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PMID: 39106301

progestin-only pill norethindrone desogestrel novel contraceptive

segesterone acetate NuvaRing Annovera contraceptive ring

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newer contraceptives 2023 2024 2025 Phexxi Annovera drospirenone-only pill Slynd new IUD FDA approved

mkdir -p /home/daytona/workspace/newer-contraceptives-ppt

~/newer-contraceptives-ppt/create_ppt.js

const pptxgen = require("pptxgenjs");

let pres = new pptxgen();
pres.layout = 'LAYOUT_16x9';
pres.author = 'Gynaecology Education';
pres.title = 'Newer Contraceptives in Gynaecology';

// ── COLOUR PALETTE ──────────────────────────────────────────────────
const DEEP_TEAL   = "1A5276";   // dominant dark background
const MED_TEAL    = "1E8BC3";   // section headers
const LIGHT_TEAL  = "D6EAF8";   // content panels
const ACCENT_GOLD = "D4AC0D";   // accent / highlights
const WHITE       = "FFFFFF";
const DARK_TEXT   = "1C2833";
const GRAY        = "7F8C8D";
const SOFT_BLUE   = "EAF4FB";

// ── HELPER: add a slide background ──────────────────────────────────
function setDarkBg(slide) {
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DEEP_TEAL } });
}
function setLightBg(slide) {
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: SOFT_BLUE } });
  // left accent bar
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.12, h: 5.625, fill: { color: MED_TEAL } });
}
function addSlideNumber(slide, num) {
  slide.addText(`${num}`, { x: 9.5, y: 5.3, w: 0.4, h: 0.2, fontSize: 8, color: GRAY, align: "right" });
}
function addFooter(slide, text) {
  slide.addText(text, { x: 0.2, y: 5.35, w: 9.4, h: 0.2, fontSize: 7, color: GRAY, italic: true });
}

// ── SLIDE 1 — TITLE ─────────────────────────────────────────────────
{
  let s = pres.addSlide();
  setDarkBg(s);
  // Decorative circle
  s.addShape(pres.shapes.OVAL, { x: 7.2, y: -0.8, w: 3.6, h: 3.6, fill: { color: MED_TEAL }, line: { color: MED_TEAL } });
  s.addShape(pres.shapes.OVAL, { x: 7.6, y: -0.4, w: 2.8, h: 2.8, fill: { color: DEEP_TEAL }, line: { color: MED_TEAL } });
  // Gold accent line
  s.addShape(pres.shapes.RECTANGLE, { x: 0.5, y: 2.2, w: 1.8, h: 0.06, fill: { color: ACCENT_GOLD }, line: { color: ACCENT_GOLD } });
  s.addText("Newer Contraceptives", { x: 0.5, y: 0.7, w: 8, h: 1.0, fontSize: 40, bold: true, color: WHITE, fontFace: "Calibri" });
  s.addText("in Gynaecology", { x: 0.5, y: 1.65, w: 8, h: 0.75, fontSize: 34, bold: false, color: ACCENT_GOLD, fontFace: "Calibri" });
  s.addText("A Comprehensive Update\nReferences: Berek & Novak's Gynecology | CDC SPR 2024 | PubMed 2022–2026", {
    x: 0.5, y: 2.5, w: 8, h: 0.9, fontSize: 13, color: LIGHT_TEAL, italic: true
  });
  s.addText("Prepared: July 2026", { x: 0.5, y: 3.6, w: 4, h: 0.35, fontSize: 11, color: GRAY });
}

// ── SLIDE 2 — OVERVIEW / CLASSIFICATION ─────────────────────────────
{
  let s = pres.addSlide();
  setLightBg(s);
  s.addShape(pres.shapes.RECTANGLE, { x: 0.12, y: 0, w: 9.88, h: 0.72, fill: { color: DEEP_TEAL }, line: { color: DEEP_TEAL } });
  s.addText("Classification of Newer Contraceptives", { x: 0.25, y: 0.1, w: 9.5, h: 0.52, fontSize: 22, bold: true, color: WHITE });

  const cats = [
    { label: "Hormonal — Oral", items: ["Drospirenone-only pill (Slynd®)", "Low-dose combined pills (24/4 regimen)", "Extended/continuous cycle OCs"] },
    { label: "Hormonal — Non-oral", items: ["Annovera® 1-year vaginal ring", "Twirla® transdermal patch (EE+LNG)", "Etonogestrel implant (Nexplanon®)", "DMPA-SC (Sayana Press®)"] },
    { label: "Intrauterine Devices", items: ["52-mg LNG-IUD: Mirena®, Liletta®", "19.5-mg LNG-IUD: Kyleena®", "13.5-mg LNG-IUD: Skyla®", "Copper T380A (ParaGard®)"] },
    { label: "Non-hormonal", items: ["Phexxi® acid-buffering vaginal gel", "Annovera (hormone-free option context)", "Male contraceptives (emerging)"] },
    { label: "Emergency", items: ["Ulipristal acetate 30 mg (ellaOne®)", "LNG 1.5 mg up to 120 hrs", "Cu-IUD (most effective EC)"] },
  ];

  const colX = [0.2, 2.1, 4.0, 5.9, 7.8];
  const colW = 1.85;
  cats.forEach((cat, i) => {
    let x = colX[i];
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: x, y: 0.82, w: colW, h: 4.6, fill: { color: WHITE }, line: { color: MED_TEAL }, rectRadius: 0.08 });
    s.addShape(pres.shapes.RECTANGLE, { x: x, y: 0.82, w: colW, h: 0.5, fill: { color: MED_TEAL }, line: { color: MED_TEAL } });
    s.addText(cat.label, { x: x + 0.05, y: 0.86, w: colW - 0.1, h: 0.42, fontSize: 9.5, bold: true, color: WHITE, align: "center" });
    const bulletItems = cat.items.map((item, j) => ({
      text: item,
      options: { bullet: { type: "bullet" }, fontSize: 8.5, color: DARK_TEXT, breakLine: j < cat.items.length - 1 }
    }));
    s.addText(bulletItems, { x: x + 0.1, y: 1.42, w: colW - 0.2, h: 3.85, valign: "top" });
  });
  addFooter(s, "Berek & Novak's Gynecology, 16e | CDC SPR 2024 (MMWR 73[RR-3]) | Al-Haddad et al., Ther Adv Reprod Health 2023");
  addSlideNumber(s, 2);
}

// ── SLIDE 3 — SLYND (DROSPIRENONE-ONLY PILL) ─────────────────────────
{
  let s = pres.addSlide();
  setLightBg(s);
  s.addShape(pres.shapes.RECTANGLE, { x: 0.12, y: 0, w: 9.88, h: 0.72, fill: { color: "1A5276" }, line: { color: "1A5276" } });
  s.addText("Slynd® — Drospirenone-Only Pill (POP)", { x: 0.25, y: 0.1, w: 9.5, h: 0.52, fontSize: 21, bold: true, color: WHITE });

  // Left panel
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.85, w: 4.6, h: 4.55, fill: { color: WHITE }, line: { color: MED_TEAL } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.85, w: 4.6, h: 0.38, fill: { color: MED_TEAL }, line: { color: MED_TEAL } });
  s.addText("Key Features", { x: 0.3, y: 0.88, w: 4.4, h: 0.32, fontSize: 11, bold: true, color: WHITE });
  s.addText([
    { text: "Formulation: ", options: { bold: true, breakLine: false, fontSize: 10, color: DARK_TEXT } },
    { text: "Drospirenone 4 mg (24 active + 4 inert tablets)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "FDA Approved: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "May 2019 (Exeltis USA)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Mechanism: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Primary — ovulation suppression (unlike older norethindrone 0.35 mg POPs)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Missed-pill window: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "24 hours (vs 3 hours for norethindrone)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Half-life: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "25–30 hours (spironolactone analog)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Efficacy: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Pearl Index 4.0 (typical use); comparable to COCs\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Bleeding profile: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Scheduled withdrawal bleed; less irregular bleeding vs norethindrone POP", options: { fontSize: 10, color: DARK_TEXT } },
  ], { x: 0.3, y: 1.28, w: 4.4, h: 4.0, valign: "top" });

  // Right panel
  s.addShape(pres.shapes.RECTANGLE, { x: 5.0, y: 0.85, w: 4.8, h: 4.55, fill: { color: WHITE }, line: { color: MED_TEAL } });
  s.addShape(pres.shapes.RECTANGLE, { x: 5.0, y: 0.85, w: 4.8, h: 0.38, fill: { color: ACCENT_GOLD }, line: { color: ACCENT_GOLD } });
  s.addText("Clinical Advantages & Indications", { x: 5.1, y: 0.88, w: 4.6, h: 0.32, fontSize: 11, bold: true, color: WHITE });
  s.addText([
    { text: "✔ Estrogen-free — suitable for:", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "  • Migraines with aura\n  • Hypertension / cardiovascular risk\n  • Breastfeeding women (postpartum)\n  • VTE risk factors\n  • Heavy smokers >35 years\n", options: { fontSize: 9.5, color: DARK_TEXT, breakLine: true } },
    { text: "✔ Antimineralcorticoid activity:", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "  • May reduce bloating & water retention\n  • Potassium-monitoring needed in renal/adrenal disease\n", options: { fontSize: 9.5, color: DARK_TEXT, breakLine: true } },
    { text: "✔ WHO MEC Category:", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "  • Category 1 for most populations\n  • Category 4: unexplained vaginal bleeding\n", options: { fontSize: 9.5, color: DARK_TEXT, breakLine: true } },
    { text: "⚠ Limitation:", options: { bold: true, fontSize: 10, color: "E74C3C", breakLine: true } },
    { text: "  • Hyperkalemia risk (renal/hepatic/adrenal)\n  • Limited data in BMI > 35", options: { fontSize: 9.5, color: DARK_TEXT } },
  ], { x: 5.1, y: 1.28, w: 4.6, h: 4.0, valign: "top" });
  addFooter(s, "Pres et al., Contraception 2019 | CDC SPR 2024 | Berek & Novak 16e Ch.14");
  addSlideNumber(s, 3);
}

// ── SLIDE 4 — ANNOVERA VAGINAL RING ────────────────────────────────
{
  let s = pres.addSlide();
  setLightBg(s);
  s.addShape(pres.shapes.RECTANGLE, { x: 0.12, y: 0, w: 9.88, h: 0.72, fill: { color: "154360" }, line: { color: "154360" } });
  s.addText("Annovera® — 1-Year Contraceptive Vaginal Ring", { x: 0.25, y: 0.1, w: 9.5, h: 0.52, fontSize: 20, bold: true, color: WHITE });

  // Three-column layout
  const cols = [
    {
      title: "Pharmacology",
      color: MED_TEAL,
      items: [
        "Active agents: Segesterone acetate (SA) 103 mg + Ethinyl estradiol (EE) 17.4 mg",
        "Daily release: SA 150 μg + EE 13 μg",
        "Duration: Single ring used cyclically for 1 YEAR (13 cycles)",
        "3 weeks in / 1 week out per cycle",
        "EE dose among lowest of combined methods",
        "Segesterone = 19-nor progesterone derivative; highly selective progestin",
      ]
    },
    {
      title: "Efficacy & Safety",
      color: "1E8449",
      items: [
        "Pearl Index: 2.98 (Phase 3; n=2308 women)",
        "Cumulative pregnancy rate: ~3% over 1 year (typical use)",
        "Ovulation suppressed in >99% of cycles",
        "Common side effects: Headache, nausea, vaginal discharge",
        "VTE risk: Similar to other combined hormonal methods",
        "BMI >29 kg/m²: Limited data — consider alternative",
      ]
    },
    {
      title: "Clinical Use",
      color: "7D3C98",
      items: [
        "Advantage: No daily/weekly/monthly action required",
        "User-controlled — can insert/remove self",
        "Stored in provided case when removed (weekly out-week)",
        "Suitable for women desiring long-acting but reversible method",
        "NOT suitable if ring expulsion risk high (pelvic floor weakness)",
        "Ref: Jensen et al., J Womens Health 2023 (PMID 37253139)",
      ]
    }
  ];

  cols.forEach((col, i) => {
    let x = 0.2 + i * 3.25;
    s.addShape(pres.shapes.RECTANGLE, { x, y: 0.82, w: 3.15, h: 4.6, fill: { color: WHITE }, line: { color: col.color } });
    s.addShape(pres.shapes.RECTANGLE, { x, y: 0.82, w: 3.15, h: 0.4, fill: { color: col.color }, line: { color: col.color } });
    s.addText(col.title, { x: x + 0.05, y: 0.86, w: 3.05, h: 0.34, fontSize: 10.5, bold: true, color: WHITE, align: "center" });
    const bullets = col.items.map((item, j) => ({
      text: item,
      options: { bullet: { type: "bullet" }, fontSize: 8.5, color: DARK_TEXT, breakLine: j < col.items.length - 1 }
    }));
    s.addText(bullets, { x: x + 0.1, y: 1.27, w: 2.95, h: 4.05, valign: "top" });
  });
  addFooter(s, "Al-Haddad et al., Ther Adv Reprod Health 2023 (PMID 37465002) | Plagianos et al., Am J Obstet Gynecol 2024 (PMID 38295968) | Berek & Novak 16e");
  addSlideNumber(s, 4);
}

// ── SLIDE 5 — TWIRLA PATCH ─────────────────────────────────────────
{
  let s = pres.addSlide();
  setLightBg(s);
  s.addShape(pres.shapes.RECTANGLE, { x: 0.12, y: 0, w: 9.88, h: 0.72, fill: { color: "6E2F8A" }, line: { color: "6E2F8A" } });
  s.addText("Twirla® — Transdermal Contraceptive Patch (EE + LNG)", { x: 0.25, y: 0.1, w: 9.5, h: 0.52, fontSize: 20, bold: true, color: WHITE });

  // Left content
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.82, w: 5.8, h: 4.6, fill: { color: WHITE }, line: { color: "6E2F8A" } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.82, w: 5.8, h: 0.38, fill: { color: "6E2F8A" }, line: { color: "6E2F8A" } });
  s.addText("Details", { x: 0.3, y: 0.86, w: 5.6, h: 0.32, fontSize: 11, bold: true, color: WHITE });
  s.addText([
    { text: "Active agents: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Ethinyl estradiol 30 μg + Levonorgestrel 120 μg per day\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "FDA Approved: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "February 2020 (Agile Therapeutics)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Regimen: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "One patch per week × 3 weeks, then patch-free week (4-week cycle)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Mechanism: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Ovulation inhibition + cervical mucus thickening\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Efficacy (BMI <30): ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Pearl Index ~4.3 typical use\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Advantage vs old Ortho Evra: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "LNG used instead of norelgestromin — different progestin profile\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Common side effects: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Application site reactions, nausea, headache, breakthrough bleeding\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "VTE risk: ", options: { bold: true, fontSize: 10, color: "E74C3C", breakLine: false } },
    { text: "Higher than oral LNG-containing pills — Black Box Warning\n", options: { fontSize: 10, color: "E74C3C", breakLine: true } },
    { text: "Berek & Novak 16e note: ", options: { bold: true, fontSize: 9, color: DARK_TEXT, breakLine: false } },
    { text: "Patch and ring provide almost constant low steroid levels; better compliance than daily OC (88.2% vs 77.7% perfect compliance)", options: { fontSize: 9, color: DARK_TEXT } },
  ], { x: 0.3, y: 1.26, w: 5.6, h: 4.1, valign: "top" });

  // Right panel — warning box
  s.addShape(pres.shapes.RECTANGLE, { x: 6.15, y: 0.82, w: 3.65, h: 2.1, fill: { color: "FDEDEC" }, line: { color: "E74C3C" } });
  s.addShape(pres.shapes.RECTANGLE, { x: 6.15, y: 0.82, w: 3.65, h: 0.4, fill: { color: "E74C3C" }, line: { color: "E74C3C" } });
  s.addText("⚠ CONTRAINDICATIONS", { x: 6.25, y: 0.86, w: 3.45, h: 0.34, fontSize: 10, bold: true, color: WHITE });
  s.addText([
    { text: "• BMI ≥ 30 kg/m²: FDA prescribing restricted\n  (↓efficacy + ↑VTE)\n", options: { fontSize: 9, color: DARK_TEXT, breakLine: true } },
    { text: "• History of DVT/PE, stroke, MI\n", options: { fontSize: 9, color: DARK_TEXT, breakLine: true } },
    { text: "• Migraines with aura\n", options: { fontSize: 9, color: DARK_TEXT, breakLine: true } },
    { text: "• Active liver disease", options: { fontSize: 9, color: DARK_TEXT } },
  ], { x: 6.25, y: 1.26, w: 3.45, h: 1.55, valign: "top" });

  s.addShape(pres.shapes.RECTANGLE, { x: 6.15, y: 3.0, w: 3.65, h: 2.42, fill: { color: "EAF4FB" }, line: { color: MED_TEAL } });
  s.addShape(pres.shapes.RECTANGLE, { x: 6.15, y: 3.0, w: 3.65, h: 0.38, fill: { color: MED_TEAL }, line: { color: MED_TEAL } });
  s.addText("Compare: Old vs New Patch", { x: 6.25, y: 3.04, w: 3.45, h: 0.32, fontSize: 9.5, bold: true, color: WHITE });
  s.addText([
    { text: "Ortho Evra (old): EE + Norelgestromin\n", options: { fontSize: 9, color: DARK_TEXT, breakLine: true } },
    { text: "Twirla (new): EE + Levonorgestrel\n", options: { fontSize: 9, color: DARK_TEXT, breakLine: true } },
    { text: "Both: Weekly change × 3 weeks\n", options: { fontSize: 9, color: DARK_TEXT, breakLine: true } },
    { text: "Both: Constant serum levels vs OC peaks", options: { fontSize: 9, color: DARK_TEXT } },
  ], { x: 6.25, y: 3.43, w: 3.45, h: 1.85, valign: "top" });

  addFooter(s, "Berek & Novak 16e p.734–750 | Al-Haddad et al., Ther Adv Reprod Health 2023 | CDC US SPR 2024");
  addSlideNumber(s, 5);
}

// ── SLIDE 6 — LNG-IUD UPDATES ──────────────────────────────────────
{
  let s = pres.addSlide();
  setLightBg(s);
  s.addShape(pres.shapes.RECTANGLE, { x: 0.12, y: 0, w: 9.88, h: 0.72, fill: { color: "1E5C40" }, line: { color: "1E5C40" } });
  s.addText("LNG-IUD — Current Lineup & Extended Duration Data", { x: 0.25, y: 0.1, w: 9.5, h: 0.52, fontSize: 20, bold: true, color: WHITE });

  // Table header
  const headers = ["Device", "LNG Dose", "Approval", "Duration", "Pearl Index", "Notes"];
  const colWidths = [1.4, 1.0, 1.0, 1.2, 1.0, 4.25];
  const rows = [
    ["Mirena®", "52 mg", "2000", "8 yrs*", "0.2", "Studies show 7-8yr efficacy; approved 8 yrs (2023 FDA update). Reduces menorrhagia by 80%"],
    ["Liletta®", "52 mg", "2015", "8 yrs*", "0.2", "Manufactured by Medicines360; similar to Mirena; data to 8 years available (Berek & Novak 16e)"],
    ["Kyleena®", "19.5 mg", "2016", "5 yrs", "0.2", "Lower LNG dose; suitable for adolescents & nulliparous; lower hormonal side effects"],
    ["Skyla®", "13.5 mg", "2013", "3 yrs", "0.4", "Smallest device (30×28 mm); lowest LNG dose; for nulliparous & younger patients"],
  ];

  let ty = 0.85;
  // Header row
  let hx = 0.15;
  s.addShape(pres.shapes.RECTANGLE, { x: 0.15, y: ty, w: 9.7, h: 0.4, fill: { color: "1E5C40" }, line: { color: "1E5C40" } });
  headers.forEach((h, i) => {
    s.addText(h, { x: hx, y: ty + 0.04, w: colWidths[i], h: 0.32, fontSize: 9, bold: true, color: WHITE, align: "center" });
    hx += colWidths[i];
  });
  ty += 0.4;

  rows.forEach((row, ri) => {
    let rx = 0.15;
    let fillColor = ri % 2 === 0 ? WHITE : SOFT_BLUE;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.15, y: ty, w: 9.7, h: 0.73, fill: { color: fillColor }, line: { color: "#D0D0D0" } });
    row.forEach((cell, ci) => {
      s.addText(cell, { x: rx + 0.04, y: ty + 0.04, w: colWidths[ci] - 0.08, h: 0.65, fontSize: ci === 5 ? 7.5 : 8.5, color: DARK_TEXT, align: ci < 5 ? "center" : "left", valign: "middle" });
      rx += colWidths[ci];
    });
    ty += 0.73;
  });

  // Mechanism note
  s.addShape(pres.shapes.RECTANGLE, { x: 0.15, y: ty + 0.05, w: 9.7, h: 1.0, fill: { color: LIGHT_TEAL }, line: { color: MED_TEAL } });
  s.addText("Mechanism (Berek & Novak 16e): LNG released at ~20 μg/day initially → thickened cervical mucus + endometrial atrophy + inflammatory response. ~85% of cycles remain ovulatory. Blood LNG ≈130–200 pg/mL (stable). CDC SPR 2024: Updated recommendations for IUD placement medications and bleeding irregularities management. *FDA approved Mirena for 8 years in 2023.", {
    x: 0.25, y: ty + 0.1, w: 9.5, h: 0.85, fontSize: 8.5, color: DARK_TEXT, italic: false
  });

  addFooter(s, "Berek & Novak 16e p.721–722 | CDC US SPR 2024 (PMID 39106301) | FDA Label Mirena 2023");
  addSlideNumber(s, 6);
}

// ── SLIDE 7 — PHEXXI (NON-HORMONAL GEL) ────────────────────────────
{
  let s = pres.addSlide();
  setLightBg(s);
  s.addShape(pres.shapes.RECTANGLE, { x: 0.12, y: 0, w: 9.88, h: 0.72, fill: { color: "7D6608" }, line: { color: "7D6608" } });
  s.addText("Phexxi® — Non-Hormonal Vaginal Contraceptive Gel", { x: 0.25, y: 0.1, w: 9.5, h: 0.52, fontSize: 20, bold: true, color: WHITE });

  // Two panels
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.82, w: 4.6, h: 4.6, fill: { color: WHITE }, line: { color: ACCENT_GOLD } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.82, w: 4.6, h: 0.38, fill: { color: ACCENT_GOLD }, line: { color: ACCENT_GOLD } });
  s.addText("Pharmacology & Mechanism", { x: 0.3, y: 0.86, w: 4.4, h: 0.32, fontSize: 11, bold: true, color: WHITE });
  s.addText([
    { text: "FDA Approved: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "May 2020 (Evofem Biosciences)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Composition: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Lactic acid 1.8% + Citric acid 1% + Potassium bitartrate 0.4% in a bioadhesive gel\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Mechanism: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Maintains vaginal pH <4.5 (normally alkaline at 7–8 during intercourse). The acidic environment is spermicidal (immobilizes/kills sperm) — purely non-hormonal.\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Route: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Single-use pre-filled applicator; applied vaginally up to 1 hour BEFORE intercourse\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Additional applications needed for repeated intercourse\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Additional benefit: ", options: { bold: true, fontSize: 10, color: "1E8449", breakLine: false } },
    { text: "Studied as microbicide for gonorrhoea/chlamydia prevention (AMPREVENCE trial ongoing)", options: { fontSize: 10, color: DARK_TEXT } },
  ], { x: 0.3, y: 1.26, w: 4.4, h: 4.1, valign: "top" });

  s.addShape(pres.shapes.RECTANGLE, { x: 5.0, y: 0.82, w: 4.8, h: 4.6, fill: { color: WHITE }, line: { color: MED_TEAL } });
  s.addShape(pres.shapes.RECTANGLE, { x: 5.0, y: 0.82, w: 4.8, h: 0.38, fill: { color: MED_TEAL }, line: { color: MED_TEAL } });
  s.addText("Efficacy, Advantages & Limitations", { x: 5.1, y: 0.86, w: 4.6, h: 0.32, fontSize: 11, bold: true, color: WHITE });
  s.addText([
    { text: "Efficacy: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Pearl Index 27.5 (typical use); 13.7 (perfect use) — LOWER than hormonal methods\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Phase 3 trial: 7.0% failure at 7 cycles (vs spermicide comparator)\n\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "✔ Advantages:\n", options: { bold: true, fontSize: 10, color: "1E8449", breakLine: true } },
    { text: "  • Hormone-free — ideal for those with CHC contraindications\n  • On-demand use — no daily compliance burden\n  • Acts as personal lubricant\n  • Potential STI protection (under investigation)\n  • Rapidly reversible\n\n", options: { fontSize: 9.5, color: DARK_TEXT, breakLine: true } },
    { text: "⚠ Limitations:\n", options: { bold: true, fontSize: 10, color: "E74C3C", breakLine: true } },
    { text: "  • Lower efficacy — best combined with condoms\n  • Must be applied before EACH act of intercourse\n  • Vaginal irritation reported\n  • Not recommended for recurrent UTI history\n  • Higher BMI — data limited", options: { fontSize: 9.5, color: DARK_TEXT } },
  ], { x: 5.1, y: 1.26, w: 4.6, h: 4.1, valign: "top" });

  addFooter(s, "Thomas MA et al., Contraception 2020 | CDC US SPR 2024 | Al-Haddad et al., Ther Adv Reprod Health 2023 (PMID 37465002)");
  addSlideNumber(s, 7);
}

// ── SLIDE 8 — EMERGENCY CONTRACEPTION UPDATES ──────────────────────
{
  let s = pres.addSlide();
  setLightBg(s);
  s.addShape(pres.shapes.RECTANGLE, { x: 0.12, y: 0, w: 9.88, h: 0.72, fill: { color: "922B21" }, line: { color: "922B21" } });
  s.addText("Emergency Contraception — Updated 2024 Guidelines", { x: 0.25, y: 0.1, w: 9.5, h: 0.52, fontSize: 20, bold: true, color: WHITE });

  const ecData = [
    {
      name: "LNG 1.5 mg\n(Plan B/i-Pill®)",
      color: MED_TEAL,
      items: [
        "Single dose (or 2×0.75 mg 12 hrs apart)",
        "Up to 120 hrs post-coitus",
        "Best efficacy <72 hrs (95% ↓risk)",
        "Mechanism: delays/prevents ovulation (NOT abortifacient)",
        "Noe et al.: effective only PRE-ovulation",
        "BMI >70 kg: reduced efficacy",
        "Available OTC since 2013 (USA)",
        "Nausea 23% (vs 50% with EE+LNG combo)",
      ]
    },
    {
      name: "Ulipristal Acetate\n30 mg (ellaOne®)",
      color: "7D3C98",
      items: [
        "Single 30 mg tablet; prescription-only",
        "FDA + EU approved up to 120 hrs",
        "Progesterone receptor modulator",
        "Delays follicular rupture even when LH surge begun",
        "Berek & Novak: 42% lower pregnancy odds vs LNG at 72 hrs",
        "65% lower in first 24 hrs",
        "May maintain efficacy in higher BMI vs LNG",
        "Avoid breastfeeding 7 days after use",
      ]
    },
    {
      name: "Copper IUD\n(ParaGard®)",
      color: "1E5C40",
      items: [
        "Most effective EC: failure rate <0.1%",
        "Insert within 120 hrs of unprotected sex",
        "Mechanism: spermicidal copper ions + endometrial changes",
        "Continues as long-term contraception for 10 yrs",
        "WHO MEC Category 1 for EC regardless of cycle day",
        "CDC SPR 2024: no need for routine STI screening prior",
        "Ideal for obese women & those who want ongoing LARC",
        "Contraindicated: current PID, Wilson's disease",
      ]
    },
  ];

  ecData.forEach((ec, i) => {
    let x = 0.2 + i * 3.25;
    s.addShape(pres.shapes.RECTANGLE, { x, y: 0.82, w: 3.15, h: 4.6, fill: { color: WHITE }, line: { color: ec.color } });
    s.addShape(pres.shapes.RECTANGLE, { x, y: 0.82, w: 3.15, h: 0.5, fill: { color: ec.color }, line: { color: ec.color } });
    s.addText(ec.name, { x: x + 0.05, y: 0.84, w: 3.05, h: 0.46, fontSize: 9.5, bold: true, color: WHITE, align: "center", valign: "middle" });
    const bullets = ec.items.map((item, j) => ({
      text: item,
      options: { bullet: { type: "bullet" }, fontSize: 8.5, color: DARK_TEXT, breakLine: j < ec.items.length - 1 }
    }));
    s.addText(bullets, { x: x + 0.1, y: 1.36, w: 2.95, h: 3.98, valign: "top" });
  });

  addFooter(s, "Berek & Novak 16e p.758–759 | CDC US SPR 2024 (PMID 39106301) | WHO Medical Eligibility Criteria 5th ed");
  addSlideNumber(s, 8);
}

// ── SLIDE 9 — ETONOGESTREL IMPLANT ─────────────────────────────────
{
  let s = pres.addSlide();
  setLightBg(s);
  s.addShape(pres.shapes.RECTANGLE, { x: 0.12, y: 0, w: 9.88, h: 0.72, fill: { color: "0B3D6B" }, line: { color: "0B3D6B" } });
  s.addText("Nexplanon® (Etonogestrel Implant) & DMPA — LARC Updates", { x: 0.25, y: 0.1, w: 9.5, h: 0.52, fontSize: 19, bold: true, color: WHITE });

  // Nexplanon panel
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.82, w: 4.6, h: 4.6, fill: { color: WHITE }, line: { color: MED_TEAL } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.82, w: 4.6, h: 0.38, fill: { color: MED_TEAL }, line: { color: MED_TEAL } });
  s.addText("Nexplanon® (Etonogestrel Implant)", { x: 0.3, y: 0.86, w: 4.4, h: 0.32, fontSize: 11, bold: true, color: WHITE });
  s.addText([
    { text: "Active agent: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Etonogestrel 68 mg (active metabolite of desogestrel)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Duration: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "3 years (studies support 4-5 years off-label in normal weight women)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Efficacy: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Pearl Index <0.1 — LOWEST failure rate of all reversible methods\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Mechanism: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Potent ovulation inhibition + cervical mucus changes. Yr 1: ~20% ovulatory cycles; Yr 4: ~41% (Berek & Novak 16e)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Insertion: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Subdermal, non-dominant inner upper arm; radiopaque (detectable on X-ray)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Key concern: ", options: { bold: true, fontSize: 10, color: "E74C3C", breakLine: false } },
    { text: "Irregular bleeding (most common reason for discontinuation)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "CDC SPR 2024: ", options: { bold: true, fontSize: 10, color: "1E5C40", breakLine: false } },
    { text: "Updated guidance for managing bleeding irregularities during implant use\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Use in obesity: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Effective; no dose adjustment needed. Consider earlier replacement in BMI >30 (limited evidence)", options: { fontSize: 10, color: DARK_TEXT } },
  ], { x: 0.3, y: 1.26, w: 4.4, h: 4.1, valign: "top" });

  // DMPA panel
  s.addShape(pres.shapes.RECTANGLE, { x: 5.0, y: 0.82, w: 4.8, h: 4.6, fill: { color: WHITE }, line: { color: "E59866" } });
  s.addShape(pres.shapes.RECTANGLE, { x: 5.0, y: 0.82, w: 4.8, h: 0.38, fill: { color: "D35400" }, line: { color: "D35400" } });
  s.addText("DMPA-SC (Sayana Press®) — Self-Injectable", { x: 5.1, y: 0.86, w: 4.6, h: 0.32, fontSize: 10.5, bold: true, color: WHITE });
  s.addText([
    { text: "DMPA-SC 104 mg/0.65 mL subcutaneous injection\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Given every 13 weeks (3 months)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "CDC SPR 2024 NEW: ", options: { bold: true, fontSize: 10, color: "1E8449", breakLine: false } },
    { text: "Formal recommendation for SELF-ADMINISTRATION of injectable contraception — major policy update improving access\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Avenant et al. (WHICH RCT, PLoS One 2024): DMPA substantially decreases testosterone and SHBG levels vs norethisterone enanthate\n", options: { fontSize: 9.5, color: DARK_TEXT, breakLine: true } },
    { text: "Hofmeyr et al. (ECHO RCT, BMC Womens Health 2024): DMPA, Cu-IUD, LNG implant differ in testosterone/SHBG effects\n", options: { fontSize: 9.5, color: DARK_TEXT, breakLine: true } },
    { text: "Key concern: ", options: { bold: true, fontSize: 10, color: "E74C3C", breakLine: false } },
    { text: "Bone mineral density loss (reversible); return to fertility delayed 6-12 months\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Amenorrhea: 50–80% after 1 year (beneficial for some)", options: { fontSize: 10, color: DARK_TEXT } },
  ], { x: 5.1, y: 1.26, w: 4.6, h: 4.1, valign: "top" });

  addFooter(s, "Berek & Novak 16e p.733 | CDC US SPR 2024 (PMID 39106301) | Avenant et al., PLoS One 2024 (PMID 39178280) | Hofmeyr et al., BMC Womens Health 2024 (PMID 38459552)");
  addSlideNumber(s, 9);
}

// ── SLIDE 10 — MALE CONTRACEPTIVES & EMERGING METHODS ─────────────
{
  let s = pres.addSlide();
  setLightBg(s);
  s.addShape(pres.shapes.RECTANGLE, { x: 0.12, y: 0, w: 9.88, h: 0.72, fill: { color: "1F618D" }, line: { color: "1F618D" } });
  s.addText("Emerging & Male Contraceptive Methods", { x: 0.25, y: 0.1, w: 9.5, h: 0.52, fontSize: 21, bold: true, color: WHITE });

  // Male contraception
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.82, w: 5.8, h: 4.6, fill: { color: WHITE }, line: { color: MED_TEAL } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.82, w: 5.8, h: 0.38, fill: { color: MED_TEAL }, line: { color: MED_TEAL } });
  s.addText("Male Hormonal Contraception (Berek & Novak 16e + EAA/ASA Guidelines 2024)", { x: 0.3, y: 0.86, w: 5.6, h: 0.32, fontSize: 10, bold: true, color: WHITE });
  s.addText([
    { text: "Principle: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Same sex steroid negative feedback that blocks ovulation also suppresses spermatogenesis\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Testosterone Undecanoate (TU) IM: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Monthly injections; 95%+ azoospermia in Asian men; 86% in Caucasians\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Chinese Trial (n=1,045): ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Cumulative pregnancy rate 1.1/100 at 30 months with TU 500 mg monthly\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "TU + Etonogestrel implant: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Only 3% fail to suppress sperm <1×10⁶/mL (Caucasian trial)\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Transdermal gels: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Nesterone (progestin) + Testosterone gel — 89% achieve sperm suppression ≤1×10⁶/mL\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Side effects: ", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: false } },
    { text: "Acne, night sweats, libido changes (usually increased), weight gain\n", options: { fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "EAA/ASA Guidelines 2024 (PMID 37727884): ", options: { bold: true, fontSize: 10, color: "7D3C98", breakLine: false } },
    { text: "Comprehensive guidance on hormonal and non-hormonal male methods; endorsed sperm suppression targets", options: { fontSize: 10, color: DARK_TEXT } },
  ], { x: 0.3, y: 1.26, w: 5.6, h: 4.1, valign: "top" });

  // Non-hormonal emerging
  s.addShape(pres.shapes.RECTANGLE, { x: 6.15, y: 0.82, w: 3.65, h: 4.6, fill: { color: WHITE }, line: { color: ACCENT_GOLD } });
  s.addShape(pres.shapes.RECTANGLE, { x: 6.15, y: 0.82, w: 3.65, h: 0.38, fill: { color: ACCENT_GOLD }, line: { color: ACCENT_GOLD } });
  s.addText("Non-Hormonal Emerging (Male)", { x: 6.25, y: 0.86, w: 3.45, h: 0.32, fontSize: 10, bold: true, color: WHITE });
  s.addText([
    { text: "RISUG (India):\n", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Styrene maleic anhydride injected into vas deferens; creates incompatible pH for sperm + blocks transport; Phase 3 trials in India\n\n", options: { fontSize: 9, color: DARK_TEXT, breakLine: true } },
    { text: "Vasalgel (USA):\n", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Styrene-alt-maleic acid polymer in DMSO; soft gel in vas deferens; blocks sperm (not water-soluble substances); Potentially reversible with NaHCO₃ injection; Animal studies only (rabbit model) as of Berek & Novak 16e\n\n", options: { fontSize: 9, color: DARK_TEXT, breakLine: true } },
    { text: "Female Non-Hormonal:\n", options: { bold: true, fontSize: 10, color: DARK_TEXT, breakLine: true } },
    { text: "Phexxi® gel (see Slide 7)\nCu-IUD (ParaGard®)\nBarrier methods update: Female condom (FC2)", options: { fontSize: 9, color: DARK_TEXT } },
  ], { x: 6.25, y: 1.26, w: 3.45, h: 4.1, valign: "top" });

  addFooter(s, "Berek & Novak 16e p.760 | Wang C et al., Andrology 2024 — EAA/ASA Guidelines (PMID 37727884)");
  addSlideNumber(s, 10);
}

// ── SLIDE 11 — CDC SPR 2024 KEY UPDATES ────────────────────────────
{
  let s = pres.addSlide();
  setLightBg(s);
  s.addShape(pres.shapes.RECTANGLE, { x: 0.12, y: 0, w: 9.88, h: 0.72, fill: { color: "922B21" }, line: { color: "922B21" } });
  s.addText("CDC U.S. Selected Practice Recommendations 2024 — Key Updates", { x: 0.25, y: 0.1, w: 9.5, h: 0.52, fontSize: 19, bold: true, color: WHITE });

  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.82, w: 9.6, h: 4.6, fill: { color: WHITE }, line: { color: "922B21" } });
  
  const updates = [
    { num: "1", title: "IUD Placement Medications", text: "Updated recs for analgesia & medications at time of IUD insertion. Evidence-based pain management now explicitly addressed. NSAIDs (ibuprofen 400–800 mg) + lidocaine paracervical block recommended; misoprostol NOT routinely recommended for nulliparous women." },
    { num: "2", title: "Implant Bleeding Management", text: "Updated guidance for managing irregular bleeding during etonogestrel implant use. NSAIDs (short course) or COC (add-back) supported as first-line. Counseling on expected bleeding patterns emphasized before insertion." },
    { num: "3", title: "Testosterone Use & Pregnancy Risk", text: "NEW: Transgender men & non-binary individuals using testosterone may still ovulate and become pregnant. Testosterone is NOT a reliable contraceptive. Clinicians should discuss and offer contraception to all patients using testosterone." },
    { num: "4", title: "Self-Administration of Injectable Contraception", text: "NEW: Formal recommendation supporting self-injection of DMPA-SC (Sayana Press®). Removes requirement for clinic visits every 3 months. Expands access in low-resource settings and for patients with clinic barriers. Bick et al., Biol Reprod 2026 confirms differential HPG axis effects of different injectables." },
  ];

  updates.forEach((u, i) => {
    let rowY = 0.95 + i * 1.06;
    s.addShape(pres.shapes.OVAL, { x: 0.28, y: rowY + 0.05, w: 0.42, h: 0.42, fill: { color: "922B21" }, line: { color: "922B21" } });
    s.addText(u.num, { x: 0.28, y: rowY + 0.06, w: 0.42, h: 0.38, fontSize: 12, bold: true, color: WHITE, align: "center", valign: "middle" });
    s.addText(u.title, { x: 0.8, y: rowY, w: 2.5, h: 0.45, fontSize: 10.5, bold: true, color: "922B21", valign: "middle" });
    s.addText(u.text, { x: 0.8, y: rowY + 0.42, w: 8.8, h: 0.58, fontSize: 9, color: DARK_TEXT, valign: "top" });
    if (i < 3) s.addShape(pres.shapes.LINE, { x: 0.3, y: rowY + 1.0, w: 9.3, h: 0, line: { color: "E8E8E8", width: 0.5 } });
  });

  addFooter(s, "Curtis KM et al., MMWR Recomm Rep 2024;73(RR-3):1-77 (PMID 39106301) | Bick AJ et al., Biol Reprod 2026 (PMID 41489365)");
  addSlideNumber(s, 11);
}

// ── SLIDE 12 — COMPARATIVE EFFICACY TABLE ──────────────────────────
{
  let s = pres.addSlide();
  setLightBg(s);
  s.addShape(pres.shapes.RECTANGLE, { x: 0.12, y: 0, w: 9.88, h: 0.72, fill: { color: DEEP_TEAL }, line: { color: DEEP_TEAL } });
  s.addText("Comparative Efficacy of Newer Contraceptive Methods", { x: 0.25, y: 0.1, w: 9.5, h: 0.52, fontSize: 20, bold: true, color: WHITE });

  const hdrs = ["Method", "Pearl Index\n(Perfect)", "Pearl Index\n(Typical)", "Duration", "Reversibility", "Special Notes"];
  const hdW  = [2.0, 1.3, 1.3, 1.3, 1.3, 2.7];
  const tRows = [
    ["Etonogestrel implant (Nexplanon®)", "<0.1", "<0.1", "3 yrs", "Immediate", "Lowest failure; best for compliance"],
    ["LNG-IUD 52 mg (Mirena®/Liletta®)", "0.2", "0.2", "8 yrs*", "Immediate", "Treats menorrhagia; *FDA 8-yr (2023)"],
    ["Copper IUD (ParaGard®)", "0.6", "0.8", "10 yrs", "Immediate", "Non-hormonal; also best EC option"],
    ["DMPA / DMPA-SC", "0.2", "4.0", "3 months", "Delayed 6-12 m", "Self-inject now approved (CDC 2024)"],
    ["Drospirenone POP (Slynd®)", "~1.0", "4.0", "Daily pill", "Immediate", "24-hr missed pill window; estrogen-free"],
    ["Annovera® vaginal ring", "2.0", "3.0", "1 year", "Immediate", "13 cycles; SA + EE 13 μg"],
    ["Twirla® patch", "1.5", "4.3", "Weekly", "Immediate", "BMI <30 only; EE + LNG; VTE risk"],
    ["NuvaRing® (EE+ENG)", "0.3", "1.2", "Monthly", "Immediate", "3 wks in / 1 wk out; lowest EE dose"],
    ["Phexxi® gel", "13.7", "27.5", "Per coitus", "N/A", "Non-hormonal; combine with condom"],
    ["UPA 30 mg (ellaOne®) EC", "N/A", "N/A", "1 dose EC", "N/A", "Up to 120 hrs; better than LNG near LH surge"],
  ];

  let ty = 0.82;
  // header
  let hx2 = 0.15;
  s.addShape(pres.shapes.RECTANGLE, { x: 0.15, y: ty, w: 9.7, h: 0.42, fill: { color: DEEP_TEAL }, line: { color: DEEP_TEAL } });
  hdrs.forEach((h, i) => {
    s.addText(h, { x: hx2, y: ty + 0.02, w: hdW[i], h: 0.38, fontSize: 8, bold: true, color: WHITE, align: "center", valign: "middle" });
    hx2 += hdW[i];
  });
  ty += 0.42;

  tRows.forEach((row, ri) => {
    let rx2 = 0.15;
    let fc = ri % 2 === 0 ? WHITE : SOFT_BLUE;
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  addFooter(s, "Berek & Novak 16e Table 14-1 | CDC US SPR 2024 | FDA product labels | Trussell J, Contraceptive Technology 2018");
  addSlideNumber(s, 12);
}

// ── SLIDE 13 — SPECIAL POPULATIONS ─────────────────────────────────
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  s.addText("Contraception in Special Populations — WHO MEC Summary", { x: 0.25, y: 0.1, w: 9.5, h: 0.52, fontSize: 19, bold: true, color: WHITE });

  const populations = [
    { pop: "Adolescents / Nulliparous", recs: "LNG-IUD (Kyleena/Skyla) — smaller size. Implant first-line LARC. Avoid DMPA as first line (BMD). COC OK with counselling." },
    { pop: "Obese Women (BMI ≥30)", recs: "Implant, IUD (Cu or LNG) — NOT affected by BMI. AVOID Twirla patch. Use UPA (not LNG) for EC if BMI >26. DMPA OK. COC: ↑VTE risk." },
    { pop: "Lactation / Postpartum", recs: "Slynd® (drospirenone POP) safe from day 1. LNG-IUD/Cu-IUD: immediate postpartum insertion. DMPA: after 6 weeks. AVOID COC <6 weeks postpartum (thrombosis/milk)." },
    { pop: "Migraines with Aura", recs: "AVOID all estrogen-containing methods (COC, patch, ring) — WHO MEC 4. POP (Slynd/norethindrone), implant, IUD all Category 1 or 2." },
    { pop: "Transgender Men on Testosterone", recs: "CDC SPR 2024 NEW: Testosterone does NOT reliably prevent pregnancy. Offer IUD, implant, or POP. Counsel all testosterone users on contraception." },
    { pop: "Cardiovascular / Hypertension", recs: "AVOID estrogen-containing methods if BP ≥160/100 or vascular disease. IUD (LNG/Cu), implant, POP all safe (MEC 1-2). DMPA: MEC 2 (>160/100)." },
    { pop: "Immunocompromised", recs: "IUD candidacy NOT excluded (Berek & Novak 16e). Hormonal methods generally safe. Counsel on drug interactions (antiepileptics ↓ efficacy of implant/POP)." },
    { pop: "Drug Interactions (EIAEDs)", recs: "Enzyme-inducing AEDs (phenytoin, carbamazepine, rifampicin): reduce efficacy of implant, POP, COC. Cu-IUD and DMPA unaffected. LNG-IUD likely OK." },
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// ── SLIDE 14 — REFERENCES ────────────────────────────────────────────
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  const refs = [
    "1. Berek JS, Berek DL. Berek & Novak's Gynecology, 16th ed. Wolters Kluwer, 2020. Chapter 14 (Contraception), pp. 718–765.",
    "2. Curtis KM, Nguyen AT, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm Rep. 2024;73(RR-3):1–77. PMID: 39106301.",
    "3. Al-Haddad S, Branham KKR, Clare CA. Advances in contraception: vaginal contraceptive rings. Ther Adv Reprod Health. 2023. PMID: 37465002.",
    "4. Jensen JT, Archer DF, Westhoff CL, et al. Satisfaction with segesterone acetate/EE contraceptive vaginal system among OC/ring users. J Womens Health. 2023. PMID: 37253139.",
    "5. Plagianos MG, Ramanadhan S, Merkatz RB, et al. Risk factors for ring expulsions with 1-year contraceptive vaginal system. Am J Obstet Gynecol. 2024. PMID: 38295968.",
    "6. Wang C, Meriggiola MC, Amory JK, et al. Practice and development of male contraception: EAA/ASA guidelines. Andrology. 2024. PMID: 37727884.",
    "7. Avenant C, Singata-Madliki M, Bick AJ, et al. Injectable contraceptives & testosterone: WHICH RCT. PLoS One. 2024. PMID: 39178280.",
    "8. Hofmeyr GJ, Singata-Madliki M, Batting J, et al. DMPA, Cu-IUD, LNG implant effects on testosterone: ECHO RCT. BMC Womens Health. 2024. PMID: 38459552.",
    "9. Bick AJ et al. Injectable contraceptives differentially affect HPG axis and amenorrhea. Biol Reprod. 2026. PMID: 41489365.",
    "10. Bounous VE, Actis S, Rosso R, et al. No-daily hormonal contraception: overview and application in specific clinical settings. Gynecol Endocrinol. 2023. PMID: 37199597.",
    "11. Jahanfar S, Mortazavi J, Lapidow A, et al. Impact of contraceptive use on mental health. BMC Pregnancy Childbirth. 2024. PMID: 38816797.",
    "12. WHO Medical Eligibility Criteria for Contraceptive Use, 5th ed. Geneva: WHO; 2015 (updated 2016).",
  ];

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// ── SLIDE 15 — SUMMARY ───────────────────────────────────────────────
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  s.addText("Key Takeaways", { x: 0.25, y: 0.08, w: 9.5, h: 0.56, fontSize: 26, bold: true, color: DEEP_TEAL });

  const points = [
    { num: "01", text: "Slynd® (drospirenone 4 mg POP): estrogen-free pill with 24-hr missed dose window and reliable ovulation suppression — improved option for patients contraindicated to estrogen." },
    { num: "02", text: "Annovera® (SA+EE vaginal ring): 1-year user-controlled ring with 13 consecutive cycles, lowest daily EE dose (13 μg), user-controlled insertion/removal." },
    { num: "03", text: "Twirla® (EE+LNG patch): new transdermal option, but FDA restricts to BMI <30 due to reduced efficacy and elevated VTE risk in obesity." },
    { num: "04", text: "LNG-IUD lifespan extended: Mirena® & Liletta® now approved for 8 years; highly effective LARC with non-contraceptive benefits." },
    { num: "05", text: "CDC SPR 2024: 4 major updates — IUD insertion pain management; implant bleeding; testosterone ≠ contraceptive for transgender men; DMPA self-injection approved." },
    { num: "06", text: "Phexxi® gel: non-hormonal on-demand option for estrogen-ineligible patients — lower efficacy (Pearl Index 27.5 typical), best combined with condoms." },
    { num: "07", text: "Male contraception: testosterone + progestin regimens approaching clinical readiness; RISUG/Vasalgel non-hormonal methods under investigation (EAA/ASA 2024)." },
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}

// ── WRITE FILE ───────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/newer-contraceptives-ppt/Newer_Contraceptives_in_Gynaecology.pptx" })
  .then(() => console.log("✅ Presentation created successfully!"))
  .catch(err => console.error("Error:", err));

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

ls -lh /home/daytona/workspace/newer-contraceptives-ppt/