ls /home/daytona/workspace/ 2>/dev/null || echo "workspace empty or not found"

mkdir -p /home/daytona/workspace/gynaecology-notes

~/gynaecology-notes/gen_pdf.py

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

OUTPUT = "/home/daytona/workspace/gynaecology-notes/Gynaecology_Exam_Notes.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=2*cm, rightMargin=2*cm,
    topMargin=2.2*cm, bottomMargin=2.2*cm,
    title="Gynaecology – 20 Mark Exam Notes",
    author="Orris Medical"
)

styles = getSampleStyleSheet()

# Custom styles
TITLE = ParagraphStyle("Title", parent=styles["Title"], fontSize=18, textColor=colors.HexColor("#1a237e"),
                        spaceAfter=6, spaceBefore=4, alignment=TA_CENTER, fontName="Helvetica-Bold")
SUBTITLE = ParagraphStyle("Subtitle", parent=styles["Normal"], fontSize=11, textColor=colors.HexColor("#4a148c"),
                           spaceAfter=4, alignment=TA_CENTER, fontName="Helvetica-Oblique")
H1 = ParagraphStyle("H1", parent=styles["Heading1"], fontSize=13, textColor=colors.white,
                     backColor=colors.HexColor("#1a237e"), spaceBefore=12, spaceAfter=4,
                     leftIndent=-6, rightIndent=-6, fontName="Helvetica-Bold",
                     borderPad=4)
H2 = ParagraphStyle("H2", parent=styles["Heading2"], fontSize=11, textColor=colors.HexColor("#1a237e"),
                     spaceBefore=8, spaceAfter=3, fontName="Helvetica-Bold",
                     borderWidth=0, borderColor=colors.HexColor("#1a237e"))
H3 = ParagraphStyle("H3", parent=styles["Heading3"], fontSize=10, textColor=colors.HexColor("#4a148c"),
                     spaceBefore=6, spaceAfter=2, fontName="Helvetica-Bold")
BODY = ParagraphStyle("Body", parent=styles["Normal"], fontSize=9.5, leading=14,
                       spaceAfter=3, alignment=TA_JUSTIFY, fontName="Helvetica")
BULLET = ParagraphStyle("Bullet", parent=styles["Normal"], fontSize=9.5, leading=13,
                         leftIndent=14, firstLineIndent=-10, spaceAfter=2,
                         bulletIndent=4, fontName="Helvetica")
TABLE_H = ParagraphStyle("TableH", parent=styles["Normal"], fontSize=9, fontName="Helvetica-Bold",
                          textColor=colors.white, alignment=TA_CENTER)
TABLE_B = ParagraphStyle("TableB", parent=styles["Normal"], fontSize=8.5, fontName="Helvetica", leading=11)
FOOTER_NOTE = ParagraphStyle("Footer", parent=styles["Normal"], fontSize=8, textColor=colors.grey,
                               alignment=TA_CENTER, fontName="Helvetica-Oblique")

def h1(text): return Paragraph(f"  {text}", H1)
def h2(text): return Paragraph(text, H2)
def h3(text): return Paragraph(text, H3)
def p(text):  return Paragraph(text, BODY)
def b(text):  return Paragraph(f"• {text}", BULLET)
def sp(n=1):  return Spacer(1, n*0.3*cm)
def hr():     return HRFlowable(width="100%", thickness=0.5, color=colors.HexColor("#1a237e"), spaceAfter=4, spaceBefore=2)

def make_table(headers, rows, col_widths=None):
    data = [[Paragraph(h, TABLE_H) for h in headers]]
    for row in rows:
        data.append([Paragraph(str(c), TABLE_B) for c in row])
    if col_widths is None:
        col_widths = [None]*len(headers)
    t = Table(data, colWidths=col_widths, hAlign='LEFT')
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,0), colors.HexColor("#1a237e")),
        ('TEXTCOLOR',  (0,0), (-1,0), colors.white),
        ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor("#e8eaf6"), colors.white]),
        ('GRID', (0,0), (-1,-1), 0.4, colors.HexColor("#90caf9")),
        ('VALIGN', (0,0), (-1,-1), 'TOP'),
        ('TOPPADDING', (0,0), (-1,-1), 3),
        ('BOTTOMPADDING', (0,0), (-1,-1), 3),
        ('LEFTPADDING', (0,0), (-1,-1), 4),
        ('RIGHTPADDING', (0,0), (-1,-1), 4),
    ]))
    return t

story = []

# ─── COVER ───────────────────────────────────────────────────────────────────
story += [
    sp(4),
    Paragraph("GYNAECOLOGY", TITLE),
    Paragraph("20-Mark Exam Notes", SUBTITLE),
    Paragraph("Covering: STDs • Shastra Karma (Surgical Procedures) • Diagnostic Tools • Gynaecological Conditions", SUBTITLE),
    sp(1),
    hr(),
    sp(1),
    Paragraph("Prepared for Ayurveda / BAMS / MS (Ayurveda) – Stree Roga & Prasuti Tantra", FOOTER_NOTE),
    PageBreak()
]

# ═══════════════════════════════════════════════════════════
# SECTION 1: STDs
# ═══════════════════════════════════════════════════════════
story += [h1("SECTION 1: SEXUALLY TRANSMITTED DISEASES (STDs)"), sp()]

story += [
    p("Sexually transmitted diseases (STDs) — also called sexually transmitted infections (STIs) — are infections passed from person to person primarily through sexual contact. They are a major global public health problem and can cause serious reproductive, neonatal, and systemic morbidity."),
    sp(),
    h2("Classification of STDs"),
    make_table(
        ["Category", "Diseases"],
        [
            ["Bacterial", "Gonorrhoea, Syphilis, Chancroid, Chlamydia, Granuloma Inguinale (Donovanosis), LGV"],
            ["Viral", "Herpes Genitalis (HSV-1/2), HIV/AIDS, HPV (Genital warts), Hepatitis B, Molluscum Contagiosum"],
            ["Protozoal", "Trichomoniasis (Trichomonas vaginalis)"],
            ["Fungal", "Vulvovaginal Candidiasis (Candida albicans)"],
            ["Parasitic", "Pubic Lice (Phthirus pubis), Scabies (Sarcoptes scabiei)"],
        ],
        col_widths=[4*cm, 12*cm]
    ),
    sp(),
]

# STD Table: Causative organism, pathology, clinical, investigations, management
story += [
    h2("1. GONORRHOEA"),
    h3("Causative Organism:"),
    p("Neisseria gonorrhoeae — Gram-negative intracellular diplococcus. Infects columnar and transitional epithelium."),
    h3("Pathology:"),
    p("Attaches via pili to columnar epithelium → endocytosis → submucosal spread → acute purulent inflammation → neutrophilic infiltrate → if untreated, fibrosis and stricture. In females: endocervicitis, salpingitis, PID. In males: urethritis, epididymitis."),
    h3("Clinical Features:"),
    b("<b>Females:</b> Often asymptomatic (up to 80%); purulent/mucopurulent vaginal discharge, dysuria, intermenstrual bleeding, pelvic pain, cervicitis (friable, red cervix)."),
    b("<b>Males:</b> Urethral discharge (yellowish-green, profuse), dysuria, frequency. Complications: epididymo-orchitis, urethral stricture."),
    b("<b>Disseminated gonococcal infection (DGI):</b> Arthritis, dermatitis, rarely endocarditis/meningitis."),
    b("<b>Neonatal ophthalmia neonatorum:</b> Purulent conjunctivitis, if untreated → corneal ulceration, blindness."),
    h3("Investigations:"),
    b("Gram stain of discharge: Gram-negative intracellular diplococci within PMNs (sensitivity ~70% female, ~90% male)."),
    b("Culture: Thayer-Martin/chocolate agar — definitive; antibiotic sensitivity testing."),
    b("NAAT (Nucleic Acid Amplification Test): Most sensitive and specific; first-void urine, swab."),
    b("ELISA / Immunochromatographic tests: Rapid bedside tests."),
    h3("Management:"),
    b("<b>Uncomplicated urogenital:</b> Ceftriaxone 500 mg IM single dose + Azithromycin 1 g oral (or Doxycycline 100 mg BD × 7 days for chlamydial co-infection)."),
    b("<b>Disseminated:</b> Ceftriaxone 1 g IV/IM daily × 7 days."),
    b("<b>Ophthalmia neonatorum prophylaxis:</b> 1% silver nitrate / erythromycin eye ointment at birth."),
    b("Partner notification and treatment; condom use counselling."),
    sp(),
]

story += [
    h2("2. SYPHILIS"),
    h3("Causative Organism:"),
    p("Treponema pallidum — thin, motile, corkscrew-shaped spirochaete. Cannot be cultured in vitro."),
    h3("Pathology:"),
    p("Obliterative endarteritis of small vessels (hallmark) with perivascular lymphoplasmacytic infiltrate. Gumma formation (tertiary). Congenital syphilis via transplacental transmission after 16th week."),
    h3("Clinical Features — Stages:"),
    b("<b>Primary:</b> Painless, indurated chancre at site of inoculation (genitalia, anus, lip) + painless regional lymphadenopathy. Heals in 3–6 weeks."),
    b("<b>Secondary (6–8 weeks later):</b> Maculopapular rash (including palms and soles), condylomata lata, mucous patches, generalised lymphadenopathy, snail-track ulcers, alopecia."),
    b("<b>Latent:</b> Asymptomatic (early <2 yr; late >2 yr). Seroreactive only."),
    b("<b>Tertiary (years later):</b> Gummas (skin, bone, liver), cardiovascular syphilis (aortitis, aortic regurgitation, aortic aneurysm), neurosyphilis (tabes dorsalis, general paralysis of insane — GPI)."),
    b("<b>Congenital:</b> Stillbirth, hydrops fetalis, saddle-nose deformity, interstitial keratitis, Hutchinson's teeth, sabre tibia, deafness (Hutchinson's triad)."),
    h3("Investigations:"),
    b("<b>Direct:</b> Dark-field microscopy of chancre exudate (spirochaetes seen)."),
    b("<b>Non-treponemal (screening):</b> VDRL, RPR — titre reflects disease activity; used to monitor treatment (4-fold fall = adequate response)."),
    b("<b>Treponemal (confirmatory):</b> TPHA, FTA-ABS, TPPA — remain positive lifelong."),
    b("CSF VDRL for neurosyphilis; PCR; IgM ELISA for congenital."),
    h3("Management:"),
    b("<b>Primary/Secondary/Early latent (<1 yr):</b> Benzathine penicillin G 2.4 million units IM single dose."),
    b("<b>Late latent/Tertiary:</b> Benzathine penicillin G 2.4 MU IM weekly × 3 doses."),
    b("<b>Neurosyphilis:</b> Aqueous crystalline penicillin G 18–24 MU/day IV × 10–14 days."),
    b("<b>Penicillin allergy:</b> Doxycycline 100 mg BD × 14 days (not in pregnancy — use penicillin desensitisation)."),
    b("Jarisch-Herxheimer reaction: Fever, chills, myalgia 2–8 hrs after 1st penicillin dose — treat with antipyretics."),
    sp(),
]

story += [
    h2("3. CHLAMYDIA"),
    h3("Causative Organism:"),
    p("Chlamydia trachomatis — obligate intracellular bacterium. Serovars D–K cause genital infections; L1–L3 cause Lymphogranuloma Venereum (LGV); A–C cause trachoma."),
    h3("Pathology:"),
    p("Infects columnar epithelium → intracellular replication in inclusions → cell death → mucosal inflammation → scarring of fallopian tubes → infertility, ectopic pregnancy."),
    h3("Clinical Features:"),
    b("<b>Females (often asymptomatic ~70%):</b> Mucopurulent cervicitis, urethritis (dysuria, frequency), PID (salpingitis, endometritis), perihepatitis (Fitz-Hugh-Curtis syndrome)."),
    b("<b>Males:</b> Non-gonococcal urethritis, epididymitis, Reiter's syndrome (urethritis + arthritis + uveitis)."),
    b("<b>LGV:</b> Painless primary genital ulcer → painful inguinal lymphadenopathy (buboes) → ulceration, fistulae, rectal stricture."),
    h3("Investigations:"),
    b("NAAT (swab/urine) — gold standard; highest sensitivity."),
    b("Cell culture — reference standard but impractical."),
    b("Direct immunofluorescence (DIF), ELISA — less sensitive."),
    h3("Management:"),
    b("<b>Uncomplicated:</b> Doxycycline 100 mg BD × 7 days OR Azithromycin 1 g single dose."),
    b("<b>Pregnancy:</b> Azithromycin 1 g single dose OR Amoxicillin 500 mg TDS × 7 days."),
    b("<b>LGV:</b> Doxycycline 100 mg BD × 21 days."),
    sp(),
]

story += [
    h2("4. CHANCROID"),
    h3("Causative Organism:"), p("Haemophilus ducreyi — small Gram-negative coccobacillus."),
    h3("Clinical Features:"),
    b("Painful soft ulcer with ragged, undermined edges on genitalia (contrast with painless syphilitic chancre)."),
    b("Tender inguinal lymphadenopathy (bubo) — may suppurate."),
    b("'School of fish' arrangement on Gram stain."),
    h3("Management:"), b("Azithromycin 1 g single dose OR Ceftriaxone 250 mg IM single dose OR Ciprofloxacin 500 mg BD × 3 days."),
    sp(),
]

story += [
    h2("5. GRANULOMA INGUINALE (DONOVANOSIS)"),
    h3("Causative Organism:"), p("Klebsiella granulomatis (formerly Calymmatobacterium granulomatis)."),
    h3("Pathology:"), p("Donovan bodies seen in large mononuclear cells (macrophages) — encapsulated rod-shaped organisms."),
    h3("Clinical Features:"),
    b("Painless, progressive, beefy-red granulomatous ulcer on genitalia — bleeds on contact."),
    b("No significant lymphadenopathy (unlike LGV)."),
    b("Pseudo-bubo: subcutaneous granuloma in inguinal region."),
    h3("Investigations:"), b("Crush preparation / tissue biopsy: Donovan bodies in Wright-Giemsa stain."),
    h3("Management:"), b("Doxycycline 100 mg BD × ≥3 weeks; continue until complete healing. Alternatives: Azithromycin, Cotrimoxazole."),
    sp(),
]

story += [
    h2("6. HERPES GENITALIS"),
    h3("Causative Organism:"), p("Herpes Simplex Virus — HSV-2 (most common, genital); HSV-1 (increasingly causing genital herpes). DNA virus, latency in sacral ganglia (S2–S4)."),
    h3("Pathology:"), p("Viral replication in epithelial cells → balloon degeneration → multinucleated giant cells → intranuclear inclusions (Cowdry type A) → vesicle formation."),
    h3("Clinical Features:"),
    b("<b>Primary attack:</b> Multiple painful vesicles → erosions/ulcers on vulva, vagina, cervix, perineum; fever, malaise, inguinal lymphadenopathy; urinary retention possible."),
    b("<b>Recurrent:</b> Milder; prodrome of tingling/burning. Triggered by stress, menstruation, immunosuppression."),
    b("<b>Neonatal herpes:</b> Life-threatening — disseminated disease, encephalitis, skin/eye/mouth involvement."),
    h3("Investigations:"),
    b("Tzanck smear: Multinucleated giant cells (not specific)."),
    b("Viral culture / PCR: Gold standard."),
    b("Direct fluorescent antibody (DFA), serology (type-specific IgG: HSV-1, HSV-2)."),
    h3("Management:"),
    b("<b>Primary:</b> Acyclovir 200 mg 5×/day × 10 days OR Valacyclovir 1 g BD × 10 days."),
    b("<b>Recurrent:</b> Acyclovir 400 mg TDS × 5 days OR suppressive Valacyclovir 500 mg OD."),
    b("<b>Neonatal:</b> IV Acyclovir 20 mg/kg/dose 8-hourly × 14–21 days."),
    b("Caesarean section if active genital lesions at term — prevents neonatal transmission."),
    sp(),
]

story += [
    h2("7. HIV / AIDS"),
    h3("Causative Organism:"), p("Human Immunodeficiency Virus (HIV-1, HIV-2) — Retrovirus. Targets CD4+ T-helper lymphocytes, macrophages, dendritic cells."),
    h3("Pathology:"), p("HIV binds CD4 receptor + co-receptors (CCR5, CXCR4) → reverse transcriptase → integration into host genome as provirus → replication → CD4 cell depletion → immunodeficiency → AIDS (CD4 <200/μL or AIDS-defining illness)."),
    h3("Clinical Features (WHO Stages):"),
    b("<b>Stage 1 (Asymptomatic / Acute HIV):</b> Seroconversion illness (2–6 wks post-exposure) — fever, pharyngitis, lymphadenopathy, rash, myalgia."),
    b("<b>Stage 2:</b> Minor weight loss (<10%), herpes zoster, recurrent URTI, oral ulcers."),
    b("<b>Stage 3:</b> Severe weight loss (>10%), chronic diarrhoea >1 month, oral candidiasis, TB, severe bacterial infections."),
    b("<b>Stage 4 (AIDS):</b> PCP, cryptococcal meningitis, CMV retinitis, Kaposi's sarcoma, cerebral toxoplasmosis, HIV encephalopathy."),
    h3("Investigations:"),
    b("ELISA (screening) → Western Blot (confirmatory). Window period: 3–4 weeks (4th gen tests detect p24 antigen earlier)."),
    b("CD4 count (immunological status), HIV RNA viral load (treatment monitoring)."),
    b("NAAT / p24 antigen assay: Early diagnosis."),
    h3("Management:"),
    b("<b>ART (Antiretroviral Therapy):</b> All HIV+ patients regardless of CD4. First-line: 2 NRTIs + 1 NNRTI or INSTI (e.g., TDF + 3TC + DTG)."),
    b("<b>PrEP:</b> TDF/FTC daily for high-risk HIV-negative individuals."),
    b("<b>PEP:</b> Within 72 hours of exposure; 28-day course of ART."),
    b("OI prophylaxis: Co-trimoxazole (CD4 <200), Fluconazole, INH (TB prophylaxis if CD4 <350 in endemic areas)."),
    sp(),
]

story += [
    h2("8. TRICHOMONIASIS"),
    h3("Causative Organism:"), p("Trichomonas vaginalis — flagellated protozoan. Only infects the genitourinary tract."),
    h3("Clinical Features:"),
    b("<b>Females:</b> Frothy, yellow-green, malodorous vaginal discharge; pruritus vulvae; 'strawberry cervix' (punctate haemorrhages)."),
    b("<b>Males:</b> Usually asymptomatic; urethritis, prostatitis."),
    h3("Investigations:"),
    b("Wet mount microscopy: Motile trichomonads (pear-shaped, flagellated)."),
    b("Culture (Diamond's medium) — gold standard. NAAT — highest sensitivity."),
    b("Vaginal pH: >4.5."),
    h3("Management:"), b("Metronidazole 2 g oral single dose OR 400–500 mg BD × 7 days. Treat partner simultaneously. Avoid alcohol (disulfiram-like reaction)."),
    sp(),
]

story += [
    h2("9. GENITAL WARTS (CONDYLOMATA ACUMINATA)"),
    h3("Causative Organism:"), p("Human Papillomavirus (HPV) — DNA virus. Types 6 & 11 cause genital warts (low risk); Types 16, 18, 31, 33 cause cervical/anogenital cancers (high risk)."),
    h3("Clinical Features:"), b("Soft, fleshy, cauliflower-like growths on vulva, vagina, cervix, perineum, anus."),
    b("Usually asymptomatic; may cause pruritus, discharge, bleeding."),
    h3("Investigations:"), b("Clinical diagnosis (aceto-white test with 5% acetic acid). Colposcopy + biopsy if uncertain. PCR for HPV typing."),
    h3("Management:"),
    b("<b>Medical:</b> Podophyllin 25% (applied by physician); Imiquimod 5% cream (self-applied); Trichloroacetic acid (TCA) 80–90%."),
    b("<b>Physical:</b> Cryotherapy, electrocautery, laser ablation, surgical excision."),
    b("<b>Prevention:</b> HPV vaccines: Bivalent (16,18), Quadrivalent (6,11,16,18), Nonavalent (9 types). Recommended 9–26 years."),
    sp(),
    PageBreak(),
]

# ═══════════════════════════════════════════════════════════
# SECTION 2: SHASTRA KARMA
# ═══════════════════════════════════════════════════════════
story += [h1("SECTION 2: SHASTRA KARMA IN STREE ROGA — SURGICAL PROCEDURES IN GYNAECOLOGY"), sp()]

story += [
    h2("a. Sterilization of Instruments, Equipment and OT Complex"),
    h3("Definition:"),
    p("Sterilization is the complete destruction or removal of ALL forms of microbial life, including spores. Disinfection reduces microbial load but may not eliminate spores."),
    h3("Methods of Sterilization:"),
    make_table(
        ["Method", "Agent/Technique", "Application", "Temp/Time"],
        [
            ["Autoclaving (Steam)", "Saturated steam under pressure", "Surgical instruments, linen, drapes", "121°C/15 psi/20 min OR 134°C/30 psi/3 min"],
            ["Dry Heat Oven", "Hot air", "Glassware, oils, powders, sharp instruments", "160°C/1 hr OR 180°C/30 min"],
            ["Ethylene Oxide (ETO)", "Chemical gas", "Heat-sensitive equipment: endoscopes, plastics, electronics", "Room temp; 4–12 hrs cycle"],
            ["Glutaraldehyde (2%)", "Chemical liquid", "Endoscopes, instruments with lenses", "20 min (disinfection); 10 hr (sterilization)"],
            ["Plasma Sterilization", "Hydrogen peroxide plasma", "Heat/moisture-sensitive instruments", "~45°C; 50–75 min"],
            ["UV Radiation", "UV light (254 nm)", "OT air, surfaces", "Surface decontamination only"],
            ["Boiling", "Boiling water (100°C)", "Low-level; not for spores", "20 min (not true sterilization)"],
        ],
        col_widths=[3.5*cm, 3.5*cm, 5*cm, 4.5*cm]
    ),
    sp(),
    h3("OT (Operation Theatre) Sterility:"),
    b("Positive pressure ventilation in OT (prevents entry of outside air)."),
    b("HEPA filters; laminar airflow in high-risk areas."),
    b("Regular fumigation: Formaldehyde vapour / OT fumigants."),
    b("Surgical scrub: Betadine / chlorhexidine; sterile gloves, gowns, drapes."),
    b("Labour room: Clean technique; sterile instruments for delivery."),
    sp(),
]

story += [
    h2("b. Garbhashaya Mukha Vistrutikarana evam Lekhana — Dilatation & Curettage (D&C)"),
    h3("Definition:"),
    p("D&C is a surgical procedure in which the cervix is dilated and the uterine cavity is evacuated/scraped using a curette."),
    h3("Indications:"),
    b("Diagnostic: Abnormal uterine bleeding, postmenopausal bleeding, suspected endometrial pathology, endometrial sampling."),
    b("Therapeutic: Incomplete/missed abortion, evacuation of retained products of conception (ERPC), hydatidiform mole removal."),
    h3("Contraindications:"),
    b("Active pelvic infection (relative), cervical carcinoma (diagnostic curettage is acceptable), coagulopathy (correct first)."),
    h3("Procedure:"),
    b("Patient in lithotomy position under general/spinal/paracervical anaesthesia."),
    b("Bimanual examination to assess uterine size/position."),
    b("Cervix exposed with Sims speculum; anterior lip held with Allis/vulsellum forceps."),
    b("Uterine sound — to measure cavity length and determine uterine axis."),
    b("Cervix dilated with Hegar dilators (progressively from smallest: 1→2→3...→8–10 mm)."),
    b("Curettage with sharp or suction curette; tissue sent for histopathology."),
    h3("Complications:"),
    b("Uterine perforation (most serious), cervical laceration, haemorrhage."),
    b("Asherman's syndrome (intrauterine adhesions — synechiae) from overzealous curettage."),
    b("Infection, cervical incompetence (repeated dilations)."),
    sp(),
]

story += [
    h2("c. Garbhashaya Mukha Dahana — Cervical Cauterization"),
    h3("Definition:"),
    p("Application of heat/chemical energy to destroy abnormal or chronically inflamed cervical epithelium."),
    h3("Types:"),
    b("<b>Electrocoagulation/Electrocautery:</b> Thermal destruction of columnar epithelium; used for cervical erosion, ectropion, chronic cervicitis."),
    b("<b>Cryocauterization:</b> Liquid nitrogen (-20 to -30°C) freezes and destroys abnormal cells; used for CIN 1/2, erosion."),
    b("<b>Laser Vaporization (CO₂ laser):</b> Precise ablation of transformation zone; for CIN lesions."),
    b("<b>LEEP/LLETZ (Loop Electrosurgical Excision Procedure):</b> Excision of transformation zone using a loop electrode; provides histological specimen — preferred for CIN 2/3."),
    b("<b>Trichloroacetic acid (TCA):</b> Chemical cauterization for condylomata."),
    h3("Indications:"), b("Cervical erosion/ectropion with symptoms, CIN 1–3 (non-invasive lesions), chronic cervicitis unresponsive to medical treatment, genital warts on cervix."),
    h3("Complications:"), b("Discharge (watery), cramping, infection, cervical stenosis, secondary haemorrhage."),
    sp(),
]

story += [
    h2("d. Vandhya Karana — Sterilization: Tubectomy & Vasectomy"),
    h3("TUBECTOMY (Female Sterilization)"),
    p("Permanent contraception by occluding / severing the fallopian tubes, preventing sperm from reaching the ovum."),
    h3("Methods:"),
    b("<b>Pomeroy's Method (most common):</b> A loop of tube is ligated and excised. Simple, effective, reversible attempts possible."),
    b("<b>Parkland Method:</b> A segment of the isthmic portion is excised after ligating both ends separately."),
    b("<b>Fimbriectomy:</b> Removal of fimbriated end — high failure and no reversal."),
    b("<b>Irving's Method:</b> Proximal tube end buried in myometrium — lowest failure rate."),
    b("<b>Uchida's Method:</b> Tube injected with saline + adrenaline; mesosalpinx opened; tube buried under serosa."),
    b("<b>Laparoscopic sterilization:</b> Falope ring (Silastic band), Filshie/Hulka clip, or bipolar coagulation through laparoscope — minimally invasive, preferred."),
    b("<b>Minilaparotomy:</b> Small suprapubic incision; postpartum (subumbilical incision) — common in resource-limited settings."),
    b("<b>Failure rate:</b> 0.2–0.5% (1–5/1000 women-years). Risk of ectopic pregnancy if failure."),
    h3("VASECTOMY (Male Sterilization)"),
    p("Division and ligation/excision of a segment of the vas deferens — prevents sperm from entering the ejaculate."),
    b("<b>Conventional vasectomy:</b> Two small scrotal incisions; vas identified, ligated, and a segment excised."),
    b("<b>No-scalpel vasectomy (NSV):</b> Puncture technique with special forceps — less bleeding, fewer complications, faster recovery. <b>Preferred method.</b>"),
    b("<b>Failure rate:</b> ~0.1%; confirm azoospermia by semen analysis at 3 months / after 20 ejaculations."),
    b("<b>Complications:</b> Haematoma, infection, sperm granuloma, epididymitis; post-vasectomy pain syndrome (rare)."),
    sp(),
]

story += [
    h2("e. Udaramarga Garbhashaya Nirharana — Abdominal Hysterectomy"),
    h3("Definition:"), p("Surgical removal of the uterus through an abdominal incision (midline or Pfannenstiel). Can be Total (TAH — uterus + cervix) or Subtotal (corpus removed, cervix retained)."),
    h3("Indications:"),
    b("Fibroid uterus (symptomatic — heavy bleeding, pressure), Endometriosis, Adenomyosis."),
    b("Dysfunctional Uterine Bleeding (DUB) unresponsive to medical therapy."),
    b("Genital prolapse, Endometrial hyperplasia/carcinoma, Cervical carcinoma (radical hysterectomy — Wertheim's)."),
    b("PID with tubo-ovarian abscess unresponsive to antibiotics."),
    h3("Procedure (TAH-BSO):"),
    b("Patient in supine; Pfannenstiel or midline incision."),
    b("Round ligaments divided; bladder flap dissected down; uterine vessels ligated; cardinal and uterosacral ligaments divided."),
    b("Vault sutured; bilateral salpingo-oophorectomy (BSO) if indicated."),
    b("Wertheim's radical hysterectomy (for cervical Ca): includes parametrium, upper vagina, pelvic lymph node dissection."),
    h3("Complications:"),
    b("<b>Intraoperative:</b> Haemorrhage, ureteric injury (at level of uterine artery — most common), bladder injury."),
    b("<b>Postoperative:</b> DVT/PE, infection, vault haematoma, vault prolapse, urinary fistula."),
    b("<b>Long-term:</b> Premature menopause (if oophorectomy), sexual dysfunction."),
    sp(),
]

story += [
    h2("f. Yonimarga Garbhashaya Nirharana — Vaginal Hysterectomy"),
    h3("Definition:"), p("Removal of the uterus through the vagina without an abdominal incision. Combined with anterior/posterior colporrhaphy when performed for prolapse."),
    h3("Indications:"),
    b("Uterovaginal prolapse (ideal indication)."),
    b("Benign conditions (fibroids if uterus <12 weeks), DUB, endometrial hyperplasia."),
    b("Manchester (Fothergill) operation: Cervical amputation + colporrhaphy for uterine descent without hysterectomy."),
    h3("Advantages over Abdominal Hysterectomy:"),
    b("No abdominal incision; less pain; shorter hospital stay; faster recovery; lower infection risk."),
    h3("Contraindications:"),
    b("Large uterus (>12 weeks), nulliparity (narrow vagina), prior pelvic surgery (adhesions), suspected malignancy, adnexal pathology."),
    h3("Complications:"),
    b("Bladder/ureteric injury, haemorrhage, infection, vault prolapse, enterocele formation."),
    sp(),
]

story += [
    h2("g. Arbudanirharana — Myomectomy"),
    h3("Definition:"), p("Surgical removal of uterine fibroids (leiomyomas) while preserving the uterus — procedure of choice in women wishing to retain fertility."),
    h3("Indications:"),
    b("Symptomatic fibroids (heavy bleeding, pressure symptoms, pain) in women desiring fertility."),
    b("Infertility due to submucous fibroids distorting the uterine cavity."),
    b("Recurrent pregnancy loss associated with fibroids."),
    h3("Types:"),
    b("<b>Open (abdominal) myomectomy:</b> For large/multiple/deep intramural fibroids."),
    b("<b>Laparoscopic myomectomy:</b> For subserosal/pedunculated fibroids; minimally invasive."),
    b("<b>Hysteroscopic myomectomy:</b> For submucous fibroids (Types 0, 1, 2 — FIGO classification)."),
    h3("Complications:"),
    b("Haemorrhage (major risk — may require transfusion), conversion to hysterectomy."),
    b("Adhesion formation (risk of infertility/bowel obstruction), recurrence of fibroids (~25–30% by 10 years)."),
    b("Uterine rupture in subsequent pregnancy (especially with deep intramural scar)."),
    sp(),
]

story += [
    h2("h. Granthinirharana — Cystectomy (Ovarian Cystectomy)"),
    h3("Definition:"), p("Surgical excision of an ovarian cyst while preserving ovarian tissue. 'Cystectomy' in gynaecology usually refers to ovarian cystectomy (not bladder surgery)."),
    h3("Indications:"),
    b("Persistent ovarian cysts >5 cm not resolving after 6–8 weeks observation."),
    b("Cysts with features of concern (solid components, septations, vascularity on Doppler)."),
    b("Dermoid cysts (mature cystic teratoma), endometrioma (chocolate cyst)."),
    b("Symptomatic cysts (pain, pressure, torsion)."),
    h3("Types:"),
    b("<b>Laparoscopic cystectomy:</b> Preferred approach; cyst wall stripped from ovarian cortex."),
    b("<b>Open cystectomy:</b> For large/complex cysts."),
    b("If malignancy suspected: unilateral salpingo-oophorectomy (USO); do NOT rupture cyst."),
    h3("Complications:"), b("Haemorrhage, infection, ovarian cortex damage (reduces ovarian reserve), cyst rupture (chemical peritonitis from dermoid contents — sebum + hair)."),
    sp(),
]

story += [
    h2("i. Arshanirharana — Polypectomy"),
    h3("Definition:"), p("Surgical removal of polyps from the uterine cavity (endometrial polyps), cervix (cervical polyps), or vagina."),
    h3("Cervical Polypectomy:"),
    b("Usually done OPD under no/local anaesthesia."),
    b("Polyp identified at cervical os; grasped with sponge-holding forceps and twisted off at its base; base cauterized."),
    b("Histopathology mandatory (rule out malignancy)."),
    h3("Endometrial Polypectomy:"),
    b("Hysteroscopic polypectomy under direct vision — gold standard."),
    b("Resectoscope loop or scissors used to excise polyp at base."),
    b("Complete excision reduces recurrence; histopathology of all specimens."),
    h3("Indications:"), b("Abnormal uterine bleeding, intermenstrual bleeding, postmenopausal bleeding, infertility, incidental finding on USS/HSG."),
    h3("Complications:"), b("Uterine perforation (hysteroscopic), fluid overload (operative hysteroscopy), bleeding, infection."),
    sp(),
    PageBreak(),
]

# ═══════════════════════════════════════════════════════════
# SECTION 3: DIAGNOSTIC TOOLS
# ═══════════════════════════════════════════════════════════
story += [h1("SECTION 3: DIAGNOSTIC TOOLS AND TECHNIQUES"), sp()]

story += [
    h2("a. Pap Smear (Papanicolaou Smear)"),
    p("<b>Purpose:</b> Cervical cancer screening — detects premalignant (CIN) and malignant cervical cells."),
    b("<b>Specimen:</b> Ectocervical scrape (Ayre's spatula) + endocervical swab (cytobrush) → smear fixed with 95% ethyl alcohol → Papanicolaou stain."),
    b("<b>Liquid-Based Cytology (LBC/ThinPrep):</b> Cell suspension in preservative fluid; more sensitive, allows HPV co-testing."),
    b("<b>Bethesda System (reporting):</b> ASC-US, LSIL, HSIL, ASC-H, AGC, adenocarcinoma in situ, invasive carcinoma."),
    b("<b>Screening protocol (India/WHO):</b> Every 3 years from age 25 (or 3 years after first sexual activity). Combined HPV + cytology every 5 years if both negative."),
    b("<b>False negatives:</b> ~20% (sampling error, interpretive error); reduced by LBC."),
    sp(),
]

story += [
    h2("b. Colposcopy"),
    p("<b>Definition:</b> Direct binocular magnified (6–40×) examination of the cervix, vagina, and vulva using a colposcope, following application of 3–5% acetic acid and Lugol's iodine."),
    b("<b>Indications:</b> Abnormal Pap smear (HSIL, persistent LSIL, ASC-H, AGC), positive hrHPV, clinically suspicious cervix, follow-up post-treatment of CIN."),
    b("<b>Aceto-white changes:</b> Abnormal areas turn white with acetic acid — reflect nuclear density."),
    b("<b>Schiller's test (Lugol's iodine):</b> Normal glycogen-rich epithelium stains brown (iodine-positive); abnormal areas remain unstained (iodine-negative = Schiller-positive)."),
    b("<b>Colposcopic features of CIN:</b> Acetowhite epithelium, abnormal vascular patterns (punctation, mosaic), coarse surface contour."),
    b("<b>Outcome:</b> Directed biopsy from most abnormal area; endocervical curettage (ECC) if transformation zone not fully visualised (unsatisfactory colposcopy)."),
    sp(),
]

story += [
    h2("c. Cervical Biopsy"),
    b("<b>Punch biopsy:</b> Colposcopy-directed; small cores taken from abnormal areas."),
    b("<b>LEEP/LLETZ cone biopsy:</b> Loop electrosurgical excision — therapeutic and diagnostic; includes transformation zone."),
    b("<b>Cold knife conisation (CKC):</b> Surgical cone excision for endocervical lesions, micro-invasive carcinoma, or unsatisfactory colposcopy."),
    b("<b>Histological grading:</b> CIN 1 (mild dysplasia), CIN 2 (moderate), CIN 3 (severe/CIS) → FIGO classification for carcinoma."),
    sp(),
]

story += [
    h2("d. Endometrial Biopsy"),
    b("<b>Indications:</b> Postmenopausal bleeding, AUB unresponsive to treatment, suspected endometrial hyperplasia/carcinoma, infertility workup (secretory phase/luteal phase defect)."),
    b("<b>Methods:</b> Pipelle aspirator (OPD, no anaesthesia — sensitivity ~80%); Vabra aspirator; fractional curettage (ECC + uterine curettage separately, to determine level of spread)."),
    b("<b>Histology:</b> Confirms normal cycling endometrium, simple/complex hyperplasia (with/without atypia), or carcinoma."),
    sp(),
]

story += [
    h2("e. Hysterosalpingography (HSG)"),
    p("<b>Definition:</b> Radiological investigation using water-soluble/oil-based contrast medium injected through the cervix into the uterine cavity and tubes, imaged under fluoroscopy."),
    b("<b>Indications:</b> Infertility (tubal patency assessment), recurrent pregnancy loss (uterine anomalies — septum, bicornuate, fibroids, adhesions), suspected tubal block (PID sequelae)."),
    b("<b>Findings:</b> Tubal patency (bilateral peritoneal spill), cornual block, hydrosalpinx, intrauterine filling defects (polyp, fibroid, Asherman's), uterine anomalies."),
    b("<b>Complications:</b> Pelvic infection (prophylactic doxycycline recommended), contrast reaction, radiation exposure. <b>Contraindicated</b> in active PID, pregnancy, iodine allergy."),
    b("<b>Best timing:</b> Days 7–10 of cycle (post-menstrual, pre-ovulatory — uterine lining thin, no risk of irradiating early pregnancy)."),
    sp(),
]

story += [
    h2("f. Ultrasonography (USG)"),
    b("<b>Transabdominal USG (TAS):</b> Full bladder required; good for large uterus/ovaries, abdominal masses; limited resolution."),
    b("<b>Transvaginal USG (TVS):</b> Empty bladder; superior resolution for endometrium, ovaries, early pregnancy, small fibroids. Preferred for gynaecological pathology."),
    b("<b>Uses:</b> Endometrial thickness (ET >4 mm in postmenopause → biopsy), fibroid mapping, ovarian cysts, adnexal pathology, IUCD position, folliculometry, Doppler studies."),
    b("<b>Sonohysterography (SIS):</b> Saline infused into uterine cavity under USS — outlines intracavitary lesions."),
    b("<b>Doppler:</b> Colour/pulsed Doppler for vascularity of ovarian masses; low resistance index (RI <0.4) suggests malignancy."),
    sp(),
]

story += [
    h2("g. Hysteroscopy"),
    p("<b>Definition:</b> Direct endoscopic visualisation of the uterine cavity using a rigid/flexible hysteroscope with distension medium (normal saline, glycine)."),
    b("<b>Diagnostic hysteroscopy:</b> Outpatient; 3.5–5 mm hysteroscope; evaluates endometrium, ostia, cavity shape, submucous fibroids, polyps, adhesions."),
    b("<b>Operative hysteroscopy:</b> Under GA/regional anaesthesia; resectoscope for TCRE (transcervical resection of endometrium), polypectomy, myomectomy, septum division, adhesiolysis."),
    b("<b>Indications:</b> AUB, infertility, recurrent miscarriage, suspected Asherman's, failed/misplaced IUCD."),
    b("<b>Complications:</b> Uterine perforation, fluid overload/hypo-osmolar syndrome (especially with glycine), bleeding, infection, air embolism."),
    sp(),
]

story += [
    h2("h. Laparoscopy"),
    p("<b>Definition:</b> Endoscopic visualisation of the pelvic and abdominal organs via a telescope (0°/30°) inserted through the umbilicus under CO₂ pneumoperitoneum."),
    b("<b>Diagnostic:</b> Unexplained pelvic pain, infertility work-up (tubal patency with methylene blue dye — chromopertubation), endometriosis staging, suspected ectopic pregnancy, adnexal mass assessment, PID."),
    b("<b>Operative:</b> Ovarian cystectomy, myomectomy, salpingectomy (ectopic), adhesiolysis, LUNA (laparoscopic uterine nerve ablation), hysterectomy (TLH/LAVH), sterilisation."),
    b("<b>Advantages:</b> Magnification, minimal invasiveness, early recovery, better cosmesis, less adhesion formation."),
    b("<b>Complications:</b> Vascular injury (aorta, iliac vessels — trocar insertion), bowel/bladder injury, gas embolism, shoulder tip pain (CO₂ irritating diaphragm), port-site hernia."),
    sp(),
]

story += [
    h2("i. Magnetic Resonance Imaging (MRI)"),
    b("<b>Best imaging for:</b> Uterine anomalies (Müllerian), deep infiltrating endometriosis, fibroid mapping (pre-UAE), endometrial and cervical carcinoma staging, adnexal mass characterisation."),
    b("<b>Advantages:</b> No radiation; superior soft-tissue contrast; multiplanar; excellent for parametrial invasion (cervical Ca staging)."),
    b("<b>Fibroid:</b> T2 low signal (compared to myometrium); distinguishes fibroid subtypes; 'bridging vessel sign'."),
    b("<b>Endometriosis:</b> T1 high signal (haemorrhagic content — 'chocolate' cysts); T2 'shading' in endometriomas."),
    b("<b>Limitations:</b> Expensive, time-consuming, contraindicated with certain metallic implants/pacemakers; claustrophobia."),
    sp(),
]

story += [
    h2("j. Computed Tomography (CT) Scan"),
    b("<b>Role in gynaecology:</b> Staging of ovarian cancer (peritoneal metastases, lymph nodes, omental cake, pleural effusion); evaluation of retroperitoneal lymph nodes in cervical/endometrial carcinoma."),
    b("<b>CT vs MRI:</b> CT better for nodal staging and distant metastases; MRI better for local staging (parametrial invasion, endometrial cavity)."),
    b("<b>PET-CT:</b> Metabolic activity assessment; recurrence detection post-treatment; lymph node involvement in gynaecological cancers."),
    b("<b>Limitations:</b> Ionising radiation; contrast nephrotoxicity; poor soft-tissue resolution compared to MRI for primary tumour extent."),
    sp(),
    PageBreak(),
]

# ═══════════════════════════════════════════════════════════
# SECTION 4: GYNAECOLOGICAL CONDITIONS
# ═══════════════════════════════════════════════════════════
story += [h1("SECTION 4: GYNAECOLOGICAL CONDITIONS"), sp()]

story += [
    h2("1. DYSMENORRHOEA"),
    h3("Definition:"), p("Painful menstruation — cramping lower abdominal pain before/during menstruation."),
    h3("Types:"),
    make_table(
        ["Feature", "Primary Dysmenorrhoea", "Secondary Dysmenorrhoea"],
        [
            ["Pathology", "No pelvic pathology; excess prostaglandin (PGF2α, PGE2) from secretory endometrium → uterine contractions + ischaemia", "Underlying pelvic disease"],
            ["Age", "Young women, starts 6–12 months after menarche (after ovulatory cycles)", "Older women; onset after pain-free menstruation years"],
            ["Pain timing", "Onset 24–48 hrs before, peaks at 24 hrs → resolves by day 2–3", "Pain starts days before menstruation; may persist throughout"],
            ["Causes", "Excess prostaglandins; increased vasopressin", "Endometriosis, adenomyosis, fibroids, PID, IUCD, cervical stenosis, polyps"],
            ["Pelvic exam", "Normal", "Abnormal findings (tender, nodularity, masses)"],
        ],
        col_widths=[3.5*cm, 7*cm, 6*cm]
    ),
    sp(),
    h3("Investigations:"), b("Primary: Clinical diagnosis; USS to exclude secondary causes. Secondary: TVS, HSG, laparoscopy, CA-125."),
    h3("Management:"),
    b("<b>NSAIDs (first-line for primary):</b> Ibuprofen 400–600 mg TDS; Mefenamic acid 500 mg TDS; start 1–2 days before menstruation. (Inhibit prostaglandin synthesis.)"),
    b("<b>OCP:</b> Combined oral contraceptive pill — reduces endometrial proliferation and prostaglandin production; effective for primary and secondary."),
    b("<b>Progestins:</b> Norethisterone, Medroxyprogesterone acetate; Levonorgestrel-IUS (Mirena) — especially for adenomyosis."),
    b("<b>GnRH analogues:</b> For endometriosis-related dysmenorrhoea (see below)."),
    b("<b>Surgical (secondary):</b> Treat underlying cause — laparoscopic excision of endometriosis, myomectomy, LUNA, presacral neurectomy (PSN) for severe primary."),
    sp(),
]

story += [
    h2("2. PRURITUS VULVAE"),
    h3("Definition:"), p("Intense itching of the vulva and surrounding external genitalia."),
    h3("Causes:"),
    b("<b>Local causes:</b> Vulvovaginal candidiasis (most common), trichomoniasis, bacterial vaginosis, threadworm infestation, contact dermatitis (soaps, detergents, sanitary pads), pubic lice."),
    b("<b>Dermatological:</b> Lichen sclerosus (white patches, figure-of-8 distribution around vulva and anus), lichen planus, lichen simplex chronicus, psoriasis."),
    b("<b>Systemic:</b> Diabetes mellitus (glycosuria promotes candida), chronic renal failure, cholestatic jaundice, iron-deficiency anaemia, lymphoma."),
    b("<b>Neoplastic:</b> Vulvar intraepithelial neoplasia (VIN), vulvar carcinoma — must be excluded in persistent cases."),
    b("<b>Psychogenic/Neurological:</b> Post-herpetic neuralgia, vulvodynia."),
    h3("Investigations:"),
    b("Vaginal swab (HVS): Microscopy, culture (Candida, Trichomonas, BV clue cells)."),
    b("Blood sugar (diabetes), FBC (anaemia), LFTs, renal function."),
    b("Vulvar biopsy: Mandatory for any persistent/suspicious lesion (thickened, ulcerated, pigmented areas) to exclude malignancy."),
    b("Patch testing for contact allergens."),
    h3("Management:"),
    b("<b>Candidiasis:</b> Topical Clotrimazole 1% cream / Miconazole; Fluconazole 150 mg single oral dose. Treat partner."),
    b("<b>Lichen sclerosus:</b> Topical ultra-potent corticosteroid (Clobetasol 0.05%) — first-line; maintenance therapy required. Topical testosterone (historical)."),
    b("<b>General:</b> Avoid irritants; loose cotton underwear; emollients (aqueous cream); antihistamines for symptom relief; manage underlying systemic causes."),
    sp(),
]

story += [
    h2("3. ENDOMETRIOSIS"),
    h3("Definition:"), p("Presence of functional endometrial glands and stroma outside the uterine cavity, most commonly on ovaries, uterosacral ligaments, Pouch of Douglas, and pelvic peritoneum."),
    h3("Pathogenesis (theories):"),
    b("<b>Sampson's retrograde menstruation theory</b> (most accepted): Menstrual debris flows back through fallopian tubes → implants on peritoneal surfaces."),
    b("<b>Coelomic metaplasia theory:</b> Peritoneal mesothelium undergoes metaplastic transformation."),
    b("<b>Lymphatic/haematogenous dissemination:</b> Explains distant sites (lung, brain)."),
    b("<b>Stem cell theory:</b> Bone marrow-derived progenitor cells differentiate into endometrial tissue."),
    h3("Clinical Features (3 Ds):"),
    b("<b>Dysmenorrhoea</b> (secondary, progressively worsening — 'crescendo' pattern), <b>Dyspareunia</b> (deep), <b>Dyschezia</b> (painful defaecation)."),
    b("Chronic pelvic pain, subfertility/infertility."),
    b("Cyclical haematuria, haemoptysis (if bladder/lung involvement — rare)."),
    b("<b>Examination:</b> Tender, fixed retroverted uterus; nodularity in Pouch of Douglas; adnexal mass (endometrioma)."),
    h3("Investigations:"),
    b("<b>CA-125:</b> Elevated (>35 U/mL) in moderate-severe disease — not diagnostic; useful for monitoring."),
    b("<b>TVS:</b> Endometrioma — 'ground glass' echogenicity; homogeneous low-level echoes; loss of follicles on affected ovary."),
    b("<b>MRI:</b> T1 bright (blood), T2 shading; excellent for deep infiltrating endometriosis."),
    b("<b>Laparoscopy + biopsy</b> — definitive diagnosis. Classic: powder-burn/gun-shot lesions, blue-black deposits; endometriomas ('chocolate cysts')."),
    h3("Management (ASRM staging: I–IV):"),
    b("<b>Medical:</b> NSAIDs (pain relief); Combined OCP / Progestins (continuous); Danazol (androgenic side effects); GnRH analogues (Leuprolide, Buserelin) — medical 'pseudomenopause', add-back HRT after 6 months; LNG-IUS (Mirena)."),
    b("<b>Surgical:</b> Laparoscopic excision/ablation of implants; cystectomy for endometrioma (preferred over aspiration — lower recurrence); hysterectomy + BSO for completed family with severe disease."),
    b("<b>Infertility:</b> Surgical cystectomy + IVF if needed."),
    sp(),
]

story += [
    h2("4. ADENOMYOSIS"),
    h3("Definition:"), p("Presence of endometrial glands and stroma within the myometrium (uterine muscle), associated with smooth muscle hyperplasia — 'internal endometriosis'. Characteristic: junctional zone >12 mm on MRI."),
    h3("Pathogenesis:"), p("Invagination of the basal endometrium into the myometrium; trauma from previous surgery (D&C, CS) may be a factor; associated with hyperestrogenism."),
    h3("Clinical Features:"),
    b("Menorrhagia (heavy periods) — most common."),
    b("Secondary dysmenorrhoea (progressively worsening)."),
    b("Uniformly enlarged, 'boggy', tender uterus (classically 8–10 weeks size)."),
    b("Dyspareunia; subfertility (debated)."),
    h3("Investigations:"),
    b("<b>TVS:</b> Heterogeneous myometrium; asymmetric thickening; myometrial cysts; poor definition of junctional zone."),
    b("<b>MRI (gold standard):</b> Junctional zone width >12 mm; 'JZ/myometrium ratio' >40% — diagnostic."),
    b("<b>Histopathology:</b> Endometrial tissue >2.5 mm from basal layer on hysterectomy specimen."),
    h3("Management:"),
    b("<b>Medical (for fertility preservation):</b> NSAIDs, Progestins, Combined OCP, LNG-IUS (Mirena) — reduces bleeding and pain significantly; GnRH analogues (temporary response)."),
    b("<b>Definitive (completed family):</b> Hysterectomy."),
    sp(),
]

story += [
    h2("5. PELVIC INFLAMMATORY DISEASE (PID)"),
    h3("Definition:"), p("Infection and inflammation of the upper female genital tract — includes endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess, and pelvic peritonitis."),
    h3("Causative Organisms:"),
    b("<b>Primary STI pathogens:</b> Neisseria gonorrhoeae (~25%), Chlamydia trachomatis (~25%)."),
    b("<b>Endogenous vaginal flora:</b> Gardnerella vaginalis, Mycoplasma genitalium, E. coli, anaerobes (Bacteroides, Prevotella), Group B Streptococcus."),
    b("<b>Risk factors:</b> Age <25, multiple partners, IUCD use (especially first 3 weeks post-insertion), prior STI, intrauterine procedures."),
    h3("Clinical Features:"),
    b("Lower abdominal/pelvic pain (bilateral); cervical excitation tenderness (CET) — hallmark."),
    b("Adnexal tenderness on bimanual examination; mucopurulent cervical discharge."),
    b("Fever (>38°C), raised WBC, elevated ESR/CRP (in moderate-severe cases)."),
    b("<b>Fitz-Hugh-Curtis syndrome:</b> Perihepatitis — right upper quadrant pain (violin-string adhesions between liver and anterior peritoneum)."),
    b("<b>Tubo-ovarian abscess (TOA):</b> Tender adnexal mass; TVUS confirms."),
    h3("Minimum Diagnostic Criteria (CDC):"),
    b("Uterine tenderness OR adnexal tenderness OR CET — treat empirically."),
    h3("Investigations:"),
    b("Endocervical swab: NAAT (gonorrhoea + chlamydia); microscopy."),
    b("Blood: FBC (leukocytosis), CRP/ESR, blood cultures (febrile)."),
    b("TVUS: TOA (complex adnexal mass); free pelvic fluid."),
    b("Laparoscopy: Gold standard — visualises tubes; hyperaemia, oedema, purulent exudate."),
    h3("Management:"),
    b("<b>Outpatient (mild–moderate):</b> Ceftriaxone 500 mg IM stat + Doxycycline 100 mg BD × 14 days + Metronidazole 400 mg BD × 14 days."),
    b("<b>Inpatient (severe/TOA):</b> Ceftriaxone 1 g IV OD + Doxycycline 100 mg IV/oral BD + Metronidazole 500 mg IV TDS; IV until 24 hours after clinical improvement, then oral to complete 14 days."),
    b("Remove IUCD if no clinical improvement in 72 hours."),
    b("TOA: Ultrasound-guided aspiration or surgical drainage if no response to antibiotics."),
    h3("Complications (Sequelae):"),
    b("Tubal factor infertility (25% after 1 episode, 50% after 3 episodes), Ectopic pregnancy (×6–10 risk), Chronic pelvic pain."),
    sp(),
]

story += [
    h2("6. PELVIC ORGAN PROLAPSE"),
    h3("Definition:"), p("Descent of pelvic organs (uterus, bladder, rectum, small bowel) into or outside the vaginal canal due to weakness of pelvic support structures."),
    h3("Classification:"),
    b("<b>Cystocele:</b> Anterior vaginal wall prolapse — bladder descends."),
    b("<b>Rectocele:</b> Posterior vaginal wall prolapse — rectum bulges."),
    b("<b>Enterocele:</b> Herniation of small bowel into the rectovaginal pouch."),
    b("<b>Uterovaginal prolapse:</b> Cervix descends; Graded I–IV (Pelvic Organ Prolapse Quantification — POP-Q system): Grade 1 (descent into vagina), Grade 2 (to introitus), Grade 3 (beyond introitus), Grade 4 (Procidentia — complete eversion)."),
    h3("Aetiology:"), b("Childbirth trauma, multiparity, menopause (oestrogen deficiency), chronic straining (constipation, cough), obesity, connective tissue disorders."),
    h3("Clinical Features:"),
    b("'Something coming down' sensation; dragging pelvic heaviness."),
    b("Urinary symptoms: Stress urinary incontinence, frequency, incomplete bladder emptying, recurrent UTIs."),
    b("Bowel: Constipation, incomplete evacuation, digital evacuation needed (rectocele)."),
    b("Sexual dysfunction; backache. Ulceration of exposed cervix/vaginal wall (Procidentia)."),
    h3("Investigations:"), b("Clinical POP-Q examination; cough stress test; uroflowmetry/urodynamics; USS (residual urine); MSU (culture)."),
    h3("Management:"),
    b("<b>Conservative:</b> Pelvic floor exercises (Kegel's), ring pessary, oestrogen cream (postmenopausal — improves tissue)."),
    b("<b>Surgical:</b> Anterior colporrhaphy (cystocele), posterior colporrhaphy (rectocele), Manchester operation/vaginal hysterectomy + colporrhaphy (uterovaginal prolapse), sacrocolpopexy (mesh — vault prolapse)."),
    sp(),
]

story += [
    h2("7. CERVICAL EROSION AND ECTROPION"),
    h3("Cervical Ectropion (Erosion):"),
    p("Eversion of the endocervical columnar epithelium onto the ectocervix (normally occupied by squamous epithelium). Appears as a raw, red area around the external os. NOT a true erosion — it is normal physiological finding in reproductive age, pregnancy, and OCP users."),
    h3("True Cervical Erosion:"),
    p("Loss of squamous epithelium from ectocervix exposing underlying stroma — due to trauma, infection, or chemical irritation."),
    h3("Clinical Features:"),
    b("Often asymptomatic (incidental finding on per-speculum examination)."),
    b("Symptoms (when present): Excessive vaginal discharge (clear/mucopurulent), post-coital bleeding, intermenstrual spotting, dyspareunia."),
    h3("Investigations:"),
    b("Per-speculum examination. Pap smear to exclude CIN/carcinoma. Colposcopy if Pap smear abnormal."),
    h3("Management:"),
    b("<b>Asymptomatic:</b> No treatment required; reassurance."),
    b("<b>Symptomatic:</b> Cryocautery, electrocautery, LEEP — destroys the columnar epithelium; regeneration by squamous metaplasia."),
    b("Treat concurrent infections (candida, chlamydia) first."),
    sp(),
]

story += [
    h2("8. DYSPAREUNIA"),
    h3("Definition:"), p("Painful sexual intercourse in women. Can be superficial (introital) or deep (pelvic)."),
    h3("Types and Causes:"),
    make_table(
        ["Type", "Causes"],
        [
            ["Superficial (introital)", "Vaginismus, vulvodynia, vulvovaginal atrophy (menopause), insufficient lubrication, Bartholin's cyst/abscess, lichen sclerosus, vaginal infections, skin conditions, episiotomy scar"],
            ["Deep (pelvic)", "Endometriosis, PID, ovarian cysts, retroverted uterus, uterine fibroids, pelvic adhesions, interstitial cystitis, bladder/rectal pathology"],
        ],
        col_widths=[4*cm, 12.5*cm]
    ),
    sp(),
    h3("Investigations:"), b("Pelvic examination, TVS/MRI (structural causes), vulvar biopsy (suspicious skin lesions), laparoscopy (endometriosis, adhesions)."),
    h3("Management:"), b("Treat underlying cause; lubricants (atrophy); topical oestrogen (postmenopausal atrophy); physiotherapy (pelvic floor); psychological/psychosexual counselling; EMLA cream for vulvodynia; surgery for structural causes."),
    sp(),
]

story += [
    h2("9. VAGINISMUS"),
    h3("Definition:"), p("Involuntary spasm of the muscles of the outer one-third of the vagina when penetration is attempted, making intercourse painful or impossible."),
    h3("Types:"),
    b("<b>Primary:</b> Never achieved penetration."),
    b("<b>Secondary:</b> Previously painless intercourse, now develops vaginismus (after trauma, dyspareunia, infection, surgery)."),
    h3("Causes:"), b("Fear of pain, previous sexual trauma/abuse, anxiety, relationship problems, negative cultural attitudes, previous painful gynaecological examination."),
    h3("Management:"),
    b("Psychosexual counselling / CBT — addressing fears and anxiety. Partner involvement essential."),
    b("Progressive vaginal dilators (smallest to largest, used daily at home)."),
    b("Pelvic floor physiotherapy."),
    b("Botulinum toxin (Botox) injection into levator ani — for severe refractory cases."),
    b("Prognosis: Excellent with appropriate therapy."),
    sp(),
]

story += [
    h2("10. PRESACRAL NEURALGIA"),
    h3("Definition:"), p("Chronic pain arising from the superior hypogastric plexus (presacral nerve) located anterior to the sacrum at L5-S1 level; manifests as intractable midline pelvic/sacral pain."),
    h3("Causes:"), b("Endometriosis, PID sequelae, pelvic adhesions, primary dysmenorrhoea (central sensitisation), uterosacral ligament pathology, tumour infiltration (cervical/rectal cancer)."),
    h3("Clinical Features:"),
    b("Deep, boring, midline sacral/presacral pain — constant or cyclical."),
    b("Radiates to perineum, buttocks, thighs. Not relieved by position change."),
    b("May be associated with bladder/bowel symptoms."),
    h3("Management:"),
    b("Medical: NSAIDs, OCPs, GnRH analogues, amitriptyline (neuropathic pain), pregabalin."),
    b("<b>LUNA (Laparoscopic Uterine Nerve Ablation):</b> Division of uterosacral ligaments near uterine attachment — disrupts afferent pain pathways."),
    b("<b>Presacral neurectomy (PSN):</b> Surgical division of superior hypogastric plexus — more effective than LUNA for midline pain; side effects: constipation, bladder dysfunction."),
    sp(),
]

story += [
    h2("11. CONSTITUTIONAL NYMPHOMANIA"),
    h3("Definition:"), p("Hypersexuality in women — persistently excessive sexual desire not due to organic cause. A psychiatric/psychosexual disorder. (Modern DSM-5 term: Hypersexual Disorder / Compulsive Sexual Behaviour Disorder)."),
    h3("Causes:"), b("Primary: Psychological (OCD spectrum, impulse control disorder, bipolar disorder hypomanic phase, personality disorder, childhood sexual abuse, anxiety/depression self-medication through sex); Secondary: Organic — hyperthyroidism, temporal lobe epilepsy, Klüver-Bucy syndrome, Parkinson's disease (dopamine agonist side effect), frontal lobe lesions."),
    h3("Clinical Features:"), b("Preoccupation with sexual thoughts interfering with daily function; repeated unsuccessful attempts to control sexual behaviour; distress to patient and partner; may lead to unsafe sexual practices → STI risk."),
    h3("Management:"),
    b("Psychosexual counselling, CBT, sex-addiction therapy groups."),
    b("SSRIs (reduce compulsive behaviour); Naltrexone (opioid antagonist — reduces reward behaviour); anti-androgens (Medroxyprogesterone acetate) for severe cases."),
    b("Treat underlying organic/psychiatric cause."),
    sp(),
]

story += [
    h2("12. EFFLUVIUM SEMINIS (SEMINAL LEAKAGE / VAGINAL FLATULENCE)"),
    h3("Definition:"), p("Effluvium seminis literally means 'flowing out of semen' — seminal emission after intercourse; sometimes refers to involuntary passage of air/fluid from the vagina (vaginal flatulence / queefing) or abnormal vaginal discharge."),
    h3("Causes of Post-Coital Seminal Discharge:"),
    b("Normal physiological drainage of semen from the vaginal canal after intercourse."),
    b("Vaginal laxity or prolapse — inability to retain seminal fluid."),
    b("Vesico-vaginal fistula, recto-vaginal fistula — abnormal communications."),
    h3("Vaginal Flatulence:"),
    b("Causes: Pelvic floor weakness (multiparity), prior surgery, pelvic organ prolapse, rectovaginal fistula."),
    b("Management: Pelvic floor rehabilitation, prolapse repair, fistula repair."),
    h3("In Ayurveda Context:"),
    b("Effluvium seminis (Shukra Srava / Shukra Dosha) — one of the Artava / Yoni Vyapat conditions. Associated with Vata aggravation, pelvic floor weakness, and post-coital complaints."),
    b("Ayurvedic management: Toning herbs (Ashwagandha, Shatavari), basti karma, yoga, Kegel exercises."),
    sp(),
    PageBreak(),
]

# SUMMARY TABLE
story += [
    h1("QUICK REVISION: STD SUMMARY TABLE"),
    sp(),
    make_table(
        ["STD", "Organism", "Hallmark Feature", "Key Investigation", "First-line Treatment"],
        [
            ["Gonorrhoea", "N. gonorrhoeae (GN diplococcus)", "Purulent discharge; intracellular diplococci", "Gram stain + NAAT", "Ceftriaxone 500 mg IM"],
            ["Syphilis", "T. pallidum (spirochaete)", "Painless chancre → rash on palms/soles", "VDRL (screen) / TPHA (confirm)", "Benzathine Penicillin G 2.4 MU IM"],
            ["Chlamydia", "C. trachomatis (intracellular)", "Asymptomatic; mucopurulent cervicitis", "NAAT (gold standard)", "Doxycycline 100 mg BD × 7 days"],
            ["Chancroid", "H. ducreyi", "Painful soft ulcer + tender bubo", "Gram stain 'school of fish'", "Azithromycin 1 g single dose"],
            ["Donovanosis", "K. granulomatis", "Painless beefy red ulcer; Donovan bodies", "Crush smear (Donovan bodies)", "Doxycycline × ≥3 weeks"],
            ["Herpes", "HSV-2 (mainly)", "Painful vesicles/ulcers; recurrences", "PCR / Viral culture", "Acyclovir 200 mg 5×/day × 10 days"],
            ["Trichomoniasis", "T. vaginalis (protozoa)", "Frothy green discharge; strawberry cervix", "Wet mount (motile trichomonads)", "Metronidazole 2 g single dose"],
            ["Genital Warts", "HPV 6 & 11", "Cauliflower-like warts; aceto-white", "Clinical + colposcopy; PCR typing", "Podophyllin / Imiquimod / LEEP"],
            ["HIV/AIDS", "HIV-1/2 (Retrovirus)", "Seroconversion illness → CD4 depletion", "ELISA → Western Blot; CD4; VL", "ART: TDF + 3TC + DTG"],
        ],
        col_widths=[2.5*cm, 3.5*cm, 4*cm, 3.5*cm, 3*cm]
    ),
    sp(2),
    hr(),
    p("<b>Sources:</b> Harrison's Principles of Internal Medicine 22E (2025); Goldman-Cecil Medicine; Robbins &amp; Cotran Pathologic Basis of Disease 11E; Orris Medical Synthesis."),
    Paragraph("Prepared by Orris AI Medical Assistant | July 2026 | For Academic/Exam Preparation Use Only", FOOTER_NOTE),
]

doc.build(story)
print("PDF generated:", OUTPUT)

cd /home/daytona/workspace/gynaecology-notes && python gen_pdf.py 2>&1

ls -lh /home/daytona/workspace/gynaecology-notes/Gynaecology_Exam_Notes.pdf