newer contraceptives women 2024 2025

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newer contraceptives 2024 2025 gynecology updates FDA approved

https://pmc.ncbi.nlm.nih.gov/articles/PMC12187473

estetrol drospirenone contraceptive pill new

ls /home/daytona/workspace/ 2>/dev/null && mkdir -p /home/daytona/workspace/newe…

~/newer-contraceptives-pptx/build.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Newer Contraceptives in Gynaecology";
pres.author = "Based on Berek & Novak's Gynecology + 2024 CDC MEC/SPR Updates";

// ─── PALETTE ────────────────────────────────────────────────────────────────
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const DARK_TEXT   = "1A2E35";
const LABEL_TEXT  = "5A8A94";

// ─── HELPERS ────────────────────────────────────────────────────────────────
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function noteBlock(slide, notes) {
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}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 1 – TITLE
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  titleSlide(s);

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  s.addText("Evidence-Based Review · Williams / Berek & Novak's Gynaecology\n2024 CDC MEC & SPR Updates", {
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  s.addText("July 2026", {
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  noteBlock(s, "Title slide.\nSource: Berek & Novak's Gynecology (ISBN 9781496380357) + 2024 CDC Medical Eligibility Criteria (MEC) and Selected Practice Recommendations (SPR) for Contraceptive Use.");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 2 – OVERVIEW / CLASSIFICATION
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bodySlide(s);
  addSectionBanner(s, "CLASSIFICATION OF MODERN CONTRACEPTIVES");
  addSlideTitle(s, "Overview: Modern Contraceptive Methods");

  const items = [
    bullet("1. Combined Hormonal Contraceptives (CHC)", 0, true),
    bullet("Combined Oral Contraceptives (COCs) – monophasic, multiphasic, extended-cycle", 1),
    bullet("Contraceptive Patch (Ortho Evra / Xulane / Twirla – E4/drospirenone)", 1),
    bullet("Vaginal Ring – NuvaRing, Annovera (segesterone acetate + EE, 1-year ring)", 1),
    bullet("", 0),
    bullet("2. Progestin-Only Contraceptives (POC)", 0, true),
    bullet("Progestin-only Pills (POP) – traditional norethindrone; newer drospirenone-only pill (Slynd)", 1),
    bullet("Injectable – DMPA (Depo-Provera), SC DMPA self-injection (2024 SPR update)", 1),
    bullet("Subdermal Implant – Nexplanon (etonogestrel) – now approved for 5 years (FDA 2024)", 1),
    bullet("", 0),
    bullet("3. Intrauterine Contraception (IUC)", 0, true),
    bullet("Copper IUD – ParaGard (T380A, 10 yr), copper ions = spermicidal + anti-fertilisation", 1),
    bullet("Levonorgestrel IUDs – Mirena 52 mg (8 yr*), Liletta 52 mg (8 yr), Kyleena 19.5 mg (5 yr), Skyla 13.5 mg (3 yr)", 1),
    bullet("", 0),
    bullet("4. Emergency Contraception (EC)", 0, true),
    bullet("Levonorgestrel (Plan B / generic) 1.5 mg ≤72 h; Ulipristal Acetate (ella) ≤120 h", 1),
    bullet("Copper IUD – most effective EC up to 5 days", 1),
    bullet("", 0),
    bullet("5. Newer & Investigational Methods (see subsequent slides)", 0, true),
  ];

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  noteBlock(s, "Berek & Novak's Gynecology Ch. 14: All hormonal contraceptives are progestin-dominant. Progestins do the primary contraceptive work (ovulation suppression + cervical mucus thickening); estrogen adds cycle control and enhances ovarian suppression.\n\nKey 2024 updates:\n• Nexplanon FDA-approved for 5 years (extended from 3; previously extended off-label label)\n• Mirena extended to 8 years for contraception (Australia 2024; supported by US efficacy data)\n• CDC SPR 2024 added self-administration of SC-DMPA and pain management guidance for IUD insertion.");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 3 – STEROID HORMONES & MECHANISMS
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bodySlide(s);
  addSectionBanner(s, "PHARMACOLOGY");
  addSlideTitle(s, "Hormonal Contraception: Pharmacology & Mechanisms");

  const col1 = [
    bullet("Estrogen Component", 0, true),
    bullet("Most COCs use Ethinyl Estradiol (EE) 10–35 μg", 1),
    bullet("New: Estetrol (E4) – naturally occurring fetal estrogen; selective ERα/ERβ modulator", 1),
    bullet("E4/Drospirenone (Nextstellis) – FDA approved 2021; lower VTE signal vs EE-based pills", 1),
    bullet("17β-estradiol (Estradiol valerate/dienogest – Natazia/Qlaira) – bioidentical estrogen", 1),
    bullet("", 0),
    bullet("Progestin Component (Generations)", 0, true),
    bullet("1st gen: Norethindrone – androgenic; still in POP (Camila, Errin)", 1),
    bullet("2nd gen: Levonorgestrel, Norgestrel – androgenic; widely used, low VTE vs 3rd gen", 1),
    bullet("3rd gen: Desogestrel, Gestodene, Norgestimate – less androgenic; higher VTE risk vs LNG", 1),
    bullet("4th gen: Drospirenone – anti-androgenic + anti-mineralocorticoid (diuretic-like effect)", 1),
    bullet("Nomegestrol acetate, Dienogest – newer selective progestins, minimal androgenicity", 1),
    bullet("Segesterone acetate (Annovera ring) – novel progestin; non-oral delivery", 1),
  ];

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    { text: "Mechanism Summary\n", options: { bold: true, fontSize: 13, color: DEEP_TEAL, breakLine: true } },
    { text: "✦ Ovulation suppression\n", options: { fontSize: 12, color: DARK_TEXT, breakLine: true } },
    { text: "   (LH/FSH suppression via -ve feedback)\n\n", options: { fontSize: 11, color: "3A5A62", breakLine: true } },
    { text: "✦ Cervical mucus thickening\n", options: { fontSize: 12, color: DARK_TEXT, breakLine: true } },
    { text: "   (progestin effect → sperm barrier)\n\n", options: { fontSize: 11, color: "3A5A62", breakLine: true } },
    { text: "✦ Endometrial atrophy\n", options: { fontSize: 12, color: DARK_TEXT, breakLine: true } },
    { text: "   (hostile to implantation)\n\n", options: { fontSize: 11, color: "3A5A62", breakLine: true } },
    { text: "✦ Tubal motility alteration\n", options: { fontSize: 12, color: DARK_TEXT, breakLine: true } },
    { text: "   (reduces ovum transport speed)\n\n", options: { fontSize: 11, color: "3A5A62", breakLine: true } },
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  noteBlock(s, "Berek & Novak's: Steroids are rapidly absorbed in gut but metabolized by liver (portal first-pass). Addition of ethynyl group at C-17 blocks hepatic 17-hydroxysteroid dehydrogenase, enabling activity at microgram doses.\n\nEstetrol (E4):\n• Naturally produced by fetal liver; selective estrogen receptor modulator activity\n• E4 15 mg + Drospirenone 3 mg (Nextstellis / Drovelis / Lydisilka) - FDA approved May 2021\n• Phase III PEARL study: Pearl Index 0.9–2.65 – efficacy comparable to EE-based pills\n• Lower thromboembolic signal in pharmacovigilance data (Didembourg 2025, Contraception journal)\n• Suitable for women with headache/migraines (less vasospasm)\n\nDrospirenone 4 mg POP (Slynd, 2019 FDA): 24-active + 4 placebo tablet schedule. Anti-androgenic – useful in PCOS & acne.");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 4 – E4/DROSPIRENONE & NEW OC PILL
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bodySlide(s);
  addSectionBanner(s, "NEWER ORAL CONTRACEPTIVES");
  addSlideTitle(s, "Estetrol / Drospirenone (E4/DRSP) – The 4th-Generation OCP");

  const items = [
    bullet("What is Estetrol (E4)?", 0, true),
    bullet("Native estrogen synthesized by fetal liver; detectable in maternal urine from 9th week of pregnancy", 1),
    bullet("Selective estrogen receptor modulator (SERM-like) – agonist in uterus/bone, weaker agonist in liver/breast", 1),
    bullet("Lower hepatic impact → potentially reduced VTE risk vs ethinylestradiol (EE)", 1),
    bullet("", 0),
    bullet("Formulation: Nextstellis® (E4 15 mg + DRSP 3 mg) – FDA approved May 2021", 0, true),
    bullet("24 active + 4 placebo tablets (24/4 regimen)", 1),
    bullet("Pearl Index: 1.54–2.65 (comparable to EE-based pills) in Phase III PEARL study", 1),
    bullet("Favourable bleeding profile – fewer unscheduled bleeds vs EE/LNG", 1),
    bullet("Lower reports of VTE events vs EE-based COCs (EudraVigilance pharmacovigilance data, 2025)", 1),
    bullet("", 0),
    bullet("Drospirenone-only Pill (Slynd® / Slinda®) – FDA 2019", 0, true),
    bullet("4 mg drospirenone; 24/4 regimen (broader ovulation suppression window vs norethindrone POP)", 1),
    bullet("Minimal 12-hour missed pill window (vs 3 h for norethindrone POP) – more forgiving", 1),
    bullet("Anti-androgenic: reduces acne, hirsutism; anti-mineralocorticoid: mild diuretic effect", 1),
    bullet("Suitable for estrogen-sensitive patients (migraine, VTE risk)", 1),
    bullet("", 0),
    bullet("OTC Progestin-Only Pill (Opill® – norgestrel 0.075 mg) – FDA OTC approval July 2023", 0, true),
    bullet("First OTC oral contraceptive in US history; available on shelves/online without prescription since 2024", 1),
  ];

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  noteBlock(s, "Estetrol reference: Battipaglia C et al. Expert Opin Drug Metab Toxicol 2023; Nelson AL. Expert Opin Pharmacother 2023; Foidart JM et al. AJOG Glob Rep 2023.\n\nE4 advantages over EE:\n1. Does NOT increase sex hormone-binding globulin (SHBG) or clotting factors as much as EE\n2. Less effect on renin-angiotensin system\n3. Lower androgenic/anabolic hepatic proteins\n\nDrospirenone POP (Slynd):\n• Unlike norethindrone POP which inhibits ovulation in only ~50% of cycles, drospirenone POP suppresses ovulation in >99% of cycles\n• Approved in >90 countries\n\nOpill (OTC):\n• Contains norgestrel 0.075 mg\n• FDA approved July 2023 as first over-the-counter daily oral contraceptive in US\n• Available on store shelves since early 2024\n• Does NOT require prescriptions; increases access for underserved populations");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 5 – NEWER PATCHES & RINGS
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bodySlide(s);
  addSectionBanner(s, "TRANSDERMAL & VAGINAL METHODS");
  addSlideTitle(s, "Contraceptive Patch & Vaginal Ring – New Developments");

  const col1 = [
    bullet("PATCHES", 0, true),
    bullet("Ortho Evra / Xulane (EE 20 μg + norelgestromin 150 μg)", 1),
    bullet("Apply weekly × 3, then 1 patch-free week", 1),
    bullet("Pearl Index 1.24 vs OC 2.18 (non-significant); better compliance 88% vs 78%", 1),
    bullet("Caution: Higher AUC of EE than OC → slightly higher VTE risk (FDA black box)", 1),
    bullet("Reduced efficacy in women >90 kg (3% of failures in heavier women)", 1),
    bullet("", 0),
    bullet("Twirla® (E4/levonorgestrel patch) – FDA approved 2020", 0, true),
    bullet("EE 30 μg + levonorgestrel 120 μg; weekly patch × 3 then 1 week off", 1),
    bullet("Considered lower VTE risk than norelgestromin patch (progestin generation difference)", 1),
    bullet("", 0),
  ];

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    bullet("VAGINAL RINGS", 0, true),
    bullet("NuvaRing (EE 15 μg + etonogestrel 120 μg/day)", 1),
    bullet("Wear 3 weeks, remove 1 week; or continuous use (no ring-free week)", 1),
    bullet("Lowest EE COC available; EE AUC ~1/3 of oral EE – favourable thrombosis profile", 1),
    bullet("Pearl Index 1.18; fewer breakthrough bleeds than LNG 150/EE 30 OC", 1),
    bullet("", 0),
    bullet("Annovera® (Segesterone Acetate 150 mg + EE 17.4 mg) – FDA 2018", 0, true),
    bullet("NOVEL: Single ring used continuously for 13 cycles (1 full year)", 1),
    bullet("Segesterone acetate = new progestin; first approved contraceptive with this progestin", 1),
    bullet("Insert for 21 days, remove for 7 days × 13 cycles from same ring", 1),
    bullet("Released daily: segesterone 150 μg + EE 13 μg; efficacy Pearl Index ~2.98", 1),
    bullet("Ideal for women who want long-term non-daily contraception without uterine device", 1),
    bullet("", 0),
    bullet("EluRyng® (generic NuvaRing) – FDA approved 2023; cost-accessible alternative", 0, true),
  ];

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  noteBlock(s, "Berek & Novak's on NuvaRing: EE levels with ring are ~1/3 of oral EE; etonogestrel ~40% of oral desogestrel pill. Despite lower systemic levels, complete ovulation suppression is maintained.\n\nAnnovera key points:\n• Segesterone acetate = 17α-acetoxy-16-methylene-19-nor-4-pregnene-3,20-dione; selective progestin\n• Phase III: Pearl Index 2.98 in typical use, 1.25 in perfect use\n• 1-year sustained release ring = reduces user burden significantly\n• Can be removed for intercourse (replace within 2 hours)\n• Does not require clinician insertion/removal\n\nNuvaRing thrombosis: Ring shows LESS prothrombotic effect than patch in comparative pharmacokinetic studies (Berek & Novak's citing crossover study data).");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 6 – IMPLANTS (Nexplanon Updates)
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bodySlide(s);
  addSectionBanner(s, "LONG-ACTING REVERSIBLE CONTRACEPTION (LARC)");
  addSlideTitle(s, "Subdermal Implant – Nexplanon (Etonogestrel) 2024 Updates");

  const items = [
    bullet("Device Specifications", 0, true),
    bullet("4 cm × 2 mm radiopaque rod; contains 68 mg etonogestrel (active metabolite of desogestrel)", 1),
    bullet("Inserted subdermally in medial upper arm (non-dominant)", 1),
    bullet("Releases ~60–70 μg/day initially, declining to ~25–30 μg/day at 3 years", 1),
    bullet("", 0),
    bullet("Duration Update – FDA 2024 (MAJOR UPDATE)", 0, true),
    bullet("Previously: approved for 3 years", 1),
    bullet("NOW: FDA approved for 5 years (December 2024 label update); REMS certification required", 1),
    bullet("Extended use data show maintained efficacy & safety through year 5", 1),
    bullet("Clinical surveys showed ~1/3 of clinicians still counselling 3 years despite 5-year evidence", 1),
    bullet("", 0),
    bullet("Mechanism", 0, true),
    bullet("Primary: ovulation suppression (suppresses LH surge)", 1),
    bullet("Secondary: cervical mucus thickening, endometrial atrophy, altered tubal motility", 1),
    bullet("1st year: ~20% ovulatory cycles; increases to ~41% by year 4 (declining serum levels)", 1),
    bullet("", 0),
    bullet("Efficacy", 0, true),
    bullet("Pearl Index <0.1 per 100 women-years – among LOWEST failure rates of all contraceptives", 1),
    bullet("Comparable to female sterilisation; no user-dependent errors", 1),
    bullet("", 0),
    bullet("Special Populations", 0, true),
    bullet("Effective in obese women (slightly lower serum levels but still suppresses ovulation)", 1),
    bullet("Safe during lactation – progestin-only; does not affect milk supply", 1),
    bullet("Suitable for oestrogen-sensitive patients (migraine, VTE history)", 1),
    bullet("", 0),
    bullet("Side Effect Profile", 0, true),
    bullet("Most common reason for removal: irregular bleeding (20–30%)", 1),
    bullet("2024 CDC SPR Update: NSAIDs (ibuprofen, naproxen) or combined hormonal back-up recommended for bothersome bleeding with implant", 1),
  ];

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  noteBlock(s, "Source: Berek & Novak's Gynecology (Ch.14 Hormonal Implants) + 2024 FDA Nexplanon label + 2024 CDC SPR.\n\nNexplanon 5-year FDA approval (December 2024):\n• Based on phase 3 extension study data\n• FDA required new REMS (Risk Evaluation and Mitigation Strategy) certification for all providers inserting/removing Nexplanon\n• Pearl Index through year 5: <0.1\n\nBerek & Novak's on etonogestrel implant: 'The more potent progestin released by the etonogestrel implant is even more effective at preventing ovulation than levonorgestrel implants.'\n\nIrregular bleeding management (2024 SPR):\n• NSAIDs for short-term management\n• Consider combined hormonal pill add-back for persistent bleeding\n• Rule out STI, pregnancy");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 7 – IUDs (LNG IUD UPDATES)
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bodySlide(s);
  addSectionBanner(s, "LONG-ACTING REVERSIBLE CONTRACEPTION (LARC)");
  addSlideTitle(s, "Intrauterine Devices – New Approvals & Extended Duration");

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  const hx   = [0.31, 2.1, 4.3, 5.85];
  const hw   = [1.78, 2.15, 1.5, 3.65];
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  const rows = [
    ["Mirena® 52 mg", "52 mg / 20 μg/day init.", "8 yr* (NEW)", "Extended to 8 yr contraception 2024 (AU/UK); 5 yr for HMB. Widely used globally."],
    ["Liletta® 52 mg", "52 mg / 20 μg/day init.", "8 yr", "FDA approved 8 yr 2023. Manufactured by Medicines360 for cost access."],
    ["Kyleena® 19.5 mg", "19.5 mg / 17.5 μg/day", "5 yr", "Lower systemic LNG → more ovulatory cycles; lighter bleeding. For nulliparous."],
    ["Skyla® 13.5 mg", "13.5 mg / 14 μg/day init.", "3 yr", "Smallest frame (28×30mm); designed for adolescents/nulliparous."],
    ["ParaGard® Cu T380A", "Copper (no hormone)", "10 yr", "Best EC for up to 5 days. 380 mm² copper. Safe in estrogen-sensitive patients."],
    ["Bayer Ballerine®", "19.5 mg LNG (frameless)", "5 yr", "INVESTIGATIONAL. Frameless anchored IUD; better for uterine anomalies."],
  ];
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        valign: "middle", align: ci === 0 ? "left" : "center", margin: 2
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  s.addText("* Mirena 8-yr: Approved Australia/UK 2024 for contraception; 5-yr still standard for HMB treatment.", {
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  noteBlock(s, "Berek & Novak's on IUDs:\n• 'All IUDs provide safe, long-term contraception with effectiveness equivalent to tubal sterilization'\n• LNG-IUD mechanism: cervical mucus thickening + endometrial atrophy + intrauterine inflammatory response\n• 85% of cycles remain ovulatory with 52 mg LNG-IUD (systemic levels: 130–200 pg/mL)\n\nLiletta 8-year (FDA 2023):\n• T380 shaped frame; bioequivalent to Mirena but more affordable (manufactured for Medicines360/Afaxys for subsidized access)\n\nMirena 8-year extension (2024):\n• Based on Jensen et al., Obstet Gynecol 2022 PK modelling showing adequate LNG levels at 8 years\n• 2024 CDC SPR: Updated guidance on pain management for IUD insertion – recommend consideration of NSAIDs, lidocaine (cervical/intrauterine), and shared decision-making\n\nNew CDC MEC 2024: Revised Category for DMPA in women with multiple CVD risk factors. IUDs remain Category 1 or 2 for most conditions including previous ectopic, nulliparity, adolescence.");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 8 – INJECTABLE CONTRACEPTION & SELF-INJECTION
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bodySlide(s);
  addSectionBanner(s, "INJECTABLE CONTRACEPTION");
  addSlideTitle(s, "DMPA & Self-Administration (2024 SPR Update)");

  const items = [
    bullet("DMPA-IM (Depo-Provera) vs DMPA-SC (Depo-SubQ Provera)", 0, true),
    bullet("DMPA-IM: 150 mg every 13 weeks (IM gluteal/deltoid)", 1),
    bullet("DMPA-SC: 104 mg every 13 weeks (subcutaneous abdomen/thigh) – lower dose, same efficacy", 1),
    bullet("Pearl Index ~0.2 per 100 women-years (typical use: 6% failure due to delayed repeat injections)", 1),
    bullet("", 0),
    bullet("2024 CDC SPR – SELF-ADMINISTRATION UPDATE (Major Policy Change)", 0, true),
    bullet("New recommendation: DMPA-SC can be safely self-administered by patients at home", 1),
    bullet("Evidence: RCT and cohort data show comparable safety/efficacy to clinic administration", 1),
    bullet("Benefits: reduces clinic barriers, improves continuation rates, especially in rural/underserved areas", 1),
    bullet("Training: brief counselling required; use of autoinjector prefilled syringe", 1),
    bullet("", 0),
    bullet("Non-Contraceptive Benefits", 0, true),
    bullet("Reduces menstrual blood loss → manages HMB and anaemia", 1),
    bullet("Reduces pain in endometriosis and adenomyosis", 1),
    bullet("Protective effect against endometrial cancer (long-term use)", 1),
    bullet("Reduces sickle cell crises (progesterone-mediated effects)", 1),
    bullet("", 0),
    bullet("Key Concerns", 0, true),
    bullet("Bone mineral density (BMD): DMPA reduces BMD; reversible after discontinuation (18–24 months)", 1),
    bullet("2024 CDC MEC: Revised risk classification for DMPA in women with multiple CVD risk factors", 1),
    bullet("Delayed return to fertility: median 10 months post-last injection; range up to 18 months", 1),
    bullet("Weight gain: ~1.5–2 kg/year in first 2 years; more pronounced in younger adolescents", 1),
    bullet("Not recommended beyond 2 years in adolescents without risk-benefit discussion (BMD concern)", 1),
  ];

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  noteBlock(s, "2024 CDC SPR on self-injection of DMPA-SC:\nThis is a new recommendation. Previous guidelines required clinic administration. The 2024 update now recommends offering self-administration as an option after brief in-clinic training.\n\nBerek & Novak's on injectables:\n• Typical use failure rate lower than OCs due to less user error\n• Comparative data with other methods shows DMPA is among the most effective user-independent contraceptives after implants and IUDs\n\n2024 CDC MEC changes for DMPA:\n• Women with multiple cardiovascular risk factors (smoking, hypertension, diabetes, dyslipidaemia): increased to Category 3 (risks generally outweigh benefits)\n• Previously Category 2 for this combination\n\nNote: SC formulation (104 mg) has lower dose than IM (150 mg) but equivalent efficacy - preferred route for self-injection.");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 9 – EMERGENCY CONTRACEPTION
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bodySlide(s);
  addSectionBanner(s, "EMERGENCY CONTRACEPTION (EC)");
  addSlideTitle(s, "Emergency Contraception – Methods & Comparative Efficacy");

  const col1 = [
    bullet("1. Levonorgestrel (LNG) 1.5 mg", 0, true),
    bullet("Plan B One-Step, generic; OTC (no prescription)", 1),
    bullet("Take within 72 h; effective up to 120 h (3.2% failure after 72 h)", 1),
    bullet("MOA: delays/inhibits ovulation; NOT abortifacient (Berek & Novak's)", 1),
    bullet("Less effective with BMI >26–30 (consider UPA or Cu-IUD)", 1),
    bullet("", 0),
    bullet("2. Ulipristal Acetate (UPA) 30 mg – ella®", 0, true),
    bullet("Prescription-only; effective up to 120 h post-unprotected intercourse", 1),
    bullet("MOA: progesterone receptor modulator → delays follicular rupture ≥5 days", 1),
    bullet("42% lower pregnancy odds vs LNG at 72 h; 65% lower within first 24 h", 1),
    bullet("Superior to LNG when ovulation is imminent", 1),
    bullet("Better efficacy in overweight/obese women vs LNG", 1),
    bullet("", 0),
    bullet("3. Copper IUD (ParaGard) – Most Effective EC", 0, true),
    bullet("Insert within 5 days of unprotected sex; >99% effective", 1),
    bullet("Can be left in place for ongoing 10-year contraception", 1),
    bullet("MOA: copper ion spermicidal + anti-fertilisation + inflammatory intrauterine response", 1),
    bullet("Ideal for women wanting long-term contraception; BMI not a limiting factor", 1),
  ];

  const col2 = [
    bullet("4. Mifepristone 10–25 mg (where available)", 0, true),
    bullet("Antiprogestin; comparable to LNG but not commercially available as EC in most countries", 1),
    bullet("10 mg dose sufficient for EC; pregnancy rate 1.3% vs 2.0% with LNG in RCT (n=2065)", 1),
    bullet("", 0),
    bullet("Comparative Efficacy", 0, true),
    bullet("Cu-IUD > UPA > LNG (general hierarchy of EC effectiveness)", 1),
    bullet("Time-sensitive: all EC methods more effective the sooner they are used", 1),
    bullet("", 0),
    bullet("Counselling Points (2024 Updates)", 0, true),
    bullet("LNG does NOT affect implantation; safe to prescribe advance supply for all patients", 1),
    bullet("UPA: avoid breastfeeding 1 week post-dose (excreted in milk)", 1),
    bullet("Cu-IUD: requires STI screen if high risk; insertion pain significant – counsel accordingly", 1),
    bullet("WHO 2024: Allows LNG up to 120 h if UPA unavailable", 1),
    bullet("", 0),
    { text: "Key Note: Postcoital LNG is NOT an abortifacient –\nit works ONLY when given BEFORE ovulation.", options: { bold: true, fontSize: 12, color: DEEP_TEAL, breakLine: true, fontFace: "Calibri" } },
  ];

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  noteBlock(s, "Berek & Novak's (Ch.14 Emergency Contraception):\n• LNG works only if administered PRIOR to day of ovulation. In Noe et al. study: 0 pregnancies in 87 women given LNG 1–5 days before ovulation; 7 pregnancies in 35 women treated on day of ovulation or after. CLEAR evidence it is NOT abortifacient.\n\n• Ulipristal vs LNG: WHO large RCT showed crude pregnancy rates 0.9% UPA vs 1.7% LNG overall. UPA maintains efficacy through the 120-h window while LNG efficacy drops significantly after 72 h.\n\n• ACOG 2023 Practice Bulletin: Advance provision of EC (prescribing supply before need arises) does NOT increase unprotected sex rates and increases timely EC use.\n\n• Interactions: Hormonal contraception started within 5 days of UPA use may reduce UPA efficacy (progesterone receptor competition). Wait 5 days after UPA before starting hormonal contraception.");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 10 – NON-HORMONAL & NOVEL METHODS
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bodySlide(s);
  addSectionBanner(s, "NON-HORMONAL & INVESTIGATIONAL METHODS");
  addSlideTitle(s, "Beyond Hormones – Non-Hormonal, Vaginal & Novel Methods");

  const items = [
    bullet("Phexxi® (Lactic Acid / Citric Acid / Potassium Bitartrate Vaginal Gel) – FDA 2020", 0, true),
    bullet("First new non-hormonal female contraceptive in decades", 1),
    bullet("MOA: Maintains vaginal pH ≤4 in the presence of semen (semen normally raises pH to 7–8)", 1),
    bullet("Acidic pH is directly spermicidal → impairs motility, decreases fertilisation", 1),
    bullet("Pearl Index: 17.7–27.5 (typical use) – used as on-demand method (insert before intercourse)", 1),
    bullet("No systemic effects; suitable for women with contraindications to hormonal methods", 1),
    bullet("Can be combined with barrier methods for improved efficacy", 1),
    bullet("", 0),
    bullet("Natural Progesterone-Releasing Vaginal Ring (PGRV) – WHO-supported", 0, true),
    bullet("Progesterone 2 g ring; approved for lactating women (LAM supplement)", 1),
    bullet("Used during breastfeeding to extend lactational amenorrhoea protection", 1),
    bullet("", 0),
    bullet("Hormonal Male Contraception (Research Phase)", 0, true),
    bullet("Testosterone undecanoate (TU) monthly IM + etonogestrel implant: 97% suppression to <1M sperm/mL (Berek & Novak's Ch.14)", 1),
    bullet("Nesterone + Testosterone transdermal gels: 89% suppression – Phase II trials", 1),
    bullet("Limitation: ethnic variability – Asian men achieve azoospermia more consistently than Caucasian men", 1),
    bullet("", 0),
    bullet("RISUG / Vasalgel (Non-Hormonal Male Contraception)", 0, true),
    bullet("RISUG: Styrene maleic anhydride injected into vas deferens → spermicidal pH", 1),
    bullet("Vasalgel: Polymer gel in vas deferens; reversible with sodium bicarbonate injection (animal data)", 1),
    bullet("Both under clinical investigation; not yet FDA approved", 1),
    bullet("", 0),
    bullet("Digital / App-Based Natural Family Planning", 0, true),
    bullet("Natural Cycles® (FDA cleared 2018): algorithm-based fertility tracking; Pearl Index 6.5 typical use", 1),
    bullet("Not recommended as sole method for women requiring highly effective contraception", 1),
  ];

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  noteBlock(s, "Phexxi (Evofem Biosciences – FDA approved May 2020):\n• Vaginal gel with lactic acid 1.8%, citric acid 1%, potassium bitartrate 0.4%\n• Phase III AMPOWER trial (n=1,384): Pearl Index 13.7–27.5 in typical use\n• Key advantage: No systemic hormones; on-demand use\n• Not effective against STIs\n• Can be used with condoms; NOT compatible with Phexxi and vaginal antifungals simultaneously\n\nBerek & Novak's on male hormonal contraception:\n• Chinese TU trial: 1,045 men, 500 mg TU IM monthly → cumulative pregnancy rate only 1.1 per 100 men at 30 months\n• Side effects: acne, night sweats, libido changes (usually increased), weight gain\n\nVasalgel: Pre-clinical animal studies only as of 2024; early clinical trials expected.\n\nNatural Cycles: FDA cleared as Class II contraceptive device (2018); typical use Pearl Index ~6.5 vs 1 in perfect use. Should be combined with barrier methods during fertile window.");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 11 – 2024 CDC MEC / SPR KEY UPDATES
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bodySlide(s);
  addSectionBanner(s, "GUIDELINES UPDATE 2024");
  addSlideTitle(s, "2024 CDC MEC & SPR – Key Contraceptive Guideline Changes");

  const col1 = [
    bullet("CDC Medical Eligibility Criteria (MEC) 2024 – Notable Changes", 0, true),
    bullet("New: Guidance for transgender men using testosterone (Category 1 for all LARC methods)", 1),
    bullet("Testosterone use + risk for pregnancy: New recommendations added", 1),
    bullet("DMPA + multiple CVD risks: Upgraded from Category 2 to Category 3", 1),
    bullet("Chronic Kidney Disease: New specific recommendations added for all method categories", 1),
    bullet("Gender-inclusive language throughout document (first time)", 1),
    bullet("", 0),
    bullet("CDC Selected Practice Recommendations (SPR) 2024 – Procedural Updates", 0, true),
    bullet("IUD Insertion Pain: New recommendations for analgesia", 1),
    bullet("  - Lidocaine paracervical block / intracervical gel recommended", 1),
    bullet("  - NSAIDs pre-insertion recommended (evidence-based addition)", 1),
    bullet("  - Misoprostol NOT routinely recommended for cervical priming (no benefit + more pain)", 1),
    bullet("Implant Irregular Bleeding: New structured management algorithm", 1),
    bullet("  - NSAIDs first-line for spotting; consider combined pill add-back", 1),
    bullet("Self-injection of SC-DMPA: Newly recommended as safe alternative to clinic injection", 1),
  ];

  const col2 = [
    bullet("MEC Category Reminder", 0, true),
    bullet("Cat 1 = No restriction; use method", 1),
    bullet("Cat 2 = Benefits generally outweigh risks; use method", 1),
    bullet("Cat 3 = Risks generally outweigh benefits; do not use unless no other option", 1),
    bullet("Cat 4 = Unacceptable health risk; do NOT use", 1),
    bullet("", 0),
    bullet("Select Category 4 Situations (Absolute Contraindications)", 0, true),
    bullet("COC in: Breastfeeding <6 wk postpartum, current VTE, migraine with aura, active breast cancer", 1),
    bullet("POP in: Current breast cancer (Cat 4)", 1),
    bullet("Copper IUD: Pregnancy, unexplained uterine bleeding, Wilson's disease", 1),
    bullet("LNG-IUD: Pregnancy, unexplained uterine bleeding, current breast cancer", 1),
    bullet("", 0),
    bullet("Quality Family Planning (QFP) 2024 Update", 0, true),
    bullet("Emphasises contraceptive autonomy and person-centred counselling", 1),
    bullet("LARC methods should be presented as ONE option – not the default recommendation", 1),
    bullet("Trauma-informed care during IUD insertion newly emphasised", 1),
  ];

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  noteBlock(s, "Reference: U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024;73(RR-3):1-77.\nReference: U.S. Medical Eligibility Criteria for Contraceptive Use, 2024 Update.\n\nIUD Insertion Pain Management (SPR 2024):\n• Systematic review found paracervical block with 1% lidocaine reduces insertion pain significantly\n• NSAIDs pre-insertion reduce post-procedure pain but have less effect on insertion pain itself\n• Misoprostol (previously used for cervical softening) is NOT recommended routinely: multiple RCTs show no significant reduction in insertion pain and patients experience more cramping from misoprostol itself\n\nKey counselling shift: 2024 QFP guidelines emphasise that providers should not steer patients toward specific methods. Every contraceptive option should be discussed, and choice should be patient-driven.\n\nTransgender men on testosterone:\n• Testosterone causes irregular/absent menses but does NOT reliably suppress ovulation\n• Pregnancy is possible; contraception counselling essential\n• IUDs (especially LNG-IUD) and implants are preferred (no oestrogen)\n• 2024 MEC = Category 1 for copper and LNG IUD, implant for testosterone users");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 12 – SPECIAL POPULATIONS
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bodySlide(s);
  addSectionBanner(s, "SPECIAL POPULATIONS");
  addSlideTitle(s, "Contraception in Special Populations");

  const items = [
    bullet("Adolescents", 0, true),
    bullet("LARC (implant, IUD) preferred for highest efficacy – recommended first-line in ACOG guidance", 1),
    bullet("COC also appropriate; improves dysmenorrhoea, acne, and cycle regularity", 1),
    bullet("Nulliparity is NOT a contraindication to IUD in adolescents", 1),
    bullet("", 0),
    bullet("Obese Women (BMI >30)", 0, true),
    bullet("COC and ring: reduced efficacy concern; some evidence of increased VTE risk in obese + EE users", 1),
    bullet("Patch (Ortho Evra): reduced efficacy at >90 kg", 1),
    bullet("LARC methods (IUD, implant) – preferred; BMI does not affect their efficacy", 1),
    bullet("LNG EC may be less effective in obese women – Cu-IUD or UPA preferred for EC", 1),
    bullet("", 0),
    bullet("Postpartum Contraception", 0, true),
    bullet("Immediate postpartum IUD insertion (within 10 min of placental delivery): expulsion rate 10–27%", 1),
    bullet("Immediate postplacental insertion is safe and highly acceptable", 1),
    bullet("POC / LNG-IUD safe from 6 weeks; COC defer to 6 weeks (VTE risk + milk reduction)", 1),
    bullet("Implant: can be inserted immediately postpartum; safe during lactation", 1),
    bullet("", 0),
    bullet("Transgender & Non-Binary Individuals", 0, true),
    bullet("Testosterone does NOT reliably prevent ovulation → ongoing pregnancy risk", 1),
    bullet("LNG-IUD preferred: reduces/eliminates uterine bleeding (gender-affirming benefit)", 1),
    bullet("Implant: progestin-only; no oestrogen; well tolerated", 1),
    bullet("", 0),
    bullet("Women with Migraine with Aura", 0, true),
    bullet("COC: Category 4 (absolute contraindication) – 2× increased ischaemic stroke risk", 1),
    bullet("Preferred: POP, DMPA, implant, IUD, or non-hormonal methods", 1),
  ];

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  noteBlock(s, "Berek & Novak's on IUDs:\n'Candidacy includes nulliparous women, adolescents, and immunocompromised women. Immediate use postpartum or after first- or second-trimester abortion broadened usage.'\n\nBerek & Novak's on obese women:\n'Pregnancy risk with the patch appears to be higher for women weighing more than 90 kg.'\n'Pregnancy rates with the Ortho Evra patch were equivalent to OCs; however... typical user results may be better with patch/ring due to better compliance.'\n\nLactation and hormonal contraception:\n• Progestin-only methods: safe from birth (do not suppress lactation)\n• Combined hormonal methods: avoid <6 weeks (inhibit prolactin + VTE risk in early postpartum)\n• NuvaRing: etonogestrel + EE; delay until 4–6 weeks postpartum if breastfeeding\n\nMigraine with aura and OCP:\n• Mechanism: oestrogen lowers seizure threshold, promotes platelet aggregation, and reduces antithrombin III\n• Even low-dose EE (20 μg) remains contraindicated in migraine with aura\n• Progestin-only methods are safe; MEC Category 2 for POP, Category 1 for LARC in migraine with aura");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 13 – NON-CONTRACEPTIVE BENEFITS
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bodySlide(s);
  addSectionBanner(s, "NON-CONTRACEPTIVE BENEFITS");
  addSlideTitle(s, "Therapeutic Uses of Newer Contraceptive Formulations");

  // 3-column grid with boxes
  const boxes = [
    {
      title: "Dysmenorrhoea & Pelvic Pain",
      points: [
        "COC (continuous/extended): reduces prostaglandin-driven pain",
        "E4/DRSP (Nextstellis): RCT (Osuga 2025, Fertil Steril): significant reduction in primary & secondary dysmenorrhoea",
        "LNG-IUD: reduces pain in adenomyosis & endometriosis",
        "DMPA: reduces endometriosis-related pain by inducing amenorrhoea",
      ]
    },
    {
      title: "Heavy Menstrual Bleeding",
      points: [
        "LNG-IUD (Mirena): 94–97% reduction in menstrual blood loss (MBL)",
        "Mirena approved for HMB for 5 years (even as 8-yr IUD)",
        "DMPA: induces amenorrhoea in 50–70% over 1 year",
        "E4/DRSP COC: fewer unscheduled bleeds, improved cycle control",
      ]
    },
    {
      title: "PCOS & Hyperandrogenism",
      points: [
        "Drospirenone-containing pills (Slynd, Nextstellis): anti-androgenic & anti-mineralocorticoid",
        "Reduces acne, hirsutism, seborrhoea",
        "Norgestimate and desogestrel: less androgenic than older progestins",
        "Yaz (EE 20 μg / DRSP 3 mg): FDA-approved for acne & PMDD",
      ]
    },
    {
      title: "Endometrial Protection",
      points: [
        "LNG-IUD: local progestin → endometrial atrophy; used in HRT to protect endometrium",
        "DMPA: long-term use reduces endometrial cancer risk",
        "COC: sustained progestin exposure → reduces endometrial cancer risk ~50%",
        "Indicated in women with Lynch syndrome, obesity, PCOS (anovulatory cycles)",
      ]
    },
    {
      title: "Migraine / Headache",
      points: [
        "Extended-cycle COC: reduces menstrually related migraine (stable oestrogen levels)",
        "E4-based COC (Nextstellis): lower vasospastic activity vs EE → may suit migraine without aura",
        "NuvaRing: continuous low EE reduces oestrogen withdrawal headache",
        "Progestin-only: safe in all migraine types",
      ]
    },
    {
      title: "Perimenopause (>40 yr)",
      points: [
        "Low-dose COC (20 μg EE) OR E4-based pill: cycle regulation + contraception + vasomotor relief",
        "LNG-IUD + systemic oestrogen = combination HRT approach",
        "FSRH 2023: Implant/IUD first-line for women >40 seeking LARC",
        "COC can mask ovarian failure – FSH unreliable on OCP; must check off-pill",
      ]
    },
  ];

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  noteBlock(s, "Non-contraceptive benefits are MAJOR reasons to choose specific contraceptive methods.\n\nE4/DRSP for dysmenorrhoea:\n• Osuga Y et al. (Fertil Steril, Apr 2025; PMID 39521109): Multicenter RCT, 15 mg E4/3 mg DRSP – significant reduction in dysmenorrhoea scores vs placebo. First RCT confirming therapeutic benefit of E4-based pill in dysmenorrhoea.\n\nDrospirenone anti-androgenic mechanism:\n• Drospirenone binds androgen receptor as antagonist AND blocks aldosterone receptor\n• Results in modest diuresis (loss of ~0.5–1 kg due to fluid) – reduces bloating, premenstrual oedema\n• Reduces sebum production, acne lesion count, hirsutism score in PCOS\n\nLNG-IUD as endometrial protection in HRT:\n• Mirena is approved in several countries as the progestogen component of HRT\n• Combination: LNG-IUD (local uterine progestogen) + systemic oestrogen = effective HRT + contraception in perimenopausal women\n\nPerimenopause contraception note (Berek & Novak's):\n'COC use masks menopausal status – check FSH/LH only during pill-free interval or off contraception for ≥6 weeks to assess ovarian reserve.'");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 14 – CHOOSING THE RIGHT METHOD (SUMMARY TABLE)
// ──────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  bodySlide(s);
  addSectionBanner(s, "CLINICAL DECISION GUIDE");
  addSlideTitle(s, "Choosing the Right Contraceptive – Decision Framework");

  const items = [
    bullet("Key Questions in Counselling", 0, true),
    bullet("1. Desire for pregnancy in: <1 yr → barrier/OCP | 1–5 yr → LARC | >5 yr → IUD/sterilisation", 1),
    bullet("2. Medical comorbidities: screen using CDC MEC before prescribing (particularly oestrogen methods)", 1),
    bullet("3. Cycle-related symptoms: dysmenorrhoea/HMB → LNG-IUD / COC; acne/PCOS → DRSP-OCP", 1),
    bullet("4. Patient preference: daily pill / monthly ring / weekly patch / quarterly injection / 3–8-year LARC", 1),
    bullet("5. Breastfeeding: progestin-only methods safe; COC delay ≥6 weeks", 1),
    bullet("", 0),
    bullet("Efficacy Summary (Typical Use Pearl Index)", 0, true),
    bullet("Most effective: Copper IUD (~0.8%), LNG-IUD Mirena (~0.2%), Implant (<0.1%)", 1),
    bullet("Effective: DMPA (6%), COC (7–8%), Patch/Ring (7–9%)", 1),
    bullet("Moderate: Drospirenone POP/Slynd (~4%), Annovera ring (~2.98%), Phexxi (~17–27%)", 1),
    bullet("Note: 'typical use' includes user error; 'perfect use' rates are ~10× better for user-dependent methods", 1),
    bullet("", 0),
    bullet("Newer Methods at a Glance", 0, true),
    bullet("E4/DRSP (Nextstellis): Lower VTE signal, good for acne/PCOS, dysmenorrhoea – FDA 2021", 1),
    bullet("Drospirenone POP (Slynd): Estrogen-free, PCOS/androgenic symptoms, 12-h missed window – FDA 2019", 1),
    bullet("Annovera 1-year ring: Annual sustained release, no insertion/removal by provider, novel progestin – FDA 2018", 1),
    bullet("Nexplanon 5 yr: New FDA duration (Dec 2024); REMS required; best efficacy of all methods", 1),
    bullet("Liletta 8 yr / Mirena 8 yr*: Extended duration LNG-IUDs approved 2023–2024", 1),
    bullet("Phexxi gel: On-demand non-hormonal contraception, no systemic effects – FDA 2020", 1),
    bullet("Opill OTC: First OTC oral contraceptive (norgestrel 0.075 mg) – available 2024", 1),
    bullet("SC-DMPA self-injection: 2024 CDC SPR endorses patient self-administration at home", 1),
  ];

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  noteBlock(s, "This slide serves as a quick clinical summary. Always use the full CDC MEC algorithm for medically complex patients.\n\nPearl Index (typical use) reference values:\n• Copper IUD: 0.8\n• LNG-IUD 52 mg: 0.1–0.2\n• Implant: <0.1\n• Female sterilisation: 0.5\n• DMPA: 6\n• COC: 7–8\n• Ring (NuvaRing): 9\n• Patch: 8\n• Drospirenone POP: ~4\n• Annovera: ~3\n• Phexxi: 13.7–27.5 (highly variable; on-demand gel)\n• Condom: 13–18\n• No method: 85\n\nShared decision-making:\n• Patient autonomy is central to contraceptive counselling\n• Avoid 'provider-directed' contraception\n• Respect reproductive goals and cultural/personal values\n• Advance EC provision should be routine for all reproductive-age patients");
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 15 – REFERENCES & CLOSING
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  const refs = [
    "1. Berek JS, Berek DL (Eds). Berek & Novak's Gynecology, 16th Ed. Wolters Kluwer, 2020 (ISBN 9781496380357). Chapter 14 – Family Planning.",
    "2. CDC. U.S. Medical Eligibility Criteria for Contraceptive Use (MEC), 2024. MMWR Recomm Rep. 2024.",
    "3. CDC. U.S. Selected Practice Recommendations for Contraceptive Use (SPR), 2024. MMWR Recomm Rep. 2024;73(RR-3):1-77.",
    "4. Battipaglia C et al. Combined oral contraceptive with estetrol plus drospirenone: pharmacokinetics to clinical applications. Expert Opin Drug Metab Toxicol 2023 Dec. [PMID 37942662]",
    "5. Nelson AL. Drospirenone and estetrol: evaluation of a newly approved novel OCP. Expert Opin Pharmacother 2023. [PMID 37691580]",
    "6. Osuga Y et al. Efficacy and safety of E4 15 mg/DRSP 3 mg for dysmenorrhoea. Fertil Steril 2025 Apr. [PMID 39521109]",
    "7. Didembourg M et al. Lower VTE reporting with natural estrogen-based COCs vs EE-containing pills. Contraception 2025;142:110727.",
    "8. PMC Article PMC12187473: Update on long- and short-acting contraceptive methods (2025). Mirena 8-yr duration data.",
    "9. FDA. Nexplanon (etonogestrel implant) 5-year label update. December 2024.",
    "10. FSRH Clinical Guideline: Contraception for Women Over 40 Years, 2023.",
    "11. Gaspard U et al. Pharmacokinetics/pharmacodynamics of progestogens in oral contraception. Front Endocrinol 2026. [PMID 41970977]",
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