Amenorrhea

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amenorrhea diagnosis management

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Amenorrhea

Definition

Primary amenorrhea is defined as:

Absence of menses by age 13 with no secondary sexual characteristics (no breast development), OR
Absence of menses by age 15 in the presence of normal secondary sexual development.

Secondary amenorrhea is cessation of menses for 3 months in a woman who previously had regular cycles, or 6 months in a woman with irregular cycles.

Physiology

Normal menstruation depends on an intact hypothalamic-pituitary-ovarian-uterine axis. The hypothalamus secretes GnRH in a pulsatile fashion, which stimulates pituitary secretion of FSH and LH. These stimulate ovarian folliculogenesis and steroidogenesis. Estradiol and progesterone drive endometrial growth and shedding, and provide negative feedback to the hypothalamus and pituitary. Disruption at any level produces amenorrhea.

Role of the hypothalamic-pituitary-gonadal axis in amenorrhea

Classification and Etiology

Amenorrhea is best approached by categorizing it anatomically.

1. Outflow Tract / Uterine Causes

Condition	Type	Notes
Imperforate hymen	Primary	Cyclic pain + hematocolpos
Transverse vaginal septum	Primary	Similar to hymen
Congenital vaginal atresia	Primary
Mullerian agenesis (MRKH syndrome)	Primary	Normal 46,XX; uterus/vagina absent; ovaries normal; caused by WNT4 mutations
Androgen Insensitivity Syndrome (AIS)	Primary	46,XY; female external genitalia; absent/sparse pubic/axillary hair; testes present; accounts for ~10% of primary amenorrhea
Asherman syndrome	Secondary	Post-traumatic intrauterine synechiae; curettage accounts for >90%; TB endemic cause
Cervical stenosis	Secondary	Post-procedure

2. Ovarian Causes (Hypergonadotropic Hypogonadism)

Condition	Type	Notes
Turner syndrome (45,X)	Primary	Most common; streak ovaries; stigmata: short stature, webbed neck, shield chest, cubitus valgus, short 4th metacarpal
Other gonadal dysgenesis (46,XX, 46,XY)	Primary	Elevated FSH/LH
Mosaic karyotypes	Primary/Secondary	Occasional estrogen, rare ovulation possible
Primary ovarian insufficiency (POI)	Secondary	FSH >25-40 mIU/mL x2 samples; idiopathic, autoimmune, chemo, radiation
PCOS	Primary or Secondary	Hyperandrogenism, oligo-anovulation
Ovarian tumor	Secondary	Rare
Resistant ovary syndrome	Primary/Secondary

3. Pituitary Causes (Hypogonadotropic Hypogonadism)

Condition	Type	Notes
Hyperprolactinemia	Secondary	Prolactinoma most common; also drugs
Sheehan syndrome	Secondary	Postpartum pituitary necrosis
Lymphocytic hypophysitis	Secondary
Acquired hypopituitarism	Secondary	Trauma, tumor, irradiation
Cushing disease	Secondary

4. Hypothalamic Causes (Hypogonadotropic Hypogonadism)

Condition	Type	Notes
Functional hypothalamic amenorrhea (FHA)	Secondary	Caloric restriction, excess exercise, psychological stress; increased CRH suppresses GnRH
Kallmann syndrome	Primary	IHH + anosmia; ~50% genetic cause; 3x more common in males
Isolated hypogonadotropic hypogonadism	Primary	No anosmia; ~50% of patients have some breast development
Tumor/infiltrative disease	Either	Craniopharyngioma, sarcoid, histiocytosis

5. Other Endocrine / Systemic Causes

Cause	Mechanism
Hypothyroidism	Elevated TSH → elevated TRH → elevated prolactin → anovulation
Hyperthyroidism	Altered sex hormone binding globulin, disrupted feedback
Adrenal: Cushing, CAH, virilizing tumor	Androgen excess → disrupted HPO axis
Late-onset CAH (21-hydroxylase deficiency)	Excess androgens
Eating disorders (anorexia nervosa)	Combined nutritional, stress, weight-loss mechanism

6. Iatrogenic Causes

Drug	Mechanism
Antipsychotics (haloperidol, risperidone, clozapine)	Dopamine blockade → hyperprolactinemia
Tricyclic antidepressants / MAOIs	Increased prolactin
Antihypertensives (methyldopa, reserpine, Ca-channel blockers)	Dopamine depletion → prolactin elevation
Chemotherapy (busulfan, chlorambucil)	Ovarian toxicity
OCP / progestational agents	Hormonal suppression
Marijuana, digitalis	Estrogenic activity

Evaluation

Step 1 - Establish the Type and Do a Pregnancy Test

A urine/serum beta-hCG must be performed first in all reproductive-age women - pregnancy is the most common cause of secondary amenorrhea.

Step 2 - Physical Examination

Presence or absence of secondary sexual characteristics (breast development, pubic/axillary hair) - key to categorizing primary amenorrhea
Pelvic anatomy - normal vs. abnormal (outflow tract defects, imperforate hymen)
Signs of hyperandrogenism (acne, hirsutism, clitoromegaly)
Signs of Turner syndrome, or other syndromic features
Galactorrhea (suggests hyperprolactinemia)

Step 3 - Initial Laboratory Work-Up (in patient with normal anatomy and normal secondary sexual characteristics)

Serum TSH - exclude thyroid disorders
Serum prolactin - obtain fasting, no recent breast stimulation, in follicular phase if cycles exist
Serum FSH (with estradiol) - key test to distinguish ovarian from central cause
Consider vaginal ultrasound for antral follicle count (PCOS vs. POI)
If prolactin elevated or hypothalamic amenorrhea suspected: MRI of sella/hypothalamus

Step 4 - Interpret FSH

FSH Level	Interpretation	Likely Causes
High (>25-40 mIU/mL on 2 samples)	Hypergonadotropic hypogonadism	POI, Turner, gonadal dysgenesis
Normal/Low	Hypogonadotropic or eugonadotropic	FHA, pituitary tumor/disease, PCOS, hypothalamic lesion
Normal + hyperandrogenism	Eugonadotropic	PCOS, CAH, androgen-secreting tumor

Step 5 - Additional Tests Based on Findings

If POI confirmed: FMR1 premutation, karyotype, 21-hydroxylase antibody
If PCOS suspected: Total testosterone, SHBG, 17-hydroxyprogesterone (to exclude CAH)
If PCOS confirmed: Fasting glucose, lipid profile
AMH: Low in POI, high in PCOS; undetectable years before final menses in POI
Karyotype: Perform in primary amenorrhea with gonadal failure (~30% have abnormal karyotype); consider in all POI regardless of age
DEXA scan: For suspected long-term hypoestrogenism (bone density)

Evaluation algorithm for amenorrhea - Harrison's Principles

Treatment

Outflow Tract Obstruction

Imperforate hymen or vaginal septum: surgical correction - must be done promptly to prevent endometriosis from retrograde flow
Mullerian agenesis: Vaginal dilation (first-line); surgical creation of neovagina if needed; ovaries are normal so surrogacy/uterine transplant can enable pregnancy
AIS: Gonadectomy (after pubertal development to allow breast development and growth spurt) + estrogen replacement + possible vaginal dilation
Asherman syndrome: Hysteroscopic lysis of adhesions + post-op estrogen to stimulate re-epithelialization

Ovarian Insufficiency / Hypergonadotropic Hypogonadism

Hormone replacement therapy (HRT): Estrogen + progesterone to restore estrogen levels, protect bone (prevent osteoporosis), and provide cycle control
Fertility: Oocyte donation is the most effective option; spontaneous pregnancy can rarely occur in POI
Y-chromosome containing gonadal material: Gonadectomy to prevent gonadoblastoma

Functional Hypothalamic Amenorrhea

Address the underlying cause: nutritional rehabilitation (weight gain), reduce exercise intensity, stress management, cognitive behavioral therapy (CBT)
Estrogen replacement / OCP for bone protection while addressing root cause
Pulsatile GnRH or gonadotropins if fertility is desired and lifestyle modifications insufficient

Hyperprolactinemia

Dopamine agonists (cabergoline, bromocriptine) - first-line for prolactinoma and hyperprolactinemia-induced amenorrhea
Surgery for resistant macroprolactinomas

PCOS

Combined OCPs for cycle regulation and hyperandrogenism control
Metformin for insulin resistance/metabolic features
Ovulation induction (letrozole, clomiphene, or gonadotropins) for fertility

Hypothyroidism / Hyperthyroidism

Thyroid hormone replacement or anti-thyroid therapy - menses typically resume with euthyroid state

Key Clinical Points

Absent menses may indicate a systemic medical condition with implications beyond fertility - always establish a cause.
When gonadal failure accompanies primary amenorrhea, karyotypic abnormality is present in ~30% of cases.
The most important diagnostic elements are: physical exam for secondary sexual characteristics and anatomy, beta-hCG, prolactin, TSH, and FSH.
The progestogen challenge test has poor sensitivity and specificity and is no longer routinely recommended to assess estrogen status.
Long-term hypoestrogenism from any cause increases fracture risk - bone mineral density assessment (DEXA) should be considered.
Functional hypothalamic amenorrhea is a diagnosis of exclusion after ruling out organic causes.

Sources: Harrison's Principles of Internal Medicine 22E, p. 3176-3178; Berek & Novak's Gynecology, pp. 1855-1890; Tietz Textbook of Laboratory Medicine 7th Ed., pp. 2353-2490; Goldman-Cecil Medicine, p. 1677

Abnormal Uterine Bleeding in short Refer DC Datta

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I have enough material for a concise, well-structured answer. Note: DC Datta's textbook is not available in the library, but I'll present content aligned with the standard teaching in DC Datta's style (definitions, patterns, PALM-COEIN classification, evaluation, management) and flag this clearly.

Abnormal Uterine Bleeding (AUB)

Note: DC Datta's Textbook of Gynecology is not in this library's collection. The following is based on Goldman-Cecil Medicine, Berek & Novak's Gynecology, and Rosen's Emergency Medicine - the content closely aligns with DC Datta's standard teaching on this topic.

Definition

AUB is any bleeding from the uterine corpus that is abnormal in regularity, frequency, duration, or volume and that occurs in the absence of pregnancy.

Normal menstrual parameters (for reference):

Parameter	Normal Range
Frequency	24-38 days
Duration	4-8 days
Volume	5-80 mL per cycle

Terminology (FIGO 2011)

Old terms like DUB (Dysfunctional Uterine Bleeding), menorrhagia, metrorrhagia have been replaced by descriptive terms:

Term	Meaning
Heavy Menstrual Bleeding (HMB)	Excessive volume interfering with quality of life
Intermenstrual Bleeding (IMB)	Bleeding between regular cycles
Irregular Menstrual Bleeding	Unpredictable timing
Prolonged Menstrual Bleeding	Duration >8 days

PALM-COEIN Classification (FIGO)

The standard classification divides causes into structural (PALM) and non-structural (COEIN):

PALM - Structural Causes

	Cause	Key Features
P	Polyp (AUB-P)	Endometrial/endocervical; IMB, postcoital bleeding
A	Adenomyosis (AUB-A)	Endometrial glands in myometrium; HMB + dysmenorrhea; bulky tender uterus
L	Leiomyoma (AUB-L)	Submucosal (AUB-LSM) causes most bleeding; other types (AUB-LO) less so
M	Malignancy & Hyperplasia (AUB-M)	Endometrial carcinoma/atypical hyperplasia; must exclude in all postmenopausal AUB

COEIN - Non-Structural Causes

	Cause	Key Features
C	Coagulopathy (AUB-C)	vWD, ITP, anticoagulant use; heavy flow since menarche
O	Ovulatory Dysfunction (AUB-O)	Most common - anovulation from PCOS, thyroid, hyperprolactinemia, perimenopause, adolescence
E	Endometrial (AUB-E)	Primary endometrial disorder; abnormal local hemostasis
I	Iatrogenic (AUB-I)	Hormonal contraceptives, anticoagulants, antipsychotics
N	Not yet classified (AUB-N)	Rare/poorly defined entities

Epidemiology

AUB affects 10-30% of women of reproductive age
~20% is postmenarchal (adolescent) - due to HPO axis immaturity → anovulation
~50% is perimenopausal - incipient ovarian failure
~75% of cases have no organic cause - i.e., anovulatory/dysfunctional bleeding

Pathophysiology of Anovulatory Bleeding

In anovulation, unopposed estrogen continuously stimulates the endometrium without the stabilizing effect of progesterone:

Endometrium proliferates and thickens irregularly
Unsynchronized shedding → irregular, unpredictable, often heavy bleeding
Estrogen withdrawal bleeding (when estrogen drops)
Estrogen breakthrough bleeding (from continuously high estrogen)

Evaluation / Diagnosis

History

Pattern, duration, quantity of bleeding; clots; flooding
LMP, sexual history, contraceptive use
Symptoms of thyroid disease, PCOS, coagulopathy
Drug history (anticoagulants, OCP, antipsychotics)

Examination

General: pallor, signs of anaemia, thyroid enlargement, hirsutism
Pelvic: uterine size, tenderness, adnexal masses; speculum for cervical/vaginal cause
Exclude pregnancy first (beta-hCG)

Investigations

Test	Purpose
Beta-hCG	Exclude pregnancy (first step always)
CBC + platelets	Anaemia; thrombocytopenia
Coagulation profile (PT, aPTT, vWF)	Exclude coagulopathy
TSH	Thyroid dysfunction
Fasting glucose	PCOS-related insulin resistance
Prolactin, FSH, LH	Anovulatory causes
Testosterone, DHEA-S	Hyperandrogenism
Transvaginal ultrasound (TVUS)	Polyps, fibroids, endometrial thickness
Endometrial biopsy / D&C	Women >35 years, risk factors for endometrial cancer, or failed medical treatment
Hysteroscopy	Gold standard to visualize endometrial cavity; directed biopsy
SIS (Saline Infusion Sonography)	Better detection of intracavitary lesions

Endometrial sampling is mandatory in women >35 years or those with prolonged anovulatory bleeding, due to risk of endometrial carcinoma.

Management

Acute / Emergency (Haemodynamically Unstable)

IV fluids, blood transfusion if needed
IV conjugated estrogen 25 mg every 4-6 hours (until bleeding stops)
Intrauterine Foley tamponade (26Fr, 30 mL saline) as temporizing measure
Surgical: urgent D&C, uterine artery embolization (UAE), endometrial ablation, or hysterectomy

Medical (Outpatient / Subacute)

Hormonal:

Drug	Dose / Route	Notes
Combined OCP	1 tablet every 6 hours x 5-7 days (acute); then cyclic	First-line for anovulatory AUB; bleeding stops within 24 hours
Progestins (MPA, norethindrone)	MPA 5-10 mg x 10 days; norethindrone 5 mg TDS x 7 days	For women with estrogen contraindications
Levonorgestrel IUD (Mirena)	Intrauterine	Excellent for HMB long-term; reduces flow by >90%
GnRH agonists	Monthly injection	Fibroid-related AUB; pre-operative use
Relugolix / Elagolix	Oral GnRH antagonists	For fibroid/adenomyosis-related bleeding

Non-Hormonal:

Drug	Dose	Mechanism
Tranexamic acid	1.3 g PO TDS x 5 days OR 10 mg/kg IV	Antifibrinolytic; reduces HMB by ~50%
NSAIDs (mefenamic acid, ibuprofen)	Start before menses	Reduces prostaglandins; modest effect on flow
Desmopressin	For vWD-related AUB

Surgical

Procedure	Indication
D&C (dilatation & curettage)	Diagnostic + acute control; not long-term solution alone
Hysteroscopic polypectomy/myomectomy	Structural causes (polyps, submucosal fibroids)
Endometrial ablation	Persistent AUB with completed family; not 100% effective
UAE	Symptomatic fibroids; preserve uterus
Myomectomy	Fibroids; fertility desired
Hysterectomy	Refractory/recurrent AUB; family complete; malignancy

Special Age Groups

Age Group	Commonest Cause	Approach
Adolescent	Anovulation (HPO axis immaturity)	Exclude coagulopathy; OCP/progestins
Reproductive age	PCOS, polyp, fibroid, pregnancy complication	PALM-COEIN workup
Perimenopausal	Anovulation (incipient ovarian failure)	Exclude endometrial pathology; hormonal
Postmenopausal	Endometrial atrophy (most common); carcinoma	Endometrial biopsy mandatory

Sources: Goldman-Cecil Medicine International Edition; Rosen's Emergency Medicine 9e; Berek & Novak's Gynecology. DC Datta's Textbook of Gynecology was not available in the library - content presented follows the same standard framework.

Generate a quick reference PDF for PALM-COEIN classification

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ls /home/daytona/workspace/ 2>/dev/null || mkdir -p /home/daytona/workspace

Running Command

mkdir -p /home/daytona/workspace/palm-coein && python3 -c "from reportlab.lib.pa…

Writing File

~/palm-coein/generate_pdf.py

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

OUTPUT = "/home/daytona/workspace/palm-coein/PALM_COEIN_Quick_Reference.pdf"

# ── Colour palette ────────────────────────────────────────────────────────────
DARK_BLUE   = colors.HexColor("#1a3c5e")
PALM_COLOR  = colors.HexColor("#c0392b")   # red for PALM
COEIN_COLOR = colors.HexColor("#1a6b3e")   # green for COEIN
LIGHT_RED   = colors.HexColor("#fdecea")
LIGHT_GREEN = colors.HexColor("#e8f5e9")
LIGHT_BLUE  = colors.HexColor("#e8f0fe")
GOLD        = colors.HexColor("#d4a017")
GREY_BG     = colors.HexColor("#f4f6f9")
MID_GREY    = colors.HexColor("#7f8c8d")
WHITE       = colors.white
BLACK       = colors.HexColor("#1c1c1c")

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=15*mm, leftMargin=15*mm,
    topMargin=15*mm,   bottomMargin=15*mm,
    title="PALM-COEIN Classification – Quick Reference",
    author="Orris Medical Reference"
)

W, H = A4
COL = W - 30*mm   # usable width

styles = getSampleStyleSheet()

def style(name, **kw):
    return ParagraphStyle(name, **kw)

# ── Custom styles ─────────────────────────────────────────────────────────────
TITLE_S = style("Title_S", fontSize=22, textColor=WHITE,
                fontName="Helvetica-Bold", alignment=TA_CENTER,
                leading=28, spaceAfter=2)
SUB_S   = style("Sub_S",   fontSize=11, textColor=colors.HexColor("#cfe2ff"),
                fontName="Helvetica", alignment=TA_CENTER, leading=14)
FOOT_S  = style("Foot_S",  fontSize=7.5, textColor=MID_GREY,
                fontName="Helvetica-Oblique", alignment=TA_CENTER)

SEC_HDR = style("SecHdr",  fontSize=13, textColor=WHITE,
                fontName="Helvetica-Bold", alignment=TA_CENTER,
                leading=16)
CELL_HDR= style("CellHdr", fontSize=9.5, textColor=WHITE,
                fontName="Helvetica-Bold", alignment=TA_CENTER, leading=12)
CELL_TXT= style("CellTxt", fontSize=8.5, textColor=BLACK,
                fontName="Helvetica", leading=11, alignment=TA_LEFT)
CELL_KEY= style("CellKey", fontSize=9, textColor=BLACK,
                fontName="Helvetica-Bold", leading=12, alignment=TA_LEFT)
BODY_S  = style("Body_S",  fontSize=8.5, textColor=BLACK,
                fontName="Helvetica", leading=12, alignment=TA_JUSTIFY)
BOLD_S  = style("Bold_S",  fontSize=8.5, textColor=BLACK,
                fontName="Helvetica-Bold", leading=12)
NOTE_S  = style("Note_S",  fontSize=8, textColor=MID_GREY,
                fontName="Helvetica-Oblique", leading=11)
PILL_S  = style("Pill_S",  fontSize=9, textColor=WHITE,
                fontName="Helvetica-Bold", alignment=TA_CENTER, leading=11)

story = []

# ══════════════════════════════════════════════════════════════════════════════
# HEADER BANNER
# ══════════════════════════════════════════════════════════════════════════════
header_data = [[
    Paragraph("<b>PALM-COEIN</b>", TITLE_S),
]]
header_table = Table(header_data, colWidths=[COL])
header_table.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), DARK_BLUE),
    ("TOPPADDING",    (0,0), (-1,-1), 12),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 10),
    ("RIGHTPADDING",  (0,0), (-1,-1), 10),
    ("ROUNDEDCORNERS",(0,0), (-1,-1), [6,6,0,0]),
]))
story.append(header_table)

sub_data = [[
    Paragraph("Classification of Abnormal Uterine Bleeding (AUB) — FIGO 2011", SUB_S),
]]
sub_table = Table(sub_data, colWidths=[COL])
sub_table.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), colors.HexColor("#2c5282")),
    ("TOPPADDING",    (0,0), (-1,-1), 6),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("LEFTPADDING",   (0,0), (-1,-1), 10),
    ("ROUNDEDCORNERS",(0,0), (-1,-1), [0,0,6,6]),
]))
story.append(sub_table)
story.append(Spacer(1, 8))

# ── Definition box ─────────────────────────────────────────────────────────
def_data = [[
    Paragraph(
        "<b>AUB</b> = Any uterine bleeding that is abnormal in <b>regularity, frequency, "
        "duration, or volume</b> in the absence of pregnancy.",
        BODY_S)
]]
def_table = Table(def_data, colWidths=[COL])
def_table.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), LIGHT_BLUE),
    ("BOX",           (0,0), (-1,-1), 0.8, DARK_BLUE),
    ("TOPPADDING",    (0,0), (-1,-1), 7),
    ("BOTTOMPADDING", (0,0), (-1,-1), 7),
    ("LEFTPADDING",   (0,0), (-1,-1), 10),
    ("RIGHTPADDING",  (0,0), (-1,-1), 10),
    ("ROUNDEDCORNERS",(0,0), (-1,-1), [4,4,4,4]),
]))
story.append(def_table)
story.append(Spacer(1, 10))

# ══════════════════════════════════════════════════════════════════════════════
# PALM — STRUCTURAL CAUSES
# ══════════════════════════════════════════════════════════════════════════════
palm_hdr = Table([[Paragraph("PALM   —   Structural Causes", SEC_HDR)]], colWidths=[COL])
palm_hdr.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), PALM_COLOR),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("ROUNDEDCORNERS",(0,0), (-1,-1), [6,6,0,0]),
]))
story.append(palm_hdr)

palm_col_w = [12*mm, 28*mm, 35*mm, 50*mm, COL - 12*mm - 28*mm - 35*mm - 50*mm]

palm_rows = [
    # header
    [
        Paragraph("Code", CELL_HDR),
        Paragraph("Category", CELL_HDR),
        Paragraph("Pathology", CELL_HDR),
        Paragraph("Clinical Features", CELL_HDR),
        Paragraph("Investigation", CELL_HDR),
    ],
    # P
    [
        Paragraph("<b>P</b>", style("PL", fontSize=16, textColor=PALM_COLOR,
                  fontName="Helvetica-Bold", alignment=TA_CENTER, leading=18)),
        Paragraph("<b>Polyp</b>\n(AUB-P)", CELL_KEY),
        Paragraph("Endometrial or endocervical epithelial overgrowth", CELL_TXT),
        Paragraph("• Intermenstrual bleeding (IMB)\n• Postcoital bleeding\n• Variable flow", CELL_TXT),
        Paragraph("TVUS / SIS\nHysteroscopy", CELL_TXT),
    ],
    # A
    [
        Paragraph("<b>A</b>", style("AL", fontSize=16, textColor=PALM_COLOR,
                  fontName="Helvetica-Bold", alignment=TA_CENTER, leading=18)),
        Paragraph("<b>Adenomyosis</b>\n(AUB-A)", CELL_KEY),
        Paragraph("Endometrial glands + stroma within myometrium", CELL_TXT),
        Paragraph("• Heavy menstrual bleeding (HMB)\n• Dysmenorrhea\n• Bulky, tender uterus", CELL_TXT),
        Paragraph("TVUS / MRI", CELL_TXT),
    ],
    # L
    [
        Paragraph("<b>L</b>", style("LL", fontSize=16, textColor=PALM_COLOR,
                  fontName="Helvetica-Bold", alignment=TA_CENTER, leading=18)),
        Paragraph("<b>Leiomyoma</b>\n(AUB-L)\n\nSubmucosal → AUB-LSM\nOther → AUB-LO", CELL_KEY),
        Paragraph("Benign smooth muscle tumour; submucosal type most likely to cause AUB", CELL_TXT),
        Paragraph("• HMB, prolonged bleeding\n• Pelvic pressure/bulk\n• Irregular uterus on exam", CELL_TXT),
        Paragraph("TVUS / SIS\nMRI for mapping", CELL_TXT),
    ],
    # M
    [
        Paragraph("<b>M</b>", style("ML", fontSize=16, textColor=PALM_COLOR,
                  fontName="Helvetica-Bold", alignment=TA_CENTER, leading=18)),
        Paragraph("<b>Malignancy &\nHyperplasia</b>\n(AUB-M)", CELL_KEY),
        Paragraph("Endometrial carcinoma; atypical hyperplasia; cervical/other malignancy", CELL_TXT),
        Paragraph("• Postmenopausal bleeding\n• Irregular, painless bleeding\n• Risk: obesity, nulliparity, unopposed estrogen", CELL_TXT),
        Paragraph("Endometrial biopsy\nD&C\nHysteroscopy\nMRI staging", CELL_TXT),
    ],
]

palm_table = Table(palm_rows, colWidths=palm_col_w, repeatRows=1)
palm_table.setStyle(TableStyle([
    # header row
    ("BACKGROUND",    (0,0), (-1,0), colors.HexColor("#8b1a10")),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",      (0,0), (-1,0), 9),
    # alternating rows
    ("BACKGROUND",    (0,1), (-1,1), LIGHT_RED),
    ("BACKGROUND",    (0,2), (-1,2), WHITE),
    ("BACKGROUND",    (0,3), (-1,3), LIGHT_RED),
    ("BACKGROUND",    (0,4), (-1,4), WHITE),
    # grid
    ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#e0b0b0")),
    ("BOX",           (0,0), (-1,-1), 0.8, PALM_COLOR),
    # padding
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ("RIGHTPADDING",  (0,0), (-1,-1), 5),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
    ("ALIGN",         (0,0), (0,-1), "CENTER"),
    ("ROUNDEDCORNERS",(0,0), (-1,-1), [0,0,6,6]),
]))
story.append(palm_table)
story.append(Spacer(1, 10))

# ══════════════════════════════════════════════════════════════════════════════
# COEIN — NON-STRUCTURAL CAUSES
# ══════════════════════════════════════════════════════════════════════════════
coein_hdr = Table([[Paragraph("COEIN   —   Non-Structural Causes", SEC_HDR)]], colWidths=[COL])
coein_hdr.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), COEIN_COLOR),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("ROUNDEDCORNERS",(0,0), (-1,-1), [6,6,0,0]),
]))
story.append(coein_hdr)

coein_col_w = [12*mm, 30*mm, 38*mm, 48*mm, COL - 12*mm - 30*mm - 38*mm - 48*mm]

coein_rows = [
    [
        Paragraph("Code", CELL_HDR),
        Paragraph("Category", CELL_HDR),
        Paragraph("Mechanism", CELL_HDR),
        Paragraph("Clinical Features", CELL_HDR),
        Paragraph("Key Tests", CELL_HDR),
    ],
    # C
    [
        Paragraph("<b>C</b>", style("CL", fontSize=16, textColor=COEIN_COLOR,
                  fontName="Helvetica-Bold", alignment=TA_CENTER, leading=18)),
        Paragraph("<b>Coagulopathy</b>\n(AUB-C)", CELL_KEY),
        Paragraph("vWD, ITP, anticoagulant therapy, liver disease", CELL_TXT),
        Paragraph("• HMB since menarche\n• Easy bruising, prolonged bleeding\n• Family history of bleeding", CELL_TXT),
        Paragraph("PT, aPTT\nvWF antigen\nPlatelet count", CELL_TXT),
    ],
    # O
    [
        Paragraph("<b>O</b>", style("OL", fontSize=16, textColor=COEIN_COLOR,
                  fontName="Helvetica-Bold", alignment=TA_CENTER, leading=18)),
        Paragraph("<b>Ovulatory\nDysfunction</b>\n(AUB-O)", CELL_KEY),
        Paragraph("Anovulation → unopposed estrogen\nCauses: PCOS, thyroid, hyperprolactinemia, perimenopause, adolescence", CELL_TXT),
        Paragraph("• Irregular, unpredictable bleeding\n• May be heavy or light\n• Intermenstrual bleeding", CELL_TXT),
        Paragraph("TSH, Prolactin\nFSH, LH\nTestosterone\nTVUS", CELL_TXT),
    ],
    # E
    [
        Paragraph("<b>E</b>", style("EL", fontSize=16, textColor=COEIN_COLOR,
                  fontName="Helvetica-Bold", alignment=TA_CENTER, leading=18)),
        Paragraph("<b>Endometrial</b>\n(AUB-E)", CELL_KEY),
        Paragraph("Primary endometrial disorder; abnormal local haemostasis (↓ vasoconstrictors, ↑ fibrinolysis)", CELL_TXT),
        Paragraph("• Regular cycles but HMB\n• No structural cause found\n• Normal ovulation", CELL_TXT),
        Paragraph("Endometrial biopsy\nHysteroscopy\n(diagnosis of exclusion)", CELL_TXT),
    ],
    # I
    [
        Paragraph("<b>I</b>", style("IL", fontSize=16, textColor=COEIN_COLOR,
                  fontName="Helvetica-Bold", alignment=TA_CENTER, leading=18)),
        Paragraph("<b>Iatrogenic</b>\n(AUB-I)", CELL_KEY),
        Paragraph("Hormonal contraceptives, IUDs, anticoagulants, antipsychotics (→ hyperprolactinemia)", CELL_TXT),
        Paragraph("• Breakthrough bleeding on OCP\n• Irregular bleeding on progestin-only\n• Drug history positive", CELL_TXT),
        Paragraph("Drug history\nProlactin if on antipsychotics", CELL_TXT),
    ],
    # N
    [
        Paragraph("<b>N</b>", style("NL", fontSize=16, textColor=COEIN_COLOR,
                  fontName="Helvetica-Bold", alignment=TA_CENTER, leading=18)),
        Paragraph("<b>Not Yet\nClassified</b>\n(AUB-N)", CELL_KEY),
        Paragraph("Rare / poorly defined entities not fitting other categories", CELL_TXT),
        Paragraph("• Arteriovenous malformations\n• Myometrial hypertrophy\n• Endometritis (rare)", CELL_TXT),
        Paragraph("Case-dependent\nspecialist workup", CELL_TXT),
    ],
]

coein_table = Table(coein_rows, colWidths=coein_col_w, repeatRows=1)
coein_table.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), colors.HexColor("#145232")),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
    ("FONTSIZE",      (0,0), (-1,0), 9),
    ("BACKGROUND",    (0,1), (-1,1), LIGHT_GREEN),
    ("BACKGROUND",    (0,2), (-1,2), WHITE),
    ("BACKGROUND",    (0,3), (-1,3), LIGHT_GREEN),
    ("BACKGROUND",    (0,4), (-1,4), WHITE),
    ("BACKGROUND",    (0,5), (-1,5), LIGHT_GREEN),
    ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#a8d5b5")),
    ("BOX",           (0,0), (-1,-1), 0.8, COEIN_COLOR),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ("RIGHTPADDING",  (0,0), (-1,-1), 5),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
    ("ALIGN",         (0,0), (0,-1), "CENTER"),
    ("ROUNDEDCORNERS",(0,0), (-1,-1), [0,0,6,6]),
]))
story.append(coein_table)
story.append(Spacer(1, 10))

# ══════════════════════════════════════════════════════════════════════════════
# NORMAL MENSTRUAL PARAMETERS + MANAGEMENT OVERVIEW  (side by side)
# ══════════════════════════════════════════════════════════════════════════════
half = (COL - 6*mm) / 2

# --- Normal Parameters ---
norm_title = Table([[Paragraph("Normal Menstrual Parameters", style("NT",
    fontSize=9.5, textColor=WHITE, fontName="Helvetica-Bold",
    alignment=TA_CENTER, leading=12))]],
    colWidths=[half])
norm_title.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), DARK_BLUE),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("ROUNDEDCORNERS",(0,0), (-1,-1), [4,4,0,0]),
]))

norm_rows = [
    [Paragraph("<b>Parameter</b>", CELL_HDR), Paragraph("<b>Normal Range</b>", CELL_HDR)],
    [Paragraph("Frequency", CELL_TXT),    Paragraph("Every 24–38 days", CELL_TXT)],
    [Paragraph("Duration",  CELL_TXT),    Paragraph("4–8 days", CELL_TXT)],
    [Paragraph("Volume",    CELL_TXT),    Paragraph("5–80 mL per cycle", CELL_TXT)],
    [Paragraph("Regularity",CELL_TXT),    Paragraph("Variation ≤7-9 days cycle-to-cycle", CELL_TXT)],
]
norm_table = Table(norm_rows, colWidths=[half*0.5, half*0.5])
norm_table.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), colors.HexColor("#34495e")),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("BACKGROUND",    (0,1), (-1,1), GREY_BG),
    ("BACKGROUND",    (0,2), (-1,2), WHITE),
    ("BACKGROUND",    (0,3), (-1,3), GREY_BG),
    ("BACKGROUND",    (0,4), (-1,4), WHITE),
    ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#bdc3c7")),
    ("BOX",           (0,0), (-1,-1), 0.8, DARK_BLUE),
    ("TOPPADDING",    (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ("ROUNDEDCORNERS",(0,0), (-1,-1), [0,0,4,4]),
]))

# --- Management Summary ---
mgmt_title = Table([[Paragraph("Management Overview", style("MT",
    fontSize=9.5, textColor=WHITE, fontName="Helvetica-Bold",
    alignment=TA_CENTER, leading=12))]],
    colWidths=[half])
mgmt_title.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), colors.HexColor("#6b2d8b")),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("ROUNDEDCORNERS",(0,0), (-1,-1), [4,4,0,0]),
]))

mgmt_rows = [
    [Paragraph("<b>Situation</b>", CELL_HDR), Paragraph("<b>First-line Treatment</b>", CELL_HDR)],
    [Paragraph("Acute / haemodynamic instability", CELL_TXT),
     Paragraph("IV conj. estrogen 25 mg q4-6h; D&C; UAE", CELL_TXT)],
    [Paragraph("Anovulatory (stable)", CELL_TXT),
     Paragraph("Combined OCP 1 tab q6h × 5–7 days, then cyclic", CELL_TXT)],
    [Paragraph("HMB (non-structural)", CELL_TXT),
     Paragraph("Tranexamic acid 1.3 g TDS × 5 days; LNG-IUD", CELL_TXT)],
    [Paragraph("Structural cause (fibroid/polyp)", CELL_TXT),
     Paragraph("Hysteroscopic resection; myomectomy; UAE", CELL_TXT)],
    [Paragraph("Postmenopausal AUB", CELL_TXT),
     Paragraph("Endometrial biopsy FIRST; treat cause", CELL_TXT)],
    [Paragraph("Refractory / family complete", CELL_TXT),
     Paragraph("Endometrial ablation; hysterectomy", CELL_TXT)],
]
mgmt_table = Table(mgmt_rows, colWidths=[half*0.52, half*0.48])
mgmt_table.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), colors.HexColor("#4a1a6b")),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("BACKGROUND",    (0,1), (-1,1), colors.HexColor("#f3e8ff")),
    ("BACKGROUND",    (0,2), (-1,2), WHITE),
    ("BACKGROUND",    (0,3), (-1,3), colors.HexColor("#f3e8ff")),
    ("BACKGROUND",    (0,4), (-1,4), WHITE),
    ("BACKGROUND",    (0,5), (-1,5), colors.HexColor("#f3e8ff")),
    ("BACKGROUND",    (0,6), (-1,6), WHITE),
    ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#d8b4fe")),
    ("BOX",           (0,0), (-1,-1), 0.8, colors.HexColor("#6b2d8b")),
    ("TOPPADDING",    (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ("ROUNDEDCORNERS",(0,0), (-1,-1), [0,0,4,4]),
]))

# combine left/right
norm_block  = [norm_title,  norm_table]
mgmt_block  = [mgmt_title,  mgmt_table]

from reportlab.platypus import BalancedColumns
side_data = [[norm_title, Spacer(6,1), mgmt_title],
             [norm_table, Spacer(6,1), mgmt_table]]
side_table = Table(
    [[norm_title, Spacer(6,1), mgmt_title],
     [norm_table, Spacer(6,1), mgmt_table]],
    colWidths=[half, 6, half]
)
side_table.setStyle(TableStyle([
    ("VALIGN",  (0,0), (-1,-1), "TOP"),
    ("LEFTPADDING",  (0,0), (-1,-1), 0),
    ("RIGHTPADDING", (0,0), (-1,-1), 0),
    ("TOPPADDING",   (0,0), (-1,-1), 0),
    ("BOTTOMPADDING",(0,0), (-1,-1), 0),
]))
story.append(side_table)
story.append(Spacer(1, 8))

# ══════════════════════════════════════════════════════════════════════════════
# INVESTIGATION ALGORITHM BOX
# ══════════════════════════════════════════════════════════════════════════════
inv_title = Table([[Paragraph("Step-wise Investigation Algorithm", style("IT",
    fontSize=9.5, textColor=WHITE, fontName="Helvetica-Bold",
    alignment=TA_CENTER, leading=12))]],
    colWidths=[COL])
inv_title.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), colors.HexColor("#b7600c")),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("ROUNDEDCORNERS",(0,0), (-1,-1), [4,4,0,0]),
]))
story.append(inv_title)

steps = [
    ["1", "Beta-hCG",          "Exclude pregnancy — always the FIRST step"],
    ["2", "CBC + Platelets",    "Assess anaemia; detect thrombocytopenia"],
    ["3", "TSH",               "Thyroid dysfunction → anovulation"],
    ["4", "Prolactin",         "Hyperprolactinemia → anovulation"],
    ["5", "Coagulation (PT, aPTT, vWF)", "Exclude coagulopathy (esp. adolescents)"],
    ["6", "FSH, LH, Testosterone", "Evaluate HPO axis; hyperandrogenism (PCOS)"],
    ["7", "TVUS / SIS",        "Structural causes — polyps, fibroids, endometrial thickness"],
    ["8", "Endometrial biopsy", "Women >35 y, prolonged anovulation, risk factors for Ca"],
    ["9", "Hysteroscopy",      "Gold standard for intracavitary pathology; directed biopsy"],
]
step_rows = [[Paragraph("<b>#</b>", CELL_HDR), Paragraph("<b>Test</b>", CELL_HDR), Paragraph("<b>Purpose</b>", CELL_HDR)]]
for s in steps:
    step_rows.append([
        Paragraph(f"<b>{s[0]}</b>", style("SN", fontSize=11, textColor=colors.HexColor("#b7600c"),
            fontName="Helvetica-Bold", alignment=TA_CENTER, leading=14)),
        Paragraph(s[1], CELL_KEY),
        Paragraph(s[2], CELL_TXT),
    ])

step_table = Table(step_rows, colWidths=[10*mm, 55*mm, COL - 65*mm])
step_table.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), colors.HexColor("#7c3a05")),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    *[("BACKGROUND",  (0,i), (-1,i), GREY_BG if i%2==1 else WHITE) for i in range(1, 10)],
    ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#e0c9b0")),
    ("BOX",           (0,0), (-1,-1), 0.8, colors.HexColor("#b7600c")),
    ("TOPPADDING",    (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
    ("ALIGN",         (0,0), (0,-1), "CENTER"),
    ("ROUNDEDCORNERS",(0,0), (-1,-1), [0,0,4,4]),
]))
story.append(step_table)
story.append(Spacer(1, 6))

# ── Footer ─────────────────────────────────────────────────────────────────
HRFlowable(width=COL, thickness=0.5, color=MID_GREY)
story.append(HRFlowable(width=COL, thickness=0.5, color=MID_GREY))
story.append(Spacer(1, 3))
story.append(Paragraph(
    "FIGO 2011 Classification  •  Sources: Goldman-Cecil Medicine · Berek &amp; Novak's Gynecology · Rosen's Emergency Medicine  •  For educational use only",
    FOOT_S))

# ══════════════════════════════════════════════════════════════════════════════
# BUILD
# ══════════════════════════════════════════════════════════════════════════════
doc.build(story)
print(f"PDF saved: {OUTPUT}")

Running Command

cd /home/daytona/workspace/palm-coein && python3 generate_pdf.py 2>&1

Running Command

ls -lh /home/daytona/workspace/palm-coein/PALM_COEIN_Quick_Reference.pdf

Your PALM-COEIN Quick Reference PDF is ready:

PALM COEIN Quick Reference

PDF Document · PDF

What's inside (single A4 page):

Section	Contents
Header	Title + AUB definition box
PALM (red)	P-A-L-M table with pathology, clinical features, investigations
COEIN (green)	C-O-E-I-N table with mechanism, features, key tests
Side-by-side	Normal menstrual parameters + Management overview
Algorithm	9-step investigation sequence
Footer	FIGO 2011 source credit

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