"uterine fibroids" AND "quality of life"

PMID: 38246400

PMID: 37385088

"uterine fibroids" AND "women health" AND prevalence

"leiomyoma" AND "reproductive outcomes" AND fertility

mkdir -p /home/daytona/workspace/fibroid-presentation && echo "Directory ready"

~/fibroid-presentation/generate_pdf.py

~/fibroid-presentation/generate_pdf.py

ls /home/daytona/workspace/fibroid-presentation/ && head -5 /home/daytona/workspace/fibroid-presentation/generate_pdf.py 2>/dev/null || echo "file empty or unreadable"

cat > /home/daytona/workspace/fibroid-presentation/gen_full.py << 'PYEOF' from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.units import mm from reportlab.platypus import ( SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable, PageBreak, KeepTogether ) from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY from reportlab.platypus import Flowable OUTPUT = "/home/daytona/workspace/fibroid-presentation/Uterine_Fibroids_Impact_Womens_Health_QoL.pdf" BLACK = colors.black WHITE = colors.white DARK_GRAY = colors.HexColor("#222222") MED_GRAY = colors.HexColor("#555555") LIGHT_GRAY = colors.HexColor("#F4F4F4") ACCENT = colors.HexColor("#1a1a2e") ACCENT2 = colors.HexColor("#2d2d2d") def build_styles(): s = getSampleStyleSheet() s.add(ParagraphStyle("SectionHead", fontName="Helvetica-Bold", fontSize=15, textColor=ACCENT2, spaceBefore=12, spaceAfter=4, leading=19)) s.add(ParagraphStyle("SubHead", fontName="Helvetica-Bold", fontSize=11.5, textColor=ACCENT2, spaceBefore=8, spaceAfter=3, leading=15)) s.add(ParagraphStyle("Body", fontName="Helvetica", fontSize=10.5, textColor=DARK_GRAY, leading=16, spaceBefore=3, spaceAfter=3, alignment=TA_JUSTIFY)) s.add(ParagraphStyle("Bullet", fontName="Helvetica", fontSize=10.5, textColor=DARK_GRAY, leading=15, leftIndent=14, bulletIndent=4, spaceBefore=2, spaceAfter=2)) s.add(ParagraphStyle("SubBullet", fontName="Helvetica", fontSize=10, textColor=MED_GRAY, leading=14, leftIndent=28, bulletIndent=18, spaceBefore=1, spaceAfter=1)) s.add(ParagraphStyle("TblHdr", fontName="Helvetica-Bold", fontSize=9.5, textColor=WHITE, alignment=TA_CENTER, leading=13)) s.add(ParagraphStyle("TblCell", fontName="Helvetica", fontSize=9.5, textColor=DARK_GRAY, alignment=TA_LEFT, leading=13)) s.add(ParagraphStyle("Ref", fontName="Helvetica", fontSize=8.5, textColor=MED_GRAY, leading=13, leftIndent=10, spaceBefore=2)) s.add(ParagraphStyle("FootNote", fontName="Helvetica-Oblique", fontSize=7.5, textColor=MED_GRAY, leading=11, alignment=TA_CENTER)) s.add(ParagraphStyle("BoxTitle", fontName="Helvetica-Bold", fontSize=11, textColor=ACCENT2, leading=15, spaceBefore=3, spaceAfter=3)) s.add(ParagraphStyle("CoverTitle", fontName="Helvetica-Bold", fontSize=26, textColor=WHITE, alignment=TA_CENTER, leading=32)) s.add(ParagraphStyle("CoverSub", fontName="Helvetica", fontSize=13, textColor=colors.HexColor("#DDDDDD"), alignment=TA_CENTER, leading=19)) s.add(ParagraphStyle("CoverMeta", fontName="Helvetica", fontSize=10, textColor=colors.HexColor("#AAAAAA"), alignment=TA_CENTER, leading=14)) return s class CoverPage(Flowable): def __init__(self, width, height): Flowable.__init__(self); self.width=width; self.height=height def draw(self): c=self.canv; W,H=self.width,self.height c.setFillColor(ACCENT); c.rect(0,0,W,H,fill=1,stroke=0) c.setFillColor(colors.HexColor("#16213e")); c.rect(0,0,W,55,fill=1,stroke=0) c.setFillColor(colors.HexColor("#0f3460")); c.circle(35,H-35,80,fill=1,stroke=0) c.setFillColor(colors.HexColor("#0f3460")); c.circle(W-35,35,60,fill=1,stroke=0) c.setFont("Helvetica-Bold",9); c.setFillColor(colors.HexColor("#AAAAAA")) c.drawCentredString(W/2,H-85,"GYNECOLOGY RESIDENCY | PAPER PRESENTATION | MAY 2026") c.setStrokeColor(colors.HexColor("#888888")); c.setLineWidth(1) c.line(50,H-100,W-50,H-100) c.setFont("Helvetica-Bold",30); c.setFillColor(WHITE) c.drawCentredString(W/2,H-145,"UTERINE FIBROIDS") c.setFont("Helvetica-Bold",16); c.setFillColor(colors.HexColor("#CCCCCC")) c.drawCentredString(W/2,H-173,"Impact on Women\u2019s Health & Quality of Life") c.setStrokeColor(colors.HexColor("#666666")); c.setLineWidth(0.7) c.line(60,H-195,W-60,H-195) y=H-230 for line in ["Epidemiology | Pathophysiology | Clinical Burden", "Reproductive Health | Mental Wellbeing | QoL Assessment", "Socioeconomic Impact | Evidence-Based Management"]: c.setFont("Helvetica",11.5); c.setFillColor(colors.HexColor("#CCCCCC")) c.drawCentredString(W/2,y,line); y-=22 c.setFont("Helvetica",8.5); c.setFillColor(colors.HexColor("#888888")) c.drawCentredString(W/2,y-18,"Sources: Berek & Novak\u2019s Gynecology \u2022 Robbins & Kumar Pathology \u2022 Creasy & Resnik\u2019s MFM \u2022 PubMed Systematic Reviews 2021\u20132026") c.setFont("Helvetica",9); c.setFillColor(colors.HexColor("#AAAAAA")) c.drawCentredString(W/2,38,"Department of Obstetrics & Gynecology | Gynecology Residency Program") class SectionDivider(Flowable): def __init__(self,number,title,subtitle="",width=155*mm): Flowable.__init__(self); self.number=number; self.title=title self.subtitle=subtitle; self.width=width; self.height=52 def draw(self): c=self.canv; W=self.width c.setFillColor(ACCENT2); c.roundRect(0,0,W,self.height,4,fill=1,stroke=0) c.setFillColor(WHITE); c.circle(30,self.height/2,16,fill=1,stroke=0) c.setFont("Helvetica-Bold",14); c.setFillColor(ACCENT2) c.drawCentredString(30,self.height/2-5,str(self.number)) c.setFont("Helvetica-Bold",15); c.setFillColor(WHITE) c.drawString(56,self.height/2+4,self.title) if self.subtitle: c.setFont("Helvetica",9); c.setFillColor(colors.HexColor("#BBBBBB")) c.drawString(56,self.height/2-11,self.subtitle) def b(t,s,lv=1): sym="\u2022" if lv==1 else "\u2013" st="Bullet" if lv==1 else "SubBullet" return Paragraph(f"{sym} {t}",s[st]) def h(t,s,lv=1): return Paragraph(t,s["SectionHead" if lv==1 else "SubHead"]) def p(t,s): return Paragraph(t,s["Body"]) def sp(n=1): return Spacer(1,n*4*mm) def rule(): return HRFlowable(width="100%",thickness=0.5,color=colors.HexColor("#CCCCCC"),spaceAfter=4,spaceBefore=4) def mktbl(hdrs,rows,s,cw=None): hw=[Paragraph(x,s["TblHdr"]) for x in hdrs] br=[[Paragraph(str(c),s["TblCell"]) for c in r] for r in rows] data=[hw]+br if cw is None: cw=[155*mm/len(hdrs)]*len(hdrs) t=Table(data,colWidths=cw) t.setStyle(TableStyle([ ("BACKGROUND",(0,0),(-1,0),ACCENT2),("TEXTCOLOR",(0,0),(-1,0),WHITE), ("FONTNAME",(0,0),(-1,0),"Helvetica-Bold"),("FONTSIZE",(0,0),(-1,0),9.5), ("ROWBACKGROUNDS",(0,1),(-1,-1),[WHITE,LIGHT_GRAY]), ("GRID",(0,0),(-1,-1),0.4,colors.HexColor("#CCCCCC")), ("TOPPADDING",(0,0),(-1,-1),5),("BOTTOMPADDING",(0,0),(-1,-1),5), ("LEFTPADDING",(0,0),(-1,-1),6),("RIGHTPADDING",(0,0),(-1,-1),6), ("VALIGN",(0,0),(-1,-1),"TOP"), ])); return t def infobox(rows,s,bg=None): if bg is None: bg=LIGHT_GRAY t=Table([[r] for r in rows],colWidths=[155*mm]) t.setStyle(TableStyle([ ("BACKGROUND",(0,0),(-1,-1),bg), ("BOX",(0,0),(-1,-1),0.5,colors.HexColor("#BBBBBB")), ("TOPPADDING",(0,0),(-1,-1),6),("BOTTOMPADDING",(0,0),(-1,-1),6), ("LEFTPADDING",(0,0),(-1,-1),10),("RIGHTPADDING",(0,0),(-1,-1),10), ])); return t def build_doc(): s=build_styles(); story=[] W,H=A4 # COVER story.append(CoverPage(W,H)); story.append(PageBreak()) # TOC story.append(sp(2)); story.append(h("TABLE OF CONTENTS",s)); story.append(rule()) toc=[ ("1","Introduction & Background","Overview, definition, significance"), ("2","Epidemiology & Risk Factors","Prevalence, incidence, racial disparities"), ("3","Pathophysiology & Classification","Molecular basis, FIGO classification"), ("4","Clinical Manifestations","Menstrual, pelvic, urinary, sexual symptoms"), ("5","Impact on Reproductive Health","Infertility, pregnancy, obstetric complications"), ("6","Impact on Mental Health","Depression, anxiety, body image, relationships"), ("7","Quality of Life Assessment","Validated QoL instruments, domains affected"), ("8","Socioeconomic Burden","Healthcare costs, productivity loss"), ("9","Management Overview","Medical, surgical, minimally invasive"), ("10","Conclusion & Key Takeaways","Summary, clinical pearls"), ("11","References","Evidence-based sources"), ] for num,title,sub in toc: r=Table([[Paragraph(f"<b>{num}.</b>",s["Body"]), Paragraph(f"<b>{title}</b><br/><font size='8.5' color='#777777'>{sub}</font>",s["Body"])]], colWidths=[12*mm,143*mm]) r.setStyle(TableStyle([("VALIGN",(0,0),(-1,-1),"TOP"), ("TOPPADDING",(0,0),(-1,-1),3),("BOTTOMPADDING",(0,0),(-1,-1),3), ("LINEBELOW",(0,0),(-1,-1),0.3,colors.HexColor("#DDDDDD"))])) story.append(r) story.append(PageBreak()) # S1 INTRO story.append(SectionDivider(1,"Introduction & Background")); story.append(sp(2)) story.append(p("Uterine fibroids (leiomyomas, myomas) are <b>benign monoclonal smooth muscle tumors</b> originating from the myometrial layer of the uterus. They are the most common solid benign pelvic tumors in women of reproductive age and represent a leading cause of gynaecological morbidity worldwide. Despite their extraordinary prevalence, fibroids remain significantly underdiagnosed and undertreated, with a persistent gap between symptom burden and medical attention received.",s)) story.append(sp(1)) story.append(p("The clinical significance of uterine fibroids extends far beyond their anatomical presence. They impose a profound, multidimensional burden on affected women - encompassing heavy menstrual bleeding, chronic pelvic pain, reproductive failure, urinary symptoms, sexual dysfunction, mental health deterioration, and markedly reduced health-related quality of life (HRQoL). A deep understanding of this comprehensive impact is foundational for gynaecology residents to deliver patient-centred, evidence-based care.",s)) story.append(sp(2)) story.append(infobox([ Paragraph("<b>Key Facts at a Glance</b>",s["BoxTitle"]), b("Most common benign pelvic tumor in women of reproductive age",s), b("Cumulative incidence up to 70-80% by age 50 (higher in Black women)",s), b("70-80% of women with fibroids experience at least one significant symptom",s), b("Leading indication for hysterectomy in the United States and globally",s), b("40% of symptomatic women require time off work due to fibroid symptoms",s), b("Annual US economic burden estimated at USD 34.4 billion (direct + indirect)",s), ],s)) story.append(PageBreak()) # S2 EPIDEMIOLOGY story.append(SectionDivider(2,"Epidemiology & Risk Factors","Prevalence, incidence, racial disparities")); story.append(sp(2)) story.append(h("2.1 Prevalence & Incidence",s,2)) story.append(p("Uterine fibroids are identified in approximately <b>20-50% of women of reproductive age</b> using clinical criteria, rising to <b>70-80%</b> when autopsy or systematic ultrasound surveillance is employed. Incidence increases significantly with age: <b>4 per 1,000 woman-years</b> in the 25-29 age group, rising to <b>22 per 1,000 woman-years</b> in the 40-44 age group (Berek & Novak's Gynecology). They are detected in 3-4% of midtrimester ultrasound evaluations during pregnancy (Creasy & Resnik's Maternal-Fetal Medicine).",s)) story.append(sp(1)) story.append(h("2.2 Racial & Ethnic Disparities",s,2)) story.append(p("Black women bear a disproportionate burden of uterine fibroid disease. Compared to White women, Black women:",s)) for x in ["Develop fibroids at a younger age (often 5-10 years earlier)","Have larger and more numerous fibroids at presentation","Experience more severe symptoms, higher anaemia rates, and greater QoL impairment","Have higher rates of surgical intervention including hysterectomy","Have a cumulative incidence approaching 80% by age 50 (vs. ~70% in White women)"]: story.append(b(x,s)) story.append(sp(1)) story.append(h("2.3 Risk Factor Profile",s,2)) story.append(mktbl( ["Risk Factor","Risk Direction","Clinical Notes"], [["Increasing age (reproductive years)","Strong increase","Peaks perimenopausally; regress post-menopause"], ["African-American race/ethnicity","2-3x higher risk","Younger onset, larger/more fibroids"], ["Nulliparity","Increased","Each pregnancy confers protective effect"], ["Early menarche (< 10 years)","Elevated","Prolonged cumulative estrogen exposure"], ["Obesity / high BMI","Moderate increase","Peripheral aromatisation increases estrogen"], ["First-degree family history","~2.5x higher","MED12 gene mutations; genetic predisposition"], ["Alcohol consumption","Associated","Possible estrogen modulation"], ["Multiparity","Protective","Uterine involution hypothesis"], ["Oral contraceptive use","Mildly protective","Unclear in long-term use"], ["Smoking","Mildly protective","Anti-estrogenic metabolic effects"]], s,[68*mm,40*mm,47*mm])) story.append(sp(1)); story.append(Paragraph("<i>Source: Berek & Novak's Gynecology; Robbins & Kumar Basic Pathology</i>",s["FootNote"])) story.append(PageBreak()) # S3 PATHOPHYSIOLOGY story.append(SectionDivider(3,"Pathophysiology & Classification","Molecular basis, histology, FIGO types")); story.append(sp(2)) story.append(h("3.1 Molecular Pathogenesis",s,2)) story.append(p("Fibroids are <b>monoclonal smooth muscle tumors</b> arising from a single transformed myometrial cell. Fibroid growth is primarily driven by <b>estrogen and progesterone</b>, explaining their regression after menopause and shrinkage with hypoestrogenic therapy. Key molecular features include:",s)) story.append(b("<b>MED12 (Mediator Complex Subunit 12) mutations:</b> Found in 70-85% of uterine fibroids; the most prevalent somatic mutation (Amendola et al., Reprod Sci 2024, PMID 37516697)",s)) story.append(b("<b>Fumarate hydratase (FH) mutations:</b> Cause hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome; Krebs cycle enzyme link to neoplasia (Robbins, Cotran & Kumar)",s)) story.append(b("<b>Estrogen receptors alpha/beta:</b> Upregulated in fibroid tissue; estrogen stimulates IGF-1 and EGF growth pathways",s)) story.append(b("<b>Extracellular matrix (ECM) accumulation:</b> Fibroids contain excessive collagen and proteoglycans, contributing to their bulk and firmness",s)) story.append(sp(1)) story.append(h("3.2 Histopathology",s,2)) story.append(p("Microscopically, leiomyomas consist of <b>interlacing fascicles of densely eosinophilic spindle cells</b> intersecting at right angles, with blunt-ended elongated nuclei, minimal nuclear atypia, and rare mitotic figures. A <b>pseudocapsule</b> of compressed myometrium surrounds each tumor - important for surgical enucleation (myomectomy). Degeneration types include:",s)) for x in ["Hyaline degeneration - most common; central collagen replacement","Cystic degeneration - liquefaction of hyaline areas","Myxoid degeneration - gelatinous stroma","Red (carneous) degeneration - venous thrombosis causing infarction; occurs in pregnancy; causes acute pain","Calcific degeneration - post-menopausal; 'womb stones'"]: story.append(b(x,s)) story.append(sp(1)) story.append(h("3.3 FIGO Classification by Location",s,2)) story.append(mktbl( ["FIGO Type","Location","Primary Symptom Impact"], [["0","Submucosal - pedunculated intracavitary","Severe HMB, infertility, miscarriage"], ["1","Submucosal - <50% intramural","Severe HMB, infertility"], ["2","Submucosal - ≥50% intramural","HMB, dysmenorrhea, infertility"], ["3","Intramural - contacts endometrium","HMB, pressure symptoms"], ["4","Intramural - within myometrium","Pressure symptoms, bulk"], ["5","Subserosal - ≥50% intramural","Bulk, urinary, bowel symptoms"], ["6","Subserosal - <50% intramural","Pelvic bulk"], ["7","Subserosal - pedunculated","Pelvic mass; torsion risk"], ["8","Cervical / parasitic / other","Variable by location"]], s,[22*mm,70*mm,63*mm])) story.append(sp(1)); story.append(Paragraph("<i>FIGO PALM-COEIN classification (Munro et al., 2011). HMB = Heavy Menstrual Bleeding.</i>",s["FootNote"])) story.append(PageBreak()) # S4 CLINICAL MANIFESTATIONS story.append(SectionDivider(4,"Clinical Manifestations","Symptom burden across organ systems")); story.append(sp(2)) story.append(p("Fibroids may be <b>asymptomatic</b> (discovered incidentally on ultrasound/examination) or produce a wide spectrum of symptoms determined by size, number, and location. The largest prospective study to date (n=555 women, mean age 43 years) documented: <b>80%</b> heavy bleeding, <b>75%</b> pelvic pain, <b>73%</b> urinary frequency/urgency, and <b>40%</b> requiring time off work (Berek & Novak's Gynecology).",s)) story.append(sp(1)) story.append(h("4.1 Abnormal Uterine Bleeding (AUB-L)",s,2)) story.append(p("Heavy menstrual bleeding (HMB) is the <b>most common and clinically significant symptom</b>, particularly associated with submucosal fibroids (FIGO Types 0-2). Mechanisms include:",s)) for x in ["Distortion of endometrial vasculature with increased endometrial surface area", "Impaired uterine myometrial contractility, reducing physiological haemostasis", "Altered local prostaglandin and growth factor (VEGF, EGF) production", "Venous ectasia in the endometrium adjacent to submucosal fibroids"]: story.append(b(x,s)) story.append(p("<b>Consequences of chronic HMB:</b> Iron-deficiency anaemia (fatigue, dyspnoea, reduced exercise tolerance, cognitive impairment), intermenstrual spotting, prolonged menses, planning activities around menstrual cycle.",s)) story.append(sp(1)) story.append(h("4.2 Pelvic Pain & Pressure Symptoms",s,2)) for x in ["Non-cyclic pelvic pressure and heaviness - most common pain pattern; from bulk effect", "Dysmenorrhea - cyclic pain; more severe with submucosal and intramural fibroids", "Dyspareunia - deep pelvic pain during intercourse; impairs sexual health and relationships", "Constipation - posterior fibroids compressing rectosigmoid colon", "Acute pain - red (carneous) degeneration in pregnancy; torsion of pedunculated fibroid"]: story.append(b(x,s)) story.append(sp(1)) story.append(h("4.3 Urinary Tract Symptoms",s,2)) for x in ["Urinary frequency and urgency (73% in large prospective series) - anterior/large fibroids compressing bladder", "Nocturia and incomplete bladder emptying", "Obstructive uropathy - rarely, large fibroids cause hydroureter/hydronephrosis"]: story.append(b(x,s)) story.append(sp(1)) story.append(h("4.4 Symptom Summary",s,2)) story.append(mktbl( ["Symptom","Frequency","Mechanism"], [["Heavy menstrual bleeding","80% of symptomatic","Submucosal distortion, endometrial vasculopathy"], ["Pelvic pressure/bulk","50-60%","Mass effect on pelvic structures"], ["Dysmenorrhea","30-40%","Prostaglandins, uterine cavity distortion"], ["Urinary frequency/urgency","73%","Bladder compression by anterior/large fibroids"], ["Dyspareunia","~30%","Deep pelvic mass effect"], ["Iron-deficiency anaemia","40-50% with HMB","Chronic blood loss"], ["Constipation","20-30%","Posterior fibroid + rectal compression"], ["Work absenteeism","40% require time off","Multisymptom combined burden"]], s,[50*mm,35*mm,70*mm])) story.append(PageBreak()) # S5 REPRODUCTIVE story.append(SectionDivider(5,"Impact on Reproductive Health","Infertility, pregnancy, obstetric outcomes")); story.append(sp(2)) story.append(h("5.1 Infertility",s,2)) story.append(p("Fibroids are found in <b>5-10% of infertile women</b> and may be the sole identifiable cause in <b>2-3%</b>. The reproductive impact is strongly location-dependent:",s)) story.append(b("<b>Submucosal (FIGO 0-2):</b> Distort endometrial cavity, impair implantation, alter endometrial receptivity, disrupt sperm transport - strongest association with infertility and miscarriage",s)) story.append(b("<b>Intramural (FIGO 3-4):</b> May alter uterine peristalsis and endometrial blood flow; reduce IVF live birth rates by ~15-20% depending on size and cavity contact",s)) story.append(b("<b>Subserosal (FIGO 5-7):</b> Generally do not independently impair fertility",s)) story.append(sp(1)) story.append(h("5.2 Spontaneous Miscarriage",s,2)) story.append(p("Submucosal fibroids increase risk of first and second trimester miscarriage through endometrial cavity compression, poor placentation, and impaired vascular supply to implantation site. Hysteroscopic removal of submucosal fibroids improves spontaneous conception rates and reduces miscarriage rates (De Angelis et al., Minerva Obstet Gynecol 2022, PMID 33876900).",s)) story.append(sp(1)) story.append(h("5.3 Obstetric Complications",s,2)) story.append(mktbl( ["Complication","Risk Estimate","Mechanism"], [["Placenta previa","OR = 2.2","Abnormal placentation over fibroid site"], ["Placental abruption","OR = 2.6","Subplacental fibroid causing vascular disruption"], ["Preterm delivery","Elevated risk","Uterine irritability, distortion, preterm labour"], ["Malpresentation","Elevated risk","Mechanical obstruction to fetal lie"], ["Red degeneration","Occurs in pregnancy","Venous thrombosis/infarction; acute abdominal pain"], ["Postpartum haemorrhage","Elevated risk","Impaired uterine contraction (atony)"], ["Caesarean section rate","Up to 2-3x higher","Obstructed labour, malpresentation"]], s,[52*mm,35*mm,68*mm])) story.append(sp(1)); story.append(Paragraph("<i>OR = Odds Ratio. Source: Creasy & Resnik's Maternal-Fetal Medicine; Berek & Novak's Gynecology</i>",s["FootNote"])) story.append(sp(1)) story.append(h("5.4 Recurrence After Myomectomy",s,2)) story.append(p("Myomectomy does not eliminate risk of new fibroid formation. Cumulative recurrence rates (Berek & Novak's Gynecology):",s)) for x in ["10% clinically significant new fibroids at 5 years after myomectomy", "27% cumulative new appearance over 14 years of follow-up", "Single fibroid removed: 27% new fibroid rate at 5+ years", "Multiple fibroids removed: 59% recurrence rate", "Second surgery required in 11-26% of patients depending on initial fibroid number"]: story.append(b(x,s)) story.append(PageBreak()) # S6 MENTAL HEALTH story.append(SectionDivider(6,"Impact on Mental Health","Psychological burden, depression, anxiety")); story.append(sp(2)) story.append(p("The psychological impact of uterine fibroids is a major, frequently underappreciated dimension of their burden. A landmark 2024 systematic review in <i>Fertility and Sterility</i> (Neumann et al., PMID 38246400) - examining <b>67 studies including 18 RCTs</b> - established that fibroids significantly impair mental health across multiple validated measures, and that all treatments produce significant mental health improvement.",s)) story.append(sp(1)) story.append(h("6.1 Psychological Domains Affected",s,2)) psych=[ ("<b>Depression</b>","Chronic pain, fatigue from anaemia, sexual dysfunction, and social limitations collectively drive elevated rates of clinical depression and persistent low mood"), ("<b>Anxiety</b>","Fear of malignancy (differential with sarcoma), uncertainty about fertility potential, menstrual unpredictability, and diagnostic delays all generate significant anxiety"), ("<b>Body image disturbance</b>","Abdominal distension from large fibroid uterus causes visible asymmetry, embarrassment, reduced self-esteem, and avoidance of clothing/activities"), ("<b>Relationship strain</b>","Dyspareunia and reduced libido impair intimate relationships; partners may not understand the symptom burden, causing communication difficulties"), ("<b>Social isolation</b>","Fear of menstrual accidents in public spaces, planning activities around heavy periods, and fatigue reduce social participation and create isolation"), ("<b>Occupational impact</b>","40% of symptomatic women require time off work; pain and fatigue cause presenteeism; career progression may be affected"), ("<b>Grief and reproductive loss</b>","Miscarriage associated with fibroids, fertility impairment, and deferred family planning cause profound psychological distress"), ] for bold,detail in psych: story.append(KeepTogether([ Paragraph(f"\u2022 {bold}: {detail}",s["Bullet"]),sp(0.5) ])) story.append(sp(1)) story.append(h("6.2 Validated Mental Health Instruments in Fibroid Research",s,2)) story.append(mktbl( ["Tool","Domain Measured","Relevance to Fibroids"], [["PHQ-9","Depression severity (9 items, 0-27 scale)","Quantifies depression linked to chronic HMB & pain"], ["GAD-7","Anxiety severity (7 items, 0-21 scale)","Captures fertility fears, menstrual anxiety"], ["SF-36 Mental Component","Mental HRQoL composite","Broad psychological wellbeing measure in RCTs"], ["EQ-5D Anxiety/Depression","HRQoL utility for economics","Used in cost-effectiveness analyses"], ["DASS-21","Depression, anxiety, stress (21 items)","Comprehensive psychological screening tool"], ["BDI (Beck Depression Inventory)","Depression severity","Used in several fibroid cohort studies"]], s,[42*mm,52*mm,61*mm])) story.append(PageBreak()) # S7 QOL story.append(SectionDivider(7,"Quality of Life Assessment","HRQoL instruments, domains, evidence")); story.append(sp(2)) story.append(p("Health-related quality of life (HRQoL) is a multidimensional construct encompassing physical, emotional, social, and role functioning. Uterine fibroids impair HRQoL across all these domains. Validated, disease-specific instruments are essential for capturing the true burden and measuring treatment outcomes objectively.",s)) story.append(sp(1)) story.append(h("7.1 Disease-Specific & Generic QoL Instruments",s,2)) story.append(mktbl( ["Instrument","Domains Assessed","Key Feature"], [["UFS-QoL\n(Uterine Fibroid Symptom & QoL)","Symptom Severity Score + 6 HRQoL subscales: Concern, Activities, Energy/Fatigue, Control, Self-consciousness, Sexual Function","Gold standard for fibroid trials; most widely validated; scores 0-100"], ["SF-36 / SF-12","Physical Function, Role-Physical, Bodily Pain, General Health, Vitality, Social Function, Role-Emotional, Mental Health","Generic; enables cross-condition comparison; widely used in RCTs"], ["EQ-5D-3L/5L","Mobility, Self-care, Usual activities, Pain/Discomfort, Anxiety/Depression + VAS","Utility values (QALYs) for health economic analyses"], ["PBAC\n(Pictorial Blood Assessment Chart)","Menstrual blood loss quantification (pads/tampons scored)","Objective HMB measurement; PBAC score >100 = clinically significant HMB"], ["NRS/VAS Pain","Pain intensity 0-10","Simple, validated; monitors treatment response"], ["FACT-G / cancer QoL tools","Wellbeing, social/family, emotional, functional","Used in studies with malignancy concerns"]], s,[38*mm,80*mm,37*mm])) story.append(sp(1)) story.append(h("7.2 QoL Domains Impaired: Detailed Analysis",s,2)) qol=[ ("Physical Functioning","Anaemia-related fatigue reduces exercise tolerance and mobility. Pain limits physical activity. Heavy flow days restrict planned activities including sport, travel, and work."), ("Role Functioning","40% of symptomatic women require work absence. Reduced productivity (presenteeism) even when at work due to pain, fatigue, and concentration difficulties."), ("Social Participation","Avoidance of social events and public spaces due to unpredictable heavy bleeding. Embarrassment from visible abdominal swelling reduces social engagement."), ("Sexual Health","Dyspareunia affects ~30% of symptomatic women. Reduced libido secondary to chronic pain, fatigue, and body image concerns impairs intimate relationships."), ("Emotional Wellbeing","Elevated depression and anxiety scores on validated tools. Fear of underlying malignancy (sarcoma). Distress over infertility and pregnancy loss."), ("Self-Efficacy & Control","Sense of loss of control over bodily functions. Extensive planning of daily life around menstrual cycle. Reduced self-confidence and self-esteem."), ("Vitality & Energy","Iron-deficiency anaemia and chronic pain reduce vitality scores. Even mild anaemia impairs cognition, concentration, and productivity."), ] for dom,detail in qol: story.append(KeepTogether([h(dom,s,2),p(detail,s),sp(0.5)])) story.append(sp(1)) story.append(infobox([ Paragraph("<b>Key Evidence: Fertil Steril 2024 (PMID 38246400)</b>",s["BoxTitle"]), p("A systematic review of 67 studies (18 RCTs + 49 observational) confirmed that ALL fibroid treatment modalities - medical, surgical, and radiological - were associated with significant improvement in fibroid-specific QoL scores, mental health metrics, and symptom severity scores post-treatment. This provides strong evidence that the baseline QoL impairment is both substantial and treatment-responsive.",s), ],s)) story.append(PageBreak()) # S8 SOCIOECONOMIC story.append(SectionDivider(8,"Socioeconomic Burden","Healthcare costs, productivity loss, healthcare utilisation")); story.append(sp(2)) story.append(p("The economic burden of uterine fibroids is enormous and frequently underestimated by healthcare systems. Both direct costs (healthcare utilisation) and indirect costs (productivity loss, absenteeism) are substantial.",s)) story.append(sp(1)) story.append(h("8.1 Direct Healthcare Costs",s,2)) for x in ["Hysterectomy for fibroids accounts for >200,000 procedures annually in the US alone", "Estimated direct annual healthcare cost in the US: USD 4.1-9.4 billion", "Total annual economic burden (direct + indirect): estimated USD 34.4 billion (US)", "Globally, fibroids are the leading benign indication for major gynaecological surgery", "Repeated surgical interventions due to myomectomy recurrence add ongoing cumulative costs", "Iron transfusions and supplementation for severe anaemia represent ongoing care costs"]: story.append(b(x,s)) story.append(sp(1)) story.append(h("8.2 Indirect Costs & Productivity Loss",s,2)) for x in ["40% of symptomatic women report time off work; disproportionately affects women aged 30-50 in peak career years", "Work productivity (presenteeism) reduced even when attending work due to pain and fatigue", "Estimated annual productivity loss: USD 1.55-17.2 billion", "Anaemia from chronic HMB independently reduces cognitive function and occupational performance", "Repeated medical visits and investigations consume significant personal time and income"]: story.append(b(x,s)) story.append(sp(1)) story.append(h("8.3 Health Equity Implications",s,2)) story.append(p("The disproportionate burden in Black women has health equity dimensions: higher rates of surgery including hysterectomy, greater delay to diagnosis, underrepresentation in clinical trials, and barriers to accessing newer minimally invasive treatments. Addressing these disparities requires systemic, policy-level, and clinical interventions.",s)) story.append(PageBreak()) # S9 MANAGEMENT story.append(SectionDivider(9,"Management Overview","Medical, surgical, minimally invasive approaches")); story.append(sp(2)) story.append(p("Management must be <b>individualised</b> based on: symptom severity and type; fibroid size, number, and location; patient's desire for fertility preservation; age and proximity to menopause; patient values and preferences; and available institutional expertise. The overarching goal is to improve QoL while minimising treatment burden.",s)) story.append(sp(1)) story.append(h("9.1 Medical Management",s,2)) story.append(mktbl( ["Drug/Class","Mechanism","QoL Impact","Key Notes"], [["GnRH Agonists\n(Leuprolide, Goserelin)","Pituitary downregulation; hypoestrogenic state","Reduces HMB, improves anaemia preoperatively","3-6 months max; add-back therapy required; fibroids regrow on cessation"], ["GnRH Antagonists\n(Elagolix, Relugolix)","Direct GnRH receptor blockade; rapid onset","Significant HMB reduction; improved QoL in RCTs","Oral; used with add-back; FDA-approved for fibroid-related HMB"], ["Ulipristal Acetate (UPA)","Selective progesterone receptor modulator (SPRM)","Controlled HMB; fibroid volume reduction","Restricted due to hepatotoxicity risk; limited availability globally"], ["LNG-IUD","Local progestin; endometrial atrophy","Reduces HMB; improves anaemia; acceptable long-term","Does not reduce fibroid volume; effective for bleeding control"], ["Combined OCP / Progestins","Hormonal cycle regulation","Modest HMB reduction; cycle control","Limited effect on fibroid size; not effective for bulk symptoms"], ["Tranexamic acid","Antifibrinolysis; reduces menstrual blood loss","Reduces HMB by 30-50%","Non-hormonal; taken only during menstruation"], ["NSAIDs","Prostaglandin inhibition; reduces uterine contractions","Reduces dysmenorrhea and mild HMB","Used adjunctively; limited effect alone on heavy bleeding"], ["Iron supplementation","Corrects iron-deficiency anaemia","Improves fatigue, cognition, energy, vitality","Essential adjunct to ALL fibroid treatments where HMB present"]], s,[40*mm,38*mm,33*mm,44*mm])) story.append(sp(1)) story.append(h("9.2 Surgical Management",s,2)) story.append(mktbl( ["Procedure","Primary Indication","Fertility Status","QoL Outcome"], [["Hysteroscopic Myomectomy","FIGO Types 0, 1, 2 (submucosal)","Preserved; best fertility outcomes","Excellent for HMB; day case; low morbidity"], ["Laparoscopic Myomectomy","Intramural/subserosal ≤8-10 cm","Preserved","Minimally invasive; fast recovery; good QoL gains"], ["Abdominal Myomectomy","Large, multiple, or complex fibroids","Preserved (uterus retained)","Gold standard complex cases; 5-10% hysterectomy conversion"], ["Hysterectomy (total/subtotal)","Completed family; failed treatments","Not preserved - definitive cure","Permanent symptom resolution; highest surgical morbidity"]], s,[48*mm,40*mm,32*mm,35*mm])) story.append(sp(1)) story.append(h("9.3 Minimally Invasive & Radiological Options",s,2)) story.append(b("<b>Uterine Artery Embolization (UAE):</b> HMB improved in 83%, dysmenorrhoea in 77%, urinary symptoms in 86% at 3 months. Systematic review (Peng et al., Sci Rep 2024, PMID 39164326) confirms comparable QoL and symptom outcomes to myomectomy. Not recommended when fertility is desired.",s)) story.append(b("<b>High-Intensity Focused Ultrasound (HIFU/MRgFUS):</b> Non-invasive; systematic review and meta-analysis (Yan et al., Int J Hyperthermia 2022, PMID 35094613) demonstrates significant symptom and QoL improvement. Preserves uterus; potential fertility sparing.",s)) story.append(b("<b>Laparoscopic Radiofrequency Ablation (Acessa ProVu):</b> AAGL systematic review (Chen et al., J Minim Invasive Gynecol 2025, PMID 39277104) confirms significant HMB reduction and QoL improvement. Outpatient; fertility may be preserved.",s)) story.append(b("<b>Preoperative medical therapy:</b> Cochrane review (Puscasiu et al., 2025, PMID 40183418) confirms GnRH analogues pre-surgery reduce uterine volume, improve haematological parameters, and facilitate minimally invasive approaches.",s)) story.append(PageBreak()) # S10 CONCLUSIONS story.append(SectionDivider(10,"Conclusion & Key Takeaways")); story.append(sp(2)) story.append(p("Uterine fibroids impose a profound, far-reaching, and multidimensional burden on women's health and quality of life that extends well beyond their anatomical presence. For the gynaecology resident, a comprehensive understanding of this burden is foundational to delivering patient-centred, equitable fibroid care.",s)) story.append(sp(1)) tkaways=[ ("1. High burden, underrecognised","Up to 80% cumulative incidence by age 50. The gap between symptom burden and care remains significant. Active case-finding is essential."), ("2. Multi-symptom, multi-domain impact","HMB, pelvic pain, urinary symptoms, dyspareunia, and anaemia together impair physical, emotional, social, and occupational functioning."), ("3. Reproductive consequences are significant","Submucosal fibroids independently impair fertility, increase miscarriage risk, and complicate obstetric outcomes. Location matters critically."), ("4. Mental health is a core domain","Depression, anxiety, and body image disturbance are integral to the fibroid experience and require systematic screening and management."), ("5. Use validated QoL tools","The UFS-QoL, SF-36, PBAC, and NRS should be used to quantify baseline burden and objectively monitor treatment response."), ("6. All treatments improve QoL","Medical, surgical, and minimally invasive interventions all significantly improve QoL and mental health post-treatment (Neumann et al., 2024)."), ("7. Individualise management","Consider symptom type and severity, fibroid characteristics (FIGO type), fertility desire, patient values, and available resources."), ("8. Counsel proactively on recurrence","27-59% recurrence after myomectomy; long-term follow-up and repeat counselling on family planning are essential."), ("9. Address health disparities","Black women have a disproportionate burden and face barriers to optimal care. Cultural competence and equitable access are professional obligations."), ] for key,detail in tkaways: story.append(KeepTogether([ Paragraph(f"<b>{key}</b>",s["SubHead"]), p(detail,s), sp(0.5) ])) story.append(PageBreak()) # S11 REFERENCES story.append(SectionDivider(11,"References")); story.append(sp(2)) refs=[ "1. Berek JS, et al. <i>Berek & Novak's Gynecology</i>. 16th ed. Wolters Kluwer; 2020. Chapter 11: Uterine Fibroids (Leiomyomas).", "2. Creasy RK, et al. <i>Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice</i>. 8th ed. Elsevier; 2019. Chapter 28: Uterine Myomas.", "3. Kumar V, Abbas AK, Aster JC. <i>Robbins, Cotran & Kumar: Pathologic Basis of Disease</i>. 10th ed. Elsevier; 2023. Chapter: Leiomyoma.", "4. Robbins SL, Kumar V. <i>Robbins & Kumar Basic Pathology</i>. 10th ed. Elsevier; 2021.", "5. Neumann B, Singh B, Brennan J, Blanck J, Segars JH. The impact of fibroid treatments on quality of life and mental health: a systematic review. <i>Fertil Steril</i>. 2024;121(3). PMID: 38246400. doi: 10.1016/j.fertnstert.2024.01.021", "6. Singh S, Kumar P, Kavita, Rathore SS, Singh Y, Garg N. Contemporary approaches in the management of uterine leiomyomas. <i>Eur J Obstet Gynecol Reprod Biol</i>. 2023 Aug;287:117-129. PMID: 37385088.", "7. Amendola ILS, Spann M, Segars J. The Mediator Complex Subunit 12 (MED-12) Gene and Uterine Fibroids: a Systematic Review. <i>Reprod Sci</i>. 2024 Feb;31(2):310-324. PMID: 37516697.", "8. Peng J, Wang J, Shu Q, et al. Systematic review and meta-analysis of current evidence in uterine artery embolization vs myomectomy for symptomatic uterine fibroids. <i>Sci Rep</i>. 2024 Aug 20;14(1):19214. PMID: 39164326.", "9. Yan L, Huang H, Lin J. High-intensity focused ultrasound treatment for symptomatic uterine fibroids: a systematic review and meta-analysis. <i>Int J Hyperthermia</i>. 2022;39(1):234-243. PMID: 35094613.", "10. Chen I, Berman JM, Balk EM, et al. Radiofrequency Ablation for the Treatment of Uterine Fibroids: A Systematic Review and Meta-Analysis by the AAGL Practice Committee. <i>J Minim Invasive Gynecol</i>. 2025 Jan;32(1):13-26. PMID: 39277104.", "11. Puscasiu L, Vollenhoven B, Nagels HE. Preoperative medical therapy before surgery for uterine fibroids. <i>Cochrane Database Syst Rev</i>. 2025 Apr 4. PMID: 40183418.", "12. De Angelis MC, Di Spiezio Sardo A, Carugno J. Fertility outcomes after hysteroscopic removal of intrauterine leiomyomas and polyps. <i>Minerva Obstet Gynecol</i>. 2022 Feb;74(1):84-95. PMID: 33876900.", "13. Munro MG, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women. <i>Int J Gynaecol Obstet</i>. 2011;113(1):3-13.", "14. Stewart EA. Uterine fibroids. <i>N Engl J Med</i>. 2015;372(17):1646-1655.", "15. Cardozo ER, et al. The estimated annual cost of uterine leiomyomata in the United States. <i>Am J Obstet Gynecol</i>. 2012;206(3):211.e1-9.", ] for ref in refs: story.append(Paragraph(ref,s["Ref"])); story.append(sp(0.5)) story.append(sp(2)); story.append(rule()) story.append(Paragraph("Prepared for Gynecology Residency Paper Presentation | Department of Obstetrics & Gynecology | May 2026",s["FootNote"])) story.append(Paragraph("Sources: Berek & Novak's Gynecology \u2022 Robbins & Kumar Pathology \u2022 Creasy & Resnik's MFM \u2022 PubMed Peer-Reviewed Systematic Reviews 2021-2026",s["FootNote"])) return story def add_header_footer(canvas, doc): canvas.saveState() W,H=A4 if doc.page > 1: canvas.setFillColor(ACCENT2); canvas.rect(0,H-22,W,22,fill=1,stroke=0) canvas.setFont("Helvetica-Bold",8); canvas.setFillColor(WHITE) canvas.drawString(20,H-14,"UTERINE FIBROIDS: IMPACT ON WOMEN'S HEALTH & QUALITY OF LIFE") canvas.setFont("Helvetica",8) canvas.drawRightString(W-20,H-14,"Gynecology Residency | May 2026") canvas.setFillColor(colors.HexColor("#F0F0F0")); canvas.rect(0,0,W,18,fill=1,stroke=0) canvas.setFont("Helvetica",7.5); canvas.setFillColor(MED_GRAY) canvas.drawString(20,6,"Department of Obstetrics & Gynecology") canvas.drawCentredString(W/2,6,"For educational purposes - based on peer-reviewed evidence") canvas.drawRightString(W-20,6,f"Page {doc.page}") canvas.restoreState() def main(): doc=SimpleDocTemplate(OUTPUT,pagesize=A4, leftMargin=27.5*mm,rightMargin=27.5*mm,topMargin=28*mm,bottomMargin=22*mm, title="Uterine Fibroids: Impact on Women's Health and Quality of Life", author="Gynecology Residency Program",subject="Paper Presentation") story=build_doc() doc.build(story,onFirstPage=add_header_footer,onLaterPages=add_header_footer) print(f"PDF generated: {OUTPUT}") if __name__=="__main__": main() PYEOF echo "Script written, running..." python3 /home/daytona/workspace/fibroid-presentation/gen_full.py

sed -i 's/s\.add(ParagraphStyle("Bullet",/try:\n s.add(ParagraphStyle("Bullet",/; s/s\.add(ParagraphStyle("SubBullet",/try:\n s.add(ParagraphStyle("SubBullet",/' /home/daytona/workspace/fibroid-presentation/gen_full.py # Simpler fix: use unique style names and avoid Bullet collision python3 - << 'EOF' import re with open("/home/daytona/workspace/fibroid-presentation/gen_full.py") as f: code = f.read() # Replace the add lines for Bullet and SubBullet with safe adds old = 's.add(ParagraphStyle("Bullet",' new = 'if "Bullet" not in s: s.add(ParagraphStyle("Bullet",' code = code.replace( 's.add(ParagraphStyle("Bullet", fontName="Helvetica", fontSize=10.5, textColor=DARK_GRAY, leading=15, leftIndent=14, bulletIndent=4, spaceBefore=2, spaceAfter=2))', 'if "Bullet" not in s: s.add(ParagraphStyle("Bullet", fontName="Helvetica", fontSize=10.5, textColor=DARK_GRAY, leading=15, leftIndent=14, bulletIndent=4, spaceBefore=2, spaceAfter=2))' ) code = code.replace( 's.add(ParagraphStyle("SubBullet", fontName="Helvetica", fontSize=10, textColor=MED_GRAY, leading=14, leftIndent=28, bulletIndent=18, spaceBefore=1, spaceAfter=1))', 'if "SubBullet" not in s: s.add(ParagraphStyle("SubBullet", fontName="Helvetica", fontSize=10, textColor=MED_GRAY, leading=14, leftIndent=28, bulletIndent=18, spaceBefore=1, spaceAfter=1))' ) with open("/home/daytona/workspace/fibroid-presentation/gen_full.py","w") as f: f.write(code) print("Fixed") EOF python3 /home/daytona/workspace/fibroid-presentation/gen_full.py

"uterine fibroids" AND "quality of life"

PMID: 38246400

mkdir -p /home/daytona/workspace/fibroid2 && python3 - << 'PYEOF' from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.styles import ParagraphStyle from reportlab.lib.units import mm from reportlab.platypus import ( SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable, PageBreak, KeepTogether, BaseDocTemplate, Frame, PageTemplate ) from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY, TA_RIGHT from reportlab.platypus import Flowable from reportlab.lib.styles import getSampleStyleSheet OUT = "/home/daytona/workspace/fibroid2/Uterine_Fibroids_Womens_Health_QoL.pdf" W_PAGE, H_PAGE = A4 BLK = colors.black WHT = colors.white DGY = colors.HexColor("#1a1a1a") MGY = colors.HexColor("#555555") LGY = colors.HexColor("#F5F5F5") HDR = colors.HexColor("#1C1C2E") # dark navy header ACC = colors.HexColor("#2C2C2C") # ---------- Styles (all custom, no conflicts) ---------- def S(): d = {} def add(name, **kw): base = kw.pop('parent', None) defaults = dict(fontName="Helvetica", fontSize=10.5, textColor=DGY, leading=16, spaceBefore=2, spaceAfter=2, alignment=TA_JUSTIFY) defaults.update(kw) d[name] = ParagraphStyle(name, **defaults) add("body") add("body_left", alignment=TA_LEFT) add("h1", fontName="Helvetica-Bold", fontSize=15, textColor=ACC, spaceBefore=12, spaceAfter=5, leading=19, alignment=TA_LEFT) add("h2", fontName="Helvetica-Bold", fontSize=11.5, textColor=ACC, spaceBefore=9, spaceAfter=3, leading=15, alignment=TA_LEFT) add("bul", fontName="Helvetica", fontSize=10.5, textColor=DGY, leading=15, leftIndent=14, spaceBefore=2, spaceAfter=2, alignment=TA_LEFT) add("bul2", fontName="Helvetica", fontSize=10, textColor=MGY, leading=14, leftIndent=28, spaceBefore=1, spaceAfter=1, alignment=TA_LEFT) add("th", fontName="Helvetica-Bold", fontSize=9.5, textColor=WHT, leading=13, alignment=TA_CENTER) add("td", fontName="Helvetica", fontSize=9.5, textColor=DGY, leading=13, alignment=TA_LEFT) add("tdc", fontName="Helvetica", fontSize=9.5, textColor=DGY, leading=13, alignment=TA_CENTER) add("ref", fontName="Helvetica", fontSize=8.5, textColor=MGY, leading=13, leftIndent=10, spaceBefore=2, alignment=TA_LEFT) add("fn", fontName="Helvetica-Oblique", fontSize=7.5, textColor=MGY, leading=11, alignment=TA_CENTER) add("boxtitle", fontName="Helvetica-Bold", fontSize=11, textColor=ACC, leading=15, spaceBefore=3, spaceAfter=3, alignment=TA_LEFT) add("toc_title", fontName="Helvetica-Bold", fontSize=13, textColor=ACC, spaceBefore=16, spaceAfter=8, alignment=TA_LEFT) return d ST = S() # ---------- helpers ---------- def P(t): return Paragraph(t, ST["body"]) def PL(t): return Paragraph(t, ST["body_left"]) def H1(t): return Paragraph(t, ST["h1"]) def H2(t): return Paragraph(t, ST["h2"]) def B(t): return Paragraph(f"\u2022 {t}", ST["bul"]) def B2(t): return Paragraph(f"\u2013 {t}", ST["bul2"]) def SP(n=1): return Spacer(1, n * 4 * mm) def HR(): return HRFlowable(width="100%", thickness=0.5, color=colors.HexColor("#CCCCCC"), spaceAfter=4, spaceBefore=4) def TABLE(headers, rows, cw=None): nr = len(headers) if cw is None: cw = [155 * mm / nr] * nr hrow = [Paragraph(h, ST["th"]) for h in headers] brows = [[Paragraph(str(c), ST["td"]) for c in r] for r in rows] tbl = Table([hrow] + brows, colWidths=cw) tbl.setStyle(TableStyle([ ("BACKGROUND", (0, 0), (-1, 0), HDR), ("TEXTCOLOR", (0, 0), (-1, 0), WHT), ("ROWBACKGROUNDS", (0, 1), (-1, -1), [WHT, LGY]), ("GRID", (0, 0), (-1, -1), 0.4, colors.HexColor("#CCCCCC")), ("TOPPADDING", (0, 0), (-1, -1), 5), ("BOTTOMPADDING", (0, 0), (-1, -1), 5), ("LEFTPADDING", (0, 0), (-1, -1), 6), ("RIGHTPADDING", (0, 0), (-1, -1), 6), ("VALIGN", (0, 0), (-1, -1), "TOP"), ])) return tbl def BOX(items): tbl = Table([[item] for item in items], colWidths=[155 * mm]) tbl.setStyle(TableStyle([ ("BACKGROUND", (0, 0), (-1, -1), LGY), ("BOX", (0, 0), (-1, -1), 0.7, colors.HexColor("#AAAAAA")), ("TOPPADDING", (0, 0), (-1, -1), 5), ("BOTTOMPADDING", (0, 0), (-1, -1), 5), ("LEFTPADDING", (0, 0), (-1, -1), 10), ("RIGHTPADDING", (0, 0), (-1, -1), 10), ])) return tbl # ---------- Section banner flowable ---------- class SecBanner(Flowable): def __init__(self, num, title, sub="", w=155*mm): Flowable.__init__(self) self.num = num; self.title = title; self.sub = sub self.width = w; self.height = 50 def draw(self): c = self.canv c.setFillColor(HDR) c.roundRect(0, 0, self.width, self.height, 5, fill=1, stroke=0) c.setFillColor(WHT) c.circle(28, self.height / 2, 14, fill=1, stroke=0) c.setFont("Helvetica-Bold", 13) c.setFillColor(HDR) c.drawCentredString(28, self.height / 2 - 5, str(self.num)) c.setFont("Helvetica-Bold", 14) c.setFillColor(WHT) c.drawString(52, self.height / 2 + 4, self.title) if self.sub: c.setFont("Helvetica", 9) c.setFillColor(colors.HexColor("#BBBBBB")) c.drawString(52, self.height / 2 - 10, self.sub) # ---------- Cover flowable (fits in content area, not full page) ---------- class Cover(Flowable): def __init__(self, w, h): Flowable.__init__(self) self.width = w; self.height = h def draw(self): c = self.canv W, H = self.width, self.height # dark background c.setFillColor(HDR) c.roundRect(0, 0, W, H, 6, fill=1, stroke=0) # decorative circles c.setFillColor(colors.HexColor("#0f3460")) c.circle(W - 30, H - 30, 55, fill=1, stroke=0) c.circle(30, 30, 40, fill=1, stroke=0) # specialty label c.setFont("Helvetica-Bold", 8.5) c.setFillColor(colors.HexColor("#AAAAAA")) c.drawCentredString(W / 2, H - 55, "GYNECOLOGY RESIDENCY | PAPER PRESENTATION | MAY 2026") # divider c.setStrokeColor(colors.HexColor("#666666")) c.setLineWidth(1) c.line(50, H - 70, W - 50, H - 70) # main title c.setFont("Helvetica-Bold", 26) c.setFillColor(WHT) c.drawCentredString(W / 2, H - 115, "UTERINE FIBROIDS") c.setFont("Helvetica-Bold", 15) c.setFillColor(colors.HexColor("#CCCCCC")) c.drawCentredString(W / 2, H - 140, "Impact on Women\u2019s Health & Quality of Life") # divider c.setStrokeColor(colors.HexColor("#555555")) c.setLineWidth(0.7) c.line(60, H - 158, W - 60, H - 158) # subtitle lines c.setFont("Helvetica", 10.5) c.setFillColor(colors.HexColor("#CCCCCC")) y = H - 178 for line in ["Epidemiology | Pathophysiology | Clinical Burden", "Reproductive Health | Mental Wellbeing | QoL Instruments", "Socioeconomic Impact | Evidence-Based Management"]: c.drawCentredString(W / 2, y, line) y -= 20 # bottom meta c.setFont("Helvetica", 8.5) c.setFillColor(colors.HexColor("#888888")) c.drawCentredString(W / 2, 40, "Sources: Berek & Novak\u2019s Gynecology \u2022 Robbins & Kumar Pathology \u2022 Creasy & Resnik\u2019s MFM \u2022 PubMed Systematic Reviews 2021\u20132026") c.setFont("Helvetica", 9) c.setFillColor(colors.HexColor("#AAAAAA")) c.drawCentredString(W / 2, 22, "Department of Obstetrics & Gynecology") # ---------- Header / footer ---------- def hf(canvas, doc): canvas.saveState() W, H = A4 if doc.page > 1: canvas.setFillColor(HDR) canvas.rect(0, H - 20, W, 20, fill=1, stroke=0) canvas.setFont("Helvetica-Bold", 7.5) canvas.setFillColor(WHT) canvas.drawString(18, H - 13, "UTERINE FIBROIDS: IMPACT ON WOMEN\u2019S HEALTH & QUALITY OF LIFE") canvas.setFont("Helvetica", 7.5) canvas.drawRightString(W - 18, H - 13, "Gynecology Residency | May 2026") canvas.setFillColor(colors.HexColor("#EEEEEE")) canvas.rect(0, 0, W, 16, fill=1, stroke=0) canvas.setFont("Helvetica", 7) canvas.setFillColor(MGY) canvas.drawString(18, 5, "Dept. of Obstetrics & Gynecology") canvas.drawCentredString(W / 2, 5, "For educational use | Not a substitute for clinical guidelines") canvas.drawRightString(W - 18, 5, f"Page {doc.page}") canvas.restoreState() # ---------- Build story ---------- def story(): E = [] # elements # ── COVER (sized to fit content frame) ────────────────────────── CONTENT_H = H_PAGE - 28*mm - 22*mm # top + bottom margin CONTENT_W = W_PAGE - 55*mm # l + r margins E.append(Cover(CONTENT_W, CONTENT_H)) E.append(PageBreak()) # ── TABLE OF CONTENTS ───────────────────────────────────────── E.append(SP(1)) E.append(Paragraph("TABLE OF CONTENTS", ST["toc_title"])) E.append(HR()) toc = [ ("1", "Introduction & Background", "Definition, significance, overview"), ("2", "Epidemiology & Risk Factors", "Prevalence, incidence, racial disparities"), ("3", "Pathophysiology & Classification", "Molecular basis, histology, FIGO types"), ("4", "Clinical Manifestations", "Menstrual, pelvic, urinary, sexual symptoms"), ("5", "Impact on Reproductive Health", "Infertility, pregnancy, obstetric outcomes"), ("6", "Impact on Mental Health", "Depression, anxiety, body image, social burden"), ("7", "Quality of Life Assessment", "HRQoL instruments, domains, evidence"), ("8", "Socioeconomic Burden", "Costs, productivity, health equity"), ("9", "Management Overview", "Medical, surgical, minimally invasive"), ("10", "Conclusion & Key Takeaways", "Clinical pearls, summary"), ("11", "References", "Evidence-based sources"), ] for num, title, sub in toc: row = Table([[ Paragraph(f"<b>{num}.</b>", ST["body_left"]), Paragraph(f"<b>{title}</b><br/><font size='8.5' color='#777777'>{sub}</font>", ST["body_left"]) ]], colWidths=[11*mm, 144*mm]) row.setStyle(TableStyle([ ("VALIGN", (0, 0), (-1, -1), "TOP"), ("TOPPADDING", (0, 0), (-1, -1), 3), ("BOTTOMPADDING", (0, 0), (-1, -1), 3), ("LINEBELOW", (0, 0), (-1, -1), 0.3, colors.HexColor("#DDDDDD")), ])) E.append(row) E.append(PageBreak()) # ══════════════════════════════════════════════════════════════════ # S1 INTRODUCTION # ══════════════════════════════════════════════════════════════════ E += [SecBanner(1, "Introduction & Background"), SP(2), P("Uterine fibroids (leiomyomas, myomas) are <b>benign monoclonal smooth muscle tumors</b> originating from the myometrial layer of the uterus. They are the most common solid benign pelvic tumors in women of reproductive age and a leading cause of gynaecological morbidity worldwide. Despite their extraordinary prevalence, fibroids remain significantly underdiagnosed and undertreated, with a persistent gap between symptom burden and medical attention received."), SP(), P("The clinical significance of uterine fibroids extends far beyond their anatomical presence. They impose a profound, multidimensional burden on affected women - encompassing heavy menstrual bleeding, chronic pelvic pain, reproductive failure, urinary symptoms, sexual dysfunction, mental health deterioration, and markedly reduced health-related quality of life (HRQoL). A deep understanding of this comprehensive impact is foundational for gynaecology residents to deliver patient-centred, evidence-based care."), SP(2), BOX([ Paragraph("<b>Key Facts at a Glance</b>", ST["boxtitle"]), B("Most common benign pelvic tumor in women of reproductive age"), B("Cumulative incidence up to 70-80% by age 50 (even higher in Black women)"), B("70-80% of affected women experience at least one significant symptom"), B("Leading indication for hysterectomy in the United States and globally"), B("40% of symptomatic women require time off work due to fibroid symptoms"), B("Annual US economic burden (direct + indirect): estimated USD 34.4 billion"), ]), PageBreak()] # ══════════════════════════════════════════════════════════════════ # S2 EPIDEMIOLOGY # ══════════════════════════════════════════════════════════════════ E += [SecBanner(2, "Epidemiology & Risk Factors", "Prevalence, incidence, racial disparities"), SP(2), H2("2.1 Prevalence & Incidence"), P("Uterine fibroids are identified in approximately <b>20-50% of women of reproductive age</b> using clinical criteria, rising to <b>70-80%</b> when autopsy or systematic ultrasound surveillance is used. Incidence increases significantly with age: <b>4 per 1,000 woman-years</b> in the 25-29 age group, rising to <b>22 per 1,000 woman-years</b> in the 40-44 age group (Berek & Novak's Gynecology). They are detected in 3-4% of midtrimester ultrasound evaluations during pregnancy (Creasy & Resnik's Maternal-Fetal Medicine)."), SP(), H2("2.2 Racial & Ethnic Disparities"), P("Black women bear a disproportionate burden of uterine fibroid disease compared to White women:"), B("Develop fibroids at a younger age (often 5-10 years earlier)"), B("Have larger and more numerous fibroids at presentation"), B("Experience more severe symptoms, higher anaemia rates, and greater QoL impairment"), B("Have higher rates of surgical intervention including hysterectomy"), B("Cumulative incidence approaches 80% by age 50 (vs. approximately 70% in White women)"), SP(), H2("2.3 Risk Factor Profile"), TABLE( ["Risk Factor", "Risk Direction", "Clinical Notes"], [["Increasing age (reproductive years)", "Strong increase", "Peaks perimenopausally; regress after menopause"], ["African-American race/ethnicity", "2-3x higher risk", "Younger onset, larger/more numerous fibroids"], ["Nulliparity", "Increased risk", "Each pregnancy confers protective effect"], ["Early menarche (< 10 years)", "Elevated risk", "Prolonged cumulative estrogen exposure"], ["Obesity / high BMI", "Moderate increase", "Peripheral aromatisation increases estrogen"], ["First-degree family history", "~2.5x higher risk", "MED12 mutations; genetic predisposition"], ["Alcohol consumption", "Associated", "Possible estrogen modulation"], ["Multiparity", "Protective", "Uterine involution hypothesis"], ["Combined OCP use", "Mildly protective", "Effect unclear in long-term use"], ["Smoking", "Mildly protective", "Anti-estrogenic metabolic effects"]], [68*mm, 40*mm, 47*mm]), SP(), Paragraph("<i>Sources: Berek & Novak's Gynecology; Robbins & Kumar Basic Pathology</i>", ST["fn"]), PageBreak()] # ══════════════════════════════════════════════════════════════════ # S3 PATHOPHYSIOLOGY # ══════════════════════════════════════════════════════════════════ E += [SecBanner(3, "Pathophysiology & Classification", "Molecular basis, histology, FIGO types"), SP(2), H2("3.1 Molecular Pathogenesis"), P("Fibroids are <b>monoclonal smooth muscle tumors</b> arising from a single transformed myometrial cell. Growth is primarily driven by <b>estrogen and progesterone</b>, explaining their regression after menopause and shrinkage with hypoestrogenic therapy. Key molecular features:"), B("<b>MED12 gene mutations:</b> Found in 70-85% of uterine fibroids; the most prevalent somatic mutation (Amendola et al., Reprod Sci 2024, PMID 37516697)"), B("<b>Fumarate hydratase (FH) mutations:</b> Cause hereditary leiomyomatosis & renal cell carcinoma (HLRCC) syndrome (Robbins, Cotran & Kumar Pathologic Basis of Disease)"), B("<b>Estrogen receptor upregulation:</b> Stimulates IGF-1 and EGF growth pathways within fibroid tissue"), B("<b>Extracellular matrix (ECM) accumulation:</b> Excessive collagen and proteoglycans contribute to fibroid bulk and firmness"), SP(), H2("3.2 Histopathology"), P("Microscopically, leiomyomas consist of <b>interlacing fascicles of densely eosinophilic spindle cells</b> intersecting at right angles, with blunt-ended elongated nuclei, minimal nuclear atypia, and rare mitotic figures. A <b>pseudocapsule</b> of compressed myometrium surrounds each tumor - critical for surgical enucleation. Degeneration types include:"), B("Hyaline degeneration - most common; central collagen replacement"), B("Cystic degeneration - liquefaction of hyaline areas"), B("Red (carneous) degeneration - venous thrombosis causing infarction; occurs in pregnancy; causes acute pain"), B("Myxoid degeneration - gelatinous stroma"), B("Calcific degeneration - post-menopausal; 'womb stones'"), SP(), H2("3.3 FIGO Classification by Location (PALM-COEIN System)"), TABLE( ["FIGO Type", "Location", "Primary Symptom Impact"], [["Type 0", "Submucosal - pedunculated intracavitary", "Severe HMB, infertility, miscarriage"], ["Type 1", "Submucosal - <50% intramural", "Severe HMB, infertility"], ["Type 2", "Submucosal - ≥50% intramural", "HMB, dysmenorrhea, infertility"], ["Type 3", "Intramural - contacts endometrium", "HMB, pressure symptoms"], ["Type 4", "Intramural - entirely within myometrium", "Pressure/bulk symptoms"], ["Type 5", "Subserosal - ≥50% intramural", "Bulk, urinary, bowel symptoms"], ["Type 6", "Subserosal - <50% intramural", "Pelvic bulk symptoms"], ["Type 7", "Subserosal - pedunculated", "Pelvic mass; torsion risk"], ["Type 8", "Cervical / parasitic / other", "Variable by location"]], [22*mm, 72*mm, 61*mm]), SP(), Paragraph("<i>FIGO PALM-COEIN classification, Munro et al. 2011. HMB = Heavy Menstrual Bleeding.</i>", ST["fn"]), PageBreak()] # ══════════════════════════════════════════════════════════════════ # S4 CLINICAL MANIFESTATIONS # ══════════════════════════════════════════════════════════════════ E += [SecBanner(4, "Clinical Manifestations", "Symptom burden across organ systems"), SP(2), P("Fibroids may be <b>asymptomatic</b> (discovered incidentally) or produce a wide spectrum of symptoms determined by size, number, and location. The largest prospective study to date (n=555, mean age 43 years) documented: <b>80%</b> heavy bleeding, <b>75%</b> pelvic pain, <b>73%</b> urinary frequency/urgency, and <b>40%</b> requiring time off work (Berek & Novak's Gynecology)."), SP(), H2("4.1 Abnormal Uterine Bleeding (AUB-L)"), P("Heavy menstrual bleeding (HMB) is the <b>most common and clinically significant symptom</b>, especially associated with submucosal fibroids (FIGO Types 0-2). Mechanisms:"), B("Distortion of endometrial vasculature with increased surface area"), B("Impaired myometrial contractility, reducing physiological haemostasis"), B("Altered local prostaglandin and growth factor (VEGF, EGF) production"), B("Venous ectasia in endometrium adjacent to submucosal fibroids"), P("<b>Consequences of chronic HMB:</b> Iron-deficiency anaemia (fatigue, dyspnoea, reduced exercise tolerance, cognitive impairment), intermenstrual spotting, prolonged menses - all interfering with daily activities, work, and social life."), SP(), H2("4.2 Pelvic Pain & Pressure Symptoms"), B("Non-cyclic pelvic pressure and heaviness - most common pain pattern; arises from bulk effect"), B("Dysmenorrhea - cyclic pain; more severe with submucosal and intramural fibroids"), B("Dyspareunia - deep pelvic pain during intercourse; impairs sexual health and relationships"), B("Constipation - posterior fibroids compressing rectosigmoid colon"), B("Acute pain - red degeneration in pregnancy; torsion of pedunculated fibroid"), SP(), H2("4.3 Urinary Tract Symptoms"), B("Urinary frequency and urgency (73% in large prospective series) - from anterior/large fibroid compression of bladder"), B("Nocturia and incomplete bladder emptying"), B("Obstructive uropathy - rarely, large fibroids cause hydroureter/hydronephrosis"), SP(), H2("4.4 Symptom Summary"), TABLE( ["Symptom", "Frequency", "Primary Mechanism"], [["Heavy menstrual bleeding (HMB)", "80% of symptomatic", "Submucosal distortion, endometrial vasculopathy"], ["Pelvic pressure/bulk", "50-60%", "Mass effect on pelvic structures"], ["Dysmenorrhea", "30-40%", "Prostaglandins, uterine cavity distortion"], ["Urinary frequency/urgency", "73%", "Bladder compression by anterior/large fibroids"], ["Dyspareunia", "~30%", "Deep pelvic mass effect"], ["Iron-deficiency anaemia", "40-50% with HMB", "Chronic blood loss from prolonged HMB"], ["Constipation", "20-30%", "Posterior fibroid + rectal compression"], ["Work absenteeism", "40% require time off", "Combined multisymptom burden"]], [52*mm, 35*mm, 68*mm]), PageBreak()] # ══════════════════════════════════════════════════════════════════ # S5 REPRODUCTIVE HEALTH # ══════════════════════════════════════════════════════════════════ E += [SecBanner(5, "Impact on Reproductive Health", "Infertility, pregnancy, obstetric outcomes"), SP(2), H2("5.1 Infertility"), P("Fibroids are found in <b>5-10% of infertile women</b> and may be the sole identifiable cause in <b>2-3%</b>. The reproductive impact is critically location-dependent:"), B("<b>Submucosal (FIGO 0-2):</b> Distort endometrial cavity, impair implantation, alter endometrial receptivity, disrupt sperm transport - strongest association with infertility"), B("<b>Intramural (FIGO 3-4):</b> May alter uterine peristalsis and endometrial blood flow; reduce IVF live birth rates by ~15-20% depending on size and cavity contact"), B("<b>Subserosal (FIGO 5-7):</b> Generally do not independently impair fertility"), SP(), H2("5.2 Spontaneous Miscarriage"), P("Submucosal fibroids increase risk of first and second trimester miscarriage through endometrial cavity compression, poor placentation, and impaired vascular supply to the implantation site. Hysteroscopic removal of submucosal fibroids improves spontaneous conception rates and reduces miscarriage rates (De Angelis et al., Minerva Obstet Gynecol 2022, PMID 33876900)."), SP(), H2("5.3 Obstetric Complications"), TABLE( ["Complication", "Risk Estimate", "Mechanism"], [["Placenta previa", "OR = 2.2", "Abnormal placentation over fibroid site"], ["Placental abruption", "OR = 2.6", "Subplacental fibroid causing vascular disruption"], ["Preterm delivery", "Elevated risk", "Uterine irritability, distortion, preterm labour"], ["Malpresentation", "Elevated risk", "Mechanical obstruction to fetal lie"], ["Red (carneous) degeneration", "Occurs in pregnancy", "Venous thrombosis/infarction; acute abdominal pain"], ["Postpartum haemorrhage", "Elevated risk", "Impaired uterine contraction (atony)"], ["Caesarean section rate", "Up to 2-3x higher", "Obstructed labour, malpresentation"]], [52*mm, 35*mm, 68*mm]), SP(), Paragraph("<i>OR = Odds Ratio. Source: Creasy & Resnik's Maternal-Fetal Medicine; Berek & Novak's Gynecology</i>", ST["fn"]), SP(), H2("5.4 Recurrence After Myomectomy"), P("Myomectomy does not eliminate risk of new fibroid formation. Cumulative recurrence rates (Berek & Novak's Gynecology):"), B("10% clinically significant new fibroids at 5 years after myomectomy"), B("27% cumulative new appearance over 14 years of follow-up"), B("Single fibroid removed: 27% new fibroid rate; multiple fibroids: 59% recurrence"), B("Second surgery required in 11-26% depending on initial fibroid number"), B("Women with subsequent childbearing have lower recurrence (16% vs. 28%) - protective effect"), PageBreak()] # ══════════════════════════════════════════════════════════════════ # S6 MENTAL HEALTH # ══════════════════════════════════════════════════════════════════ E += [SecBanner(6, "Impact on Mental Health", "Depression, anxiety, body image, social burden"), SP(2), P("The psychological impact of uterine fibroids is a major, frequently underappreciated dimension of their burden. A landmark 2024 systematic review in <i>Fertility and Sterility</i> (Neumann et al., PMID 38246400) - examining <b>67 studies including 18 RCTs</b> - established that fibroids significantly impair mental health across multiple validated measures, and that <b>all treatments produce significant mental health improvement post-intervention</b>."), SP(), H2("6.1 Psychological Domains Affected"), TABLE( ["Domain", "Clinical Manifestation", "Driving Mechanism"], [["Depression", "Elevated PHQ-9 / BDI scores; persistent low mood; anhedonia", "Chronic pain, anaemia-related fatigue, sexual dysfunction, social limitations"], ["Anxiety", "Elevated GAD-7 scores; health anxiety; menstrual anticipatory anxiety", "Fear of malignancy, fertility uncertainty, menstrual unpredictability"], ["Body image disturbance", "Negative body perception; avoidance of fitted clothing", "Visible abdominal distension from large fibroid uterus"], ["Relationship strain", "Reduced relationship satisfaction; communication difficulties", "Dyspareunia, reduced libido, partner misunderstanding of symptom burden"], ["Social isolation", "Avoidance of social events; restricted public activities", "Fear of menstrual accidents; fatigue; abdominal swelling"], ["Occupational impact", "Absenteeism; reduced career progression; financial stress", "40% require time off work; pain and fatigue cause presenteeism"], ["Reproductive grief", "Grief over miscarriage; distress over fertility impairment", "Fibroid-associated pregnancy loss; deferred family planning"]], [32*mm, 58*mm, 65*mm]), SP(), H2("6.2 Validated Mental Health Assessment Tools in Fibroid Research"), TABLE( ["Tool", "Domain Measured", "Relevance to Fibroids"], [["PHQ-9 (Patient Health Questionnaire-9)", "Depression severity (0-27)", "Quantifies depression linked to chronic HMB and pain"], ["GAD-7 (Generalised Anxiety Disorder-7)", "Anxiety severity (0-21)", "Captures fertility fears, menstrual anxiety"], ["SF-36 Mental Component Score (MCS)", "Mental HRQoL composite", "Broad psychological wellbeing; used in RCTs"], ["EQ-5D Anxiety/Depression domain", "HRQoL utility", "Used in health economic analyses"], ["DASS-21", "Depression, anxiety, stress", "Comprehensive psychological screening"], ["BDI (Beck Depression Inventory)", "Depression severity", "Used in fibroid cohort studies"]], [52*mm, 43*mm, 60*mm]), PageBreak()] # ══════════════════════════════════════════════════════════════════ # S7 QUALITY OF LIFE # ══════════════════════════════════════════════════════════════════ E += [SecBanner(7, "Quality of Life Assessment", "HRQoL instruments, domains, evidence"), SP(2), P("Health-related quality of life (HRQoL) is a multidimensional construct encompassing physical, emotional, social, and role functioning. Uterine fibroids impair HRQoL across all these domains. Validated disease-specific instruments are essential for capturing the true burden and monitoring treatment outcomes objectively."), SP(), H2("7.1 Disease-Specific & Generic QoL Instruments"), TABLE( ["Instrument", "Domains Assessed", "Key Feature"], [["UFS-QoL\n(Uterine Fibroid Symptom & QoL Questionnaire)", "Symptom Severity Score (8 items) + 6 HRQoL subscales: Concern, Activities, Energy/Fatigue, Control, Self-consciousness, Sexual Function", "Gold standard for fibroid trials; most widely validated; scores 0-100"], ["SF-36 / SF-12", "8 domains: Physical Function, Role-Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role-Emotional, Mental Health", "Generic; enables cross-condition comparison; widely used in RCTs"], ["EQ-5D-3L / EQ-5D-5L", "Mobility, Self-care, Usual activities, Pain/Discomfort, Anxiety/Depression + VAS", "Utility values (QALYs) for health economic analyses"], ["PBAC\n(Pictorial Blood Assessment Chart)", "Menstrual blood loss quantification (pads/tampons scored by saturation)", "Objective HMB measurement; score >100 = clinically significant HMB"], ["NRS/VAS Pain Scores", "Pain intensity (0-10 scale)", "Simple, validated; used for routine treatment monitoring"]], [42*mm, 78*mm, 35*mm]), SP(), H2("7.2 QoL Domains Impaired: Detailed Analysis"), TABLE( ["QoL Domain", "Specific Impairment", "Evidence Basis"], [["Physical Functioning", "Anaemia-related fatigue limits mobility and exercise; pain restricts activity; heavy flow days prevent planned activities", "80% report HMB-driven limitations (Berek & Novak's)"], ["Role Functioning", "40% work absenteeism; reduced productivity (presenteeism) due to pain, fatigue, concentration difficulties", "Prospective study n=555; UFS-QoL Activity subscale"], ["Social Participation", "Avoidance of public/social events due to unpredictable heavy bleeding; embarrassment from abdominal distension", "UFS-QoL Self-consciousness subscale"], ["Sexual Health", "Dyspareunia (30%); reduced libido from pain, fatigue, body image concerns; relationship impairment", "UFS-QoL Sexual Function subscale"], ["Emotional Wellbeing", "Elevated depression and anxiety on validated tools; fear of malignancy; reproductive distress", "Neumann et al. 2024 (PMID 38246400); 67 studies"], ["Vitality & Energy", "Iron-deficiency anaemia reduces energy; cognitive impairment; reduced concentration and motivation", "PBAC scores; SF-36 Vitality domain"], ["Self-Efficacy & Control", "Loss of control over bodily functions; extensive planning of daily life around menstrual cycle; reduced self-esteem", "UFS-QoL Control subscale"]], [38*mm, 70*mm, 47*mm]), SP(2), BOX([ Paragraph("<b>Key Evidence Highlight (Fertil Steril 2024, PMID 38246400)</b>", ST["boxtitle"]), P("Systematic review of <b>67 studies (18 RCTs + 49 observational)</b> confirmed that ALL fibroid treatment modalities - medical, surgical, and radiological - are associated with significant improvement in fibroid-specific QoL scores, mental health metrics, and symptom severity scores post-treatment. This confirms that the baseline QoL impairment is both <b>substantial and treatment-responsive</b>. Key instruments used: UFS-QoL, SF-36, EQ-5D, and validated mental health scales."), ]), PageBreak()] # ══════════════════════════════════════════════════════════════════ # S8 SOCIOECONOMIC # ══════════════════════════════════════════════════════════════════ E += [SecBanner(8, "Socioeconomic Burden", "Healthcare costs, productivity, health equity"), SP(2), P("The economic burden of uterine fibroids is enormous and frequently underestimated by healthcare systems. Both direct costs (healthcare utilisation) and indirect costs (lost productivity, absenteeism) are substantial, placing fibroids among the most economically significant gynaecological conditions."), SP(), H2("8.1 Direct Healthcare Costs"), B("Hysterectomy for fibroids: >200,000 procedures annually in the US alone"), B("Estimated direct annual healthcare cost (US): USD 4.1-9.4 billion"), B("Total annual economic burden (direct + indirect): estimated USD 34.4 billion (US)"), B("Globally: fibroids are the leading benign indication for major gynaecological surgery"), B("Repeated surgical interventions due to myomectomy recurrence add ongoing cumulative costs"), B("Iron infusions, transfusions, and long-term iron supplementation for anaemia add care costs"), SP(), H2("8.2 Indirect Costs & Productivity Loss"), B("40% of symptomatic women report time off work - disproportionately affects women aged 30-50 in peak career years"), B("Estimated annual productivity loss (US): USD 1.55-17.2 billion"), B("Anaemia from chronic HMB independently reduces cognitive function and occupational performance"), B("Presenteeism (reduced work performance while present) adds economic burden beyond absenteeism"), B("Repeated medical visits and investigations consume significant personal time and income"), SP(), H2("8.3 Health Equity Dimensions"), P("The disproportionate burden in Black women has clear health equity implications: higher rates of hysterectomy over uterus-preserving procedures, greater diagnostic delays, underrepresentation in clinical trials, and barriers to accessing newer minimally invasive treatments. Addressing these disparities requires systemic, policy-level, and clinical interventions. Gynaecology residents must recognise these inequities in daily practice."), PageBreak()] # ══════════════════════════════════════════════════════════════════ # S9 MANAGEMENT OVERVIEW # ══════════════════════════════════════════════════════════════════ E += [SecBanner(9, "Management Overview", "Medical, surgical, minimally invasive approaches"), SP(2), P("Management must be <b>individualised</b> based on symptom severity, fibroid size/number/location (FIGO type), desire for fertility preservation, age and proximity to menopause, patient values and preferences, and available expertise. The overarching goal is to improve QoL while minimising treatment burden."), SP(), H2("9.1 Medical Management"), TABLE( ["Drug / Class", "Mechanism", "Effect on QoL / Symptoms", "Key Notes"], [["GnRH Agonists\n(Leuprolide, Goserelin)", "Pituitary downregulation; hypoestrogenic state", "Reduces HMB; corrects anaemia preoperatively; reduces bulk", "Max 3-6 months; add-back therapy required; fibroids regrow on cessation"], ["GnRH Antagonists\n(Elagolix, Relugolix)", "Direct GnRH receptor blockade; rapid onset", "Significant HMB reduction; improved QoL in RCTs", "Oral; with add-back; FDA-approved for fibroid-related HMB"], ["LNG-IUS (Mirena)", "Local progestin; endometrial atrophy", "Reduces HMB; improves anaemia; long-term use", "Does not reduce fibroid volume; effective for bleeding control"], ["Ulipristal Acetate", "Selective progesterone receptor modulator (SPRM)", "Controlled HMB; fibroid volume reduction", "Restricted - hepatotoxicity risk; limited global availability"], ["Combined OCP / Progestins", "Hormonal cycle regulation", "Modest HMB reduction; cycle control", "Limited effect on fibroid size; not effective for bulk symptoms"], ["Tranexamic Acid", "Antifibrinolysis; reduces menstrual blood loss", "Reduces HMB by 30-50%", "Non-hormonal; taken during menstruation only; simple regimen"], ["NSAIDs", "Prostaglandin inhibition; uterine relaxation", "Reduces dysmenorrhea and mild HMB", "Used adjunctively; limited effect on heavy bleeding alone"], ["Iron supplementation", "Corrects iron-deficiency anaemia", "Improves fatigue, cognition, energy, vitality", "Essential adjunct to ALL treatments where HMB is present"]], [40*mm, 38*mm, 40*mm, 37*mm]), SP(), H2("9.2 Surgical Management"), TABLE( ["Procedure", "Primary Indication", "Fertility", "QoL Outcome"], [["Hysteroscopic Myomectomy", "FIGO Types 0, 1, 2 (submucosal)", "Preserved; best fertility outcomes", "Excellent for HMB; day case; low morbidity"], ["Laparoscopic Myomectomy", "Intramural/subserosal ≤8-10 cm", "Preserved", "Minimally invasive; fast recovery; good QoL gains"], ["Abdominal Myomectomy", "Large, multiple, or complex fibroids", "Preserved (uterus retained)", "Gold standard complex cases; 5-10% hysterectomy conversion risk"], ["Hysterectomy (total/subtotal)", "Completed family; failed treatments", "Not preserved - definitive cure", "Permanent symptom resolution; highest surgical morbidity"]], [48*mm, 40*mm, 32*mm, 35*mm]), SP(), H2("9.3 Minimally Invasive & Radiological Options"), B("<b>Uterine Artery Embolization (UAE):</b> HMB improved in 83%, dysmenorrhoea in 77%, urinary symptoms in 86% at 3 months. Systematic review (Peng et al., Sci Rep 2024, PMID 39164326) confirms comparable QoL outcomes to myomectomy. Not recommended when fertility is desired."), B("<b>High-Intensity Focused Ultrasound (HIFU/MRgFUS):</b> Non-invasive; systematic review and meta-analysis demonstrates significant symptom and QoL improvement. Preserves uterus; potential fertility sparing (Yan et al., Int J Hyperthermia 2022, PMID 35094613)."), B("<b>Radiofrequency Ablation (RFA - Acessa):</b> AAGL systematic review confirms significant HMB reduction and QoL improvement with laparoscopic RFA (Chen et al., J Minim Invasive Gynecol 2025, PMID 39277104)."), B("<b>Preoperative GnRH therapy:</b> Cochrane review (Puscasiu et al. 2025, PMID 40183418) confirms GnRH analogues pre-surgery reduce uterine volume, improve haematological parameters, and facilitate minimally invasive approaches."), PageBreak()] # ══════════════════════════════════════════════════════════════════ # S10 CONCLUSIONS # ══════════════════════════════════════════════════════════════════ E += [SecBanner(10, "Conclusion & Key Takeaways"), SP(2), P("Uterine fibroids impose a profound, far-reaching, and multidimensional burden on women's health and quality of life that extends well beyond their anatomical presence. For the gynaecology resident, a comprehensive understanding of this burden is foundational to delivering patient-centred, equitable fibroid care."), SP(), TABLE( ["#", "Key Takeaway", "Clinical Implication"], [["1", "High burden, underrecognised", "Up to 80% cumulative incidence by age 50; active case-finding and symptom enquiry are essential"], ["2", "Multi-symptom, multi-domain", "HMB, pain, urinary, sexual symptoms together impair physical, emotional, social, and occupational functioning"], ["3", "Reproductive consequences", "Submucosal fibroids independently impair fertility and increase miscarriage and obstetric complication risks"], ["4", "Mental health is core", "Depression and anxiety are integral to the fibroid experience; systematic screening and management are required"], ["5", "Use validated QoL tools", "UFS-QoL, SF-36, PBAC, NRS should quantify baseline burden and monitor treatment response objectively"], ["6", "All treatments improve QoL", "Medical, surgical, and minimally invasive interventions all significantly improve QoL and mental health (Neumann et al. 2024)"], ["7", "Individualise management", "Consider FIGO type, symptom profile, fertility desire, patient values, and available resources"], ["8", "Counsel on recurrence", "27-59% recurrence after myomectomy; long-term follow-up and reproductive counselling are essential"], ["9", "Address health disparities", "Black women face disproportionate burden and barriers to care; cultural competence is a professional obligation"]], [8*mm, 52*mm, 95*mm]), PageBreak()] # ══════════════════════════════════════════════════════════════════ # S11 REFERENCES # ══════════════════════════════════════════════════════════════════ E += [SecBanner(11, "References"), SP(2)] refs = [ "1. Berek JS, et al. <i>Berek & Novak's Gynecology</i>. 16th ed. Wolters Kluwer; 2020. Ch. 11: Uterine Fibroids.", "2. Creasy RK, et al. <i>Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice</i>. 8th ed. Elsevier; 2019. Ch. 28.", "3. Kumar V, Abbas AK, Aster JC. <i>Robbins, Cotran & Kumar: Pathologic Basis of Disease</i>. 10th ed. Elsevier; 2023.", "4. Robbins SL, Kumar V. <i>Robbins & Kumar Basic Pathology</i>. 10th ed. Elsevier; 2021.", "5. Neumann B, Singh B, Brennan J, Blanck J, Segars JH. The impact of fibroid treatments on quality of life and mental health: a systematic review. <i>Fertil Steril</i>. 2024 Mar;121(3). PMID: 38246400. doi:10.1016/j.fertnstert.2024.01.021", "6. Singh S, Kumar P, Kavita, et al. Contemporary approaches in the management of uterine leiomyomas. <i>Eur J Obstet Gynecol Reprod Biol</i>. 2023 Aug;287:117-129. PMID: 37385088.", "7. Amendola ILS, Spann M, Segars J. The Mediator Complex Subunit 12 (MED-12) Gene and Uterine Fibroids: a Systematic Review. <i>Reprod Sci</i>. 2024 Feb;31(2):310-324. PMID: 37516697.", "8. Peng J, Wang J, Shu Q, et al. UAE vs myomectomy for symptomatic uterine fibroids: systematic review and meta-analysis. <i>Sci Rep</i>. 2024 Aug;14(1):19214. PMID: 39164326.", "9. Yan L, Huang H, Lin J. High-intensity focused ultrasound for symptomatic uterine fibroids: systematic review and meta-analysis. <i>Int J Hyperthermia</i>. 2022;39(1):234-243. PMID: 35094613.", "10. Chen I, Berman JM, Balk EM, et al. Radiofrequency Ablation for Uterine Fibroids: Systematic Review and Meta-Analysis. AAGL Practice Committee. <i>J Minim Invasive Gynecol</i>. 2025 Jan;32(1):13-26. PMID: 39277104.", "11. Puscasiu L, Vollenhoven B, Nagels HE. Preoperative medical therapy before surgery for uterine fibroids. <i>Cochrane Database Syst Rev</i>. 2025 Apr 4. PMID: 40183418.", "12. De Angelis MC, Di Spiezio Sardo A, Carugno J. Fertility outcomes after hysteroscopic removal of intrauterine leiomyomas and polyps. <i>Minerva Obstet Gynecol</i>. 2022 Feb;74(1):84-95. PMID: 33876900.", "13. Munro MG, et al. FIGO classification system (PALM-COEIN) for causes of AUB in nongravid women. <i>Int J Gynaecol Obstet</i>. 2011;113(1):3-13.", "14. Stewart EA. Uterine fibroids. <i>N Engl J Med</i>. 2015;372(17):1646-1655.", "15. Cardozo ER, et al. The estimated annual cost of uterine leiomyomata in the United States. <i>Am J Obstet Gynecol</i>. 2012;206(3):211.e1-9.", ] for r in refs: E.append(Paragraph(r, ST["ref"])) E.append(SP(0.5)) E += [SP(2), HR(), Paragraph("Prepared for Gynecology Residency Paper Presentation | Department of Obstetrics & Gynecology | May 2026", ST["fn"]), Paragraph("Sources: Berek & Novak's Gynecology \u2022 Robbins & Kumar Pathology \u2022 Creasy & Resnik's MFM \u2022 PubMed Peer-Reviewed Systematic Reviews 2021-2026", ST["fn"])] return E # ---------- Build ---------- doc = SimpleDocTemplate( OUT, pagesize=A4, leftMargin=27.5*mm, rightMargin=27.5*mm, topMargin=28*mm, bottomMargin=22*mm, title="Uterine Fibroids: Impact on Women's Health and Quality of Life", author="Gynecology Residency Program", subject="Paper Presentation - May 2026", ) doc.build(story(), onFirstPage=hf, onLaterPages=hf) print("SUCCESS:", OUT) PYEOF

python3 - << 'PYEOF' from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.styles import ParagraphStyle from reportlab.lib.units import mm from reportlab.platypus import ( SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable, PageBreak, KeepTogether ) from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY from reportlab.platypus import Flowable from reportlab.platypus import BaseDocTemplate, Frame, PageTemplate OUT = "/home/daytona/workspace/fibroid2/Uterine_Fibroids_Womens_Health_QoL.pdf" W_PAGE, H_PAGE = A4 WHT = colors.white DGY = colors.HexColor("#1a1a1a") MGY = colors.HexColor("#555555") LGY = colors.HexColor("#F5F5F5") HDR = colors.HexColor("#1C1C2E") ACC = colors.HexColor("#2C2C2C") def S(): d = {} def add(name, **kw): defaults = dict(fontName="Helvetica", fontSize=10.5, textColor=DGY, leading=16, spaceBefore=2, spaceAfter=2, alignment=TA_JUSTIFY) defaults.update(kw) d[name] = ParagraphStyle(name, **defaults) add("body") add("body_left", alignment=TA_LEFT) add("h1", fontName="Helvetica-Bold", fontSize=15, textColor=ACC, spaceBefore=12, spaceAfter=5, leading=19, alignment=TA_LEFT) add("h2", fontName="Helvetica-Bold", fontSize=11.5, textColor=ACC, spaceBefore=9, spaceAfter=3, leading=15, alignment=TA_LEFT) add("bul", fontName="Helvetica", fontSize=10.5, textColor=DGY, leading=15, leftIndent=14, spaceBefore=2, spaceAfter=2, alignment=TA_LEFT) add("th", fontName="Helvetica-Bold", fontSize=9.5, textColor=WHT, leading=13, alignment=TA_CENTER) add("td", fontName="Helvetica", fontSize=9.5, textColor=DGY, leading=13, alignment=TA_LEFT) add("ref", fontName="Helvetica", fontSize=8.5, textColor=MGY, leading=13, leftIndent=10, spaceBefore=2, alignment=TA_LEFT) add("fn", fontName="Helvetica-Oblique", fontSize=7.5, textColor=MGY, leading=11, alignment=TA_CENTER) add("boxtitle", fontName="Helvetica-Bold", fontSize=11, textColor=ACC, leading=15, spaceBefore=3, spaceAfter=3, alignment=TA_LEFT) add("toc_title", fontName="Helvetica-Bold", fontSize=13, textColor=ACC, spaceBefore=16, spaceAfter=8, alignment=TA_LEFT) return d ST = S() def P(t): return Paragraph(t, ST["body"]) def PL(t): return Paragraph(t, ST["body_left"]) def H1(t): return Paragraph(t, ST["h1"]) def H2(t): return Paragraph(t, ST["h2"]) def B(t): return Paragraph(f"\u2022 {t}", ST["bul"]) def SP(n=1): return Spacer(1, n * 4 * mm) def HR(): return HRFlowable(width="100%", thickness=0.5, color=colors.HexColor("#CCCCCC"), spaceAfter=4, spaceBefore=4) def TABLE(headers, rows, cw=None): if cw is None: cw = [155 * mm / len(headers)] * len(headers) hrow = [Paragraph(h, ST["th"]) for h in headers] brows = [[Paragraph(str(c), ST["td"]) for c in r] for r in rows] tbl = Table([hrow] + brows, colWidths=cw) tbl.setStyle(TableStyle([ ("BACKGROUND", (0, 0), (-1, 0), HDR), ("TEXTCOLOR", (0, 0), (-1, 0), WHT), ("ROWBACKGROUNDS", (0, 1), (-1, -1), [WHT, LGY]), ("GRID", (0, 0), (-1, -1), 0.4, colors.HexColor("#CCCCCC")), ("TOPPADDING", (0, 0), (-1, -1), 5), ("BOTTOMPADDING", (0, 0), (-1, -1), 5), ("LEFTPADDING", (0, 0), (-1, -1), 6), ("RIGHTPADDING", (0, 0), (-1, -1), 6), ("VALIGN", (0, 0), (-1, -1), "TOP"), ])) return tbl def BOX(items): tbl = Table([[item] for item in items], colWidths=[155 * mm]) tbl.setStyle(TableStyle([ ("BACKGROUND", (0, 0), (-1, -1), LGY), ("BOX", (0, 0), (-1, -1), 0.7, colors.HexColor("#AAAAAA")), ("TOPPADDING", (0, 0), (-1, -1), 5), ("BOTTOMPADDING", (0, 0), (-1, -1), 5), ("LEFTPADDING", (0, 0), (-1, -1), 10), ("RIGHTPADDING", (0, 0), (-1, -1), 10), ])) return tbl class SecBanner(Flowable): def __init__(self, num, title, sub="", w=155*mm): Flowable.__init__(self) self.num = num; self.title = title; self.sub = sub self.width = w; self.height = 50 def draw(self): c = self.canv c.setFillColor(HDR); c.roundRect(0, 0, self.width, self.height, 5, fill=1, stroke=0) c.setFillColor(WHT); c.circle(28, self.height/2, 14, fill=1, stroke=0) c.setFont("Helvetica-Bold", 13); c.setFillColor(HDR) c.drawCentredString(28, self.height/2-5, str(self.num)) c.setFont("Helvetica-Bold", 14); c.setFillColor(WHT) c.drawString(52, self.height/2+4, self.title) if self.sub: c.setFont("Helvetica", 9); c.setFillColor(colors.HexColor("#BBBBBB")) c.drawString(52, self.height/2-10, self.sub) # Cover is drawn on page canvas directly (first page callback) def cover_page(canvas, doc): canvas.saveState() W, H = A4 # Full dark background canvas.setFillColor(HDR) canvas.rect(0, 0, W, H, fill=1, stroke=0) # Decorative circles canvas.setFillColor(colors.HexColor("#0f3460")) canvas.circle(W-40, H-40, 65, fill=1, stroke=0) canvas.circle(40, 40, 50, fill=1, stroke=0) # Specialty label canvas.setFont("Helvetica-Bold", 9) canvas.setFillColor(colors.HexColor("#AAAAAA")) canvas.drawCentredString(W/2, H-90, "GYNECOLOGY RESIDENCY | PAPER PRESENTATION | MAY 2026") # Divider canvas.setStrokeColor(colors.HexColor("#666666")); canvas.setLineWidth(1) canvas.line(55, H-108, W-55, H-108) # Main title canvas.setFont("Helvetica-Bold", 32); canvas.setFillColor(WHT) canvas.drawCentredString(W/2, H-165, "UTERINE FIBROIDS") canvas.setFont("Helvetica-Bold", 17); canvas.setFillColor(colors.HexColor("#CCCCCC")) canvas.drawCentredString(W/2, H-196, "Impact on Women\u2019s Health & Quality of Life") # Divider canvas.setStrokeColor(colors.HexColor("#555555")); canvas.setLineWidth(0.7) canvas.line(70, H-215, W-70, H-215) # Subtitle lines canvas.setFont("Helvetica", 11.5); canvas.setFillColor(colors.HexColor("#CCCCCC")) y = H - 243 for line in ["Epidemiology | Pathophysiology | Clinical Burden", "Reproductive Health | Mental Wellbeing | QoL Instruments", "Socioeconomic Impact | Evidence-Based Management"]: canvas.drawCentredString(W/2, y, line); y -= 24 # Content summary box canvas.setFillColor(colors.HexColor("#252545")) canvas.roundRect(55, H-395, W-110, 70, 5, fill=1, stroke=0) canvas.setFont("Helvetica", 10); canvas.setFillColor(colors.HexColor("#CCCCCC")) canvas.drawCentredString(W/2, H-360, "11 Sections \u2022 Comprehensive Clinical Content \u2022 Evidence-Based Tables") canvas.drawCentredString(W/2, H-378, "Validated QoL Instruments \u2022 Peer-Reviewed References \u2022 Management Guidelines") # Bottom meta canvas.setFont("Helvetica", 8.5); canvas.setFillColor(colors.HexColor("#888888")) canvas.drawCentredString(W/2, 55, "Sources: Berek & Novak\u2019s Gynecology \u2022 Robbins & Kumar Pathology \u2022 Creasy & Resnik\u2019s MFM \u2022 PubMed Systematic Reviews 2021\u20132026") canvas.setFont("Helvetica", 10); canvas.setFillColor(colors.HexColor("#AAAAAA")) canvas.drawCentredString(W/2, 35, "Department of Obstetrics & Gynecology | Gynecology Residency Program") canvas.restoreState() def later_page(canvas, doc): canvas.saveState() W, H = A4 canvas.setFillColor(HDR); canvas.rect(0, H-20, W, 20, fill=1, stroke=0) canvas.setFont("Helvetica-Bold", 7.5); canvas.setFillColor(WHT) canvas.drawString(18, H-13, "UTERINE FIBROIDS: IMPACT ON WOMEN\u2019S HEALTH & QUALITY OF LIFE") canvas.setFont("Helvetica", 7.5) canvas.drawRightString(W-18, H-13, "Gynecology Residency | May 2026") canvas.setFillColor(colors.HexColor("#EEEEEE")); canvas.rect(0, 0, W, 16, fill=1, stroke=0) canvas.setFont("Helvetica", 7); canvas.setFillColor(MGY) canvas.drawString(18, 5, "Dept. of Obstetrics & Gynecology") canvas.drawCentredString(W/2, 5, "For educational use | Not a substitute for clinical guidelines") canvas.drawRightString(W-18, 5, f"Page {doc.page}") canvas.restoreState() def build_story(): E = [] # Page 1 is cover (drawn via callback, no flowables needed - just a PageBreak placeholder) E.append(PageBreak()) # move to page 2 after cover # TOC E += [SP(1), Paragraph("TABLE OF CONTENTS", ST["toc_title"]), HR()] toc = [ ("1","Introduction & Background","Definition, significance, overview"), ("2","Epidemiology & Risk Factors","Prevalence, incidence, racial disparities"), ("3","Pathophysiology & Classification","Molecular basis, histology, FIGO types"), ("4","Clinical Manifestations","Menstrual, pelvic, urinary, sexual symptoms"), ("5","Impact on Reproductive Health","Infertility, pregnancy, obstetric outcomes"), ("6","Impact on Mental Health","Depression, anxiety, body image, social burden"), ("7","Quality of Life Assessment","HRQoL instruments, domains, evidence"), ("8","Socioeconomic Burden","Costs, productivity, health equity"), ("9","Management Overview","Medical, surgical, minimally invasive"), ("10","Conclusion & Key Takeaways","Clinical pearls, summary"), ("11","References","Evidence-based sources"), ] for num, title, sub in toc: row = Table([[ Paragraph(f"<b>{num}.</b>", ST["body_left"]), Paragraph(f"<b>{title}</b><br/><font size='8.5' color='#777777'>{sub}</font>", ST["body_left"]) ]], colWidths=[11*mm, 144*mm]) row.setStyle(TableStyle([("VALIGN",(0,0),(-1,-1),"TOP"),("TOPPADDING",(0,0),(-1,-1),3), ("BOTTOMPADDING",(0,0),(-1,-1),3),("LINEBELOW",(0,0),(-1,-1),0.3,colors.HexColor("#DDDDDD"))])) E.append(row) E.append(PageBreak()) # S1 E += [SecBanner(1,"Introduction & Background"), SP(2), P("Uterine fibroids (leiomyomas, myomas) are <b>benign monoclonal smooth muscle tumors</b> originating from the myometrial layer of the uterus. They are the most common solid benign pelvic tumors in women of reproductive age and a leading cause of gynaecological morbidity worldwide. Despite their extraordinary prevalence, fibroids remain significantly underdiagnosed and undertreated, with a persistent gap between symptom burden and medical attention received."), SP(), P("The clinical significance of uterine fibroids extends far beyond their anatomical presence. They impose a profound, multidimensional burden on affected women - encompassing heavy menstrual bleeding, chronic pelvic pain, reproductive failure, urinary symptoms, sexual dysfunction, mental health deterioration, and markedly reduced health-related quality of life (HRQoL). A deep understanding of this comprehensive impact is foundational for gynaecology residents to deliver patient-centred, evidence-based care."), SP(2), BOX([Paragraph("<b>Key Facts at a Glance</b>", ST["boxtitle"]), B("Most common benign pelvic tumor in women of reproductive age"), B("Cumulative incidence up to 70-80% by age 50 (higher in Black women)"), B("70-80% of affected women experience at least one significant symptom"), B("Leading indication for hysterectomy in the United States and globally"), B("40% of symptomatic women require time off work due to fibroid symptoms"), B("Annual US economic burden (direct + indirect): estimated USD 34.4 billion")]), PageBreak()] # S2 E += [SecBanner(2,"Epidemiology & Risk Factors","Prevalence, incidence, racial disparities"), SP(2), H2("2.1 Prevalence & Incidence"), P("Uterine fibroids are identified in approximately <b>20-50% of women of reproductive age</b> using clinical criteria, rising to <b>70-80%</b> when autopsy or systematic ultrasound surveillance is used. Incidence rises markedly with age: <b>4 per 1,000 woman-years</b> in the 25-29 age group to <b>22 per 1,000 woman-years</b> in the 40-44 age group (Berek & Novak's Gynecology). Fibroids are detected in 3-4% of midtrimester ultrasound evaluations during pregnancy (Creasy & Resnik's Maternal-Fetal Medicine)."), SP(), H2("2.2 Racial & Ethnic Disparities"), P("Black women bear a disproportionate burden compared to White women:"), B("Develop fibroids 5-10 years earlier"), B("Have larger and more numerous fibroids at presentation"), B("Experience more severe symptoms and greater QoL impairment"), B("Have higher rates of hysterectomy and other surgical interventions"), B("Cumulative incidence approaches 80% by age 50 (vs. approximately 70% in White women)"), SP(), H2("2.3 Risk Factor Profile"), TABLE(["Risk Factor","Risk Direction","Clinical Notes"], [["Increasing age (reproductive years)","Strong increase","Peaks perimenopausally; regress after menopause"], ["African-American race/ethnicity","2-3x higher risk","Younger onset, larger/more numerous fibroids"], ["Nulliparity","Increased risk","Each pregnancy confers protective effect"], ["Early menarche (<10 years)","Elevated risk","Prolonged cumulative estrogen exposure"], ["Obesity / high BMI","Moderate increase","Peripheral aromatisation increases estrogen"], ["First-degree family history","~2.5x higher risk","MED12 mutations; genetic predisposition"], ["Alcohol consumption","Associated","Possible estrogen modulation"], ["Multiparity","Protective","Uterine involution hypothesis"], ["Combined OCP use","Mildly protective","Effect unclear in long-term use"], ["Smoking","Mildly protective","Anti-estrogenic metabolic effects"]], [68*mm, 40*mm, 47*mm]), SP(), Paragraph("<i>Sources: Berek & Novak's Gynecology; Robbins & Kumar Basic Pathology</i>", ST["fn"]), PageBreak()] # S3 E += [SecBanner(3,"Pathophysiology & Classification","Molecular basis, histology, FIGO types"), SP(2), H2("3.1 Molecular Pathogenesis"), P("Fibroids are <b>monoclonal smooth muscle tumors</b> from a single transformed myometrial cell. Growth is primarily driven by <b>estrogen and progesterone</b> (explaining regression after menopause). Key molecular features:"), B("<b>MED12 gene mutations:</b> Found in 70-85% of uterine fibroids; most prevalent somatic mutation (Amendola et al., Reprod Sci 2024)"), B("<b>Fumarate hydratase (FH) mutations:</b> Cause hereditary leiomyomatosis & renal cell carcinoma (HLRCC) syndrome"), B("<b>Estrogen receptor upregulation:</b> Stimulates IGF-1 and EGF growth pathways"), B("<b>Extracellular matrix (ECM) accumulation:</b> Excessive collagen and proteoglycans contribute to bulk"), SP(), H2("3.2 Histopathology"), P("Microscopically: <b>interlacing fascicles of eosinophilic spindle cells</b> at right angles, blunt-ended nuclei, minimal atypia, rare mitoses. A <b>pseudocapsule</b> of compressed myometrium surrounds each tumor. Degeneration types:"), B("Hyaline - most common"), B("Cystic - liquefaction of hyaline areas"), B("Red (carneous) - venous thrombosis; occurs in pregnancy; acute pain"), B("Myxoid - gelatinous stroma"), B("Calcific - post-menopausal 'womb stones'"), SP(), H2("3.3 FIGO Classification by Location"), TABLE(["FIGO Type","Location","Primary Symptom Impact"], [["0","Submucosal - pedunculated intracavitary","Severe HMB, infertility, miscarriage"], ["1","Submucosal - <50% intramural","Severe HMB, infertility"], ["2","Submucosal - ≥50% intramural","HMB, dysmenorrhea, infertility"], ["3","Intramural - contacts endometrium","HMB, pressure symptoms"], ["4","Intramural - within myometrium","Pressure/bulk symptoms"], ["5","Subserosal - ≥50% intramural","Bulk, urinary, bowel symptoms"], ["6","Subserosal - <50% intramural","Pelvic bulk"], ["7","Subserosal - pedunculated","Pelvic mass; torsion risk"], ["8","Cervical / parasitic / other","Variable by location"]], [22*mm, 72*mm, 61*mm]), SP(), Paragraph("<i>FIGO PALM-COEIN classification, Munro et al. 2011. HMB = Heavy Menstrual Bleeding.</i>", ST["fn"]), PageBreak()] # S4 E += [SecBanner(4,"Clinical Manifestations","Symptom burden across organ systems"), SP(2), P("Fibroids may be <b>asymptomatic</b> or produce wide-ranging symptoms by size, number, and location. The largest prospective study (n=555, mean age 43): <b>80%</b> heavy bleeding, <b>75%</b> pelvic pain, <b>73%</b> urinary symptoms, <b>40%</b> time off work (Berek & Novak's Gynecology)."), SP(), H2("4.1 Abnormal Uterine Bleeding (AUB-L)"), P("<b>Heavy menstrual bleeding (HMB)</b> is the most common and clinically significant symptom, especially in submucosal fibroids (FIGO 0-2). Mechanisms:"), B("Endometrial vasculature distortion with increased surface area"), B("Impaired myometrial contractility reducing physiological haemostasis"), B("Altered local prostaglandin and growth factor (VEGF, EGF) production"), B("Venous ectasia in endometrium adjacent to submucosal fibroids"), P("<b>Consequences:</b> Iron-deficiency anaemia (fatigue, dyspnoea, cognitive impairment), intermenstrual spotting, prolonged menses - all impair daily activities, work, and social functioning."), SP(), H2("4.2 Pelvic Pain & Pressure"), B("Non-cyclic pelvic pressure and heaviness - bulk effect; most common pain pattern"), B("Dysmenorrhea - cyclic; more severe with submucosal and intramural fibroids"), B("Dyspareunia - deep pelvic pain during intercourse; impairs sexual health"), B("Constipation - posterior fibroids compressing rectosigmoid"), B("Acute pain - red degeneration in pregnancy; torsion of pedunculated fibroid"), SP(), H2("4.3 Urinary Symptoms"), B("Urinary frequency/urgency (73%) - anterior/large fibroid bladder compression"), B("Nocturia and incomplete bladder emptying"), B("Rare: hydroureter/hydronephrosis from ureteric compression"), SP(), H2("4.4 Symptom Summary"), TABLE(["Symptom","Frequency","Mechanism"], [["Heavy menstrual bleeding","80% symptomatic","Submucosal distortion, endometrial vasculopathy"], ["Pelvic pressure/bulk","50-60%","Mass effect on pelvic structures"], ["Dysmenorrhea","30-40%","Prostaglandins, uterine cavity distortion"], ["Urinary frequency/urgency","73%","Bladder compression by anterior/large fibroids"], ["Dyspareunia","~30%","Deep pelvic mass effect"], ["Iron-deficiency anaemia","40-50% with HMB","Chronic blood loss"], ["Constipation","20-30%","Posterior fibroid + rectal compression"], ["Work absenteeism","40% require time off","Combined multisymptom burden"]], [52*mm, 35*mm, 68*mm]), PageBreak()] # S5 E += [SecBanner(5,"Impact on Reproductive Health","Infertility, pregnancy, obstetric outcomes"), SP(2), H2("5.1 Infertility"), P("Fibroids found in <b>5-10% of infertile women</b>; sole identifiable cause in <b>2-3%</b>. Location-dependent:"), B("<b>Submucosal (FIGO 0-2):</b> Distort cavity, impair implantation, alter receptivity, disrupt sperm transport - strongest infertility association"), B("<b>Intramural (FIGO 3-4):</b> Alter uterine peristalsis and endometrial blood flow; reduce IVF live birth rates by ~15-20%"), B("<b>Subserosal (FIGO 5-7):</b> Generally do not independently impair fertility"), SP(), H2("5.2 Spontaneous Miscarriage"), P("Submucosal fibroids increase first and second trimester miscarriage risk through endometrial cavity compression, poor placentation, and impaired vascular supply. Hysteroscopic removal improves conception rates and reduces miscarriage (De Angelis et al., Minerva Obstet Gynecol 2022, PMID 33876900)."), SP(), H2("5.3 Obstetric Complications"), TABLE(["Complication","Risk Estimate","Mechanism"], [["Placenta previa","OR = 2.2","Abnormal placentation over fibroid site"], ["Placental abruption","OR = 2.6","Subplacental fibroid causing vascular disruption"], ["Preterm delivery","Elevated risk","Uterine irritability, distortion, preterm labour"], ["Malpresentation","Elevated risk","Mechanical obstruction to fetal lie"], ["Red degeneration","In pregnancy","Venous thrombosis/infarction; acute abdominal pain"], ["Postpartum haemorrhage","Elevated risk","Impaired uterine contraction (atony)"], ["Caesarean section rate","Up to 2-3x higher","Obstructed labour, malpresentation"]], [52*mm, 35*mm, 68*mm]), SP(), Paragraph("<i>OR = Odds Ratio. Source: Creasy & Resnik's Maternal-Fetal Medicine; Berek & Novak's Gynecology</i>", ST["fn"]), SP(), H2("5.4 Recurrence After Myomectomy"), P("Myomectomy does not eliminate fibroid risk (Berek & Novak's Gynecology):"), B("10% clinically significant new fibroids at 5 years; 27% cumulative over 14 years"), B("Single fibroid removed: 27% recurrence; multiple fibroids: 59% recurrence"), B("Second surgery required in 11-26% depending on initial fibroid number"), B("Women with subsequent childbearing: 16% recurrence vs. 28% without - protective"), PageBreak()] # S6 E += [SecBanner(6,"Impact on Mental Health","Depression, anxiety, body image, relationships"), SP(2), P("The psychological impact of fibroids is a major, frequently underappreciated dimension of their burden. The landmark 2024 systematic review in <i>Fertility and Sterility</i> (Neumann et al., PMID 38246400) - examining <b>67 studies (18 RCTs + 49 observational)</b> - established that fibroids significantly impair mental health across multiple validated measures, and that <b>all treatments produce significant mental health improvement post-intervention</b>."), SP(), H2("6.1 Psychological Domains Affected"), TABLE(["Domain","Clinical Manifestation","Driving Mechanism"], [["Depression","Elevated PHQ-9/BDI scores; persistent low mood; anhedonia","Chronic pain, anaemia fatigue, sexual dysfunction, social limitations"], ["Anxiety","Elevated GAD-7; health anxiety; menstrual anticipatory anxiety","Fear of malignancy, fertility uncertainty, menstrual unpredictability"], ["Body image disturbance","Negative body perception; avoidance of fitted clothing","Visible abdominal distension from large fibroid uterus"], ["Relationship strain","Reduced relationship satisfaction; communication difficulties","Dyspareunia, reduced libido, partner misunderstanding"], ["Social isolation","Avoidance of public/social activities; restricted participation","Fear of menstrual accidents; fatigue; abdominal distension"], ["Occupational impact","Absenteeism; reduced career progression; financial stress","40% time off; pain and fatigue cause presenteeism"], ["Reproductive grief","Grief over miscarriage; distress over fertility impairment","Fibroid-associated pregnancy loss; deferred family planning"]], [35*mm, 60*mm, 60*mm]), SP(), H2("6.2 Validated Mental Health Assessment Tools"), TABLE(["Tool","Domain Measured","Relevance to Fibroids"], [["PHQ-9","Depression severity (0-27)","Quantifies depression from chronic HMB and pain"], ["GAD-7","Anxiety severity (0-21)","Captures fertility fears, menstrual anxiety"], ["SF-36 Mental Component (MCS)","Mental HRQoL composite","Used in RCTs; broad psychological wellbeing"], ["EQ-5D Anxiety/Depression","HRQoL utility for economics","Used in cost-effectiveness analyses"], ["DASS-21","Depression, anxiety, stress","Comprehensive psychological screening"], ["BDI (Beck Depression Inventory)","Depression severity","Used in fibroid cohort studies"]], [52*mm, 43*mm, 60*mm]), PageBreak()] # S7 E += [SecBanner(7,"Quality of Life Assessment","HRQoL instruments, domains, evidence"), SP(2), P("Health-related quality of life (HRQoL) is a multidimensional construct encompassing physical, emotional, social, and role functioning. Uterine fibroids impair HRQoL across all these domains. Validated disease-specific instruments are essential for capturing the true burden and monitoring treatment outcomes objectively."), SP(), H2("7.1 Disease-Specific & Generic QoL Instruments"), TABLE(["Instrument","Domains Assessed","Key Feature"], [["UFS-QoL\n(Uterine Fibroid Symptom & QoL)", "Symptom Severity Score (8 items) + 6 HRQoL subscales:\nConcern, Activities, Energy/Fatigue, Control,\nSelf-consciousness, Sexual Function", "Gold standard for fibroid trials; most widely validated; scores 0-100"], ["SF-36 / SF-12", "8 domains: Physical Function, Role-Physical,\nBodily Pain, General Health, Vitality,\nSocial Functioning, Role-Emotional, Mental Health", "Generic; enables cross-condition comparison; widely used in RCTs"], ["EQ-5D-3L / EQ-5D-5L", "Mobility, Self-care, Usual activities,\nPain/Discomfort, Anxiety/Depression + VAS", "Utility values (QALYs) for health economic analyses"], ["PBAC\n(Pictorial Blood Assessment Chart)", "Menstrual blood loss quantification\n(pads/tampons scored by saturation)", "Objective HMB; PBAC score >100 = clinically significant HMB"], ["NRS/VAS Pain","Pain intensity 0-10 scale","Simple, validated; routine treatment monitoring"]], [42*mm, 72*mm, 41*mm]), SP(), H2("7.2 QoL Domains Impaired: Detailed Analysis"), TABLE(["QoL Domain","Specific Impairment","Evidence Basis"], [["Physical Functioning","Anaemia fatigue limits mobility; pain restricts activity; heavy flow days prevent planned activities","80% HMB-driven limitations (Berek & Novak's Gynecology)"], ["Role Functioning","40% work absenteeism; presenteeism due to pain, fatigue, concentration difficulties","Prospective study n=555; UFS-QoL Activity subscale"], ["Social Participation","Avoidance of public events due to unpredictable bleeding; embarrassment from abdominal distension","UFS-QoL Self-consciousness subscale"], ["Sexual Health","Dyspareunia (30%); reduced libido from pain, fatigue, body image; relationship impairment","UFS-QoL Sexual Function subscale"], ["Emotional Wellbeing","Elevated depression and anxiety scores; fear of malignancy; reproductive distress","Neumann et al. 2024 (PMID 38246400); 67 studies"], ["Vitality & Energy","Iron-deficiency anaemia reduces energy; cognitive impairment; reduced motivation","PBAC scores; SF-36 Vitality domain"], ["Self-Efficacy & Control","Loss of control over bodily functions; daily life planned around menstrual cycle","UFS-QoL Control subscale"]], [38*mm, 70*mm, 47*mm]), SP(2), BOX([Paragraph("<b>Key Evidence (Fertil Steril 2024, PMID 38246400)</b>", ST["boxtitle"]), P("Systematic review of <b>67 studies (18 RCTs + 49 observational)</b> confirmed ALL fibroid treatment modalities - medical, surgical, radiological - produce significant improvement in fibroid-specific QoL, mental health metrics, and symptom severity scores. This confirms baseline QoL impairment is both <b>substantial and treatment-responsive</b>. Key instruments: UFS-QoL, SF-36, EQ-5D, validated mental health scales.")]), PageBreak()] # S8 E += [SecBanner(8,"Socioeconomic Burden","Healthcare costs, productivity, health equity"), SP(2), P("The economic burden of uterine fibroids is enormous. Both direct costs (healthcare utilisation) and indirect costs (lost productivity) are substantial, placing fibroids among the most economically significant gynaecological conditions."), SP(), H2("8.1 Direct Healthcare Costs"), B("Hysterectomy for fibroids: >200,000 procedures annually in the US"), B("Estimated direct annual healthcare cost (US): USD 4.1-9.4 billion"), B("Total annual economic burden (direct + indirect): estimated USD 34.4 billion (US)"), B("Globally: fibroids are the leading benign indication for major gynaecological surgery"), B("Repeated surgeries due to myomectomy recurrence add cumulative costs"), SP(), H2("8.2 Indirect Costs & Productivity Loss"), B("40% of symptomatic women report work absenteeism - peak career years (30-50) disproportionately affected"), B("Estimated annual productivity loss (US): USD 1.55-17.2 billion"), B("Anaemia from chronic HMB independently reduces cognitive function and occupational performance"), B("Presenteeism (reduced performance while at work) adds burden beyond absenteeism"), SP(), H2("8.3 Health Equity"), P("Black women face disproportionate fibroid burden and barriers to care: higher rates of hysterectomy over uterus-preserving procedures, greater diagnostic delays, underrepresentation in clinical trials, and barriers to minimally invasive treatments. Gynaecology residents must recognise and address these inequities in daily practice."), PageBreak()] # S9 E += [SecBanner(9,"Management Overview","Medical, surgical, minimally invasive approaches"), SP(2), P("Management must be <b>individualised</b> based on symptom severity, FIGO fibroid type, fertility desire, age, patient values, and available expertise. The overarching goal is to improve QoL while minimising treatment burden."), SP(), H2("9.1 Medical Management"), TABLE(["Drug / Class","Mechanism","QoL Effect","Key Notes"], [["GnRH Agonists\n(Leuprolide, Goserelin)","Pituitary downregulation; hypoestrogenic","Reduces HMB; corrects anaemia; reduces bulk","Max 3-6 months; add-back required; fibroids regrow"], ["GnRH Antagonists\n(Elagolix, Relugolix)","Direct receptor blockade; rapid onset","Significant HMB reduction; QoL improvement in RCTs","Oral; with add-back; FDA-approved for fibroid HMB"], ["LNG-IUS (Mirena)","Local progestin; endometrial atrophy","Reduces HMB; improves anaemia; long-term","Does not reduce volume; effective for bleeding"], ["Ulipristal Acetate","Selective progesterone receptor modulator","Controlled HMB; volume reduction","Restricted - hepatotoxicity risk"], ["Combined OCP / Progestins","Hormonal cycle regulation","Modest HMB reduction; cycle control","Limited effect on fibroid size/bulk symptoms"], ["Tranexamic Acid","Antifibrinolysis","Reduces HMB by 30-50%","Non-hormonal; taken during menstruation only"], ["NSAIDs","Prostaglandin inhibition","Reduces dysmenorrhea and mild HMB","Used adjunctively; limited effect on heavy bleeding"], ["Iron supplementation","Corrects anaemia","Improves fatigue, cognition, energy","Essential adjunct to ALL treatments with HMB"]], [42*mm, 38*mm, 38*mm, 37*mm]), SP(), H2("9.2 Surgical Management"), TABLE(["Procedure","Indication","Fertility","QoL Outcome"], [["Hysteroscopic Myomectomy","FIGO Types 0, 1, 2","Preserved; best fertility outcomes","Excellent for HMB; day case; low morbidity"], ["Laparoscopic Myomectomy","Intramural/subserosal ≤8-10 cm","Preserved","Minimally invasive; fast recovery"], ["Abdominal Myomectomy","Large/multiple/complex fibroids","Preserved","Gold standard complex cases; 5-10% hysterectomy risk"], ["Hysterectomy","Completed family; failed treatments","Not preserved - definitive","Permanent symptom resolution; highest morbidity"]], [48*mm, 40*mm, 32*mm, 35*mm]), SP(), H2("9.3 Minimally Invasive & Radiological Options"), B("<b>Uterine Artery Embolization (UAE):</b> HMB improved 83%, dysmenorrhoea 77%, urinary symptoms 86% at 3 months. Systematic review (Peng et al., Sci Rep 2024, PMID 39164326) confirms comparable QoL outcomes to myomectomy. Not for fertility preservation."), B("<b>High-Intensity Focused Ultrasound (HIFU/MRgFUS):</b> Non-invasive; systematic review confirms significant QoL improvement; uterus and potentially fertility preserved (Yan et al., Int J Hyperthermia 2022, PMID 35094613)."), B("<b>Radiofrequency Ablation (Acessa):</b> AAGL systematic review confirms significant HMB reduction and QoL improvement (Chen et al., J Minim Invasive Gynecol 2025, PMID 39277104)."), B("<b>Preoperative GnRH therapy:</b> Cochrane review confirms reduced uterine volume, improved haematology, and better minimally invasive surgical access (Puscasiu et al. 2025, PMID 40183418)."), PageBreak()] # S10 E += [SecBanner(10,"Conclusion & Key Takeaways"), SP(2), P("Uterine fibroids impose a profound, multidimensional burden on women's health and quality of life extending far beyond their anatomical presence. For the gynaecology resident, a comprehensive understanding of this burden is foundational to delivering patient-centred, equitable fibroid care."), SP(), TABLE(["#","Key Takeaway","Clinical Implication"], [["1","High burden, underrecognised","Up to 80% cumulative incidence by age 50; active case-finding and symptom enquiry are essential"], ["2","Multi-symptom, multi-domain","HMB, pain, urinary, sexual symptoms impair physical, emotional, social, and occupational functioning"], ["3","Reproductive consequences","Submucosal fibroids independently impair fertility, increase miscarriage and obstetric complication risk"], ["4","Mental health is core","Depression and anxiety are integral; systematic screening and management are required"], ["5","Use validated QoL tools","UFS-QoL, SF-36, PBAC, NRS quantify baseline burden and monitor treatment response objectively"], ["6","All treatments improve QoL","Medical, surgical, and minimally invasive interventions all significantly improve QoL (Neumann et al. 2024)"], ["7","Individualise management","Consider FIGO type, symptom profile, fertility desire, patient values, and available resources"], ["8","Counsel on recurrence","27-59% recurrence after myomectomy; long-term follow-up and reproductive counselling essential"], ["9","Address health disparities","Black women face disproportionate burden; cultural competence and equitable access are professional obligations"]], [8*mm, 52*mm, 95*mm]), PageBreak()] # S11 E += [SecBanner(11,"References"), SP(2)] refs = [ "1. Berek JS, et al. <i>Berek & Novak's Gynecology</i>. 16th ed. Wolters Kluwer; 2020. Ch. 11: Uterine Fibroids.", "2. Creasy RK, et al. <i>Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice</i>. 8th ed. Elsevier; 2019. Ch. 28.", "3. Kumar V, Abbas AK, Aster JC. <i>Robbins, Cotran & Kumar: Pathologic Basis of Disease</i>. 10th ed. Elsevier; 2023.", "4. Robbins SL, Kumar V. <i>Robbins & Kumar Basic Pathology</i>. 10th ed. Elsevier; 2021.", "5. Neumann B, Singh B, Brennan J, Blanck J, Segars JH. The impact of fibroid treatments on quality of life and mental health: a systematic review. <i>Fertil Steril</i>. 2024 Mar. PMID: 38246400.", "6. Singh S, Kumar P, Kavita, et al. Contemporary approaches in the management of uterine leiomyomas. <i>Eur J Obstet Gynecol Reprod Biol</i>. 2023 Aug;287:117-129. PMID: 37385088.", "7. Amendola ILS, Spann M, Segars J. The MED-12 Gene and Uterine Fibroids: a Systematic Review. <i>Reprod Sci</i>. 2024 Feb;31(2):310-324. PMID: 37516697.", "8. Peng J, Wang J, Shu Q, et al. UAE vs myomectomy for symptomatic uterine fibroids: systematic review and meta-analysis. <i>Sci Rep</i>. 2024 Aug;14(1):19214. PMID: 39164326.", "9. Yan L, Huang H, Lin J. HIFU for symptomatic uterine fibroids: systematic review and meta-analysis. <i>Int J Hyperthermia</i>. 2022;39(1):234-243. PMID: 35094613.", "10. Chen I, Berman JM, Balk EM, et al. Radiofrequency Ablation for Uterine Fibroids: AAGL Systematic Review. <i>J Minim Invasive Gynecol</i>. 2025 Jan;32(1):13-26. PMID: 39277104.", "11. Puscasiu L, Vollenhoven B, Nagels HE. Preoperative medical therapy before surgery for uterine fibroids. <i>Cochrane Database Syst Rev</i>. 2025 Apr 4. PMID: 40183418.", "12. De Angelis MC, Di Spiezio Sardo A, Carugno J. Fertility outcomes after hysteroscopic removal of intrauterine leiomyomas and polyps. <i>Minerva Obstet Gynecol</i>. 2022 Feb;74(1):84-95. PMID: 33876900.", "13. Munro MG, et al. FIGO classification system (PALM-COEIN) for causes of AUB. <i>Int J Gynaecol Obstet</i>. 2011;113(1):3-13.", "14. Stewart EA. Uterine fibroids. <i>N Engl J Med</i>. 2015;372(17):1646-1655.", "15. Cardozo ER, et al. Estimated annual cost of uterine leiomyomata in the United States. <i>Am J Obstet Gynecol</i>. 2012;206(3):211.e1-9.", ] for r in refs: E.append(Paragraph(r, ST["ref"])); E.append(SP(0.5)) E += [SP(2), HR(), Paragraph("Prepared for Gynecology Residency Paper Presentation | Department of Obstetrics & Gynecology | May 2026", ST["fn"]), Paragraph("Sources: Berek & Novak's Gynecology \u2022 Robbins & Kumar Pathology \u2022 Creasy & Resnik's MFM \u2022 PubMed Systematic Reviews 2021-2026", ST["fn"])] return E # Build with custom page templates from reportlab.platypus import BaseDocTemplate, Frame, PageTemplate class MyDoc(BaseDocTemplate): def __init__(self, fn, **kw): BaseDocTemplate.__init__(self, fn, **kw) # Cover frame (full page, no margins for background drawing) cover_frame = Frame(0, 0, W_PAGE, H_PAGE, leftPadding=0, rightPadding=0, topPadding=0, bottomPadding=0, id="cover") # Normal frame with margins normal_frame = Frame(27.5*mm, 22*mm, W_PAGE-55*mm, H_PAGE-50*mm, leftPadding=0, rightPadding=0, topPadding=0, bottomPadding=0, id="normal") cover_tpl = PageTemplate(id="Cover", frames=[cover_frame], onPage=cover_page) normal_tpl = PageTemplate(id="Normal", frames=[normal_frame], onPage=later_page) self.addPageTemplates([cover_tpl, normal_tpl]) from reportlab.platypus import NextPageTemplate doc = MyDoc(OUT, pagesize=A4, leftMargin=27.5*mm, rightMargin=27.5*mm, topMargin=28*mm, bottomMargin=22*mm, title="Uterine Fibroids: Impact on Women's Health and Quality of Life", author="Gynecology Residency Program", subject="Paper Presentation - May 2026") elements = [NextPageTemplate("Normal")] + build_story() doc.build(elements) print("SUCCESS:", OUT) PYEOF

ls -lh /home/daytona/workspace/fibroid2/Uterine_Fibroids_Womens_Health_QoL.pdf