"endometriosis"[MeSH Terms] AND "recurrence"[MeSH Terms] AND "prevention"

"endometriosis"[MeSH Terms] AND "secondary prevention" AND "medical therapy"

PMID: 39098538

"endometriosis"[MeSH Terms] AND "recurrence" AND "hormonal treatment"

"endometriosis"[MeSH Terms] AND "GnRH agonist" AND "recurrence prevention"

"endometriosis"[MeSH Terms] AND "surgical treatment" AND "recurrence"

"endometriosis"[MeSH Terms] AND "dienogest" AND "recurrence"

"endometriosis"[MeSH Terms] AND "elagolix" OR "relugolix" OR "linzagolix"

PMID: 39259620

PMID: 37217824

PMID: 35717987

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

~/endometriosis-ppt/create_ppt.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = 'LAYOUT_16x9';
pres.author = 'Medical Education';
pres.title = 'Endometriosis Recurrence: Prevention and Management';

// ─── Colour palette ───────────────────────────────────────────────────────────
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};

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// ─── SLIDE 1: Title ────────────────────────────────────────────────────────────
titleSlide(pres,
  'Endometriosis Recurrence:\nPrevention and Management',
  'Evidence-Based Approach | Gynecology Grand Rounds 2026'
);

// ─── SLIDE 2: Learning Objectives ─────────────────────────────────────────────
contentSlide(pres, 'Learning Objectives', [
  'Define recurrence of endometriosis and understand its clinical significance',
  'Identify the epidemiology and risk factors for recurrence after surgery and medical therapy',
  'Describe the pathophysiology underlying disease recurrence',
  'Review the rAFS/ASRM staging system and its relevance to recurrence risk',
  'Evaluate postoperative hormonal strategies for prevention of recurrence',
  'Discuss the role of GnRH analogues, progestins, combined OCP, and newer agents (relugolix, elagolix)',
  'Outline surgical principles to minimize recurrence risk',
  'Present an individualised multidisciplinary management algorithm',
  'Summarise the latest Level-1 evidence including ESHRE 2022 guidelines'
], 'Berek & Novak\'s Gynecology, 16e | ESHRE Endometriosis Guideline 2022');

// ─── SLIDE 3: Definition & Overview ───────────────────────────────────────────
contentSlide(pres, 'Endometriosis: Overview', [
  'Endometriosis: Presence of endometrial-like glands and stroma outside the uterine cavity',
  'Prevalence: ~10% of reproductive-age women; 15–20% of infertile women; >30% of women with CPP',
  'Sites: Pelvis (cul-de-sac, ovaries, peritoneum, uterosacral ligaments), bowel, bladder, diaphragm, thorax',
  'Classified by ASRM (rAFS) staging I–IV based on implants, adhesions, and endometrioma size',
  'Recurrence: Re-emergence of disease (symptoms or anatomical lesions) after documented remission from surgery or medical therapy',
  'Recurrence Rate: Up to 40–80% histological and 20–50% symptomatic recurrence at 5 years without suppressive therapy',
  'Spontaneous regression can occur, but is uncommon; disease is progressive in many patients'
], 'Berek & Novak\'s Gynecology, p.577 | Williams Gynecology, 4e');

// ─── SLIDE 4: Key Statistics ───────────────────────────────────────────────────
keyStatSlide(pres, 'Key Epidemiological Facts on Recurrence',
  [
    { value: '27%', label: 'Endometrioma recurrence at 24 months post-surgery (no hormonal therapy)', color: COL.accent },
    { value: '40–80%', label: '5-year symptomatic recurrence without postoperative suppression', color: '4A235A' },
    { value: '~10%', label: 'Prevalence in reproductive-age women worldwide', color: COL.teal }
  ],
  'Veth VB et al. Fertil Steril. 2024 Dec (Systematic Review & Meta-Analysis, PMID: 39098538)'
);

// ─── SLIDE 5: Section Divider 1 ───────────────────────────────────────────────
sectionDivider(pres, 1, 'Pathophysiology of Recurrence', 'Why does endometriosis come back?');

// ─── SLIDE 6: Pathophysiology ─────────────────────────────────────────────────
contentSlide(pres, 'Pathophysiology of Recurrence', [
  'Three accepted theories of origin — retrograde menstruation (Sampson), coelomic metaplasia, hematogenous/lymphatic spread',
  'Residual disease: Incomplete surgical excision (especially deep infiltrating endometriosis, DIE) leaves viable implants',
  'De novo implants: Continued retrograde menstruation deposits new fragments; ongoing menstrual cycles sustain disease',
  'Estrogen dependence: Endometriotic tissue expresses aromatase P450 (CYP19A1), producing local estrogen → growth stimulus',
  'Immune dysregulation: Reduced NK-cell activity, increased peritoneal macrophages, IL-1β, TNF-α, VEGF promote implant survival',
  'Nerve fiber infiltration: Pain fibres grow into lesions; sensitisation leads to symptomatic recurrence even with minimal new lesions',
  'Epigenetic changes: Altered methylation in HOXA10, WT1 and steroid receptor genes allow implants to resist apoptosis'
], 'Berek & Novak\'s Gynecology | Vannuccini S et al. Rev Endocr Metab Disord. 2022 (PMID: 34405378)');

// ─── SLIDE 7: Risk Factors for Recurrence ─────────────────────────────────────
twoColSlide(pres, 'Risk Factors for Endometriosis Recurrence',
  [
    'Stage III–IV (rAFS) disease at index surgery',
    'Incomplete surgical excision / residual disease',
    'Bilateral ovarian endometriomas',
    'DIE involving bowel, ureter, POD',
    'Young age (<30 years) — longer reproductive exposure',
    'Early menarche / short cycle interval',
    'No postoperative hormonal suppression'
  ],
  [
    'Family history of endometriosis (1st-degree relative)',
    'Müllerian anomaly (outflow obstruction)',
    'Previous multiple surgeries / adhesions',
    'High CA-125 at follow-up',
    'BMI ≤18 kg/m² (low fat mass, lower SHBG, higher free E2)',
    'Smoking: conflicting evidence',
    'Non-use of combined hormonal contraception'
  ],
  'Patient & Disease Factors', 'Surgical & Hormonal Factors',
  'Berek & Novak\'s Gynecology, p.656 | ESHRE Endometriosis Guideline 2022'
);

// ─── SLIDE 8: ASRM Staging & Recurrence Risk ──────────────────────────────────
tableSlide(pres, 'ASRM/rAFS Staging and Recurrence Risk',
  ['Stage', 'Description', 'Points', 'Recurrence Risk (5-yr)'],
  [
    ['I – Minimal', 'Isolated superficial implants, no adhesions', '1–5', '~30%'],
    ['II – Mild', 'Superficial implants < 5 cm, mild adhesions', '6–15', '~40%'],
    ['III – Moderate', 'Multiple implants, endometrioma, peritubal/ovarian adhesions', '16–40', '~55%'],
    ['IV – Severe', 'Large endometrioma, dense adhesions, DIE, cul-de-sac obliteration', '>40', '~75%'],
  ],
  'ASRM Practice Committee 2014 | Berek & Novak\'s Gynecology; note: staging poorly correlates with pain severity'
);

// ─── SLIDE 9: Section Divider 2 ────────────────────────────────────────────────
sectionDivider(pres, 2, 'Prevention of Recurrence', 'Medical Strategies to Suppress Disease');

// ─── SLIDE 10: Postoperative Suppression Overview ─────────────────────────────
contentSlide(pres, 'Rationale for Postoperative Hormonal Suppression', [
  'Surgery removes visible lesions but cannot eliminate microscopic implants or prevent retrograde menstruation',
  'Goal of medical therapy: Suppress ovarian estrogen production or block estrogen action → deprive implants of growth stimulus',
  'ESHRE 2022 Guideline: Recommends postoperative hormonal therapy to reduce recurrence of pain and anatomical disease',
  'Evidence: Postoperative use of hormonal agents significantly delays recurrence compared to surgery alone (Level A)',
  'Options: Combined oral contraceptive pill (COCP), progestins, GnRH agonists/antagonists, LNG-IUS, danazol (now rarely used)',
  'Duration: At least 18–24 months recommended; long-term "ovarian suppression" in those not seeking fertility',
  'Key principle: Match therapy to patient goals (pain control vs. fertility vs. hormonal side-effect tolerance)'
], 'ESHRE Endometriosis Guideline 2022 | Berek & Novak\'s Gynecology | Farkas W et al. Curr Opin Obstet Gynecol. 2023 (PMID: 37610988)');

// ─── SLIDE 11: Combined OCP ────────────────────────────────────────────────────
contentSlide(pres, 'Combined Oral Contraceptive Pill (COCP)', [
  'Mechanism: Suppresses LH/FSH surge → reduces estrogen production; progestogenic decidualisation of implants; inhibits prostaglandin synthesis',
  'Route: Cyclic or continuous administration; continuous may reduce breakthrough bleeding and dysmenorrhoea',
  'Efficacy: Reduces pain recurrence; 40% improvement in pain scores maintained at 36 months (PRE-EMPT RCT, 2024)',
  'COCP vs. LARC: PRE-EMPT trial (n=405) — no significant difference in pain at 36 months between COCP and long-acting progestogen (adjusted mean difference −0.8, 95% CI −5.7 to +4.2)',
  'COCP group: Higher rate of repeat surgery vs. LARC group (97 vs. 73 procedures; HR 0.67)',
  'Cost-effectiveness: COCP cost-effective at <£20,000/QALY threshold; LARC preferred for fewer re-operations',
  'Side effects: VTE risk (especially in smokers), headache, mood changes; contraindicated in migraine with aura'
], 'Cooper KG et al. PRE-EMPT RCT. Health Technol Assess. 2024 Sep (PMID: 39259620)');

// ─── SLIDE 12: Progestins ──────────────────────────────────────────────────────
contentSlide(pres, 'Progestin Therapy for Recurrence Prevention', [
  'Mechanism: Decidualisation → necrosis of endometriotic implants; suppress gonadotropins; antiproliferative effect on ectopic endometrium',
  'Dienogest 2 mg/day: First-line progestin for endometriosis; selective for progesterone receptor; anti-angiogenic',
  '  → Muzii et al. Meta-analysis 2023 (n=1668): Dienogest significantly reduced cyst recurrence vs. placebo (p<0.0001)',
  '  → Dienogest = GnRHa efficacy in preventing recurrence; fewer hot flushes, less vaginal dryness vs. GnRHa',
  '  → Side effects: Irregular spotting (vs. GnRHa; p=0.0007), weight gain (p=0.03)',
  'Medroxyprogesterone acetate (DMPA 150 mg IM q3mo): Effective, amenorrhoea induction, lower cost',
  'LNG-IUS (52 mg, Mirena): Local progestin release; reduces dysmenorrhoea and recurrence post-surgery; systemic effects minimal',
  'Norethindrone acetate (2.5–5 mg/day): Add-back with GnRHa; also used standalone'
], 'Muzii L et al. Reprod Sci. 2023 Nov (PMID: 37217824) | Berek & Novak\'s Gynecology, p.603');

// ─── SLIDE 13: GnRH Agonists ──────────────────────────────────────────────────
contentSlide(pres, 'GnRH Agonists for Prevention of Recurrence', [
  'Mechanism: Initial "flare" effect → downregulation of GnRH receptors → medical pseudo-menopause (estrogen <20 pg/mL)',
  'Agents: Leuprolide (3.75 mg IM monthly), nafarelin nasal spray, goserelin (3.6 mg SC monthly)',
  'Duration: Typically 3–6 months; up to 12 months with add-back therapy',
  'Efficacy: Recurrence rates significantly reduced post-surgery; comparable to dienogest at 12 and 24 months',
  'Add-back therapy: Tibolone, norethindrone acetate 2.5 mg + conjugated estrogen 0.625 mg — prevents bone loss and hypoestrogenic symptoms',
  'Bone mineral density: Loss of ~5–8% at lumbar spine over 6 months; recoverable with add-back; limit to <12 months without add-back',
  'Disadvantages: Parenteral route (mostly), cost, menopausal symptoms, limited to 6-month courses without add-back',
  'Role: Second-line agent when first-line fails; pre/post-surgical use in severe DIE'
], 'Berek & Novak\'s Gynecology | Vannuccini S et al. Rev Endocr Metab Disord. 2022 | ESHRE Guideline 2022');

// ─── SLIDE 14: GnRH Antagonists (New Agents) ──────────────────────────────────
contentSlide(pres, 'GnRH Antagonists: New Oral Agents (2022–2024)', [
  'Mechanism: Immediate, competitive blockade of GnRH receptor → rapid suppression without initial flare',
  'Relugolix combination therapy (Relugolix 40 mg + E2 1 mg + NETA 0.5 mg, once daily oral):',
  '  → SPIRIT 1 & 2 Phase-3 RCTs (Lancet 2022, n=1261): 75% vs 27% dysmenorrhoea responder rate (vs. placebo)',
  '  → 2-year open-label extension (Hum Reprod 2024): Sustained pain control; maintained bone mineral density with add-back',
  'Elagolix (200 mg BID): FDA approved; used in endometriosis pain; dose-dependent estrogen suppression',
  'Linzagolix (75–200 mg OD): Phase-3 trials; flexible dosing, partial-to-full suppression options',
  'Advantages over GnRHa: Oral, no flare, rapid reversibility, stable serum levels, add-back built-in (relugolix combo)',
  'Current role: Pain management + prevention of recurrence; suitable for long-term use (up to 24 months shown safe)'
], 'Giudice LC et al. SPIRIT 1&2. Lancet. 2022 (PMID: 35717987) | Becker CM et al. Hum Reprod. 2024 (PMID: 38243752)');

// ─── SLIDE 15: LNG-IUS & Non-Hormonal Options ─────────────────────────────────
twoColSlide(pres, 'LNG-IUS & Adjunctive Approaches',
  [
    'LNG-IUS (52 mg levonorgestrel):',
    '• Local progestin → decidualisation + amenorrhoea',
    '• Reduces endometrioma recurrence and pain scores',
    '• PRE-EMPT RCT: LARC group had 73 vs 97 re-operations (HR 0.67) compared to COCP group',
    '• Ideal for women not seeking immediate fertility',
    '• Duration: 5–7 years; reversible',
    '',
    'DMPA 150 mg IM q3mo:',
    '• Induces amenorrhoea; cost-effective',
    '• Reduces pain recurrence in 70–85% at 12 months'
  ],
  [
    'Non-Hormonal Adjuncts:',
    '• NSAIDs: Cyclo-oxygenase inhibitors reduce dysmenorrhoea; celecoxib explored',
    '• Aromatase inhibitors (letrozole, anastrozole): Effective for castration-resistant/recurrent DIE; use with add-back',
    '• N-Acetylcysteine (NAC): Antioxidant; small studies show reduction in endometrioma size',
    '• Pentoxifylline: TNF-α inhibitor; limited evidence',
    '• TENS / physiotherapy: Adjunct for pain management',
    '• Dietary modifications: Omega-3 PUFA, anti-inflammatory diet — supportive evidence'
  ],
  'LNG-IUS & DMPA', 'Non-Hormonal Strategies',
  'Cooper KG et al. PRE-EMPT RCT 2024 | ESHRE Guideline 2022 | Anastasi E et al. Int J Environ Res Public Health 2023 (PMID: 36981595)'
);

// ─── SLIDE 16: Section Divider 3 ──────────────────────────────────────────────
sectionDivider(pres, 3, 'Surgical Management of Recurrence', 'Principles, Techniques & Outcomes');

// ─── SLIDE 17: Surgical Principles for Recurrent Disease ──────────────────────
contentSlide(pres, 'Surgical Management of Recurrent Endometriosis', [
  'Indication for repeat surgery: Failure of optimal medical therapy; new endometrioma ≥3 cm; significant DIE with bowel/ureteral involvement; infertility',
  'Fundamental principle: Complete excision at primary surgery minimises recurrence; repeat surgery has diminishing returns',
  'ESHRE 2022: Recommends referral to specialised endometriosis centre for recurrent or complex disease',
  'Laparoscopy is gold standard; laparotomy may be needed for very extensive DIE or bowel resection',
  'Peritoneal lesions: Excision preferred over ablation — allows histological confirmation; equal pain relief (Berek & Novak, p.657)',
  'Ovarian endometrioma: Cystectomy (stripping) preferred over drainage/ablation:',
  '  → OR for recurrence after cystectomy vs ablation: 0.41 (95% CI 0.18–0.93) — Berek & Novak p.656',
  '  → Cochrane review: Excision ↓ endometrioma recurrence, ↓ pain, ↑ spontaneous pregnancy (OR 5.21)',
  'Multidisciplinary team: Colorectal + urological surgeons for bowel/ureteral DIE'
], 'Berek & Novak\'s Gynecology, p.655–657 | ESHRE Endometriosis Guideline 2022');

// ─── SLIDE 18: Cystectomy vs Ablation Evidence ─────────────────────────────────
tableSlide(pres, 'Cystectomy vs. Drainage & Ablation for Endometrioma',
  ['Outcome', 'Cystectomy', 'Drainage & Ablation', 'Odds Ratio'],
  [
    ['Dysmenorrhoea recurrence', 'Lower', 'Higher', 'OR 0.15 (95% CI 0.06–0.38)'],
    ['Dyspareunia recurrence', 'Lower', 'Higher', 'OR 0.08 (95% CI 0.01–0.51)'],
    ['NMPP recurrence', 'Lower', 'Higher', 'OR 0.10 (95% CI 0.02–0.56)'],
    ['Endometrioma recurrence', 'Lower', 'Higher', 'OR 0.41 (95% CI 0.18–0.93)'],
    ['Subsequent surgery rate', 'Lower', 'Higher', 'OR 0.21 (95% CI 0.05–0.79)'],
    ['Spontaneous pregnancy (infertile)', 'Higher', 'Lower', 'OR 5.21 (95% CI 2.04–13.29)'],
  ],
  'Cochrane Systematic Review (Ref 272) cited in Berek & Novak\'s Gynecology, p.656 | ESHRE Guideline 2022'
);

// ─── SLIDE 19: Surgical Recurrence Rates ──────────────────────────────────────
keyStatSlide(pres, 'Endometrioma Recurrence Rates After Surgery (No Hormonal Therapy)',
  [
    { value: '4%', label: 'Recurrence at 3 months post-surgery', color: COL.teal },
    { value: '17%', label: 'Recurrence at 12 months post-surgery', color: '7B4A8A' },
    { value: '27%', label: 'Recurrence at 24 months post-surgery', color: COL.accent }
  ],
  'Veth VB et al. Fertil Steril. 2024 Dec — Systematic Review & Meta-Analysis of 55 studies (PMID: 39098538)'
);

// ─── SLIDE 20: Deep Infiltrating Endometriosis ─────────────────────────────────
contentSlide(pres, 'Surgery for Deep Infiltrating Endometriosis (DIE)', [
  'DIE: Lesions penetrating >5 mm below peritoneal surface; involves uterosacral ligaments, rectovaginal septum, bowel, bladder, ureter',
  'Complete excision in ONE surgical procedure is strongly recommended to avoid multiple surgeries (ESHRE 2022)',
  'Bowel endometriosis: Options include shaving, disc excision, or segmental bowel resection — decision based on depth/extent',
  '  → Full-thickness bowel involvement or stenosis: Segmental resection with colorectal surgeon',
  'Ureteral endometriosis: Ureterolysis if extrinsic; ureteroneocystostomy if intrinsic; pre-op ureteral stenting',
  'Bladder endometriosis: Partial cystectomy with urology support',
  'Retroperitoneal dissection: Requires surgeon trained in nerve-sparing technique to preserve autonomic nerves',
  'Posterior cul-de-sac obliteration: Associated with highest recurrence risk — requires experienced surgeon',
  'Post-surgical hormonal suppression: Mandatory in DIE to minimise residual disease activation'
], 'Berek & Novak\'s Gynecology, p.657–658 | ESHRE Endometriosis Guideline 2022 | D\'Alterio MN et al. Minerva Obstet Gynecol. 2021 (PMID: 34008386)');

// ─── SLIDE 21: Section Divider 4 ──────────────────────────────────────────────
sectionDivider(pres, 4, 'Long-Term Management', 'Fertility, Surveillance & Special Situations');

// ─── SLIDE 22: Fertility-Preserving Management ────────────────────────────────
twoColSlide(pres, 'Management in Women Desiring Fertility',
  [
    'Immediate fertility desired:',
    '• Cystectomy preferred over medical therapy for endometrioma ≥3 cm',
    '• Surgery improves spontaneous conception rates (OR 5.21 vs. ablation)',
    '• IVF for severe/bilateral endometrioma — consider oocyte preservation',
    '• Do NOT use GnRHa for fertility suppression before IVF cycle without good indication',
    '• Post-surgical: 6–12 months spontaneous conception attempt, then ART',
    '',
    'ART considerations:',
    '• Endometrioma ≥4 cm: Drain before oocyte retrieval',
    '• Risk of diminished ovarian reserve with repeat cystectomy (AMH ↓)',
    '• ICSI preferred for poor ovarian reserve post-multiple surgeries'
  ],
  [
    'Balancing fertility and recurrence:',
    '• Every cystectomy carries risk of losing ovarian cortex and follicles',
    '• Avoid unnecessary repeat surgery in women with small (<3 cm) asymptomatic endometriomas',
    '• Hormonal suppression post-IVF cycle may reduce recurrence',
    '',
    'Ovarian reserve monitoring:',
    '• AMH + AFC at baseline and annually',
    '• Early fertility referral if AMH declining',
    '• Oocyte/embryo cryopreservation in young women with bilateral endometriomas before re-operation'
  ],
  'Fertility Goal: Surgical Priority', 'Fertility Goal: ART & Reserve',
  'Berek & Novak\'s Gynecology | ESHRE Guideline 2022 | Williams Gynecology, 4e'
);

// ─── SLIDE 23: Monitoring & Follow-Up ────────────────────────────────────────
contentSlide(pres, 'Surveillance and Long-Term Follow-Up', [
  'No universal surveillance protocol; individualise based on disease stage and symptoms',
  'Clinical review every 3–6 months initially after surgery; annually once stable on suppressive therapy',
  'Transvaginal ultrasound: Preferred imaging for detecting endometrioma recurrence; MRI if DIE suspected',
  'CA-125: Not recommended as sole surveillance tool; can monitor trends in moderate-severe disease',
  'Pain scores: Use validated tools — Endometriosis Health Profile-30 (EHP-30) or Numerical Rating Scale (NRS)',
  'Bone mineral density: DEXA scan if GnRHa used >6 months without add-back; annual review',
  'Psychological support: Endometriosis significantly impacts quality of life, sexual function, and mental health',
  'Patient education: Discuss natural history, recurrence risk, importance of adherence to suppressive therapy',
  'Menopause transition: Recurrence uncommon post-naturally induced menopause; HRT possible in bilateral salpingo-oophorectomy cases with caution'
], 'Berek & Novak\'s Gynecology | ESHRE Endometriosis Guideline 2022 | Cooper KG et al. PRE-EMPT 2024');

// ─── SLIDE 24: Management Algorithm ───────────────────────────────────────────
contentSlide(pres, 'Clinical Management Algorithm: Recurrent Endometriosis', [
  '① CONFIRM RECURRENCE: Clinical assessment + TVUS ± MRI; rule out other causes of pain',
  '② FERTILITY STATUS: Determine if patient desires near-term fertility → divergent pathways',
  '③ NOT SEEKING FERTILITY:',
  '   • First-line: Continuous COCP or dienogest 2 mg/day (minimum 12–24 months)',
  '   • Failure of first-line: GnRHa + add-back OR GnRH antagonist (relugolix combo)',
  '   • Endometrioma ≥3 cm symptomatic: Offer laparoscopic cystectomy + postoperative hormones',
  '   • DIE causing organ dysfunction: MDT surgical approach + mandatory postoperative suppression',
  '   • Last resort: Hysterectomy ± BSO in completed family; counsel about HRT nuances',
  '④ SEEKING FERTILITY:',
  '   • Symptomatic endometrioma ≥3 cm: Laparoscopic cystectomy → spontaneous conception 6–12 months → ART',
  '   • ART directly: Small asymptomatic endometrioma; advanced maternal age; MFI; poor ovarian reserve',
  '⑤ POST-TREATMENT: Long-term hormonal suppression, psychological support, multidisciplinary follow-up'
], 'ESHRE Endometriosis Guideline 2022 | Berek & Novak\'s Gynecology | Williams Gynecology');

// ─── SLIDE 25: Summary & Key Messages ─────────────────────────────────────────
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const keyMessages = [
  { label: '1.', msg: 'Recurrence is common — up to 27% anatomical recurrence at 24 months and 40–80% symptomatic at 5 years without suppression.' },
  { label: '2.', msg: 'Complete surgical excision (cystectomy preferred over ablation) remains the cornerstone of reducing recurrence.' },
  { label: '3.', msg: 'Postoperative hormonal suppression is MANDATORY in most patients — COCP, dienogest, or LNG-IUS as first-line.' },
  { label: '4.', msg: 'Dienogest 2 mg/day is equivalent to GnRHa in preventing recurrence with fewer hypoestrogenic side effects (Meta-analysis 2023).' },
  { label: '5.', msg: 'New oral GnRH antagonists (relugolix combination) offer sustained pain control over 24 months with preserved bone density.' },
  { label: '6.', msg: 'PRE-EMPT RCT (2024) confirms both COCP and long-acting progestogen provide ~40% pain improvement post-surgery.' },
  { label: '7.', msg: 'Individualise therapy: fertility goals, stage, symptom profile, and side-effect tolerance must guide agent selection.' },
  { label: '8.', msg: 'Multidisciplinary team approach (endometriosis centre) is recommended for recurrent, DIE, or organ-involved disease.' },
];

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sl25.addText('Sources: Berek & Novak\'s Gynecology 16e | Williams Gynecology 4e | ESHRE 2022 | Fertil Steril 2024 | Lancet 2022 | Health Technol Assess 2024', {
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// ─── Write file ────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: '/home/daytona/workspace/endometriosis-ppt/Endometriosis_Recurrence_Prevention_Management.pptx' })
  .then(() => console.log('SUCCESS: PPTX created!'))
  .catch(err => console.error('ERROR:', err));

cd /home/daytona/workspace/endometriosis-ppt && node create_ppt.js

ls -lh /home/daytona/workspace/endometriosis-ppt/