#!/usr/bin/env python3
"""
Build a professional PDF slide deck:
"Comparison of Medical vs Surgical Management of Adenomyosis"
Target audience: Gynecology Resident Doctors
"""

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

# ─── Colour Palette ────────────────────────────────────────────────────────────
TEAL       = colors.HexColor('#1B6CA8')   # header / accent
DARK_TEAL  = colors.HexColor('#0D4A7A')   # title bg
LIGHT_BLUE = colors.HexColor('#D6E9F8')   # row shading
MINT       = colors.HexColor('#E8F6EF')   # callout boxes
ORANGE     = colors.HexColor('#E8732A')   # highlight accent
WHITE      = colors.white
DARK_GRAY  = colors.HexColor('#2C2C2C')
MED_GRAY   = colors.HexColor('#5A5A5A')
LIGHT_GRAY = colors.HexColor('#F4F4F4')
GREEN      = colors.HexColor('#27AE60')
RED        = colors.HexColor('#C0392B')

PAGE_W, PAGE_H = A4   # 595 x 842 pt
MARGIN = 1.8 * cm

# ─── Styles ────────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

def S(name, **kw):
    """Helper: clone a base style with overrides."""
    base = styles.get(name, styles['Normal'])
    s = ParagraphStyle(
        f"custom_{name}_{id(kw)}",
        parent=base,
        **kw
    )
    return s

# ─── Slide builder helpers ──────────────────────────────────────────────────────
CONTENT_W = PAGE_W - 2 * MARGIN

def slide_title_page(title, subtitle, authors="", institution="", date=""):
    """Full-page title slide."""
    elems = []
    elems.append(Spacer(1, 2.5 * cm))
    elems.append(HRFlowable(width=CONTENT_W, thickness=4, color=ORANGE, spaceAfter=6))
    elems.append(Paragraph(title, S('Title',
        fontSize=28, textColor=DARK_TEAL, alignment=TA_CENTER,
        leading=36, spaceAfter=8)))
    elems.append(HRFlowable(width=CONTENT_W, thickness=2, color=TEAL, spaceBefore=4, spaceAfter=14))
    elems.append(Paragraph(subtitle, S('Normal',
        fontSize=15, textColor=TEAL, alignment=TA_CENTER, leading=20, spaceAfter=30)))
    if authors:
        elems.append(Paragraph(authors, S('Normal',
            fontSize=11, textColor=MED_GRAY, alignment=TA_CENTER, spaceAfter=4)))
    if institution:
        elems.append(Paragraph(institution, S('Normal',
            fontSize=10, textColor=MED_GRAY, alignment=TA_CENTER, spaceAfter=4)))
    if date:
        elems.append(Paragraph(date, S('Normal',
            fontSize=10, textColor=MED_GRAY, alignment=TA_CENTER)))
    elems.append(Spacer(1, 2 * cm))
    elems.append(HRFlowable(width=CONTENT_W, thickness=1.5, color=LIGHT_BLUE, spaceAfter=8))
    tagline = (
        "A structured clinical overview for Gynecology Resident Doctors | "
        "Sources: Berek & Novak's Gynecology · Bailey & Love's Surgery · "
        "PubMed systematic reviews 2021-2025"
    )
    elems.append(Paragraph(tagline, S('Normal',
        fontSize=8, textColor=MED_GRAY, alignment=TA_CENTER, leading=12)))
    return elems

def slide_header(slide_num, slide_title):
    """Header bar for each content slide."""
    data = [[
        Paragraph(slide_title, S('Normal',
            fontSize=15, textColor=WHITE, leading=18, fontName='Helvetica-Bold')),
        Paragraph(f"Slide {slide_num}", S('Normal',
            fontSize=9, textColor=LIGHT_BLUE, alignment=TA_RIGHT))
    ]]
    t = Table(data, colWidths=[CONTENT_W - 1.5*cm, 1.5*cm])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), DARK_TEAL),
        ('ROWBACKGROUNDS', (0,0), (-1,-1), [DARK_TEAL]),
        ('VALIGN', (0,0), (-1,-1), 'MIDDLE'),
        ('TOPPADDING', (0,0), (-1,-1), 8),
        ('BOTTOMPADDING', (0,0), (-1,-1), 8),
        ('LEFTPADDING', (0,0), (0,-1), 12),
        ('RIGHTPADDING', (-1,0), (-1,-1), 10),
        ('ROUNDEDCORNERS', [4, 4, 0, 0]),
    ]))
    return [t, Spacer(1, 8)]

def bullet(text, level=0, color=DARK_GRAY, size=10.5):
    indent = level * 14
    marker = "\u2022" if level == 0 else "\u2013"
    return Paragraph(
        f"<font color='#{format(color.hexval() & 0xFFFFFF, \"06x\")}' size='{size+1}'>{marker}</font>"
        f"&nbsp; {text}",
        S('Normal', fontSize=size, textColor=color, leading=16,
          leftIndent=10 + indent, spaceAfter=3)
    )

def section_label(text, bg=LIGHT_BLUE, fg=DARK_TEAL):
    data = [[Paragraph(text, S('Normal', fontSize=10.5, textColor=fg,
                                fontName='Helvetica-Bold'))]]
    t = Table(data, colWidths=[CONTENT_W])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), bg),
        ('LEFTPADDING', (0,0), (-1,-1), 10),
        ('TOPPADDING', (0,0), (-1,-1), 5),
        ('BOTTOMPADDING', (0,0), (-1,-1), 5),
    ]))
    return [t, Spacer(1, 4)]

def callout(text, bg=MINT, fg=DARK_TEAL):
    data = [[Paragraph(text, S('Normal', fontSize=10, textColor=fg, leading=15))]]
    t = Table(data, colWidths=[CONTENT_W])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), bg),
        ('LEFTPADDING', (0,0), (-1,-1), 12),
        ('RIGHTPADDING', (0,0), (-1,-1), 12),
        ('TOPPADDING', (0,0), (-1,-1), 7),
        ('BOTTOMPADDING', (0,0), (-1,-1), 7),
        ('BOX', (0,0), (-1,-1), 1.5, TEAL),
    ]))
    return [Spacer(1, 6), t, Spacer(1, 6)]

def two_col_table(headers, rows, col_ratios=None):
    if col_ratios is None:
        col_ratios = [0.38, 0.62]
    col_w = [CONTENT_W * r for r in col_ratios]
    header_style = S('Normal', fontSize=10, textColor=WHITE,
                      fontName='Helvetica-Bold', leading=14)
    cell_style = S('Normal', fontSize=9.5, textColor=DARK_GRAY, leading=13)
    data = [[Paragraph(h, header_style) for h in headers]]
    for row in rows:
        data.append([Paragraph(str(c), cell_style) for c in row])
    t = Table(data, colWidths=col_w)
    row_colors = [LIGHT_BLUE if i % 2 == 0 else WHITE for i in range(len(rows))]
    ts = TableStyle([
        ('BACKGROUND', (0, 0), (-1, 0), DARK_TEAL),
        ('VALIGN', (0, 0), (-1, -1), 'TOP'),
        ('TOPPADDING', (0, 0), (-1, -1), 5),
        ('BOTTOMPADDING', (0, 0), (-1, -1), 5),
        ('LEFTPADDING', (0, 0), (-1, -1), 7),
        ('RIGHTPADDING', (0, 0), (-1, -1), 7),
        ('ROWBACKGROUNDS', (0, 1), (-1, -1), [LIGHT_BLUE, WHITE]),
        ('GRID', (0, 0), (-1, -1), 0.4, colors.HexColor('#AAAAAA')),
    ])
    t.setStyle(ts)
    return t

def three_col_table(headers, rows, col_ratios=None):
    if col_ratios is None:
        col_ratios = [0.3, 0.35, 0.35]
    col_w = [CONTENT_W * r for r in col_ratios]
    header_style = S('Normal', fontSize=9.5, textColor=WHITE,
                      fontName='Helvetica-Bold', leading=13)
    cell_style = S('Normal', fontSize=9, textColor=DARK_GRAY, leading=13)
    data = [[Paragraph(h, header_style) for h in headers]]
    for row in rows:
        data.append([Paragraph(str(c), cell_style) for c in row])
    t = Table(data, colWidths=col_w)
    t.setStyle(TableStyle([
        ('BACKGROUND', (0, 0), (-1, 0), DARK_TEAL),
        ('VALIGN', (0, 0), (-1, -1), 'TOP'),
        ('TOPPADDING', (0, 0), (-1, -1), 5),
        ('BOTTOMPADDING', (0, 0), (-1, -1), 5),
        ('LEFTPADDING', (0, 0), (-1, -1), 7),
        ('RIGHTPADDING', (0, 0), (-1, -1), 7),
        ('ROWBACKGROUNDS', (0, 1), (-1, -1), [LIGHT_BLUE, WHITE]),
        ('GRID', (0, 0), (-1, -1), 0.4, colors.HexColor('#AAAAAA')),
    ]))
    return t

def footer_note(text):
    return Paragraph(
        f"<font color='#888888' size='7.5'>{text}</font>",
        S('Normal', fontSize=7.5, textColor=MED_GRAY, leading=11, spaceAfter=2)
    )

# ─── Build Story ───────────────────────────────────────────────────────────────
story = []

# ══════════════════════════════════════════════════════════════
# SLIDE 1 — Title
# ══════════════════════════════════════════════════════════════
story += slide_title_page(
    title="Comparison of Medical versus Surgical\nManagement of Adenomyosis",
    subtitle="A Clinical Overview for the Gynecology Resident",
    date="Paper Presentation | May 2026"
)
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════
# SLIDE 2 — Outline
# ══════════════════════════════════════════════════════════════
story += slide_header(2, "Presentation Outline")
outline_items = [
    ("1.", "Definition, Epidemiology &amp; Pathophysiology"),
    ("2.", "Clinical Features &amp; Diagnosis"),
    ("3.", "Overview of Management Strategies"),
    ("4.", "Medical Management — Agents &amp; Evidence"),
    ("5.", "Surgical Management — Options &amp; Techniques"),
    ("6.", "Head-to-Head Comparison"),
    ("7.", "Special Considerations: Fertility &amp; Recurrence"),
    ("8.", "Current Evidence &amp; Recommendations"),
    ("9.", "Key Takeaways &amp; Clinical Algorithm"),
]
for num, item in outline_items:
    data = [[
        Paragraph(num, S('Normal', fontSize=11, textColor=ORANGE,
                          fontName='Helvetica-Bold', alignment=TA_CENTER)),
        Paragraph(item, S('Normal', fontSize=11, textColor=DARK_GRAY, leading=15))
    ]]
    t = Table(data, colWidths=[0.8*cm, CONTENT_W - 0.8*cm])
    t.setStyle(TableStyle([
        ('VALIGN', (0,0), (-1,-1), 'MIDDLE'),
        ('TOPPADDING', (0,0), (-1,-1), 4),
        ('BOTTOMPADDING', (0,0), (-1,-1), 4),
    ]))
    story.append(t)
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════
# SLIDE 3 — Definition, Epidemiology & Pathophysiology
# ══════════════════════════════════════════════════════════════
story += slide_header(3, "Definition, Epidemiology & Pathophysiology")

story += section_label("DEFINITION")
story.append(Paragraph(
    "Adenomyosis is a <b>benign uterine disorder</b> characterised by the presence of ectopic "
    "endometrial glands and stroma within the myometrium, accompanied by "
    "<b>smooth muscle hypertrophy/hyperplasia</b>. It may be diffuse or focal (adenomyoma).",
    S('Normal', fontSize=10.5, textColor=DARK_GRAY, leading=16, spaceAfter=8)
))

story += section_label("EPIDEMIOLOGY")
epi_data = [
    ["Prevalence", "1%–70% (variable diagnostic criteria); often in reproductive-age women, peak 4th–5th decade"],
    ["Association", "Endometriosis (co-exists in up to 40% cases), leiomyomas"],
    ["Gold standard", "Histopathological diagnosis at hysterectomy (historically)"],
    ["Non-invasive Dx", "Transvaginal USS and MRI now enable pre-operative diagnosis"],
]
story.append(two_col_table(["Parameter", "Details"], epi_data))
story.append(Spacer(1, 8))

story += section_label("PATHOPHYSIOLOGY")
patho_items = [
    "Invasion theory: direct extension of basal endometrium through disrupted junctional zone (JZ)",
    "de Novo metaplasia of Mullerian remnants within myometrium",
    "Stem cell dysregulation promoting ectopic implantation",
    "Oestrogen-dependent growth: JZ thickening (>12 mm on MRI = diagnostic criterion)",
    "Leads to uterine enlargement, altered uterine contractility, impaired implantation",
]
for item in patho_items:
    story.append(bullet(item))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════
# SLIDE 4 — Clinical Features & Diagnosis
# ══════════════════════════════════════════════════════════════
story += slide_header(4, "Clinical Features & Diagnosis")

story += section_label("SYMPTOMS")
symp_data = [
    ["Dysmenorrhoea", "Most common; worsens with age; secondary, progressive"],
    ["Abnormal Uterine Bleeding", "Menorrhagia, metrorrhagia; often leads to anaemia"],
    ["Chronic Pelvic Pain", "Non-cyclical; may mimic endometriosis/fibroids"],
    ["Subfertility", "Impaired implantation; miscarriage; infertility"],
    ["Dyspareunia", "Deep; associated with posterior adenomyosis"],
    ["Uterine Enlargement", "Symmetrical, globular, tender uterus on examination"],
]
story.append(two_col_table(["Symptom", "Key Features"], symp_data))
story.append(Spacer(1, 8))

story += section_label("DIAGNOSTIC TOOLS")
diag_data = [
    ["Transvaginal USS (TVUSS)",
     "MUSA criteria: myometrial cysts, fan-shaped shadowing, asymmetric thickening, irregular JZ, "
     "hyperechoic islands. ≥3 features required. Sensitivity 72–82%, Specificity 85%"],
    ["MRI Pelvis",
     "JZ thickness ≥12 mm; low-signal intensity JZ on T2; differentiates adenomyoma from fibroid. "
     "Sensitivity 77–78%, Specificity 89%"],
    ["Histopathology",
     "Gold standard: endometrial glands/stroma >2.5 mm from basal endometrium within myometrium"],
    ["Hysteroscopy",
     "Irregular endometrium, cystic haemorrhagic lesions, altered vascularisation"],
]
story.append(two_col_table(["Investigation", "Details"], diag_data))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════
# SLIDE 5 — Overview of Management Strategies
# ══════════════════════════════════════════════════════════════
story += slide_header(5, "Overview of Management Strategies")

story += section_label("GUIDING PRINCIPLES")
principles = [
    "Management depends on <b>age</b>, <b>desire for future fertility</b>, <b>symptom severity</b>, "
    "and <b>extent of disease</b>",
    "Hysterectomy is definitive/curative — but uterus-sparing options are preferred for younger women",
    "No medical therapy is curative; symptoms may recur after stopping treatment",
    "Combination of medical + procedural therapy shows superior outcomes over monotherapy",
]
for p in principles:
    story.append(bullet(p))
story.append(Spacer(1, 10))

# Overview table
data = [
    ["Category", "Options", "Curative?", "Fertility Preserved?"],
    ["Medical", "NSAIDs, COC, Progestins, GnRH agonists/antagonists, LNG-IUS, Aromatase inhibitors", "No", "Yes"],
    ["Procedural / Minimally Invasive",
     "HIFU / MRgFUS, UAE, RFA, PMWA, Endometrial ablation", "No", "Limited"],
    ["Surgical — Uterus-Sparing", "Adenomyomectomy (focal / diffuse techniques)", "No", "Possible"],
    ["Surgical — Definitive", "Total Hysterectomy ± BSO", "Yes", "No"],
]
col_w = [2.8*cm, 6.5*cm, 1.8*cm, 3*cm]
header_s = S('Normal', fontSize=9, textColor=WHITE, fontName='Helvetica-Bold', leading=13)
cell_s = S('Normal', fontSize=9, textColor=DARK_GRAY, leading=13)
tdata = [[Paragraph(str(c), header_s if i == 0 else cell_s)
          for c in row]
         for i, row in enumerate(data)]
ot = Table(tdata, colWidths=col_w)
ot.setStyle(TableStyle([
    ('BACKGROUND', (0, 0), (-1, 0), DARK_TEAL),
    ('VALIGN', (0, 0), (-1, -1), 'TOP'),
    ('TOPPADDING', (0, 0), (-1, -1), 5),
    ('BOTTOMPADDING', (0, 0), (-1, -1), 5),
    ('LEFTPADDING', (0, 0), (-1, -1), 6),
    ('RIGHTPADDING', (0, 0), (-1, -1), 6),
    ('ROWBACKGROUNDS', (0, 1), (-1, -1), [LIGHT_BLUE, WHITE, LIGHT_BLUE, WHITE]),
    ('GRID', (0, 0), (-1, -1), 0.4, colors.HexColor('#AAAAAA')),
]))
story.append(ot)
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════
# SLIDE 6 — Medical Management
# ══════════════════════════════════════════════════════════════
story += slide_header(6, "Medical Management — Agents & Evidence")

med_data = [
    ["Drug / Class", "Mechanism", "Evidence / Key Points"],
    ["NSAIDs\n(Ibuprofen, Mefenamic acid)",
     "COX inhibition — reduces prostaglandin-mediated pain",
     "First-line for mild dysmenorrhoea; symptomatic relief only; no disease modification"],
    ["Combined Oral Contraceptive\n(COC)",
     "Suppress ovulation; reduce menstrual flow; pseudo-decidualisation",
     "Reduces AUB and dysmenorrhoea; continuous use preferred; no volume reduction"],
    ["Progestogens\n(Dienogest 2 mg/day; MPA)",
     "Decidualisation and atrophy of ectopic endometrium; anti-angiogenic",
     "Dienogest: significant pain reduction + uterine volume decrease (superior to LNG-IUS for pain in 2024 meta-analysis, PMID 39032312)"],
    ["LNG-IUS (Mirena)",
     "Local progestogenic effect on endometrium; reduces menstrual blood loss",
     "Effective for menorrhagia; superior haemoglobin vs dienogest; does not consistently reduce uterine volume"],
    ["GnRH Agonists\n(Leuprolide, Triptorelin)",
     "Down-regulate HPO axis → hypo-oestrogenic state; temporary menopause",
     "Highly effective; max 6 months without add-back; causes bone loss; used pre-operatively"],
    ["GnRH Antagonists\n(Relugolix, Elagolix)",
     "Competitive GnRH receptor block; faster onset than agonists",
     "Emerging agents; oral administration; relugolix + add-back approved for AUB/pain"],
    ["Aromatase Inhibitors\n(Letrozole, Anastrozole)",
     "Inhibit local oestrogen synthesis in ectopic tissue",
     "Used in refractory/post-menopausal adenomyosis; often combined with progestogen/GnRH-a"],
    ["Danazol",
     "Androgenic; suppresses HPO axis",
     "Effective but significant side effects (acne, virilisation); largely replaced by newer agents"],
]

col_w2 = [3.2*cm, 4.0*cm, CONTENT_W - 7.2*cm]
h_s = S('Normal', fontSize=8.5, textColor=WHITE, fontName='Helvetica-Bold', leading=12)
c_s = S('Normal', fontSize=8.5, textColor=DARK_GRAY, leading=12)
mdata = [[Paragraph(str(c), h_s if i == 0 else c_s) for c in row]
         for i, row in enumerate(med_data)]
mt = Table(mdata, colWidths=col_w2)
mt.setStyle(TableStyle([
    ('BACKGROUND', (0, 0), (-1, 0), DARK_TEAL),
    ('VALIGN', (0, 0), (-1, -1), 'TOP'),
    ('TOPPADDING', (0, 0), (-1, -1), 4),
    ('BOTTOMPADDING', (0, 0), (-1, -1), 4),
    ('LEFTPADDING', (0, 0), (-1, -1), 5),
    ('RIGHTPADDING', (0, 0), (-1, -1), 5),
    ('ROWBACKGROUNDS', (0, 1), (-1, -1), [LIGHT_BLUE, WHITE]),
    ('GRID', (0, 0), (-1, -1), 0.4, colors.HexColor('#AAAAAA')),
]))
story.append(mt)
story.append(Spacer(1, 6))
story.append(footer_note(
    "Sources: Berek & Novak's Gynecology; Bailey & Love's Surgery 28th ed; "
    "Akhigbe et al. 2024 Systematic Review & Meta-Analysis (PMID 39032312)"
))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════
# SLIDE 7 — Procedural / Minimally Invasive
# ══════════════════════════════════════════════════════════════
story += slide_header(7, "Procedural & Minimally Invasive Interventions")

story += section_label("UTERUS-SPARING PROCEDURAL OPTIONS")
proc_data = [
    ["Procedure", "Mechanism", "Efficacy", "Limitations"],
    ["HIFU / MRgFUS\n(High-Intensity Focused\nUltrasound)",
     "Thermal ablation of adenomyotic tissue; non-invasive",
     "60–75% volume reduction; significant AUB + pain improvement; combination with GnRH-a superior (2025 NMA, PMID 39648811)",
     "Not FDA-approved for adenomyosis; limited US access; AEs: abdominal pain, skin burns, sciatic nerve injury"],
    ["Uterine Artery Embolisation (UAE)",
     "Devascularisation of uterus via femoral artery catheter; ischaemic necrosis of adenomyotic tissue",
     "72–90% symptom improvement; durable 2–3 yr outcomes",
     "Post-embolisation syndrome (pain, fever, nausea); ovarian reserve impairment; reintervention rate ~20% at 5 yr"],
    ["Radiofrequency Ablation (RFA)",
     "Transcervical or percutaneous thermal ablation",
     "Effective for focal adenomyosis; low reintervention",
     "Limited long-term data; not suitable for diffuse disease"],
    ["Percutaneous Microwave\nAblation (PMWA)",
     "Image-guided microwave energy delivery",
     "Promising outcomes; emerging evidence",
     "Limited RCTs; not widely available"],
    ["Endometrial Ablation /\nResection",
     "Destroy endometrial lining; reduces menstrual blood loss",
     "Useful for AUB in women not seeking fertility; may fail in deep adenomyosis",
     "Not curative; recurrence; Asherman's syndrome risk; not for fertility-seeking"],
]
col_w3 = [2.8*cm, 3.2*cm, 3.5*cm, CONTENT_W - 9.5*cm]
h_s3 = S('Normal', fontSize=8.5, textColor=WHITE, fontName='Helvetica-Bold', leading=12)
c_s3 = S('Normal', fontSize=8.5, textColor=DARK_GRAY, leading=12)
pdata = [[Paragraph(str(c), h_s3 if i == 0 else c_s3) for c in row]
         for i, row in enumerate(proc_data)]
pt = Table(pdata, colWidths=col_w3)
pt.setStyle(TableStyle([
    ('BACKGROUND', (0, 0), (-1, 0), DARK_TEAL),
    ('VALIGN', (0, 0), (-1, -1), 'TOP'),
    ('TOPPADDING', (0, 0), (-1, -1), 4),
    ('BOTTOMPADDING', (0, 0), (-1, -1), 4),
    ('LEFTPADDING', (0, 0), (-1, -1), 5),
    ('RIGHTPADDING', (0, 0), (-1, -1), 5),
    ('ROWBACKGROUNDS', (0, 1), (-1, -1), [LIGHT_BLUE, WHITE]),
    ('GRID', (0, 0), (-1, -1), 0.4, colors.HexColor('#AAAAAA')),
]))
story.append(pt)
story.append(Spacer(1, 6))
story.append(footer_note("Sources: Zeccola & Allen, Curr Opin Obstet Gynecol 2024 (PMID 38837727); Song & Wang, J Ultrasound Med 2025 (PMID 39648811)"))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════
# SLIDE 8 — Surgical Management
# ══════════════════════════════════════════════════════════════
story += slide_header(8, "Surgical Management — Options & Techniques")

story += section_label("A. UTERUS-PRESERVING: ADENOMYOMECTOMY")
adeno_items = [
    ("<b>Indication:</b> Fertility-desiring women with focal or symptomatic diffuse adenomyosis "
     "who have failed medical therapy"),
    ("<b>Techniques for FOCAL adenomyosis:</b> Complete excision — double-flap method, triple-flap "
     "method, asymmetric dissection method"),
    ("<b>Techniques for DIFFUSE adenomyosis:</b> Wedge resection, wedge-shaped uterine wall removal, "
     "modified reductive surgery, transverse H-incision"),
    ("<b>Non-excisional:</b> Thermal coagulation of diseased myometrium (for selected cases)"),
    ("<b>Risk:</b> Uterine rupture ~6% in subsequent pregnancy (vs 0.26% after myomectomy); "
     "placenta accreta, Asherman's syndrome; disease recurrence"),
    ("<b>Post-operative medical therapy</b> (GnRH-a / LNG-IUS) reduces recurrence risk"),
]
for item in adeno_items:
    story.append(bullet(item))
story.append(Spacer(1, 8))

story += section_label("B. DEFINITIVE: HYSTERECTOMY")
hyst_items = [
    "<b>Total hysterectomy preferred</b> over subtotal (cervical stump recurrence reported)",
    "BSO: consider in peri/post-menopausal women (reduces oestrogen drive); not routine in premenopausal",
    "Routes: laparoscopic (preferred if feasible), abdominal, vaginal — surgeon/patient dependent",
    "<b>Indication:</b> Completed family; failed conservative treatment; severe/refractory symptoms",
    "Cure rate: near 100% for adenomyosis symptoms",
    "Complications: infection, haemorrhage, bladder/ureter injury, VTE, premature menopause if oophorectomy",
]
for item in hyst_items:
    story.append(bullet(item))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════
# SLIDE 9 — Head-to-Head Comparison Table
# ══════════════════════════════════════════════════════════════
story += slide_header(9, "Head-to-Head Comparison: Medical vs Surgical")

comp_data = [
    ["Parameter", "Medical Management", "Surgical (Conservative)", "Surgical (Hysterectomy)"],
    ["Curative?", "No", "No (recurrence possible)", "Yes — definitive"],
    ["Fertility Preserved?", "Yes", "Possible (with precautions)", "No"],
    ["Onset of Relief", "Weeks–months", "Weeks–months", "Immediate"],
    ["Duration of Effect", "Temporary; recurs on cessation", "Variable; 1–5 yr", "Permanent"],
    ["Recurrence Rate", "High after stopping", "~20–50% (diffuse > focal)", "None"],
    ["Uterine Volume Reduction",
     "Dienogest > LNG-IUS; GnRH-a highest",
     "Moderate–significant",
     "N/A (uterus removed)"],
    ["Pain Control (VAS)",
     "Dienogest superior to LNG-IUS; GnRH-a effective",
     "Good (especially HIFU + GnRH-a)",
     "Excellent (>95%)"],
    ["Anaemia / AUB",
     "LNG-IUS superior for Hb levels; COC reduces blood loss",
     "UAE/HIFU effective for AUB",
     "Resolves completely"],
    ["Side Effects",
     "Hormonal SE (mood, weight, bone loss with GnRH-a); amenorrhoea",
     "Post-procedural pain, UAE syndrome, ovarian reserve↓",
     "Surgical risks; premature menopause"],
    ["Cost", "Low–moderate (ongoing)", "Moderate–high (one-time)",
     "High (one-time; recovery costs)"],
    ["Patient Preference", "Non-invasive; preferred initially", "Uterus-sparing; good for fertility",
     "Acceptable when family complete"],
]
col_w4 = [2.5*cm, 3.5*cm, 3.5*cm, 3.5*cm]
h_s4 = S('Normal', fontSize=8.5, textColor=WHITE, fontName='Helvetica-Bold', leading=12)
c_s4 = S('Normal', fontSize=8.5, textColor=DARK_GRAY, leading=12)
cdata = [[Paragraph(str(c), h_s4 if i == 0 else c_s4) for c in row]
         for i, row in enumerate(comp_data)]
ct = Table(cdata, colWidths=col_w4)
ct.setStyle(TableStyle([
    ('BACKGROUND', (0, 0), (-1, 0), DARK_TEAL),
    ('VALIGN', (0, 0), (-1, -1), 'TOP'),
    ('TOPPADDING', (0, 0), (-1, -1), 4),
    ('BOTTOMPADDING', (0, 0), (-1, -1), 4),
    ('LEFTPADDING', (0, 0), (-1, -1), 5),
    ('RIGHTPADDING', (0, 0), (-1, -1), 5),
    ('ROWBACKGROUNDS', (0, 1), (-1, -1), [LIGHT_BLUE, WHITE]),
    ('GRID', (0, 0), (-1, -1), 0.4, colors.HexColor('#AAAAAA')),
]))
story.append(ct)
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════
# SLIDE 10 — Special Considerations: Fertility & Recurrence
# ══════════════════════════════════════════════════════════════
story += slide_header(10, "Special Considerations: Fertility & Recurrence")

story += section_label("ADENOMYOSIS & FERTILITY")
fert_items = [
    "Adenomyosis impairs implantation: distorted uterine contractility, altered endometrial receptivity (HOXA10↓, integrin αvβ3↓)",
    "IVF outcomes: live birth rates reduced by ~30% in adenomyosis (systematic review evidence)",
    "GnRH-a pre-treatment (3–6 months) before IVF improves pregnancy rates in adenomyosis",
    "LNG-IUS use pre-IVF: emerging evidence for improved endometrial receptivity",
    "Adenomyomectomy before IVF: controversial; uterine rupture risk 6% in pregnancy; careful counselling required",
    "Medical downregulation remains first-line before ART in adenomyosis",
]
for item in fert_items:
    story.append(bullet(item))
story.append(Spacer(1, 8))

story += section_label("RECURRENCE AFTER TREATMENT")
rec_data = [
    ["Treatment", "Recurrence Rate", "Notes"],
    ["Medical (on cessation)", "High — symptoms return within months", "Indicates need for long-term or maintenance therapy"],
    ["LNG-IUS", "Low during use; moderate after removal", "Continued use maintains suppression; re-insertion an option"],
    ["HIFU / UAE", "~15–25% at 2 yr; ~30–40% at 5 yr", "Younger age and diffuse disease = higher recurrence"],
    ["Adenomyomectomy", "20–50% at 5 yr", "Post-op GnRH-a / LNG-IUS reduces recurrence significantly"],
    ["Total Hysterectomy", "Near 0% (isolated cases in cervical stump)", "Subtotal hysterectomy: cervical stump recurrence reported"],
]
story.append(three_col_table(["Treatment", "Recurrence Rate", "Notes"], rec_data[1:],
                              col_ratios=[0.25, 0.35, 0.4]))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════
# SLIDE 11 — Current Evidence & Recommendations
# ══════════════════════════════════════════════════════════════
story += slide_header(11, "Current Evidence & Recommendations (2021-2025)")

story += section_label("KEY RECENT EVIDENCE")
ev_items = [
    ("<b>Akhigbe et al. 2024 (Meta-Analysis; PMID 39032312):</b> Dienogest superior to LNG-IUS "
     "for pelvic pain reduction (lower VAS) and uterine volume decrease. LNG-IUS superior for "
     "haemoglobin levels. Side effects comparable. N=707 women."),
    ("<b>Zeccola &amp; Allen 2024 (Review; PMID 38837727):</b> UAE, RFA, HIFU, PMWA, and "
     "adenomyomectomy all proven effective for AUB and dysmenorrhoea. Combination therapy "
     "more effective than monotherapy. Overall low reintervention rates."),
    ("<b>Song &amp; Wang 2025 (Network Meta-Analysis; PMID 39648811):</b> HIFU combined with "
     "medication (GnRH-a) significantly outperforms either alone for adenomyosis outcomes."),
    ("<b>Shi et al. 2024 (Review; PMID 38836931):</b> Long-term LNG-IUS use safe and effective "
     "for adenomyosis management with sustained suppression of AUB."),
]
for item in ev_items:
    story.append(bullet(item))
story.append(Spacer(1, 8))

story += section_label("EVIDENCE GAPS & LIMITATIONS")
gap_items = [
    "Most RCTs are from Asia; generalisation to other populations limited",
    "No standardised diagnostic criteria across studies (histological vs imaging)",
    "Long-term RCT data comparing all management strategies lacking",
    "FDA approval for HIFU/ablative therapies in adenomyosis absent in the USA",
    "Fertility outcomes after conservative procedures need higher-quality prospective trials",
]
for item in gap_items:
    story.append(bullet(item))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════
# SLIDE 12 — Clinical Algorithm
# ══════════════════════════════════════════════════════════════
story += slide_header(12, "Clinical Algorithm: Management Decision Pathway")

story.append(Paragraph(
    "A practical stepwise approach to managing adenomyosis based on patient profile:",
    S('Normal', fontSize=10.5, textColor=MED_GRAY, leading=15, spaceAfter=6)
))

algo_data = [
    ["Step", "Patient Profile", "Preferred Management"],
    ["Step 1\n(First-Line)",
     "Any patient with mild symptoms; premenopausal",
     "NSAIDs ± COC pill; trial 3–6 months"],
    ["Step 2\n(Second-Line)",
     "Persistent symptoms; no fertility desire in short term",
     "Progestins (Dienogest) OR LNG-IUS; GnRH agonist if severe"],
    ["Step 3A\n(Fertility-Seeking)",
     "Failed medical therapy; wishes pregnancy",
     "GnRH-a pre-treatment (3–6 months) → ART/IVF; "
     "consider adenomyomectomy for focal adenomyoma (with counselling)"],
    ["Step 3B\n(No Fertility Wish)",
     "Failed medical therapy; uterus preservation desired",
     "HIFU or UAE (if accessible) ± post-procedure LNG-IUS/GnRH-a for maintenance"],
    ["Step 4\n(Definitive)",
     "Family complete; failed conservative management; severe symptoms",
     "Total laparoscopic / abdominal hysterectomy (± BSO in peri-menopausal)"],
    ["Adjunct",
     "Pre-operative (any surgery)",
     "GnRH agonist 3 months pre-op to reduce uterine size, correct anaemia"],
]
col_w5 = [1.8*cm, 4.5*cm, CONTENT_W - 6.3*cm]
h_s5 = S('Normal', fontSize=9, textColor=WHITE, fontName='Helvetica-Bold', leading=13)
c_s5 = S('Normal', fontSize=9, textColor=DARK_GRAY, leading=13)
aldata = [[Paragraph(str(c), h_s5 if i == 0 else c_s5) for c in row]
          for i, row in enumerate(algo_data)]
alt = Table(aldata, colWidths=col_w5)
alt.setStyle(TableStyle([
    ('BACKGROUND', (0, 0), (-1, 0), DARK_TEAL),
    ('VALIGN', (0, 0), (-1, -1), 'TOP'),
    ('TOPPADDING', (0, 0), (-1, -1), 5),
    ('BOTTOMPADDING', (0, 0), (-1, -1), 5),
    ('LEFTPADDING', (0, 0), (-1, -1), 6),
    ('RIGHTPADDING', (0, 0), (-1, -1), 6),
    ('ROWBACKGROUNDS', (0, 1), (-1, -1), [LIGHT_BLUE, WHITE]),
    ('GRID', (0, 0), (-1, -1), 0.4, colors.HexColor('#AAAAAA')),
]))
story.append(alt)
story.append(Spacer(1, 8))
story += callout(
    "<b>Key Principle:</b> Always individualise management. Consider: age, parity, fertility desire, "
    "severity of disease, co-existing pathology, patient preference, and local resource availability.",
    bg=MINT
)
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════
# SLIDE 13 — Key Takeaways
# ══════════════════════════════════════════════════════════════
story += slide_header(13, "Key Takeaways")

takeaways = [
    ("1", "Adenomyosis is common but often under-diagnosed; TVUSS is the first-line imaging tool "
          "(MUSA criteria; ≥3 features needed)"),
    ("2", "No medical therapy is curative — all provide symptom control but recurrence occurs on cessation"),
    ("3", "Dienogest is superior to LNG-IUS for pain and uterine volume reduction; LNG-IUS is better "
          "for correcting anaemia (2024 meta-analysis)"),
    ("4", "GnRH agonists remain the most potent medical option but are limited to 6 months without add-back therapy"),
    ("5", "HIFU + GnRH-a combination therapy is the most effective procedural approach — superior to either alone"),
    ("6", "Adenomyomectomy is an option for fertility-seeking women but carries significant uterine rupture "
          "risk (6%) in subsequent pregnancy"),
    ("7", "Total hysterectomy is the only definitive cure — indicated when family is complete and conservative "
          "measures have failed"),
    ("8", "Combination therapy (medical + procedural/surgical) consistently outperforms monotherapy across all outcomes"),
    ("9", "High-quality RCTs comparing all treatment modalities are still lacking — management must be "
          "individualised and shared decision-making is essential"),
]
for num, text in takeaways:
    data = [[
        Paragraph(num, S('Normal', fontSize=13, textColor=WHITE,
                          fontName='Helvetica-Bold', alignment=TA_CENTER)),
        Paragraph(text, S('Normal', fontSize=10, textColor=DARK_GRAY, leading=15))
    ]]
    bg = DARK_TEAL if int(num) % 2 == 1 else TEAL
    t = Table(data, colWidths=[0.85*cm, CONTENT_W - 0.85*cm])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0, 0), (0, 0), bg),
        ('VALIGN', (0, 0), (-1, -1), 'MIDDLE'),
        ('TOPPADDING', (0, 0), (-1, -1), 5),
        ('BOTTOMPADDING', (0, 0), (-1, -1), 5),
        ('LEFTPADDING', (0, 0), (0, 0), 0),
        ('LEFTPADDING', (1, 0), (1, 0), 8),
    ]))
    story.append(t)
    story.append(Spacer(1, 3))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════
# SLIDE 14 — References
# ══════════════════════════════════════════════════════════════
story += slide_header(14, "References")
refs = [
    "1. Berek JS et al. <i>Berek &amp; Novak's Gynecology</i>, 16th ed. (2020). Management of Adenomyosis, pp. 581–582.",
    "2. Williams NS et al. <i>Bailey &amp; Love's Short Practice of Surgery</i>, 28th ed. (2023). Table 87.4: Adenomyosis Management Options, pp. 1604–1605.",
    "3. Kumar V et al. <i>Robbins, Cotran &amp; Kumar Pathologic Basis of Disease</i>, 10th ed. (2024). Endometriosis &amp; Adenomyosis.",
    "4. Akhigbe RE et al. Comparison of the effectiveness of levonorgestrel intrauterine system and dienogest in adenomyosis: systematic review and meta-analysis. <i>Eur J Obstet Gynecol Reprod Biol.</i> 2024 Sep. PMID: 39032312.",
    "5. Zeccola AM, Allen SE. Alternative treatments of adenomyosis — an update in procedural management and clinical outcomes. <i>Curr Opin Obstet Gynecol.</i> 2024 Aug. PMID: 38837727.",
    "6. Shi J et al. Long-term efficacy and safety of levonorgestrel releasing intrauterine system in adenomyosis: evidence mapping. <i>Arch Gynecol Obstet.</i> 2024 Jul. PMID: 38836931.",
    "7. Song Y, Wang L. Combining medication with high-intensity-focused ultrasound for adenomyosis: network meta-analysis. <i>J Ultrasound Med.</i> 2025 Mar. PMID: 39648811.",
    "8. MUSA Group. Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses. <i>Ultrasound Obstet Gynecol.</i> 2015.",
    "9. ESHRE Working Group on Adenomyosis. Working definitions and diagnostic criteria for adenomyosis. <i>Hum Reprod Open.</i> 2021.",
]
for ref in refs:
    story.append(Paragraph(ref, S('Normal', fontSize=9, textColor=DARK_GRAY,
                                   leading=14, spaceAfter=4, leftIndent=8)))

story.append(Spacer(1, 1.2*cm))
story += callout(
    "<b>Disclosure:</b> This presentation is for educational purposes for postgraduate medical "
    "training. Clinical decisions should be individualised and guided by current institutional "
    "protocols and patient-specific factors.",
    bg=LIGHT_BLUE, fg=DARK_TEAL
)

# ─── Page numbering callback ───────────────────────────────────────────────────
def on_page(canvas, doc):
    canvas.saveState()
    canvas.setFont('Helvetica', 7.5)
    canvas.setFillColor(MED_GRAY)
    canvas.drawRightString(PAGE_W - MARGIN, 0.6*cm,
                           f"Adenomyosis: Medical vs Surgical Management | Page {doc.page}")
    canvas.drawString(MARGIN, 0.6*cm,
                      "For Gynecology Resident Education | May 2026")
    canvas.restoreState()

# ─── Build PDF ─────────────────────────────────────────────────────────────────
out_path = "/home/daytona/workspace/adenomyosis-presentation/Adenomyosis_Medical_vs_Surgical_Management.pdf"
doc = SimpleDocTemplate(
    out_path,
    pagesize=A4,
    leftMargin=MARGIN, rightMargin=MARGIN,
    topMargin=MARGIN, bottomMargin=1.4*cm,
    title="Comparison of Medical vs Surgical Management of Adenomyosis",
    author="Gynecology Resident Presentation",
    subject="Adenomyosis — Medical vs Surgical Management"
)
doc.build(story, onFirstPage=on_page, onLaterPages=on_page)
print(f"PDF created: {out_path}")
print(f"File size: {os.path.getsize(out_path):,} bytes")

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/adenomyosis-presentation/build_slides.py'

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/adenomyosis-presentation/build_slides.py'