BG       = "0D1B2A";   // deep navy
const ACCENT1  = "1B6CA8";   // sapphire blue
const ACCENT2  = "E84393";   // vivid rose (ovarian/hormonal)
const ACCENT3  = "00C9A7";   // teal-green
const WHITE    = "FFFFFF";
const OFFWHITE = "EAF0FB";
const LIGHTG   = "B0C4DE";
const DARKTEXT = "1A1A2E";
const CARD_BG  = "132338";

// ── HELPER FUNCTIONS ─────────────────────────────────────────────────────────
function addHeader(slide, title, subtitle = "") {
  // Header bar
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.72,
    fill: { color: ACCENT1 }, line: { color: ACCENT1 } });
  // Accent stripe
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0.72, w: 10, h: 0.06,
    fill: { color: ACCENT2 }, line: { color: ACCENT2 } });
  slide.addText(title, { x: 0.3, y: 0.05, w: 9.4, h: 0.6,
    fontSize: 22, bold: true, color: WHITE, fontFace: "Calibri", margin: 0, valign: "middle" });
  if (subtitle) {
    slide.addText(subtitle, { x: 0.3, y: 0.78, w: 9.4, h: 0.32,
      fontSize: 11, color: LIGHTG, fontFace: "Calibri", italic: true, margin: 0 });
  }
}

function addFooter(slide, ref = "") {
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.38, w: 10, h: 0.245,
    fill: { color: CARD_BG }, line: { color: CARD_BG } });
  const refText = ref || "Sources: Lancet Diab Endocrinol 2022 | Nat Rev Dis Primers 2024 | Harrison's 22e | Berek & Novak's Gynecology | Goldman-Cecil Medicine";
  slide.addText(refText, { x: 0.2, y: 5.39, w: 9.6, h: 0.22,
    fontSize: 7.5, color: LIGHTG, fontFace: "Calibri", margin: 0, italic: true });
}

function addBGShape(slide) {
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625,
    fill: { color: BG }, line: { color: BG } });
}

function card(slide, x, y, w, h, title, bullets, titleColor = ACCENT3) {
  slide.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w, h,
    fill: { color: CARD_BG }, line: { color: ACCENT1, width: 1 }, rectRadius: 0.08,
    shadow: { type: "outer", color: "000000", blur: 5, offset: 3, angle: 135, opacity: 0.3 } });
  slide.addText(title, { x: x + 0.12, y: y + 0.06, w: w - 0.24, h: 0.3,
    fontSize: 11, bold: true, color: titleColor, fontFace: "Calibri", margin: 0 });
  const items = bullets.map((b, i) => ({
    text: b,
    options: { bullet: { type: "bullet" }, fontSize: 9.5, color: OFFWHITE, fontFace: "Calibri",
      paraSpaceBefore: i === 0 ? 2 : 1, breakLine: i < bullets.length - 1 }
  }));
  slide.addText(items, { x: x + 0.12, y: y + 0.38, w: w - 0.24, h: h - 0.44,
    valign: "top", margin: 0 });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  // Full dark BG
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: BG }, line: { color: BG } });
  // Left accent bar
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT2 }, line: { color: ACCENT2 } });
  // Decorative circle top-right
  s.addShape(pres.shapes.OVAL, { x: 7.8, y: -1.2, w: 3.5, h: 3.5,
    fill: { color: ACCENT1, transparency: 80 }, line: { color: ACCENT1, transparency: 80 } });
  s.addShape(pres.shapes.OVAL, { x: 8.2, y: -0.8, w: 2.5, h: 2.5,
    fill: { color: ACCENT2, transparency: 85 }, line: { color: ACCENT2, transparency: 85 } });

  s.addText("POLYENDOCRINE METABOLIC\nOVARIAN SYNDROME", {
    x: 0.4, y: 0.7, w: 9.2, h: 1.7,
    fontSize: 36, bold: true, color: WHITE, fontFace: "Calibri",
    align: "left", valign: "middle", lineSpacingMultiple: 1.15
  });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.4, y: 2.55, w: 4.5, h: 0.05, fill: { color: ACCENT2 }, line: { color: ACCENT2 } });
  s.addText("The New Identity of PCOS — A Comprehensive Review", {
    x: 0.4, y: 2.65, w: 9, h: 0.45, fontSize: 16, color: LIGHTG, fontFace: "Calibri", italic: true
  });
  s.addText([
    { text: "Formerly: Polycystic Ovary Syndrome (PCOS)\n", options: { bold: false, color: OFFWHITE } },
    { text: "Proposed New Name: Polyendocrine Metabolic Ovarian Syndrome (PEMOS)", options: { bold: true, color: ACCENT3 } }
  ], { x: 0.4, y: 3.2, w: 9, h: 0.7, fontSize: 12.5, fontFace: "Calibri" });

  s.addText([
    { text: "Sources: ", options: { bold: true, color: LIGHTG } },
    { text: "Lancet Diabetes Endocrinol 2022 • Nat Rev Dis Primers 2024 • Harrison's 22e • Berek & Novak's Gynecology", options: { color: LIGHTG } }
  ], { x: 0.4, y: 4.1, w: 9, h: 0.35, fontSize: 9.5, fontFace: "Calibri", italic: true });

  s.addText("Medical Education Presentation  |  May 2026", {
    x: 0.4, y: 5.1, w: 9, h: 0.3, fontSize: 10, color: "5577AA", fontFace: "Calibri"
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 — WHY THE NAME IS CHANGING
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBGShape(s);
  addHeader(s, "Why the Name Is Changing", "From PCOS → Polyendocrine Metabolic Ovarian Syndrome (PEMOS)");

  // Two columns
  card(s, 0.2, 0.95, 4.6, 2.05, "🔴  Problems with 'PCOS'", [
    "Name fixates on polycystic ovaries — absent in ~30% of patients",
    "Ovarian cysts are a consequence, not the cause",
    "Misleads clinicians toward purely gynecological framing",
    "Ignores systemic endocrine & metabolic burden",
    "Delays diagnosis — up to 2–3 years on average (Lancet 2022)"
  ], ACCENT2);

  card(s, 5.0, 0.95, 4.6, 2.05, "✅  Why PEMOS Is More Accurate", [
    "\"Polyendocrine\" → HPG axis, adrenal, pancreatic, thyroid involvement",
    "\"Metabolic\" → insulin resistance, dyslipidaemia, T2DM risk",
    "\"Ovarian\" → retained anatomical location",
    "\"Syndrome\" → preserved clinical heterogeneity",
    "Better reflects multi-organ burden and lifespan trajectory"
  ], ACCENT3);

  // Timeline box
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.2, y: 3.1, w: 9.4, h: 1.15,
    fill: { color: CARD_BG }, line: { color: ACCENT1, width: 1 }, rectRadius: 0.07 });
  s.addText("Historical Milestones", { x: 0.35, y: 3.15, w: 4, h: 0.28,
    fontSize: 11, bold: true, color: ACCENT3, fontFace: "Calibri", margin: 0 });
  const milestones = [
    ["1935", "Stein & Leventhal: Bilateral PCO + amenorrhea + obesity described"],
    ["1990", "NIH Criteria: Hyperandrogenism + anovulation"],
    ["2003", "Rotterdam Criteria: 2 of 3 features (HA, cycles, PCO morphology)"],
    ["2013", "Endocrine Society ratifies Rotterdam criteria for adults"],
    ["2023–25", "Calls to rename PCOS to PEMOS / EMIT to reflect metabolic-endocrine reality"]
  ];
  milestones.forEach(([yr, txt], i) => {
    const xPos = 0.35 + i * 1.88;
    s.addShape(pres.shapes.OVAL, { x: xPos - 0.02, y: 3.48, w: 0.22, h: 0.22,
      fill: { color: ACCENT2 }, line: { color: ACCENT2 } });
    s.addText(yr, { x: xPos + 0.05, y: 3.46, w: 1.3, h: 0.22,
      fontSize: 9, bold: true, color: ACCENT2, fontFace: "Calibri", margin: 0 });
    s.addText(txt, { x: xPos - 0.02, y: 3.72, w: 1.78, h: 0.44,
      fontSize: 7.8, color: OFFWHITE, fontFace: "Calibri", margin: 0, wrap: true });
  });

  addFooter(s);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 — EPIDEMIOLOGY & BURDEN
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBGShape(s);
  addHeader(s, "Epidemiology & Global Burden", "Lancet Diabetes & Endocrinology 2022 • Nature Reviews Disease Primers 2024");

  // Big stat boxes
  const stats = [
    { val: "5–18%", lbl: "of women affected\nglobally", color: ACCENT2 },
    { val: "11–13%", lbl: "prevalence (Nature\nRev Dis Primers 2024)", color: ACCENT3 },
    { val: "#1", lbl: "cause of anovulatory\ninfertility worldwide", color: "F5A623" },
    { val: "2–3 yrs", lbl: "average delay\nto diagnosis", color: "FF6B6B" },
    { val: "T2DM ×4", lbl: "increased odds of\nearly type 2 diabetes", color: ACCENT3 }
  ];
  stats.forEach((st, i) => {
    const x = 0.15 + i * 1.95;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y: 0.9, w: 1.75, h: 1.4,
      fill: { color: CARD_BG }, line: { color: st.color, width: 2 }, rectRadius: 0.1 });
    s.addText(st.val, { x, y: 0.95, w: 1.75, h: 0.7,
      fontSize: 22, bold: true, color: st.color, fontFace: "Calibri", align: "center", valign: "middle" });
    s.addText(st.lbl, { x, y: 1.62, w: 1.75, h: 0.62,
      fontSize: 9.5, color: OFFWHITE, fontFace: "Calibri", align: "center", valign: "top", wrap: true });
  });

  // Below: three feature cards
  card(s, 0.15, 2.45, 3.0, 1.7, "Reproductive Impact", [
    "Most common cause of hirsutism & HA in developed countries",
    "Anovulatory infertility: up to 80% respond to oral induction agents",
    "Elevated risk: miscarriage, gestational DM, preeclampsia, preterm birth",
    "Endometrial cancer risk increased (chronic anovulation → unopposed oestrogen)"
  ]);
  card(s, 3.45, 2.45, 3.0, 1.7, "Metabolic Impact", [
    "Insulin resistance in 50–70% regardless of BMI",
    "Dyslipidaemia: ↑ LDL, ↓ HDL, ↑ triglycerides",
    "Increased odds for early-onset type 2 diabetes",
    "Cardiovascular risk — BP, inflammation, atherosclerosis",
    "Non-alcoholic fatty liver disease (NAFLD) association"
  ], "F5A623");
  card(s, 6.75, 2.45, 3.0, 1.7, "Psychological Impact", [
    "Anxiety & depression significantly elevated",
    "Eating disorders and negative body image",
    "Psychosexual dysfunction",
    "Reduced health-related quality of life",
    "Symptoms often dismissed or delayed — worsening burden"
  ], ACCENT2);

  addFooter(s, "Joham AE et al., Lancet Diabetes Endocrinol 2022 | Stener-Victorin E et al., Nat Rev Dis Primers 2024");
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 — PATHOPHYSIOLOGY
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBGShape(s);
  addHeader(s, "Pathophysiology of PEMOS (PCOS)", "Multi-System Endocrine & Metabolic Dysregulation");

  // Central node
  s.addShape(pres.shapes.OVAL, { x: 3.8, y: 1.8, w: 2.2, h: 1.2,
    fill: { color: ACCENT2 }, line: { color: ACCENT2 } });
  s.addText("PEMOS\nCore Defects", { x: 3.8, y: 1.8, w: 2.2, h: 1.2,
    fontSize: 11, bold: true, color: WHITE, fontFace: "Calibri", align: "center", valign: "middle" });

  // Surrounding mechanism cards
  const nodes = [
    { x: 0.1, y: 0.88, w: 2.4, h: 1.42, title: "HPG Axis Dysfunction", bullets: ["↑ GnRH pulse frequency", "↑↑ LH secretion relative to FSH", "Elevated LH:FSH ratio (~2:1)", "Impaired folliculogenesis → anovulation"], col: ACCENT3 },
    { x: 0.1, y: 2.5, w: 2.4, h: 1.38, title: "Androgen Excess", bullets: ["Ovarian theca cell ↑ androgen production", "Adrenal functional hyperandrogenism", "↓ SHBG (liver, driven by insulin)", "Clinical: hirsutism, acne, alopecia"], col: ACCENT2 },
    { x: 7.3, y: 0.88, w: 2.5, h: 1.42, title: "Insulin Resistance", bullets: ["Post-receptor defect in classic tissues", "Ovarian 'paradox' — preserved PI3K signalling", "Hyperinsulinaemia → ↑ ovarian androgen", "Central adiposity ↔ worsens IR"], col: "F5A623" },
    { x: 7.3, y: 2.5, w: 2.5, h: 1.38, title: "Adipose Tissue Dysfunction", bullets: ["Visceral adiposity & adipokine dysregulation", "↑ Adiponectin deficiency → ↑ IR", "Chronic low-grade inflammation", "↑ TNF-α, IL-6, CRP"], col: ACCENT1 },
    { x: 0.1, y: 4.05, w: 3.5, h: 0.78, title: "Genetic & Epigenetic Susceptibility", bullets: ["Polygenic/multifactorial inheritance", "Epigenetic androgen exposure in utero implicated (Nat Rev 2024)"], col: LIGHTG },
    { x: 5.8, y: 4.05, w: 3.9, h: 0.78, title: "Neuroendocrine & Gut Microbiome", bullets: ["↑ Glutamate, ↓ GABA/5-HT/DA → elevated GnRH pulses", "Gut dysbiosis linked to IR and androgen metabolism"], col: LIGHTG }
  ];
  nodes.forEach(n => card(s, n.x, n.y, n.w, n.h, n.title, n.bullets, n.col));

  // Connector lines (approximate)
  [[2.5, 2.5, 3.8, 2.3], [2.5, 3.2, 3.8, 2.8], [6.0, 2.3, 7.3, 2.3], [6.0, 2.8, 7.3, 2.9]].forEach(([x1,y1,x2,y2]) => {
    s.addShape(pres.shapes.LINE, { x: x1, y: y1, w: x2-x1, h: 0.01,
      line: { color: LIGHTG, width: 1, dashType: "dash" } });
  });

  addFooter(s);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 — DIAGNOSTIC CRITERIA
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBGShape(s);
  addHeader(s, "Diagnostic Criteria", "Rotterdam 2003 (Endorsed by Endocrine Society 2013) · AE-PCOS Society");

  // Rotterdam box
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.2, y: 0.92, w: 4.5, h: 2.05,
    fill: { color: CARD_BG }, line: { color: ACCENT3, width: 2 }, rectRadius: 0.1 });
  s.addText("Rotterdam 2003 Criteria", { x: 0.35, y: 0.97, w: 4.0, h: 0.3,
    fontSize: 12, bold: true, color: ACCENT3, fontFace: "Calibri", margin: 0 });
  s.addText("Requires 2 of 3 features (other causes excluded):", {
    x: 0.35, y: 1.3, w: 4.1, h: 0.28, fontSize: 9.5, color: OFFWHITE, fontFace: "Calibri", margin: 0 });
  const rott = [
    "1. Hyperandrogenism — clinical (hirsutism, acne, alopecia) or biochemical (↑ free testosterone, ↑ DHEA-S)",
    "2. Oligo-ovulation or anovulation (irregular/absent menstrual cycles)",
    "3. Polycystic ovarian morphology on USS (≥20 follicles per ovary OR ovarian volume >10 mL)"
  ];
  rott.forEach((r, i) => {
    s.addText(r, { x: 0.35, y: 1.6 + i * 0.38, w: 4.2, h: 0.38,
      fontSize: 9.5, color: OFFWHITE, fontFace: "Calibri", margin: 0, wrap: true });
  });

  // 4 Phenotypes table
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 4.9, y: 0.92, w: 4.85, h: 2.05,
    fill: { color: CARD_BG }, line: { color: ACCENT1, width: 1.5 }, rectRadius: 0.08 });
  s.addText("Four Rotterdam Phenotypes", { x: 5.05, y: 0.97, w: 4.5, h: 0.28,
    fontSize: 12, bold: true, color: ACCENT1, fontFace: "Calibri", margin: 0 });
  const phenotypes = [
    ["Phenotype A (Classic)", "HA + Anovulation + PCO morphology", "Severest metabolic risk"],
    ["Phenotype B", "HA + Anovulation", "High androgenic"],
    ["Phenotype C (Ovulatory)", "HA + PCO morphology", "Mild metabolic risk"],
    ["Phenotype D", "Anovulation + PCO morphology", "Non-androgenic"]
  ];
  phenotypes.forEach(([ph, feat, note], i) => {
    const yp = 1.32 + i * 0.39;
    s.addShape(pres.shapes.RECTANGLE, { x: 4.9, y: yp, w: 4.85, h: 0.37,
      fill: { color: i % 2 === 0 ? "0F2030" : CARD_BG }, line: { color: "transparent" } });
    s.addText(ph, { x: 5.0, y: yp + 0.04, w: 1.55, h: 0.28,
      fontSize: 9, bold: true, color: ACCENT3, fontFace: "Calibri", margin: 0 });
    s.addText(feat, { x: 6.62, y: yp + 0.04, w: 1.72, h: 0.28,
      fontSize: 8.5, color: OFFWHITE, fontFace: "Calibri", margin: 0 });
    s.addText(note, { x: 8.38, y: yp + 0.04, w: 1.3, h: 0.28,
      fontSize: 8, color: LIGHTG, fontFace: "Calibri", margin: 0, italic: true });
  });

  // Special populations
  card(s, 0.2, 3.1, 4.5, 1.28, "Adolescents — Special Criteria (Lancet 2022)", [
    "Requires BOTH hyperandrogenism AND irregular cycles (>2 yr post-menarche)",
    "Ovarian morphology NOT included — poor specificity in teens",
    "Anti-Müllerian hormone (AMH) not yet validated for routine adolescent use"
  ], ACCENT2);
  card(s, 4.9, 3.1, 4.85, 1.28, "Exclusion of Mimics (Always Required)", [
    "Congenital adrenal hyperplasia (non-classic 21-OHase deficiency)",
    "Cushing syndrome • Thyroid disease • Hyperprolactinaemia",
    "Androgen-secreting tumours • Hypo/hypergonadotropic disorders"
  ], "F5A623");

  addFooter(s, "Berek & Novak's Gynecology | Endocrine Society 2013 | Lancet Diabetes Endocrinol 2022 (Joham et al.)");
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 — CLINICAL FEATURES
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBGShape(s);
  addHeader(s, "Clinical Features Across the Lifespan", "Features typically arise at puberty and evolve through adult life");

  const systems = [
    { title: "Reproductive & Gynaecological", items: ["Oligomenorrhoea / secondary amenorrhoea", "Anovulatory infertility", "Hirsutism (Ferriman-Gallwey score ≥8)", "Acne vulgaris / seborrhoea", "Androgenic alopecia", "Endometrial hyperplasia / cancer risk"], col: ACCENT2, x: 0.15, y: 0.95 },
    { title: "Metabolic & Cardiometabolic", items: ["Obesity / central adiposity (≥40–80%)", "Insulin resistance & hyperinsulinaemia", "Impaired glucose tolerance / T2DM", "Dyslipidaemia (↑ LDL/TG, ↓ HDL)", "Hypertension — early onset", "NAFLD / metabolic-associated steatosis"], col: "F5A623", x: 3.45, y: 0.95 },
    { title: "Endocrine / Hormonal", items: ["↑ LH:FSH ratio (LH dominant)", "↑ Total & free testosterone", "↑ DHEA-S (adrenal contribution)", "↓ SHBG (liver, insulin-driven)", "Elevated AMH (antral follicle excess)", "Possible thyroid autoimmunity association"], col: ACCENT3, x: 6.75, y: 0.95 }
  ];
  systems.forEach(sys => {
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: sys.x, y: sys.y, w: 3.1, h: 2.6,
      fill: { color: CARD_BG }, line: { color: sys.col, width: 1.5 }, rectRadius: 0.1 });
    s.addText(sys.title, { x: sys.x + 0.12, y: sys.y + 0.1, w: 2.86, h: 0.3,
      fontSize: 10.5, bold: true, color: sys.col, fontFace: "Calibri", margin: 0 });
    const items = sys.items.map((b, i) => ({
      text: b,
      options: { bullet: { type: "bullet" }, fontSize: 9, color: OFFWHITE, fontFace: "Calibri",
        paraSpaceBefore: 2, breakLine: i < sys.items.length - 1 }
    }));
    s.addText(items, { x: sys.x + 0.12, y: sys.y + 0.45, w: 2.86, h: 2.05, valign: "top", margin: 0 });
  });

  // Psychological & long-term row
  card(s, 0.15, 3.7, 4.6, 1.15, "Psychological & Quality of Life", [
    "Anxiety (OR ~5×) and depression significantly elevated",
    "Eating disorders and body dysmorphia",
    "Psychosexual dysfunction; negative body image",
    "Reduced health-related QoL — often undertreated"
  ], ACCENT2);
  card(s, 5.0, 3.7, 4.75, 1.15, "Long-Term & Perimenopausal Risk", [
    "PCOS features persist into menopause (metabolic risk ongoing)",
    "Endometrial cancer (anovulation → unopposed oestrogen)",
    "Cardiovascular disease risk elevated lifelong",
    "Possible association with male relatives (family clustering)"
  ], LIGHTG);

  addFooter(s);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 — INVESTIGATIONS & BIOMARKERS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBGShape(s);
  addHeader(s, "Investigations & Biomarkers", "Evidence-Based Assessment of PEMOS");

  const labs = [
    { cat: "Hormonal Profile", tests: ["LH, FSH, LH:FSH ratio", "Total & free testosterone", "DHEA-S, androstenedione", "SHBG (often ↓ in PCOS)", "Anti-Müllerian hormone (AMH ↑)", "17-OH progesterone (exclude CAH)"], col: ACCENT3, x: 0.2, y: 0.9 },
    { cat: "Metabolic Screen", tests: ["Fasting glucose + 2-hr OGTT", "HbA1c", "Fasting insulin & HOMA-IR", "Fasting lipid profile", "LFTs (NAFLD screening)", "Blood pressure measurement"], col: "F5A623", x: 3.55, y: 0.9 },
    { cat: "Imaging & Other", tests: ["Pelvic USS (follicle count, ovarian volume)", "Follicle count ≥20/ovary or vol >10 mL", "Thyroid function (TSH ± TPO antibodies)", "Prolactin (exclude hyperprolactinaemia)", "Short Synacthen test if 17-OHP ↑", "BMI, waist circumference, BP"], col: ACCENT2, x: 6.85, y: 0.9 }
  ];
  labs.forEach(l => {
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: l.x, y: l.y, w: 3.1, h: 2.5,
      fill: { color: CARD_BG }, line: { color: l.col, width: 1.5 }, rectRadius: 0.09 });
    s.addText(l.cat, { x: l.x + 0.12, y: l.y + 0.1, w: 2.8, h: 0.28,
      fontSize: 11, bold: true, color: l.col, fontFace: "Calibri", margin: 0 });
    const items = l.tests.map((t, i) => ({
      text: t,
      options: { bullet: { type: "bullet" }, fontSize: 9.5, color: OFFWHITE, fontFace: "Calibri",
        paraSpaceBefore: 2, breakLine: i < l.tests.length - 1 }
    }));
    s.addText(items, { x: l.x + 0.12, y: l.y + 0.42, w: 2.86, h: 1.96, valign: "top", margin: 0 });
  });

  // Key notes
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.2, y: 3.52, w: 9.5, h: 1.05,
    fill: { color: CARD_BG }, line: { color: ACCENT1, width: 1 }, rectRadius: 0.08 });
  s.addText("Key Clinical Notes", { x: 0.35, y: 3.57, w: 3, h: 0.28,
    fontSize: 11, bold: true, color: ACCENT1, fontFace: "Calibri", margin: 0 });
  const notes = [
    "• AMH is emerging as a surrogate for polycystic ovarian morphology (not yet universally validated in adolescents)",
    "• HOMA-IR ≥2.5 suggests clinically significant insulin resistance",
    "• Screening for T2DM every 1–3 yrs recommended; depression/anxiety screening at diagnosis and follow-up",
    "• Lipid profile at diagnosis for overweight/obese; hypertension screening at every visit"
  ];
  const noteItems = notes.map((n, i) => ({
    text: n, options: { breakLine: i < notes.length - 1, fontSize: 9.5, color: OFFWHITE, fontFace: "Calibri" }
  }));
  s.addText(noteItems, { x: 0.35, y: 3.88, w: 9.3, h: 0.62, valign: "top", margin: 0, wrap: true });

  addFooter(s, "Lancet Diabetes Endocrinol 2022 • Nat Rev Dis Primers 2024 • Harrison's Principles of Internal Medicine 22e");
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 — MANAGEMENT
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBGShape(s);
  addHeader(s, "Evidence-Based Management of PEMOS", "Lifestyle · Metabolic · Reproductive · Psychological (Lancet 2022 Guidelines)");

  // 4 pillars
  const pillars = [
    { num: "01", title: "Lifestyle Optimisation", subs: [
      "First-line for ALL patients regardless of BMI",
      "Balanced diet (Mediterranean preferred) + regular aerobic exercise",
      "5–10% weight loss improves menstrual regularity, hyperandrogenism, IR",
      "Prepregnancy counselling for all women planning pregnancy",
      "Psychological support integrated into care"
    ], col: ACCENT3, x: 0.15, y: 0.9 },
    { num: "02", title: "Metabolic Management", subs: [
      "Metformin: first-line for overweight/obese + cardiometabolic risk",
      "Improves insulin resistance, lipids, menstrual regularity",
      "Combined OCP: regulates cycles + treats hyperandrogenism",
      "If OCP inadequate after 6 months → add spironolactone or flutamide",
      "Screen/treat hypertension, dyslipidaemia, T2DM per standard guidelines"
    ], col: "F5A623", x: 5.1, y: 0.9 }
  ];
  pillars.forEach(p => {
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: p.x, y: p.y, w: 4.75, h: 2.2,
      fill: { color: CARD_BG }, line: { color: p.col, width: 2 }, rectRadius: 0.1 });
    s.addShape(pres.shapes.OVAL, { x: p.x + 0.12, y: p.y + 0.1, w: 0.42, h: 0.42,
      fill: { color: p.col }, line: { color: p.col } });
    s.addText(p.num, { x: p.x + 0.12, y: p.y + 0.1, w: 0.42, h: 0.42,
      fontSize: 12, bold: true, color: WHITE, fontFace: "Calibri", align: "center", valign: "middle" });
    s.addText(p.title, { x: p.x + 0.65, y: p.y + 0.12, w: 3.85, h: 0.38,
      fontSize: 12, bold: true, color: p.col, fontFace: "Calibri", margin: 0, valign: "middle" });
    const items = p.subs.map((b, i) => ({
      text: b, options: { bullet: { type: "bullet" }, fontSize: 9.5, color: OFFWHITE, fontFace: "Calibri",
        paraSpaceBefore: 2, breakLine: i < p.subs.length - 1 }
    }));
    s.addText(items, { x: p.x + 0.18, y: p.y + 0.58, w: 4.42, h: 1.52, valign: "top", margin: 0 });
  });

  const pillars2 = [
    { num: "03", title: "Reproductive / Fertility", subs: [
      "Ovulation induction 1st-line: Letrozole (aromatase inhibitor) — superior to clomiphene",
      "Clomiphene citrate with/without metformin: 60–80% ovulation rate",
      "Injectable gonadotropins: risk of OHSS, use judiciously",
      "IVF with GnRH antagonist protocol preferred (reduces OHSS risk)",
      "Screen for gestational DM, preeclampsia in pregnancy"
    ], col: ACCENT2, x: 0.15, y: 3.22 },
    { num: "04", title: "Psychological & Long-Term", subs: [
      "Screen for depression & anxiety at diagnosis and every review",
      "CBT, mindfulness, and support groups recommended",
      "Anti-androgens (spironolactone 25–100 mg) for hirsutism/acne",
      "Progestin protection of endometrium (MPA 10 mg × 10–14 d / 3 months or LNG-IUD)",
      "Lifelong cardiometabolic surveillance (lipids, BP, HbA1c)"
    ], col: ACCENT1, x: 5.1, y: 3.22 }
  ];
  pillars2.forEach(p => {
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: p.x, y: p.y, w: 4.75, h: 2.08,
      fill: { color: CARD_BG }, line: { color: p.col, width: 2 }, rectRadius: 0.1 });
    s.addShape(pres.shapes.OVAL, { x: p.x + 0.12, y: p.y + 0.1, w: 0.42, h: 0.42,
      fill: { color: p.col }, line: { color: p.col } });
    s.addText(p.num, { x: p.x + 0.12, y: p.y + 0.1, w: 0.42, h: 0.42,
      fontSize: 12, bold: true, color: WHITE, fontFace: "Calibri", align: "center", valign: "middle" });
    s.addText(p.title, { x: p.x + 0.65, y: p.y + 0.12, w: 3.85, h: 0.38,
      fontSize: 12, bold: true, color: p.col, fontFace: "Calibri", margin: 0, valign: "middle" });
    const items = p.subs.map((b, i) => ({
      text: b, options: { bullet: { type: "bullet" }, fontSize: 9.5, color: OFFWHITE, fontFace: "Calibri",
        paraSpaceBefore: 2, breakLine: i < p.subs.length - 1 }
    }));
    s.addText(items, { x: p.x + 0.18, y: p.y + 0.58, w: 4.42, h: 1.38, valign: "top", margin: 0 });
  });

  addFooter(s, "Harrison's Principles of Internal Medicine 22e | Lancet Diabetes Endocrinol 2022 | Berek & Novak's Gynecology");
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 — EMERGING RESEARCH & FUTURE DIRECTIONS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBGShape(s);
  addHeader(s, "Emerging Research & Future Directions", "Nature Reviews Disease Primers 2024 • Nat Rev Dis Primers PMC10471160");

  card(s, 0.15, 0.92, 3.0, 2.1, "Novel Biomarkers", [
    "AMH as primary diagnostic marker replacing USS",
    "Galectin-3 — emerging cardiometabolic biomarker in PCOS",
    "Adipokines (adiponectin, leptin, resistin) — IR surrogates",
    "Gut microbiome profiling as diagnostic aid",
    "Metabolomic & proteomic signatures under investigation"
  ], ACCENT3);

  card(s, 3.45, 0.92, 3.0, 2.1, "Therapeutic Innovation", [
    "GLP-1 receptor agonists (semaglutide, liraglutide) — weight & IR",
    "Inositol (myo + D-chiro) supplementation — insulin signalling",
    "SGLT-2 inhibitors — cardiometabolic benefit under study",
    "Anti-androgen advances (selective AR modulators)",
    "Neuroendocrine targeting — kisspeptin pathway research"
  ], "F5A623");

  card(s, 6.75, 0.92, 3.0, 2.1, "Personalised Medicine", [
    "Phenotype-specific treatment algorithms",
    "Genetic & epigenetic stratification of risk",
    "Refining criteria for lean PCOS vs obese PCOS",
    "Male relatives — broader PCOS-related metabolic risk",
    "Patient-centred outcomes & shared decision-making"
  ], ACCENT2);

  // Renaming consensus box
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.15, y: 3.15, w: 9.6, h: 1.62,
    fill: { color: CARD_BG }, line: { color: ACCENT2, width: 2 }, rectRadius: 0.1 });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.15, y: 3.15, w: 0.12, h: 1.62,
    fill: { color: ACCENT2 }, line: { color: ACCENT2 } });
  s.addText("The Case for PEMOS — Renaming Consensus", {
    x: 0.38, y: 3.2, w: 9.0, h: 0.32,
    fontSize: 13, bold: true, color: ACCENT2, fontFace: "Calibri", margin: 0 });
  const renamePoints = [
    "The term 'polycystic' is a misnomer — the ovaries show multifollicular appearance, not true cysts",
    "International advocates (Teede, Stener-Victorin, Legro, Goodarzi — Nat Rev 2024) call for a name reflecting systemic disease",
    "PEMOS / EMIT (Endocrine-Metabolic Infertility Triad) proposed alternatives emphasise multi-system pathology",
    "A new name would reduce stigma, accelerate diagnosis, and guide more comprehensive multidisciplinary care"
  ];
  const renameItems = renamePoints.map((r, i) => ({
    text: r, options: { bullet: { type: "bullet" }, fontSize: 10, color: OFFWHITE, fontFace: "Calibri",
      paraSpaceBefore: 3, breakLine: i < renamePoints.length - 1 }
  }));
  s.addText(renameItems, { x: 0.38, y: 3.55, w: 9.2, h: 1.15, valign: "top", margin: 0 });

  addFooter(s, "Stener-Victorin E et al., Nat Rev Dis Primers 2024 (PMID 38637590) | Joham AE et al., Lancet Diabetes Endocrinol 2022 (PMID 35934017)");
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 — REFERENCES
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addBGShape(s);
  addHeader(s, "Key References & Evidence Sources", "");

  const refs = [
    { label: "Lancet Diabetes Endocrinol 2022", text: "Joham AE, Norman RJ, Stener-Victorin E, et al. Polycystic ovary syndrome. Lancet Diabetes Endocrinol. 2022;10(9):668–680. PMID: 35934017", col: ACCENT2 },
    { label: "Nat Rev Dis Primers 2024", text: "Stener-Victorin E, Teede H, Norman RJ, et al. Polycystic ovary syndrome. Nat Rev Dis Primers. 2024;10(1):27. PMID: 38637590", col: ACCENT3 },
    { label: "Harrison's Medicine 22e", text: "Harrison's Principles of Internal Medicine, 22nd Edition (2025). McGraw Hill Medical. Chapter on Polycystic Ovary Syndrome.", col: ACCENT1 },
    { label: "Berek & Novak's Gynecology", text: "Berek & Novak's Gynecology, 16th Edition. Chapter 35: Hyperandrogenism, Hirsutism, and the Polycystic Ovary Syndrome. Lippincott Williams & Wilkins.", col: "F5A623" },
    { label: "Goldman-Cecil Medicine", text: "Goldman-Cecil Medicine International Edition, 2-Volume Set. Chapter on Polycystic Ovary Syndrome. Elsevier.", col: LIGHTG },
    { label: "J Clin Endocrinol Metab 2023", text: "Bril F, Ezeh U, Amiri M, et al. Adipose Tissue Dysfunction in Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2023 Dec 21. PMID: 37329216 (Systematic Review)", col: ACCENT3 },
    { label: "Fertil Steril 2025", text: "Dokras A. Polycystic ovary syndrome in 2025 — insights and innovations. Fertil Steril. 2025 Nov. PMID: 40992713", col: ACCENT2 }
  ];

  refs.forEach((r, i) => {
    const y = 0.92 + i * 0.63;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: y, w: 0.08, h: 0.48,
      fill: { color: r.col }, line: { color: r.col } });
    s.addText(r.label, { x: 0.38, y: y + 0.01, w: 2.5, h: 0.22,
      fontSize: 10, bold: true, color: r.col, fontFace: "Calibri", margin: 0 });
    s.addText(r.text, { x: 0.38, y: y + 0.23, w: 9.3, h: 0.26,
      fontSize: 8.5, color: LIGHTG, fontFace: "Calibri", margin: 0, italic: true });
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// WRITE FILE
// ═══════════════════════════════════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/pcos-ppt/PEMOS_PCOS_Presentation.pptx" })
  .then(() => console.log("✅ PPTX saved successfully!"))
  .catch(e => { console.error("❌ Error:", e); process.exit(1); });

cd /home/daytona/workspace/pcos-ppt && node build.js 2>&1

~/pcos-ppt/build.js

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/pcos-ppt/build.js'

cd /home/daytona/workspace/pcos-ppt && node build.js 2>&1 && ls -lh PEMOS_PCOS_P…