📚 MENOPAUSE - Exam-Oriented Notes

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

OUTPUT = "/home/daytona/workspace/menopause-notes/Menopause_Notes.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=1.5*cm, rightMargin=1.5*cm,
    topMargin=1.5*cm, bottomMargin=1.5*cm,
)

W = A4[0] - 3*cm  # usable width

# ── Colour palette ──────────────────────────────────────────────
DARK_BLUE  = colors.HexColor("#1a3a5c")
MED_BLUE   = colors.HexColor("#2563a8")
LIGHT_BLUE = colors.HexColor("#dbeafe")
ACCENT     = colors.HexColor("#dc2626")   # red for high-yield
GOLD       = colors.HexColor("#b45309")
TABLE_HDR  = colors.HexColor("#1e40af")
TABLE_ALT  = colors.HexColor("#eff6ff")
WHITE      = colors.white
LIGHT_GREY = colors.HexColor("#f8fafc")
BORDER     = colors.HexColor("#93c5fd")

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

def S(name, **kw):
    return ParagraphStyle(name, **kw)

title_s = S("TitleS", fontName="Helvetica-Bold", fontSize=22,
            textColor=WHITE, alignment=TA_CENTER, spaceAfter=4)
sub_title_s = S("SubT", fontName="Helvetica", fontSize=10,
                textColor=LIGHT_BLUE, alignment=TA_CENTER, spaceAfter=2)
sec_s = S("Sec", fontName="Helvetica-Bold", fontSize=10,
          textColor=WHITE, alignment=TA_LEFT,
          leftIndent=4, spaceAfter=2, spaceBefore=6)
body_s = S("Body", fontName="Helvetica", fontSize=8.2,
           textColor=colors.HexColor("#1e293b"), leading=12,
           spaceAfter=3, alignment=TA_JUSTIFY)
bullet_s = S("Bul", fontName="Helvetica", fontSize=8.2,
             textColor=colors.HexColor("#1e293b"), leading=11.5,
             leftIndent=12, firstLineIndent=-8, spaceAfter=2)
bold_s = S("Bold", fontName="Helvetica-Bold", fontSize=8.2,
           textColor=DARK_BLUE, leading=12, spaceAfter=2)
high_s = S("High", fontName="Helvetica-Bold", fontSize=8,
           textColor=ACCENT, leading=11, spaceAfter=2)
note_s = S("Note", fontName="Helvetica-Oblique", fontSize=7.5,
           textColor=GOLD, leading=10, spaceAfter=2)

def section_header(text):
    """Blue banner heading."""
    data = [[Paragraph(text, sec_s)]]
    t = Table(data, colWidths=[W])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), TABLE_HDR),
        ("TOPPADDING",  (0,0), (-1,-1), 3),
        ("BOTTOMPADDING",(0,0),(-1,-1), 3),
        ("LEFTPADDING", (0,0), (-1,-1), 6),
        ("ROWBACKGROUNDS",(0,0),(-1,-1),[TABLE_HDR]),
    ]))
    return t

def mini_header(text):
    return Paragraph(f"<font color='#1e40af'><b>▌ {text}</b></font>", bold_s)

def bullet(text):
    return Paragraph(f"• {text}", bullet_s)

def body(text):
    return Paragraph(text, body_s)

def high(text):
    return Paragraph(f"★ {text}", high_s)

def note(text):
    return Paragraph(f"📝 {text}", note_s)

def sp(h=4):
    return Spacer(1, h)

def hr():
    return HRFlowable(width=W, thickness=0.5, color=BORDER, spaceAfter=3, spaceBefore=3)

def make_table(headers, rows, col_widths=None):
    data = [[Paragraph(f"<b>{h}</b>", ParagraphStyle("th", fontName="Helvetica-Bold",
            fontSize=7.5, textColor=WHITE, alignment=TA_CENTER)) for h in headers]]
    for i, row in enumerate(rows):
        data.append([Paragraph(str(c), ParagraphStyle("td", fontName="Helvetica",
                     fontSize=7.5, textColor=colors.HexColor("#1e293b"),
                     leading=10, alignment=TA_LEFT)) for c in row])
    if col_widths is None:
        col_widths = [W / len(headers)] * len(headers)
    t = Table(data, colWidths=col_widths, repeatRows=1)
    style = [
        ("BACKGROUND",    (0,0), (-1,0),  TABLE_HDR),
        ("TEXTCOLOR",     (0,0), (-1,0),  WHITE),
        ("FONTNAME",      (0,0), (-1,0),  "Helvetica-Bold"),
        ("FONTSIZE",      (0,0), (-1,-1), 7.5),
        ("ALIGN",         (0,0), (-1,-1), "LEFT"),
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, TABLE_ALT]),
        ("GRID",          (0,0), (-1,-1), 0.4, BORDER),
        ("TOPPADDING",    (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ("LEFTPADDING",   (0,0), (-1,-1), 4),
        ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ]
    t.setStyle(TableStyle(style))
    return t

# ═══════════════════════════════════════════════════════════════
# BUILD CONTENT
# ═══════════════════════════════════════════════════════════════
story = []

# ── TITLE BANNER ─────────────────────────────────────────────────
title_data = [[
    Paragraph("MENOPAUSE", title_s),
    Paragraph("Chapter 6 · Exam-Oriented Concise Notes", sub_title_s),
]]
title_tbl = Table([[Paragraph("MENOPAUSE", title_s)],
                   [Paragraph("Chapter 6  ·  Exam-Oriented Concise Notes", sub_title_s)]],
                  colWidths=[W])
title_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), DARK_BLUE),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("LEFTPADDING",   (0,0), (-1,-1), 10),
]))
story.append(title_tbl)
story.append(sp(6))

# ── ROW 1: Two-column layout: Definition + Age of Menopause ──────
def two_col(left_items, right_items, left_w=None, right_w=None):
    lw = left_w or W*0.5 - 3
    rw = right_w or W*0.5 - 3
    left_tbl  = Table([[i] for i in left_items],  colWidths=[lw])
    right_tbl = Table([[i] for i in right_items], colWidths=[rw])
    outer = Table([[left_tbl, right_tbl]], colWidths=[lw+4, rw+4])
    outer.setStyle(TableStyle([
        ("VALIGN",       (0,0),(-1,-1),"TOP"),
        ("LEFTPADDING",  (0,0),(-1,-1), 0),
        ("RIGHTPADDING", (0,0),(-1,-1), 0),
        ("TOPPADDING",   (0,0),(-1,-1), 0),
        ("BOTTOMPADDING",(0,0),(-1,-1), 0),
    ]))
    return outer

# SECTION 1 — Definition
sec1 = [
    section_header("1. DEFINITION"),
    sp(2),
    bullet("<b>Menopause</b> = Permanent cessation of menstruation due to <b>loss of ovarian follicular activity</b>"),
    bullet("Confirmed after <b>12 consecutive months of amenorrhea</b> — NO other pathology"),
    high("Declared ONLY RETROSPECTIVELY"),
    bullet("Serum <b>FSH elevated</b> at 45–55 years"),
    sp(2),
    mini_header("Menopause Transition"),
    bullet("Reproductive → Non-reproductive; covers <b>4–7 years on either side</b>"),
    bullet("Features: elevated FSH, variable cycle length, missed menses"),
    bullet("<b>Postmenopause</b> = phase after menopause"),
]

# SECTION 2 — Age
sec2 = [
    section_header("2. AGE OF MENOPAUSE"),
    sp(2),
    high("Age is GENETICALLY PREDETERMINED"),
    bullet("<b>NOT related to:</b> menarche age, last pregnancy, parity, lactation, OCP use, socioeconomics, race, height, weight"),
    bullet("<b>Early menopause:</b> thin women, cigarette smoking, severe malnutrition"),
    bullet("<b>Range:</b> 45–55 years | <b>Average: 50 years</b>"),
    sp(4),
    section_header("3. CLINICAL IMPORTANCE"),
    sp(2),
    bullet("Increased life expectancy → women spend large part of life in <b>estrogen deficiency stage</b>"),
    bullet("Long-term: symptomatic + metabolic complications"),
]

story.append(two_col(sec1, sec2))
story.append(sp(5))

# ── SECTION 4: Endocrinology ──────────────────────────────────────
story.append(section_header("4. ENDOCRINOLOGY OF MENOPAUSAL TRANSITION"))
story.append(sp(3))

endo_left = [
    mini_header("Hypothalamo-Pituitary-Gonadal Axis"),
    bullet("Follicles become <b>resistant to gonadotropins</b> → impaired folliculogenesis → ↓ estradiol"),
    bullet("Estradiol: <b>50–300 pg/mL</b> (before) → <b>10–20 pg/mL</b> (after menopause)"),
    bullet("↓ Estradiol → ↓ negative feedback → <b>↑ FSH</b> (also due to ↓ Inhibin from granulosa cells)"),
    bullet("<b>Inhibin</b> secreted by granulosa cells; its decrease → ↑ FSH"),
    bullet("<b>LH increases</b> subsequently"),
    bullet("Disturbed folliculogenesis → anovulation, oligoovulation, corpus luteal insufficiency"),
    bullet("Mean cycle length <b>shorter</b> (follicular phase ↓; luteal phase constant)"),
    bullet("Late menopausal transition: <b>accelerated follicular depletion</b>"),
    high("Ultimately: Estradiol drops to 20 pg/mL → no endometrial growth → NO MENSTRUATION"),
]

endo_right = [
    mini_header("Estrogens After Menopause"),
    bullet("Predominant estrogen = <b>ESTRONE</b> (not estradiol)"),
    bullet("Estrone: 30–70 pg/mL; Estradiol: 10–20 pg/mL"),
    bullet("Main source: <b>Peripheral aromatization of androgens</b> (mainly adrenals) at muscle & adipose tissue"),
    bullet("Estrone is <b>1/10th biologically potent</b> vs estradiol"),
    high("5–10 yrs after menopause = TRUE MENOPAUSE (sharp fall in all hormones)"),
    sp(3),
    mini_header("Gonadotropins"),
    bullet("<b>Both FSH & LH increased</b> — absent negative feedback of estradiol & inhibin"),
    bullet("<b>FSH rises 10–20 fold</b>; LH rises only <b>3-fold</b>"),
    bullet("GnRH pulse frequency & amplitude increased"),
    bullet("<b>AMH (Anti-Mullerian Hormone)</b> markedly decreased — loss of ovarian reserve"),
]

story.append(two_col(endo_left, endo_right))
story.append(sp(3))

# Hormones table
story.append(mini_header("Hormone Summary Table"))
story.append(sp(2))
story.append(make_table(
    ["Hormone", "Level After Menopause", "Key Reason"],
    [
        ["FSH", "↑↑ (10–20 fold)", "↓ Estradiol & ↓ Inhibin → lost negative feedback"],
        ["LH", "↑ (3-fold)", "↓ Estradiol feedback"],
        ["Estrone", "30–70 pg/mL (dominant)", "Peripheral aromatization of androgens"],
        ["Estradiol", "10–20 pg/mL (↓)", "Ovarian follicular depletion"],
        ["Progesterone", "Trace (adrenal)", "No corpus luteum"],
        ["Androgens", "Relatively ↑ (ratio)", "Stromal ovarian cells continue production"],
        ["AMH", "Markedly ↓", "Severe loss of ovarian reserve"],
    ],
    col_widths=[W*0.18, W*0.22, W*0.60]
))
story.append(sp(5))

# ── SECTION 5: Organ Changes ─────────────────────────────────────
story.append(section_header("5. ORGAN CHANGES"))
story.append(sp(3))
story.append(make_table(
    ["Organ", "Key Changes"],
    [
        ["Ovaries", "Shrink, wrinkled/white; cortex thins; stromal cells ↑ (secretory)"],
        ["Fallopian Tubes", "Atrophy; muscle coat thins; cilia disappear; plicae less prominent"],
        ["Uterus", "Smaller; body:cervix ratio → 1:1; endometrium thin/atrophic; cervical secretion scanty"],
        ["Vagina", "Narrow; epithelium thin; no glycogen; no Doderlein's bacilli; pH ALKALINE; maturation index 10/85/5"],
        ["Vulva", "Atrophy; labia flattened; pubic hair less; NARROW INTROITUS"],
        ["Breasts", "Breast fat reabsorbed; glands atrophy; nipples ↓; flat and pendulous"],
        ["Bladder/Urethra", "Thin epithelium; prone to infection; dysuria, frequency, urgency, stress incontinence"],
        ["Muscle Tone", "↓ → Pelvic relaxation, uterine descent; ligaments lose tone; pelvic tissue becomes scanty"],
    ],
    col_widths=[W*0.22, W*0.78]
))
story.append(sp(5))

# ── SECTION 6: Bone Metabolism ───────────────────────────────────
story.append(section_header("6. BONE METABOLISM & OSTEOPOROSIS"))
story.append(sp(3))

bone_left = [
    mini_header("Key Concepts"),
    bullet("Post-menopause bone loss: <b>3–5% per year</b> (up to 5% during menopause)"),
    bullet("<b>Osteoporosis</b> = ↓ bone mass; bone mineral:matrix ratio NORMAL"),
    bullet("Bone loss mainly in <b>trabecular bone</b> (vertebra, distal radius) & cortical bone"),
    sp(3),
    mini_header("T-Score Classification (BMD)"),
    make_table(
        ["T-Score", "Diagnosis"],
        [
            ["+2.5 to −1.0", "Normal BMD"],
            ["−1.0 to −2.5", "Osteopenia (precursor to osteoporosis)"],
            ["< −2.5", "OSTEOPOROSIS"],
        ],
        col_widths=[W*0.25*0.9, W*0.25*1.6]
    ),
]

bone_right = [
    mini_header("Estrogen's Role in Bone"),
    bullet("Inhibits <b>osteoclastic activity</b>"),
    bullet("Inhibits release of <b>IL-1 by monocytes</b>"),
    bullet("↑ Calcium absorption from gut"),
    bullet("Stimulates <b>calcitonin</b> from thyroid C cells"),
    bullet("↑ 1,25-dihydroxyvitamin D → ↑ bone mineralization"),
    sp(3),
    mini_header("Detection"),
    bullet("<b>DEXA</b> = gold standard (less radiation than CT)"),
    bullet("<b>FRAX tool (WHO-2001)</b>: 10-year fracture risk probability; uses 11 risk factors + femoral neck BMD"),
    bullet("Biochemical: Urinary Ca/Cr and hydroxyproline/Cr ratios"),
    high("PTH and IL-1 promote bone resorption in menopause"),
]

story.append(two_col(bone_left, bone_right, left_w=W*0.48, right_w=W*0.48))
story.append(sp(3))

# Risk factors table
story.append(mini_header("Risk Factors for Osteoporosis (Table 6.1)"))
story.append(sp(2))
story.append(make_table(
    ["Patient Factors", "Lifestyle Factors", "Medications/Diseases"],
    [
        ["Family history, Age >65", "↓ Calcium & Vit D, ↑ caffeine", "Heparin, Corticosteroids"],
        ["Asian/White race, Low BMI/weight", "↑ Smoking, ↑ Alcohol", "GnRH analogs, Anticonvulsants"],
        ["Lack of estrogen, Hypogonadism", "Sedentary habit", "RA, Hyperparathyroidism, DM"],
        ["Fragility fracture, Osteopenia", "Early menopause (surgical/radiation)", "Malabsorption, Multiple myeloma, Thyroid disorders"],
    ],
    col_widths=[W*0.33, W*0.33, W*0.34]
))
story.append(sp(5))

# ── SECTION 7: Cardiovascular ────────────────────────────────────
story.append(section_header("7. CARDIOVASCULAR SYSTEM"))
story.append(sp(3))

cv_left = [
    mini_header("Estrogen Protects Heart By:"),
    bullet("↑ <b>HDL2</b>; ↓ <b>LDL</b> and total cholesterol"),
    bullet("Inhibits platelet & macrophage (foam cell) aggregation"),
    bullet("↑ <b>NO (nitric oxide)</b> & prostacyclin → vasodilation"),
    bullet("Prevents atherosclerosis via <b>antioxidant property</b>"),
]

cv_right = [
    mini_header("Without Estrogen (Post-menopause):"),
    bullet("Oxidation of LDL + foam cell formation → endothelial injury"),
    bullet("→ Smooth muscle proliferation → <b>insulin resistance</b>"),
    bullet("→ Central (android) obesity → atherosclerosis & thrombus"),
    bullet("↑ Risk: ischemic heart disease, stroke, coronary artery disease"),
    make_table(
        ["CV Risk Factors (Table 6.2)"],
        [["Hypertension, Familial hyperlipidemia"],
         ["Smoking habit, Impaired glucose tolerance"]],
        col_widths=[W*0.45]
    ),
]
story.append(two_col(cv_left, cv_right))
story.append(sp(5))

# ── SECTION 8: Symptoms ──────────────────────────────────────────
story.append(section_header("8. MENOPAUSAL SYMPTOMS"))
story.append(sp(3))

story.append(make_table(
    ["Category", "Key Symptoms"],
    [
        ["Menstrual", "Shorter cycles (common), irregular bleeding"],
        ["Vasomotor ★", "Hot flashes, Night sweats, Sleep disturbances"],
        ["Psychological", "Irritability, Mood swings, Poor memory, Depression"],
        ["Sexual Dysfunction", "Vaginal dryness, Dyspareunia"],
        ["Urinary", "Incontinence, Urgency, Dysuria"],
        ["Skin & Hair", "Thinning, Loss of elasticity, Purse-string wrinkling (mouth), Crow feet (eyes)"],
        ["Others", "Back aches, Joint aches"],
    ],
    col_widths=[W*0.22, W*0.78]
))
story.append(sp(4))

symp_left = [
    mini_header("HOT FLASH — Most Characteristic Symptom"),
    high("Sudden feeling of heat + profuse sweating"),
    bullet("<b>Low estrogen</b> is prerequisite"),
    bullet("Coincides with <b>GnRH pulse secretion → ↑ LH surge</b>"),
    bullet("Duration: <b>1–10 minutes</b>; may be unbearable"),
    bullet("<b>Thermoregulatory center in hypothalamus</b> involved"),
    bullet("Neurotransmitters: <b>norepinephrine & serotonin</b> lower the thermoregulatory set-point"),
    bullet("Physiologic changes: <b>perspiration + cutaneous vasodilation</b>"),
    sp(3),
    mini_header("Skin & Hair"),
    bullet("Skin collagen ↓ <b>1–2%/year</b>"),
    bullet("<b>Purse string</b> wrinkling (mouth) | <b>Crow feet</b> (eyes)"),
    bullet("Estrogen receptors max in <b>facial skin</b>"),
    bullet("Loss of pubic & axillary hair; slight balding (↓ testosterone)"),
]

symp_right = [
    mini_header("Dyspareunia / Vaginal"),
    bullet("Estradiol deficiency → vaginal dryness/atrophy"),
    bullet("Rx: <b>17β-estradiol tablet</b> or <b>CEE cream</b> (vaginally/orally)"),
    bullet("Endometrial hyperplasia risk: <b>less with vaginal tablets than cream</b>"),
    bullet("Vaginal lubricants: <b>K-Y jelly</b> (water soluble)"),
    bullet("Vaginal: minimal trauma → bleeding, dyspareunia, infections, leucorrhea"),
    sp(3),
    mini_header("Psychological"),
    bullet("Anxiety, headache, insomnia, irritability, depression"),
    bullet("Estrogen ↑ opioid activity in brain → important for <b>memory</b>"),
    bullet("Dementia: estrogen improves cerebral perfusion; unclear if prevents Alzheimer's"),
    sp(3),
    mini_header("Osteoporosis & Fracture"),
    bullet("Bone loss ↑ to <b>5%/year</b> during menopause"),
    bullet("<b>Primary (Type 1)</b>: estrogen loss, age, Ca/Vit D deficiency, hereditary"),
    bullet("<b>Secondary (Type 2)</b>: endocrine (parathyroid, DM) or medications"),
    bullet("Fracture sites: <b>vertebral body, femoral neck, distal forearm (Colles')</b>"),
    high("Fracture = FALL risk (↓ muscle mass, cognitive impairment)"),
]

story.append(two_col(symp_left, symp_right))
story.append(sp(5))

# ── SECTION 9: Menstrual Patterns ────────────────────────────────
story.append(section_header("9. MENSTRUAL PATTERNS PRIOR TO MENOPAUSE"))
story.append(sp(3))
story.append(make_table(
    ["Pattern", "Description"],
    [
        ["Abrupt cessation", "Sudden stopping — RARE"],
        ["Gradual decrease ★", "↓ amount & duration → spotting/delay → cessation (most common)"],
        ["Irregular", "With/without excessive bleeding — EXCLUDE genital malignancy first"],
    ],
    col_widths=[W*0.25, W*0.75]
))
story.append(sp(5))

# ── SECTION 10: Diagnosis ────────────────────────────────────────
story.append(section_header("10. DIAGNOSIS OF MENOPAUSE"))
story.append(sp(3))
story.append(make_table(
    ["Criterion", "Value"],
    [
        ["Amenorrhea duration", "12 consecutive months during climacteric"],
        ["Average age", "50 years"],
        ["Symptoms", "Hot flash + Night sweats"],
        ["Vaginal cytology (maturation index)", "≥ 10/85/5 (features of low estrogen)"],
        ["Serum estradiol", "< 20 pg/mL"],
        ["Serum FSH & LH", "> 40 mIU/mL (3 values at weekly intervals required)"],
    ],
    col_widths=[W*0.40, W*0.60]
))
story.append(sp(5))

# ── SECTION 11: Management ───────────────────────────────────────
story.append(section_header("11. MANAGEMENT"))
story.append(sp(3))

story.append(mini_header("Prevention & Counseling"))
story.append(bullet("Spontaneous menopause: unavoidable"))
story.append(bullet("<b>Artificial menopause</b> (surgery/radiation/chemo): can be <b>prevented or delayed</b>"))
story.append(high("Counseling & Reassurance is ESSENTIAL — addresses anxiety, depression, insomnia"))
story.append(sp(3))

story.append(mini_header("Non-Hormonal Treatment"))
story.append(sp(2))
story.append(make_table(
    ["Treatment", "Details"],
    [
        ["Lifestyle modification", "Physical activity; ↓ caffeine, smoking, alcohol; adequate calcium (300 mL milk); ↓ corticosteroids"],
        ["Nutritious diet", "Balanced — calcium + protein rich"],
        ["Supplementary calcium", "Daily <b>1–1.5 g</b> → reduces osteoporosis & fracture"],
        ["Exercise", "Weight-bearing: walking, jogging"],
        ["Vitamin D₃", "1500–2000 IU/day + calcium; sunlight synthesizes cholecalciferol (Vit D₃)"],
        ["Bisphosphonates", "Prevents osteoclastic resorption; preferred for OLDER women; common: Ibandronate, Alendronate, Risedronate (fewer SE)"],
        ["Bisphosphonates — How to take", "Empty stomach; remain UPRIGHT 30 min after oral dose"],
        ["Bisphosphonates — Side effects", "Gastric/esophageal ulceration, osteomyelitis, OSTEONECROSIS OF JAW; cannot alone prevent hot flashes or CVD"],
        ["Calcitonin", "Inhibits osteoclasts (polypeptide hormone); always give WITH calcium + Vit D"],
        ["Cessation", "Stop smoking & alcohol"],
    ],
    col_widths=[W*0.30, W*0.70]
))
story.append(sp(5))

# ── SECTION 12: High-Yield Summary ───────────────────────────────
story.append(section_header("12. HIGH-YIELD EXAM RAPID RECALL"))
story.append(sp(3))
story.append(make_table(
    ["Key Point", "Fact to Remember"],
    [
        ["Diagnosis declared", "RETROSPECTIVELY after 12 months amenorrhea"],
        ["Average age", "50 years (range 45–55)"],
        ["Post-menopausal dominant estrogen", "ESTRONE (not estradiol)"],
        ["Source of estrone", "Peripheral aromatization of androgens (adrenals → adipose/muscle)"],
        ["FSH rise", "10–20 fold  |  LH rises only 3-fold"],
        ["AMH", "Markedly decreased"],
        ["Bone loss rate", "3–5%/year; up to 5% during menopause"],
        ["T-score: Osteoporosis", "< −2.5"],
        ["T-score: Osteopenia", "−1.0 to −2.5"],
        ["Serum FSH for diagnosis", "> 40 mIU/mL (3 values weekly)"],
        ["Serum estradiol for diagnosis", "< 20 pg/mL"],
        ["Skin collagen loss", "1–2%/year"],
        ["Hot flash mechanism", "Low estrogen → GnRH pulse → LH surge → thermoregulatory center"],
        ["Characteristic wrinkling", "Purse-string (mouth)  |  Crow-feet (eyes)"],
        ["Fracture site (Colles')", "Distal forearm"],
        ["Bisphosphonate rule", "Empty stomach; upright 30 min; SE: osteonecrosis of jaw"],
        ["Vaginal pH post-menopause", "Alkaline (no Doderlein's bacilli, no glycogen)"],
        ["Estrogen + CVD protection", "↑ HDL2, ↓ LDL, ↑ NO, antioxidant"],
        ["FRAX tool", "10-year fracture probability (WHO-2001), 11 risk factors"],
        ["Most common menstrual pattern", "Gradual decrease → spotting → cessation"],
        ["Obese women risk", "More estrone conversion → ↑ endometrial hyperplasia/carcinoma risk"],
    ],
    col_widths=[W*0.40, W*0.60]
))

story.append(sp(4))
story.append(note("These notes are compiled from Chapter 6 — Menopause. Focus especially on: diagnostic criteria, T-scores, hormonal changes, vasomotor mechanism, bisphosphonate side effects, and the estrone/estradiol distinction."))

# ── Build ─────────────────────────────────────────────────────────
doc.build(story)
print(f"PDF created: {OUTPUT}")

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

os.makedirs("/home/daytona/workspace/genital-prolapse", exist_ok=True)
OUTPUT = "/home/daytona/workspace/genital-prolapse/Genital_Prolapse_Notes.pdf"

doc = SimpleDocTemplate(
    OUTPUT, pagesize=A4,
    leftMargin=1.4*cm, rightMargin=1.4*cm,
    topMargin=1.4*cm, bottomMargin=1.4*cm,
)
W = A4[0] - 2.8*cm

# ── Colours ──────────────────────────────────────────────────────
DARK      = colors.HexColor("#1a3a5c")
MED_BLUE  = colors.HexColor("#1e40af")
LT_BLUE   = colors.HexColor("#dbeafe")
RED       = colors.HexColor("#dc2626")
GOLD      = colors.HexColor("#92400e")
TBL_HDR   = colors.HexColor("#1e3a8a")
TBL_ALT   = colors.HexColor("#f0f4ff")
BORDER    = colors.HexColor("#93c5fd")
WHITE     = colors.white
SLATE     = colors.HexColor("#1e293b")
GREEN_HDR = colors.HexColor("#166534")
GREEN_BG  = colors.HexColor("#dcfce7")

def S(name, **kw): return ParagraphStyle(name, **kw)

title_s  = S("T",  fontName="Helvetica-Bold", fontSize=20, textColor=WHITE, alignment=TA_CENTER)
subt_s   = S("ST", fontName="Helvetica",      fontSize=9,  textColor=LT_BLUE, alignment=TA_CENTER)
sec_s    = S("SE", fontName="Helvetica-Bold", fontSize=9,  textColor=WHITE, leftIndent=5)
mini_s   = S("MI", fontName="Helvetica-Bold", fontSize=8.5,textColor=MED_BLUE, spaceAfter=2, spaceBefore=4)
body_s   = S("BO", fontName="Helvetica",      fontSize=7.8,textColor=SLATE, leading=11, spaceAfter=2, alignment=TA_JUSTIFY)
bul_s    = S("BU", fontName="Helvetica",      fontSize=7.8,textColor=SLATE, leading=11, leftIndent=10, firstLineIndent=-8, spaceAfter=1.5)
high_s   = S("HI", fontName="Helvetica-Bold", fontSize=7.8,textColor=RED,   leading=11, spaceAfter=2, leftIndent=10, firstLineIndent=-8)
note_s   = S("NO", fontName="Helvetica-Oblique",fontSize=7.2,textColor=GOLD,leading=10, spaceAfter=2)
th_s     = S("TH", fontName="Helvetica-Bold", fontSize=7.5,textColor=WHITE, alignment=TA_LEFT)
td_s     = S("TD", fontName="Helvetica",      fontSize=7.5,textColor=SLATE, leading=10, alignment=TA_LEFT)
tdb_s    = S("TDB",fontName="Helvetica-Bold", fontSize=7.5,textColor=SLATE, leading=10, alignment=TA_LEFT)

def sec(text, bg=TBL_HDR):
    t = Table([[Paragraph(text, sec_s)]], colWidths=[W])
    t.setStyle(TableStyle([
        ("BACKGROUND",(0,0),(-1,-1),bg),
        ("TOPPADDING",(0,0),(-1,-1),3),("BOTTOMPADDING",(0,0),(-1,-1),3),
        ("LEFTPADDING",(0,0),(-1,-1),6),("RIGHTPADDING",(0,0),(-1,-1),4),
    ]))
    return t

def mini(text): return Paragraph(f"<font color='#1e40af'><b>▌ {text}</b></font>", mini_s)
def bul(text):  return Paragraph(f"• {text}", bul_s)
def high(text): return Paragraph(f"★ {text}", high_s)
def body(text): return Paragraph(text, body_s)
def note(text): return Paragraph(f"💡 {text}", note_s)
def sp(h=3):    return Spacer(1, h)
def hr():       return HRFlowable(width=W, thickness=0.4, color=BORDER, spaceAfter=2, spaceBefore=2)

def tbl(headers, rows, widths=None):
    data = [[Paragraph(h, th_s) for h in headers]]
    for row in rows:
        data.append([Paragraph(str(c[0]), tdb_s) if (isinstance(c, tuple) and c[1]=='b') else Paragraph(str(c), td_s) for c in row])
    if widths is None: widths = [W/len(headers)]*len(headers)
    t = Table(data, colWidths=widths, repeatRows=1)
    t.setStyle(TableStyle([
        ("BACKGROUND",(0,0),(-1,0),TBL_HDR),
        ("ROWBACKGROUNDS",(0,1),(-1,-1),[WHITE,TBL_ALT]),
        ("GRID",(0,0),(-1,-1),0.35,BORDER),
        ("VALIGN",(0,0),(-1,-1),"TOP"),
        ("TOPPADDING",(0,0),(-1,-1),2.5),("BOTTOMPADDING",(0,0),(-1,-1),2.5),
        ("LEFTPADDING",(0,0),(-1,-1),4),("RIGHTPADDING",(0,0),(-1,-1),4),
        ("FONTSIZE",(0,0),(-1,-1),7.5),
    ]))
    return t

def two_col(L, R, lw=None, rw=None):
    lw = lw or W*0.495; rw = rw or W*0.495
    lt = Table([[i] for i in L], colWidths=[lw])
    rt = Table([[i] for i in R], colWidths=[rw])
    ot = Table([[lt, rt]], colWidths=[lw+2, rw+2])
    ot.setStyle(TableStyle([("VALIGN",(0,0),(-1,-1),"TOP"),
        ("LEFTPADDING",(0,0),(-1,-1),0),("RIGHTPADDING",(0,0),(-1,-1),0),
        ("TOPPADDING",(0,0),(-1,-1),0),("BOTTOMPADDING",(0,0),(-1,-1),0)]))
    return ot

# ══════════════════════════════════════════════════════════════════
story = []

# ── TITLE ─────────────────────────────────────────────────────────
tb = Table([[Paragraph("GENITAL PROLAPSE", title_s)],
            [Paragraph("Chapter 16 · Displacement of the Uterus  ·  Exam-Oriented Concise Notes", subt_s)]],
           colWidths=[W])
tb.setStyle(TableStyle([("BACKGROUND",(0,0),(-1,-1),DARK),
    ("TOPPADDING",(0,0),(-1,-1),7),("BOTTOMPADDING",(0,0),(-1,-1),7),
    ("LEFTPADDING",(0,0),(-1,-1),8)]))
story += [tb, sp(5)]

# ── 1. DEFINITION & SUPPORTS ──────────────────────────────────────
story += [sec("1. DEFINITION & PELVIC SUPPORTS"), sp(2)]
left1 = [
    mini("Definition"),
    bul("<b>Genital prolapse</b> = descent of pelvic organs from their normal position due to weakness of supporting structures"),
    bul("Factors may be <b>anatomical</b> (structural) or <b>clinical</b> (predisposing/aggravating)"),
    sp(2),
    mini("Key Pelvic Supports"),
    bul("<b>Levator ani muscles</b> — main support; pubococcygeus part attaches to urethra, vagina, rectum"),
    bul("<b>Levator plate</b> — horizontal shelf upon which rectum, upper vagina, uterus rest"),
    bul("<b>Pubovisceral fibers</b> — squeeze rectum, vagina, urethra against pubic bone"),
    bul("Damage → <b>widening of hiatus urogenitalis</b> → vagina pushed down → organs prolapse"),
    high("Recto-genitourinary hiatus enlargement = key anatomic predisposition"),
]
right1 = [
    mini("Levator Plate"),
    bul("Formed by medial fibers of two levator ani muscles"),
    bul("Is the <b>anococcygeal raphe</b> extending from anorectal junction to coccyx"),
    bul("Horizontal position prevents prolapse; when damaged → organs descend"),
    sp(2),
    mini("Biomechanical Note"),
    bul("Delancey (1992): three levels of uterovaginal support"),
    bul("<b>Level I</b>: cardinal/uterosacral ligaments (upper vagina/uterus)"),
    bul("<b>Level II</b>: lateral attachment of mid-vagina (paravaginal)"),
    bul("<b>Level III</b>: fusion of distal vagina to surrounding structures"),
    high("Loss of normal vaginal axis → prolapse"),
]
story += [two_col(left1, right1), sp(4)]

# ── 2. ETIOLOGY TABLE ─────────────────────────────────────────────
story += [sec("2. ETIOLOGY OF PELVIC ORGAN PROLAPSE (POP) — TABLE 16.1"), sp(2)]
story.append(tbl(
    ["Anatomical Factors", "Predisposing Factors (Acquired/Congenital)", "Aggravating Factors"],
    [
        ["Gravitational stress (bipedal posture)",
         "ACQUIRED: Vaginal delivery trauma → ligaments, endopelvic fascia, levator muscle, nerve (pudendal) injury",
         "Postmenopausal atrophy"],
        ["Anterior pelvic inclination directing force anteriorly",
         "Overstretching Mackenrodt's & uterosacral ligaments (premature pushing, forceps, prolonged 2nd stage, precipitate labor)",
         "Poor collagen repair with age"],
        ["Stress of parturition — max damage to puborectal fibers",
         "CONGENITAL: Genetic connective tissue disorders, ↓ Type I collagen ratio",
         "↑ Intra-abdominal pressure: COPD, constipation, occupation (weight lifting)"],
        ["Pelvic floor weakness → urogenital hiatus ↑ + ↓ obstetric axis through hiatus",
         "Spina bifida",
         "Obesity, smoking; Uterine weight ↑ (fibroids, myohyperplasia); Multiparity"],
        ["Inherent weakness of supporting structures", "—", "These act where supports are already weakened"],
    ],
    widths=[W*0.27, W*0.40, W*0.33]
))
story += [sp(2), note("MOST IMPORTANT acquired factor = Vaginal delivery with injury to supporting structures. Prolapse unusual after cesarean delivery."), sp(4)]

# ── 3. CLINICAL TYPES ─────────────────────────────────────────────
story += [sec("3. CLINICAL TYPES OF PELVIC ORGAN PROLAPSE"), sp(2)]
story.append(tbl(
    ["Type", "Location / Structure", "Description"],
    [
        ["VAGINAL — ANTERIOR WALL","",""],
        ["Cystocele","Upper 2/3 of anterior vaginal wall","Laxity of upper 2/3 → herniation of bladder base through lax anterior wall (most common)"],
        ["Urethrocele","Lower 1/3 of anterior vaginal wall","Laxity of lower 1/3 → urethra herniates through it (often with cystocele = cystourethrocele)"],
        ["VAGINAL — POSTERIOR WALL","",""],
        ["Relaxed Perineum","Perineal body","Torn perineal body → gaping introitus with bulge of lower posterior vaginal wall"],
        ["Rectocele","Middle 1/3 posterior vaginal wall","Laxity of middle 1/3 + adjacent rectovaginal septum → herniation of rectum"],
        ["VAULT PROLAPSE","",""],
        ["Enterocele","Upper 1/3 posterior vaginal wall","Laxity of upper 1/3 → herniation of pouch of Douglas (omentum/small bowel); secondary to uterovaginal prolapse"],
        ["Secondary vault prolapse","After hysterectomy","Follows vaginal or abdominal hysterectomy; undetected enterocele at initial op → secondary vault prolapse"],
        ["UTERINE PROLAPSE","",""],
        ["Uterovaginal prolapse","Uterus, cervix, upper vagina","Most common type; cystocele occurs first, then traction on cervix causes retroversion → uterus descends"],
        ["Congenital prolapse","Nulliparous women","No cystocele; uterus descends with inverted vagina; congenital weakness of supports"],
    ],
    widths=[W*0.22, W*0.28, W*0.50]
))
story += [sp(4)]

# ── 4. DEGREES OF UTERINE PROLAPSE ───────────────────────────────
story += [sec("4. DEGREES OF UTERINE PROLAPSE (TABLE 16.2) & POP-Q STAGING (TABLE 16.3)"), sp(2)]
left4 = [
    mini("Clinical Degrees (Table 16.2)"),
    tbl(
        ["Degree", "Description"],
        [
            ["Normal", "External os at level of ischial spines; no prolapse"],
            ["1st Degree", "Uterus descends from normal position; external os still ABOVE introitus"],
            ["2nd Degree", "External os protrudes outside vaginal introitus; uterine body still inside"],
            ["3rd Degree\n(Procidentia)", "Uterine cervix AND fundus lie OUTSIDE introitus; complete prolapse"],
            ["Procidentia", "Prolapse of uterus with EVERSION of entire vagina"],
        ],
        widths=[W*0.22, W*0.26]
    ),
]
right4 = [
    mini("POP-Q Staging (ICS/AUGS/SGS 1996) — Table 16.3"),
    bul("Hymen = fixed reference point (zero level)"),
    bul("Measurements: NEGATIVE = above hymen; POSITIVE = below hymen"),
    bul("Measured with wooden PAP spatula; patient in lithotomy/standing; Valsalva maneuver"),
    tbl(
        ["Stage", "Description"],
        [
            ["0", "No descent of pelvic organs"],
            ["I", "Leading edge ≥1 cm ABOVE hymenal ring (≤ −1 cm)"],
            ["II", "Leading edge between −1 cm and +1 cm of hymenal ring"],
            ["III", "Leading edge >1 cm BEYOND hymenal ring; no complete eversion"],
            ["IV", "Essentially complete vaginal eversion"],
        ],
        widths=[W*0.08, W*0.38]
    ),
    high("POP-Q recommended by ICS — objective, site-specific, anatomical"),
]
story += [two_col(left4, right4, lw=W*0.50, rw=W*0.46), sp(4)]

# ── 5. MORBID CHANGES ─────────────────────────────────────────────
story += [sec("5. MORBID CHANGES IN PROLAPSE"), sp(2)]
story.append(tbl(
    ["Structure", "Morbid Change"],
    [
        ["Vaginal Mucosa", "Stretched, thickened, dry, surface keratinization; may show pigmentation"],
        ["Decubitus Ulcer", "Trophic ulcer at dependent part of prolapsed mass; initial surface → cracks → infection → sloughing → ulceration; complete surface epithelium loss; diminished circulation due to constriction by vaginal opening"],
        ["Decubitus Mgmt", "(a) Cervical cytology to exclude malignancy (b) Colposcopy & directed biopsy if needed (c) Manual reduction (d) Vaginal pack with antiseptic glycerin + acriflavine or estrogen cream (postmenopausal)"],
        ["Cervix — Vaginal part", "Chronic congestion → hyperplasia & hypertrophy of fibromuscular components → bulky, congested; infection → blood-stained discharge from ulceration"],
        ["Cervix — Supravaginal part", "Elongated due to strain of cardinal ligaments trying to keep cervix in position + weight of uterus pulling it through vaginal axis"],
        ["Urinary — Bladder", "Incomplete emptying → sharp angulation of urethra against pubourethral ligament → bladder wall hypertrophy + trabeculation; incomplete evacuation → cystitis"],
        ["Urinary — Ureters", "Carried downwards with elongated Mackenrodt's ligaments → mechanically obstructed by hiatus of pelvic floor → compression by uterine arteries at crossing → hydroureteric changes; bladder infection → pyelitis/pyelonephritis; long-standing procidentia → uraemia"],
        ["Incarceration", "Infection of paravaginal/cervical tissues → entire prolapsed mass becomes edematous/congested → IRREDUCIBLE"],
        ["Peritonitis", "Rarely, peritoneal infection (pelvic peritonitis) through posterior vaginal wall"],
        ["Carcinoma", "Rarely develops on decubitus ulcer"],
    ],
    widths=[W*0.25, W*0.75]
))
story += [sp(4)]

# ── 6. SYMPTOMS ───────────────────────────────────────────────────
story += [sec("6. SYMPTOMS OF GENITAL PROLAPSE"), sp(2)]
left6 = [
    mini("General Symptoms"),
    bul("<b>Something coming down</b> per vaginum (worse when moving/walking; comes out when mass outside introitus)"),
    bul("<b>Backache or dragging pain</b> in pelvis"),
    bul("Both above relieved on <b>lying down</b>"),
    bul("Dyspareunia"),
    sp(2),
    mini("Urinary Symptoms (with cystocele)"),
    bul("<b>Difficulty</b> passing urine — more straining = less evacuation; patient elevates anterior vaginal wall to void"),
    bul("<b>Incomplete evacuation</b> → frequent desire to urinate"),
    bul("<b>Urgency and frequency</b> — may be due to cystitis"),
    bul("<b>Painful micturition</b> — due to infection"),
    bul("<b>Stress incontinence</b> — associated urethrocele"),
    bul("<b>Retention</b> of urine may rarely occur"),
]
right6 = [
    mini("Bowel Symptoms (with rectocele)"),
    bul("Difficulty passing stool — must push back posterior vaginal wall to complete evacuation"),
    bul("Fecal incontinence may be associated"),
    sp(2),
    mini("Discharge"),
    bul("Excessive white or blood-stained discharge per vaginam — associated vaginitis or decubitus ulcer"),
    sp(2),
    mini("Important Exam Points"),
    high("Minor prolapse may be asymptomatic — even severe degree may have no symptoms"),
    high("Prolapse of one organ (uterus) usually associated with adjacent organ prolapse (bladder, rectum)"),
    high("Symptoms RELIEVED on lying down — classic for prolapse"),
    bul("Etiological aspect + risk factors should always be evaluated"),
]
story += [two_col(left6, right6), sp(4)]

# ── 7. CLINICAL EXAMINATION & DIAGNOSIS ──────────────────────────
story += [sec("7. CLINICAL EXAMINATION & DIAGNOSIS OF POP"), sp(2)]
left7 = [
    mini("Examination Protocol"),
    bul("<b>Composite examination</b>: inspection + palpation; vaginal, rectal, rectovaginal, or under anesthesia"),
    bul("<b>General examination</b>: BMI, signs of myopathy/neuropathy, COPD features, abdominal mass"),
    bul("<b>POP evaluated</b> in both dorsal AND standing positions"),
    bul("Patient strains (Valsalva) during examination — helps demonstrate prolapse not seen at rest"),
    bul("<b>Negative finding on dorsal inspection</b> → reconfirm by asking to strain on squatting position"),
    sp(2),
    mini("Pelvic Exam Assesses:"),
    bul("Staging (POP-Q), levator ani muscle tone, urinary incontinence"),
    bul("Decubitus ulcer, uterine size, mobility, perineal body, anal sphincter tone"),
]
right7 = [
    mini("Specific Examination Findings"),
    bul("<b>Cystocele</b>: bulge on anterior vaginal wall; ↑ when straining; use Sims' speculum in lateral position to demonstrate"),
    bul("<b>Cystourethrocele</b>: bulging of entire anterior wall + lower third; urine escapes through urethral meatus on coughing (bladder must be full to test)"),
    bul("<b>Relaxed perineum</b>: gaping introitus; old scar of perineal tear; ↓ distance introitus → anal verge; lower posterior vaginal wall visible"),
    bul("<b>Rectocele vs Enterocele</b>: transverse sulcus between two with midvaginal one being rectocele (diffuse margins, reducible); enterocele closer to cervix, cannot reach by finger in rectum"),
    high("3rd degree: thumb anteriorly + fingers posteriorly outside introitus = apposed = 3rd degree prolapse"),
    bul("<b>Levator ani tone</b>: index + middle fingers inside vagina, thumb outside; pubovaginalis palpated in lower 1/3"),
]
story += [two_col(left7, right7), sp(4)]

# ── 8. DIFFERENTIAL DIAGNOSIS ─────────────────────────────────────
story += [sec("8. DIFFERENTIAL DIAGNOSIS"), sp(2)]
story.append(tbl(
    ["Condition", "vs Prolapse", "Distinguishing Features"],
    [
        ["Gartner's Cyst (vs Cystocele)",
         "Cyst in anterior vaginal wall — retention cyst in Wolffian duct remnants",
         "Situated anteriorly/anterolaterally; variable size; rugosities of vaginal mucosa LOST over it; mucosa tense & shiny; well-defined margins; NOT reducible; NO impulse on coughing; metal catheter tip per urethra FAILS to come underneath vaginal mucosa"],
        ["Congenital cervical elongation (vs Uterine prolapse)",
         "Cervix elongated WITHOUT actual uterine descent",
         "Not associated with prolapse (usually); vaginal part elongated; external os below ischial spines; vaginal fornices narrow & deep; cervix CONICAL; uterine body NORMAL size & position; Rectal exam — NO prolapse"],
        ["Chronic inversion (vs Uterine prolapse)",
         "Inverted uterus prolapsing through introitus",
         "Leading protruding mass is BROAD; NO opening visible; internal exam — cervical rim on top around mass; rectal exam — absence of uterine body + cup-like depression"],
        ["Fibroid polyp (vs Uterine prolapse)",
         "Pedunculated fibroid through cervix/introitus",
         "Mass is SHAGGY with broad leading part; NO opening visible; internal exam — pedicle from cervical canal or cervix; rectal exam — normal uterine shape and position"],
    ],
    widths=[W*0.22, W*0.28, W*0.50]
))
story += [sp(4)]

# ── 9. MANAGEMENT ─────────────────────────────────────────────────
story += [sec("9. MANAGEMENT OF PROLAPSE"), sp(2)]

# 9A: Prevention + Conservative
left9 = [
    mini("A. Preventive Measures"),
    bul("<b>Adequate antenatal/intranatal care</b>: avoid injury during vaginal delivery"),
    bul("<b>Adequate postnatal care</b>: early ambulation; encourage pelvic floor exercises (Kegel's) in puerperium"),
    bul("General: avoid strenuous activities, chronic cough, constipation, heavy lifting"),
    bul("Avoid future pregnancy too soon/too many — contraceptive practice"),
    sp(2),
    mini("B. Conservative Management"),
    bul("<b>Indications:</b> Asymptomatic women; old woman not willing for surgery; mild degree prolapse; POP in early pregnancy"),
    bul("<b>Estrogen replacement therapy</b> may improve minor degree prolapse in postmenopausal women"),
    bul("<b>Pelvic floor exercises (Kegel's)</b>: strengthen muscles"),
    bul("<b>Pessary treatment</b>: cannot CURE but relieves symptoms by stretching hiatus urogenitalis → prevents descent"),
    sp(2),
    mini("Pessary — Indications of Use"),
    bul("Early pregnancy — up to 18 weeks (until uterus sits on brim of pelvis)"),
    bul("Puerperium — to facilitate involution"),
    bul("Patients absolutely unfit for surgery (short life expectancy)"),
    bul("Patient's unwillingness for operation"),
    bul("While waiting for operation"),
    bul("<i>Additional benefits</i>: improvement of urinary symptoms (voiding problems, urgency)"),
]

right9 = [
    mini("C. Surgical Management"),
    bul("Surgery = treatment of symptomatic prolapse where conservative management failed/not indicated"),
    bul("<b>(A) Restorative</b>: correcting own support / compensatory (permanent graft material)"),
    bul("<b>(B) Extirpative</b>: removing uterus and correcting support"),
    bul("<b>(C) Obliterative</b>: closing the vagina (colpocleisis)"),
    high("No single procedure for ALL types of prolapse"),
    bul("<b>Factors determining surgery choice:</b> Patient's age, parity, degree & type of prolapse, any prior surgery, associated factors (urinary/fecal incontinence, PID), comorbidities (cardiac disease)"),
    sp(2),
    mini("Anterior Colporrhaphy"),
    bul("Designed to correct cystocele and urethrocele"),
    bul("Principle: excise relaxed anterior vaginal wall → mobilize bladder upward after cutting vesicovervical ligament → support bladder by plicating endopelvic fascia and pubocervical fascia under bladder neck in midline"),
    bul("<b>Steps:</b> GA/epidural; lithotomy; antiseptic swab; sterile perineum draped; empty bladder by metal catheter; vaginal exam for degree of prolapse"),
    high("Sims' speculum introduced; anterior lip of cervix held by multiple-toothed vulsellum; metal catheter to know lower limit of bladder; inverted 'I' incision on anterior vaginal wall"),
]
story += [two_col(left9, right9), sp(4)]

# ── 10. SURGICAL REPAIR TABLE ─────────────────────────────────────
story += [sec("10. TYPE OF PROLAPSE & SURGICAL REPAIR PROCEDURES (TABLE 16.4)"), sp(2)]
story.append(tbl(
    ["Organ Descent", "Clinical Condition", "Type of Operation"],
    [
        ["VAGINAL WALL — Anterior (Upper 2/3) or whole", "Cystocele / Cystourethrocele / Paravaginal defect", "• Anterior colporrhaphy\n• Paravaginal defect repair"],
        ["Posterior (Lower 2/3)", "Rectocele", "• Colpoperineorrhaphy"],
        ["Posterior (Upper 1/3)", "Enterocele", "• Vaginal repair of enterocele with PFR\n• McCall culdoplasty\n• Moskowitz procedure"],
        ["Combined anterior and posterior", "Cystocele and rectocele", "• PFR (combined procedure)"],
        ["UTEROVAGINAL — Uterus along with vaginal walls", "Uterovaginal prolapse", "• Vaginal hysterectomy with PFR (elderly, family completed)\n• Fothergill's operation (preservation of uterus)"],
        ["VAGINAL WALL — Following hysterectomy (vaginal or abdominal)", "Vault prolapse (secondary)", "Vaginal: (i) Repair of vaginal vault along with PFR  (ii) Sacrospinous colpopexy  (iii) Colpocleisis (Le Fort)\nAbdominal: (i) Sacral colpopexy"],
        ["Uterus (without vaginal walls)", "Congenital or nulliparous prolapse (young women)", "• Cervicopexy or Sling (Purandare's) operation"],
        ["Pelvic organ prolapse (POP) with stress incontinence", "POP with stress incontinence", "Vaginal: TOT operation\nAbdominal: Burch operation"],
    ],
    widths=[W*0.25, W*0.30, W*0.45]
))
story += [sp(2), note("Abbreviations: PFR = Pelvic Floor Repair; TOT = Transobturator Tape Procedure"), sp(4)]

# ── 11. HIGH-YIELD RAPID RECALL ───────────────────────────────────
story += [sec("11. HIGH-YIELD EXAM RAPID RECALL"), sp(2)]
story.append(tbl(
    ["Key Point", "Fact to Remember"],
    [
        ["Most important acquired cause", "Vaginal delivery — injury to supporting structures"],
        ["Prolapse unusual after", "Cesarean delivery"],
        ["Congenital cause", "Genetic connective tissue disorders; ↓ Type I collagen; Spina bifida"],
        ["Levator plate position", "Horizontal — prevents prolapse; damage → organs descend"],
        ["Cystocele = laxity of", "Upper 2/3 of anterior vaginal wall (bladder herniates)"],
        ["Urethrocele = laxity of", "Lower 1/3 of anterior vaginal wall (urethra herniates)"],
        ["Rectocele = laxity of", "Middle 1/3 of posterior vaginal wall (rectum herniates)"],
        ["Enterocele = laxity of", "Upper 1/3 of posterior vaginal wall (pouch of Douglas herniates)"],
        ["Procidentia", "3rd degree uterine prolapse + complete eversion of vagina"],
        ["Prolapse diagnosis criterion", "Thumb anteriorly + fingers posteriorly APPOSED outside introitus = 3rd degree"],
        ["POP-Q reference point", "Plane of hymen = ZERO level (negative = above, positive = below)"],
        ["POP-Q Stage IV", "Essentially complete eversion of vagina"],
        ["POP-Q recommended by", "ICS, AUGS, SGS (1996) — objective, site-specific, anatomical"],
        ["Decubitus ulcer management", "Cytology to exclude malignancy → manual reduction → vaginal pack (antiseptic glycerin + acriflavine)"],
        ["Ureteric complication", "Hydroureteric changes; pyelonephritis; uraemia (long-standing procidentia)"],
        ["Symptom classic for prolapse", "Comes down when walking; RELIEVED on lying down"],
        ["Stress incontinence associated with", "Urethrocele (cystourethrocele)"],
        ["Gartner's cyst vs cystocele", "Gartner's: no rugosities, shiny, NOT reducible, NO impulse on cough, metal catheter does NOT pass under"],
        ["Pessary does NOT cure prolapse", "Only relieves symptoms; cannot cure"],
        ["No single operation for all", "Type, degree, age, parity, comorbidities determine surgical choice"],
        ["Surgery type: Obliterative", "Colpocleisis — closing the vagina"],
        ["Surgery: young nulliparous", "Cervicopexy or Sling (Purandare's) operation"],
        ["Surgery: vault prolapse (vaginal)", "Sacrospinous colpopexy, Le Fort colpocleisis, or vault repair + PFR"],
        ["Surgery: uterovaginal (elderly)", "Vaginal hysterectomy with PFR"],
        ["Fothergill's operation", "Preserves uterus — for uterovaginal prolapse"],
        ["TOT operation indication", "POP with stress incontinence (vaginal approach)"],
    ],
    widths=[W*0.40, W*0.60]
))
story += [sp(4)]
story.append(note("Notes compiled from Chapter 16: Displacement of the Uterus — Textbook of Gynecology. Focus on: Types of prolapse & their exact anatomical locations, POP-Q stages, degrees of uterine prolapse, differential diagnosis features, and surgical procedure matching."))

doc.build(story)
print(f"Done: {OUTPUT}")