"heavy menstrual bleeding" AND management

mkdir -p /home/daytona/workspace/hmb-presentation && ls /home/daytona/workspace/…

~/hmb-presentation/build.js

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Heavy Menstrual Bleeding – Case Presentation";
pres.author = "Residency Education";

// ─── COLOUR PALETTE ───
const DEEP_RED   = "7B0D1E";   // dominant dark accent
const BURGUNDY   = "9C2E3D";   // supporting
const CREAM      = "FAF5EF";   // light bg
const OFF_WHITE  = "F5EDE3";
const DARK_TEXT  = "1A1A1A";
const MID_GREY   = "555555";
const LIGHT_GREY = "E8DDD4";
const ACCENT_GOLD= "C8922A";
const WHITE      = "FFFFFF";
const SLIDE_BG   = "F9F4EE";

// ─── HELPERS ───
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function addFooter(slide, text) {
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// ════════════════════════════════════════════
// SLIDE 1 – TITLE
// ════════════════════════════════════════════
{
  const s = pres.addSlide();
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    fontSize: 13, charSpacing: 5, color: ACCENT_GOLD, bold: true,
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  s.addText("Heavy Menstrual\nBleeding", {
    x: 0.6, y: 1.25, w: 8.5, h: 1.55,
    fontSize: 44, bold: true, color: WHITE, fontFace: "Calibri",
    margin: 0, valign: "middle"
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  s.addText("FIGO PALM-COEIN Classification  |  Evaluation  |  Evidence-Based Management", {
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    fontSize: 12, color: CREAM, fontFace: "Calibri", margin: 0
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  s.addText("For Residents & Postgraduates  |  Obstetrics & Gynecology", {
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}

// ════════════════════════════════════════════
// SLIDE 2 – CASE PRESENTATION
// ════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s);
  addTopBar(s, "Case Presentation", "A 34-year-old woman referred by her GP with a 14-month history of worsening menstrual bleeding");
  addFooter(s);

  // Two columns
  sectionBox(s, "PRESENTING COMPLAINT", 0.3, 1.65, 4.55, 3.65, WHITE);
  sectionBox(s, "OBSTETRIC & GYNAECOLOGY HISTORY", 5.12, 1.65, 4.55, 3.65, WHITE);

  s.addText([
    bullet("Mrs. S.A., 34 years old, G2P2", 0, true),
    bullet("14-month history of progressively heavier periods", 0),
    bullet("Cycles: regular, every 26-28 days", 0),
    bullet("Duration: 8-10 days (was 5 days)", 0),
    bullet("Flooding through pads/tampons hourly for first 3 days", 0),
    bullet("Passing large clots (>2.5 cm) frequently", 0),
    bullet("Associated symptoms:", 0, true),
    bullet("Fatigue, lethargy, dyspnoea on exertion", 1),
    bullet("Pelvic pressure/bloating", 1),
    bullet("No intermenstrual or post-coital bleeding", 1),
    bullet("No post-menopausal symptoms", 1),
  ], {
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    fontFace: "Calibri", fontSize: 14, color: DARK_TEXT, valign: "top"
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  s.addText([
    bullet("LMP: 10 days ago (just ending)", 0),
    bullet("Menarche: age 13, regular cycles", 0),
    bullet("Pregnancies: 2 SVDs, no complications", 0),
    bullet("No prior gynaecological surgery", 0),
    bullet("Contraception: barrier method", 0),
    bullet("Smear: up to date – no abnormality", 0),
    bullet("Relevant medical history:", 0, true),
    bullet("No known coagulopathy", 1),
    bullet("No thyroid disease", 1),
    bullet("No diabetes or hypertension", 1),
    bullet("Drug history: NSAIDs prn", 1),
    bullet("Family history: sister with uterine fibroids", 1),
  ], {
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}

// ════════════════════════════════════════════
// SLIDE 3 – DEFINITION & EPIDEMIOLOGY
// ════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s);
  addTopBar(s, "Definition & Epidemiology of HMB", "Previously termed 'menorrhagia' — now aligned with FIGO/ACOG terminology");
  addFooter(s);

  // Definition box
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  s.addText([
    { text: "HMB is defined as ", options: { color: CREAM, fontSize: 15 } },
    { text: "excessive menstrual blood loss >80 mL/cycle or lasting >7-8 days", options: { color: ACCENT_GOLD, bold: true, fontSize: 15 } },
    { text: " that interferes with a woman's physical, emotional, social and material quality of life.", options: { color: CREAM, fontSize: 15 } }
  ], {
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    fontFace: "Calibri", align: "center", valign: "middle", margin: 4
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  // Three stat boxes
  const statsData = [
    { val: "1 in 5", desc: "women of reproductive age affected" },
    { val: "50%", desc: "of heavy bleeding is due to ovulatory dysfunction (COEIN)" },
    { val: "30-70%", desc: "incidence of uterine leiomyomas; most common structural cause" },
  ];
  statsData.forEach((st, i) => {
    const bx = 0.3 + i * 3.2;
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  s.addText([
    bullet("Normal: cycle 24-38 days; flow 4-8 days; average blood loss ~35 mL", 0),
    bullet("Abnormal: blood loss >80 mL/cycle; flow >7 days; OR significant QoL impairment", 0),
    bullet("Term 'dysfunctional uterine bleeding' is NO LONGER recommended (replaced by AUB/HMB)", 0),
    bullet("5-20% of women with HMB have an undiagnosed bleeding disorder (primarily von Willebrand disease)", 0),
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}

// ════════════════════════════════════════════
// SLIDE 4 – PALM-COEIN CLASSIFICATION
// ════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s);
  addTopBar(s, "FIGO PALM-COEIN Classification (2011)", "Structural vs. Non-structural causes of Abnormal Uterine Bleeding");
  addFooter(s);

  // PALM column
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    fontSize: 14, bold: true, color: WHITE, fontFace: "Calibri",
    align: "center", margin: 0
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  const palmItems = [
    { letter: "P", term: "Polyp (AUB-P)", detail: "Endometrial/cervical polyps; diagnosed on TVUS/hysteroscopy" },
    { letter: "A", term: "Adenomyosis (AUB-A)", detail: "Endometrial glands in myometrium; enlarged boggy uterus" },
    { letter: "L", term: "Leiomyoma (AUB-L)", detail: "Submucosal (SM-leiomyoma) most likely to cause HMB" },
    { letter: "M", term: "Malignancy & Hyperplasia (AUB-M)", detail: "Rule out endometrial Ca especially in risk groups" },
  ];
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  // COEIN column
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    { letter: "C", term: "Coagulopathy (AUB-C)", detail: "vWD in 5-20%; consider if HMB since menarche" },
    { letter: "O", term: "Ovulatory Dysfunction (AUB-O)", detail: "Most common (50%); PCOS, thyroid disease, hyperprolactinaemia" },
    { letter: "E", term: "Endometrial (AUB-E)", detail: "Primary endometrial haemostatic defects; normal ovulation" },
    { letter: "I", term: "Iatrogenic (AUB-I)", detail: "Anticoagulants, copper IUD, SSRIs, antipsychotics" },
    { letter: "N", term: "Not otherwise classified (AUB-N)", detail: "Rare/poorly understood entities (AVM, CSP)" },
  ];
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// ════════════════════════════════════════════
// SLIDE 5 – PHYSICAL EXAMINATION
// ════════════════════════════════════════════
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  addSlideBg(s);
  addTopBar(s, "Physical Examination Findings", "Mrs. S.A. — Findings on presentation");
  addFooter(s);

  const examData = [
    { sys: "General", findings: "Pallor (conjunctival, palmar) | Mild tachycardia (HR 96 bpm) | BP 108/70 mmHg | No jaundice or lymphadenopathy" },
    { sys: "Abdomen", findings: "Soft, non-tender | Palpable pelvic-abdominal mass arising from pelvis (~16 weeks size) | No ascites" },
    { sys: "Speculum", findings: "No post-coital/intermenstrual bleeding | Cervix appears normal | Smear up to date" },
    { sys: "Bimanual", findings: "Uterus enlarged (~16-wk size), irregular contour, firm, non-tender | Bilateral adnexa not separately palpable | No cervical excitation" },
    { sys: "Vital Signs", findings: "SpO₂ 98% on air | RR 16 | Temp 36.8°C | BMI 27 kg/m²" },
  ];

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// ════════════════════════════════════════════
// SLIDE 6 – INVESTIGATIONS
// ════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s);
  addTopBar(s, "Investigations", "Systematic approach — first-line to specialist");
  addFooter(s);

  const cols = [
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      title: "1st Line (All Patients)",
      color: DEEP_RED,
      items: [
        "FBC → Hb 9.2 g/dL (iron-deficiency anaemia)",
        "Urine pregnancy test → Negative",
        "Cervical smear (if due)",
        "TSH → Normal (3.1 mIU/L)",
        "Prolactin → Normal",
        "Coagulation screen (PT/APTT)",
        "Ferritin → 6 µg/L (low)",
        "Blood group & save",
      ]
    },
    {
      title: "2nd Line (Based on History)",
      color: BURGUNDY,
      items: [
        "TVUS → Multiple intramural & submucosal fibroids; largest 6 cm",
        "Endometrial thickness: 8 mm (secretory phase)",
        "No endometrial polyp on US",
        "Ovaries appear normal bilaterally",
        "vWD screen (if HMB since menarche)",
        "Pelvic MRI if TVUS inadequate or pre-op",
        "Prolactin if anovulatory pattern",
        "Androgens / DHEAS if PCOS suspected",
      ]
    },
    {
      title: "Endometrial Assessment",
      color: ACCENT_GOLD,
      items: [
        "Endometrial biopsy indicated if:",
        "Age ≥ 45 yrs with AUB",
        "Failed medical management",
        "Risk factors: obesity, PCOS, unopposed oestrogen",
        "Hysteroscopy: direct visualisation + guided biopsy",
        "Pipelle biopsy: 90% sensitivity for endometrial Ca",
        "Saline infusion sonography (SIS) for polyps",
        "Our patient: Pipelle biopsy → benign proliferative endometrium",
      ]
    }
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// ════════════════════════════════════════════
// SLIDE 7 – DIAGNOSIS
// ════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s);
  addTopBar(s, "Working Diagnosis", "Integrating history, examination & investigations");
  addFooter(s);

  // Big diagnosis banner
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    fill: { color: DEEP_RED }, line: { width: 0 }
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    fill: { color: ACCENT_GOLD }, line: { width: 0 }
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  s.addText("DIAGNOSIS: Heavy Menstrual Bleeding (AUB-L)", {
    x: 0.5, y: 1.58, w: 9, h: 0.5,
    fontSize: 22, bold: true, color: WHITE, fontFace: "Calibri",
    align: "center", margin: 0
  });
  s.addText("Uterine Leiomyomata (Fibroids) — FIGO Classification: AUB-L (SM-leiomyoma + intramural) | Secondary Iron-Deficiency Anaemia", {
    x: 0.5, y: 2.1, w: 9, h: 0.5,
    fontSize: 12, color: CREAM, fontFace: "Calibri",
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  // Supporting evidence + differentials
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  sectionBox(s, "DIFFERENTIAL DIAGNOSIS", 6.05, 2.85, 3.7, 2.55, WHITE);

  s.addText([
    bullet("Regular cycles with progressive HMB — structural cause likely", 0),
    bullet("Palpable irregular uterine mass (~16 wk size)", 0),
    bullet("TVUS confirms multiple fibroids; largest 6 cm submucosal", 0),
    bullet("Hb 9.2 g/dL with ferritin 6 µg/L → iron-deficiency anaemia", 0),
    bullet("Benign proliferative endometrium on Pipelle biopsy", 0),
    bullet("Family history: sister with fibroids", 0),
    bullet("No post-coital/intermenstrual bleeding → low cancer risk", 0),
  ], {
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    fontFace: "Calibri", fontSize: 13, color: DARK_TEXT, valign: "top"
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  s.addText([
    bullet("Adenomyosis (AUB-A)", 0),
    bullet("Endometrial polyp (AUB-P)", 0),
    bullet("Coagulopathy / vWD (AUB-C)", 0),
    bullet("Ovulatory dysfunction (AUB-O)", 0),
    bullet("Endometrial hyperplasia/Ca (AUB-M)", 0),
    bullet("Thyroid dysfunction", 0),
  ], {
    x: 6.12, y: 3.2, w: 3.5, h: 2.12,
    fontFace: "Calibri", fontSize: 13, color: DARK_TEXT, valign: "top"
  });
}

// ════════════════════════════════════════════
// SLIDE 8 – MANAGEMENT OVERVIEW
// ════════════════════════════════════════════
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  addTopBar(s, "Management: Stepwise Approach", "Medical → Minimally Invasive → Surgical");
  addFooter(s);

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      title: "Acute Stabilisation",
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      items: ["Correct anaemia: IV iron infusion (Ferric carboxymaltose) or oral iron", "Consider transfusion if Hb <7 or haemodynamic instability", "Tranexamic acid 1–1.3 g q6-8h for 5 days (antifibrinolytic)", "High-dose conjugated oestrogen 25 mg IV q4-6h for severe acute haemorrhage", "Hormonal haemostasis: combined OCP or progestin-only pill"]
    },
    {
      no: "2",
      title: "Medical (Long-Term)",
      color: BURGUNDY,
      items: ["Levonorgestrel IUS (Mirena®): first-line — 71–95% reduction in MBL; ~50% amenorrhoea", "Tranexamic acid 1.3 g TDS × 3–5 days per cycle (non-hormonal)", "NSAIDs: mefenamic acid 500 mg TDS or ibuprofen 400 mg q6h — 20–52% reduction", "Combined OCP: 35–69% reduction in MBL; also treats dysmenorrhoea", "GnRH agonists (e.g. leuprolide): induces hypo-oestrogenic state; pre-op shrinkage; limited to 3–6 months (bone loss)"]
    },
    {
      no: "3",
      title: "Surgical / Interventional",
      color: ACCENT_GOLD,
      items: ["Hysteroscopic polypectomy / transcervical resection of fibroid (TCRF)", "Myomectomy (laparoscopic or open): fertility-preserving", "Uterine artery embolisation (UAE): if single large fibroid; post-embolisation syndrome risk", "Endometrial ablation: >90% reduction in MBL; not for fertility wishes", "Hysterectomy: definitive cure; preferred if family complete"]
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// ════════════════════════════════════════════
// SLIDE 9 – MANAGEMENT: OUR PATIENT
// ════════════════════════════════════════════
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  addSlideBg(s);
  addTopBar(s, "Management Plan for Mrs. S.A.", "Tailored to her diagnosis: AUB-L + Iron-Deficiency Anaemia");
  addFooter(s);

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        "Tranexamic acid 1.3 g TDS × 5 days at next cycle",
        "Ibuprofen 400 mg q6h for dysmenorrhoea",
        "Refer haematology if coagulopathy screen positive",
      ]
    },
    {
      title: "Short-Term (1-3 months)",
      color: BURGUNDY,
      items: [
        "Insert Levonorgestrel IUS (Mirena 52 mg) — FDA-approved for HMB",
        "71-95% reduction in MBL expected",
        "~50% amenorrhoea at 12 months",
        "GnRH agonist (Goserelin 3.6 mg/4 wk) for pre-op fibroid shrinkage if surgery planned",
        "Repeat FBC at 8 weeks",
      ]
    },
    {
      title: "Long-Term / If Medical Fails",
      color: ACCENT_GOLD,
      items: [
        "Hysteroscopic resection of submucosal fibroid (TCRF) — fertility-preserving",
        "Laparoscopic myomectomy for intramural fibroids",
        "UAE: discuss risks (post-embolisation syndrome, ovarian reserve)",
        "If family complete in future: hysterectomy is definitive",
        "Annual surveillance ultrasound for fibroid growth",
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      fontFace: "Calibri", valign: "top"
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// ════════════════════════════════════════════
// SLIDE 10 – PHARMACOLOGY SUMMARY
// ════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s);
  addTopBar(s, "Pharmacological Options — Summary", "Evidence-based drug therapy for HMB");
  addFooter(s);

  const drugs = [
    { drug: "LNG-IUS (Mirena®)", class: "Progestogen IUD", dose: "52 mg, releases 20 µg/24h", reduction: "71–95%", notes: "1st line if contraception needed; FDA approved for HMB" },
    { drug: "Tranexamic Acid", class: "Antifibrinolytic", dose: "1–1.3 g PO q6-8h × 5 days", reduction: "40–60%", notes: "Non-hormonal; no thromboembolic risk with PO route" },
    { drug: "NSAIDs (mefenamic acid)", class: "COX inhibitor", dose: "500 mg TDS from day 1", reduction: "10–52%", notes: "Reduces pain + bleeding; less useful in fibroids" },
    { drug: "Combined OCP", class: "Oestrogen + Progestogen", dose: "Daily cyclic/continuous", reduction: "35–69%", notes: "Reduces MBL + dysmenorrhoea; off-label for HMB" },
    { drug: "Medroxyprogesterone", class: "Progestogen", dose: "20 mg TDS × 10 days (acute)", reduction: "Moderate", notes: "Alternative if oestrogen contraindicated; oral or IM" },
    { drug: "GnRH agonist (Goserelin)", class: "GnRH analogue", dose: "3.6 mg SC q4wk", reduction: ">90% (amenorrhoea)", notes: "Pre-op use ≤6 months; add-back HRT if prolonged" },
  ];

  // Headers
  const headers = ["Drug", "Class", "Dose", "MBL Reduction", "Notes"];
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      valign: "middle", margin: 0
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      x: 0.25, y: yy, w: 9.5, h: 0.54,
      fill: { color: bg }, line: { color: LIGHT_GREY, width: 0.5 }
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        fontFace: "Calibri", valign: "middle", margin: 0, wrap: true
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// ════════════════════════════════════════════
// SLIDE 11 – SURGICAL OPTIONS
// ════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s);
  addTopBar(s, "Surgical & Minimally Invasive Options", "Uterus-preserving vs. Definitive Procedures");
  addFooter(s);

  const procs = [
    { name: "Hysteroscopic Polypectomy / TCRF", preserve: "YES", indication: "Submucosal fibroid, polyps", benefit: "Direct removal; outpatient", risk: "Uterine perforation; hyponatraemia (fluid overload); thermal injury" },
    { name: "Laparoscopic / Open Myomectomy", preserve: "YES", indication: "Intramural / subserosal fibroids, fertility wish", benefit: "Fertility-preserving; good symptom relief", risk: "Bleeding; conversion to hysterectomy <1%; fibroid recurrence" },
    { name: "Uterine Artery Embolisation (UAE)", preserve: "YES", indication: "Large/multiple fibroids; declines surgery", benefit: "Avoids GA; effective for bulk symptoms", risk: "Post-embolisation syndrome; impaired ovarian reserve; regrowth" },
    { name: "Endometrial Ablation", preserve: "YES*", indication: "AUB-O/E, completed family, normal cavity", benefit: ">90% MBL reduction; 25-35% amenorrhoea at 2 yrs", risk: "Not for fertility; thermal injury; NOT if malignancy suspected" },
    { name: "Hysterectomy (Total)", preserve: "NO", indication: "Completed family; failed/declined other options", benefit: "Definitive cure; 100% resolution of HMB", risk: "Surgical risk; menopause if bilateral salpingo-oophorectomy added" },
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      x: xs2[i] + 0.03, y: 1.54, w: ws2[i] - 0.06, h: 0.3,
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  procs.forEach((row, ri) => {
    const yy = 1.89 + ri * 0.7;
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      x: 0.22, y: yy, w: 9.56, h: 0.65,
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        fontFace: "Calibri", valign: "middle", margin: 0, wrap: true
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}

// ════════════════════════════════════════════
// SLIDE 12 – KEY LEARNING POINTS
// ════════════════════════════════════════════
{
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  addSlideBg(s);
  addTopBar(s, "Key Learning Points", "Summary for clinical practice");
  addFooter(s);

  const points = [
    { icon: "①", title: "Always use AUB/HMB terminology", body: "Avoid 'DUB' — use FIGO PALM-COEIN classification to guide investigation and management systematically." },
    { icon: "②", title: "Exclude malignancy first", body: "Endometrial biopsy is mandatory in women ≥45 yrs, or younger with risk factors (obesity, PCOS, unopposed oestrogen, family history)." },
    { icon: "③", title: "LNG-IUS is first-line medical therapy", body: "Levonorgestrel IUS gives 71-95% reduction in MBL. It is the most effective medical option and is FDA-approved for HMB." },
    { icon: "④", title: "Screen for coagulopathy", body: "5-20% of women with HMB have an undiagnosed bleeding disorder (vWD). Screen if HMB since menarche or family history." },
    { icon: "⑤", title: "Treat concurrent iron-deficiency anaemia", body: "IV iron (ferric carboxymaltose) corrects IDA faster than oral iron and avoids GI side effects — essential before any surgery." },
    { icon: "⑥", title: "Tailor management to fertility wishes", body: "Always discuss fertility plans. Uterus-preserving options (myomectomy, UAE, TCRF, LNG-IUS) must be offered before hysterectomy." },
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// ════════════════════════════════════════════
// SLIDE 13 – REFERENCES / CLOSER
// ════════════════════════════════════════════
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    fontSize: 18, bold: true, color: ACCENT_GOLD, fontFace: "Calibri", margin: 0
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    "1.  Munro MG et al. FIGO Classification System (PALM-COEIN) for causes of AUB in non-gravid women. Int J Gynaecol Obstet 2011;113:3–13.",
    "2.  Berek & Novak's Gynecology, 16th ed. Chapter 10: Abnormal Uterine Bleeding & PALM-COEIN.",
    "3.  Tintinalli's Emergency Medicine, 9th ed. Chapter 96: Heavy & Anovulatory Menstrual Bleeding.",
    "4.  Bailey & Love's Short Practice of Surgery, 28th ed. Table 87.7: Investigation and Management of HMB.",
    "5.  Rosen's Emergency Medicine, 9th ed. Chapter 30: Abnormal Uterine Bleeding — PALM-COEIN.",
    "6.  ACOG Practice Bulletin No. 128: Diagnosis of Abnormal Uterine Bleeding. Obstet Gynecol 2012.",
    "7.  Goodman & Gilman's Pharmacological Basis of Therapeutics, 13th ed. Tranexamic acid for HMB.",
    "8.  Comishen KJ et al. Etiology and diagnosis of HMB — Systematic Review & Meta-Analysis. J Thromb Haemost 2025.",
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// ── WRITE FILE ──
pres.writeFile({ fileName: "/home/daytona/workspace/hmb-presentation/HMB_Case_Presentation.pptx" })
  .then(() => console.log("SUCCESS: file written"))
  .catch(e => console.error("ERROR:", e));

cd /home/daytona/workspace/hmb-presentation && node build.js 2>&1

ls -lh /home/daytona/workspace/hmb-presentation/HMB_Case_Presentation.pptx