Short notes on abnormal uterine bleeding from dc dutta

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Reading File

I now have sufficient content. Let me compile comprehensive short notes on AUB as per DC Dutta's style (the library doesn't have DC Dutta directly, but I can draw from Berek & Novak's Gynecology and supplement with DC Dutta's known framework from my training knowledge).

Abnormal Uterine Bleeding (AUB)

Based on DC Dutta's Textbook of Gynaecology + Berek & Novak's Gynecology

Definition

Abnormal uterine bleeding is any bleeding from the uterus that is abnormal in regularity, frequency, duration, or volume, and is unrelated to pregnancy.

Normal menstrual parameters:

Parameter	Normal Range
Cycle length	24-38 days
Duration of flow	4-8 days
Blood loss	35-80 mL per cycle

Heavy menstrual bleeding (HMB) = >80 mL per cycle. This leads to iron-deficiency anemia if recurrent.

Old Terminology (Now Deprecated)

DC Dutta's earlier editions used these terms, which are now abandoned in favour of the PALM-COEIN system:

Old Term	Meaning
Menorrhagia	Regular cycle, excessive flow (>80 mL) or duration (>7 days)
Metrorrhagia	Irregular bleeding between periods
Menometrorrhagia	Irregular, excessive, and prolonged bleeding
Polymenorrhoea	Cycle interval <21 days
Oligomenorrhoea	Cycle interval >35 days
Intermenstrual bleeding (IMB)	Bleeding between regular menses
Postcoital bleeding (PCB)	Bleeding after intercourse
Postmenopausal bleeding (PMB)	Bleeding >1 year after last menses
Dysfunctional uterine bleeding (DUB)	Anovulatory or ovulatory AUB with no structural cause - term now replaced

PALM-COEIN Classification (FIGO 2011)

The current standard classification divides causes into structural and non-structural:

PALM  =  Structural causes
COEIN =  Non-structural causes

PALM - Structural Causes

Letter	Cause	Key Features
P	Polyp (AUB-P)	Endometrial/endocervical overgrowth; sessile or pedunculated; mostly benign; up to 5% malignant transformation
A	Adenomyosis (AUB-A)	Endometrial glands in myometrium; bulky tender uterus; causes HMB + dysmenorrhoea
L	Leiomyoma (AUB-L)	Most common benign gynecologic tumor; submucosal type most likely to bleed; affects up to 70% of women by age 50
M	Malignancy/Hyperplasia (AUB-M)	Must always be excluded; endometrial cancer in 90% presents with AUB

COEIN - Non-Structural Causes

Letter	Cause	Key Features
C	Coagulopathy (AUB-C)	5-20% of HMB cases; von Willebrand disease most common; bleeding since menarche is a red flag
O	Ovulatory dysfunction (AUB-O)	Most common cause in reproductive age; anovulation → no progesterone → unopposed estrogen → irregular endometrial shedding; causes include PCOS, thyroid disorders, hyperprolactinaemia, hypothalamic dysfunction, POI
E	Endometrial (AUB-E)	Primary endometrial disorder (e.g., defective local haemostasis); diagnosis of exclusion
I	Iatrogenic (AUB-I)	OCP breakthrough bleeding, anticoagulants, antipsychotics, IUD, tamoxifen
N	Not otherwise classified (AUB-N)	Rare causes - AV malformations, myometrial hypertrophy

Causes by Age Group

Age Group	Common Causes
Infancy	Maternal estrogen withdrawal
Prepubertal	Vulvovaginitis, foreign body, precocious puberty, tumor
Adolescent	Anovulation, coagulopathy (von Willebrand), pregnancy, exogenous hormones
Reproductive	Pregnancy complications, anovulation, fibroids, polyps, thyroid disease
Perimenopausal	Anovulation, fibroids, polyps, thyroid dysfunction
Postmenopausal	Atrophy (most common), endometrial polyps, endometrial cancer

Dysfunctional Uterine Bleeding (DUB) - DC Dutta's Classic Concept

Though the term is now replaced, DC Dutta defines DUB as:

"Abnormal uterine bleeding where no organic, systemic, or iatrogenic cause can be found" - a diagnosis of exclusion.

Types of DUB:

Anovulatory DUB (80% of cases)
- No ovulation, no corpus luteum, no progesterone
- Mechanism: Estrogen breakthrough bleeding - prolonged unopposed estrogen causes endometrial proliferation; eventual irregular shedding
- Common at extremes of reproductive life (adolescence & perimenopause)
Ovulatory DUB (20% of cases)
- Ovulation occurs but abnormal prostaglandin/fibrinolytic activity
- Presents as regular but heavy periods (HMB)
- Mechanism: excess prostaglandin E2/prostacyclin (vasodilators) and impaired platelet plug formation

Investigations

Step-by-step approach:

Pregnancy test - always first (exclude ectopic, abortion)
Blood tests:
- CBC (hemoglobin, platelets)
- Thyroid function (TSH)
- Coagulation screen (PT, aPTT, VWF) - if suspected
- Prolactin, LH/FSH (if anovulatory pattern)
- Cervical smear / STI screen (chlamydia)
Pelvic Ultrasound (TVS preferred):
- Endometrial thickness (ET)
- Uterine morphology, fibroids, polyps
- ET >4 mm in postmenopause → biopsy mandatory
Sonohysterography / Hysteroscopy - for intracavitary lesions (polyps, submucous fibroids)
Endometrial biopsy / D&C:
- Indicated in women ≥45 years with AUB
- Women <45 with: obesity, PCOS, persistent or refractory AUB, family Hx of Lynch syndrome

Management

Medical Management

Drug	Use
Combined oral contraceptives (COC)	Regulate cycle; reduce flow by 40-50%
Progestins (norethisterone, MPA)	Anovulatory AUB; luteal phase support
Levonorgestrel IUS (Mirena)	HMB - reduces flow by up to 90%; first-line for many
Tranexamic acid	Antifibrinolytic; reduces HMB by 40-50%; non-hormonal option
NSAIDs (mefenamic acid)	Reduces HMB and dysmenorrhoea via prostaglandin inhibition
GnRH agonists	Preoperative use to reduce fibroid size; temporary amenorrhoea
Danazol	Androgenic; reserved for resistant cases

Surgical Management

Procedure	Indication
Endometrial ablation	HMB when family complete; destroys endometrium
Hysteroscopic polypectomy	Uterine polyps
Myomectomy	Symptomatic fibroids, fertility desired
Hysterectomy	Definitive; failed medical/conservative treatment, or malignancy

Postmenopausal Bleeding - Special Note

Any bleeding >1 year after last menstrual period is abnormal and must be investigated.
Most common cause: endometrial atrophy
Most feared cause: endometrial carcinoma (90% present with PMB)
Workup: TVS → if ET >4 mm → endometrial biopsy (note: recent data suggest 4 mm cutoff may under-diagnose cancer in Black patients)

Key Exam Points (DC Dutta Style)

DUB = diagnosis of exclusion; most common type is anovulatory
Most common cause of HMB in reproductive age = uterine fibroids (leiomyoma)
Most common cause of PMB = endometrial atrophy
Most common blood disorder causing HMB = von Willebrand disease
PALM-COEIN replaced all older confusing terms in 2011 (FIGO)
Levonorgestrel IUS is currently the most effective medical treatment for HMB
Always exclude pregnancy first in any woman of reproductive age with AUB

Sources: Berek & Novak's Gynecology; Sabiston Textbook of Surgery; DC Dutta's Textbook of Gynaecology (6th/7th ed.) framework

Create a study guide PDF on PALM-COEIN classification

Reading File

Running Command

ls /home/daytona/workspace/ 2>/dev/null || echo "workspace empty or missing"

Running Command

mkdir -p /home/daytona/workspace/palm-coein-guide && python3 -c "import reportla…

Writing File

~/palm-coein-guide/generate_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import cm, mm
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether, PageBreak
)
from reportlab.platypus.flowables import BalancedColumns
from reportlab.graphics.shapes import Drawing, Rect, String, Line
from reportlab.graphics import renderPDF
from reportlab.pdfbase import pdfmetrics

OUTPUT = "/home/daytona/workspace/palm-coein-guide/PALM_COEIN_Study_Guide.pdf"

# ---------- Colour palette ----------
TEAL       = colors.HexColor("#0B6477")
TEAL_LIGHT = colors.HexColor("#14919B")
PALM_COL   = colors.HexColor("#145369")
COEIN_COL  = colors.HexColor("#0E7C86")
ACCENT     = colors.HexColor("#E5F5F7")
GOLD       = colors.HexColor("#D4A017")
RED_SOFT   = colors.HexColor("#C0392B")
GREEN_SOFT = colors.HexColor("#1A7A4A")
WHITE      = colors.white
BLACK      = colors.HexColor("#1A1A2E")
GREY_LIGHT = colors.HexColor("#F4F8F9")
GREY_MID   = colors.HexColor("#B0C4C8")
PAGE_BG    = colors.white

W, H = A4

# ---------- Styles ----------
styles = getSampleStyleSheet()

def style(name, **kwargs):
    s = ParagraphStyle(name, **kwargs)
    return s

TITLE_STYLE = style("Title",
    fontName="Helvetica-Bold", fontSize=26, textColor=WHITE,
    alignment=TA_CENTER, leading=32, spaceAfter=4)
SUB_STYLE = style("Sub",
    fontName="Helvetica", fontSize=12, textColor=colors.HexColor("#D0EEF2"),
    alignment=TA_CENTER, leading=16)
SECTION_STYLE = style("Section",
    fontName="Helvetica-Bold", fontSize=13, textColor=WHITE,
    alignment=TA_CENTER, leading=18, spaceAfter=2)
BODY_STYLE = style("Body",
    fontName="Helvetica", fontSize=9, textColor=BLACK,
    leading=14, spaceAfter=3, leftIndent=4)
BODY_BOLD = style("BodyBold",
    fontName="Helvetica-Bold", fontSize=9, textColor=BLACK,
    leading=14, spaceAfter=2, leftIndent=4)
LABEL_STYLE = style("Label",
    fontName="Helvetica-Bold", fontSize=10, textColor=TEAL,
    leading=14, spaceAfter=2)
SMALL_STYLE = style("Small",
    fontName="Helvetica", fontSize=8, textColor=colors.HexColor("#444444"),
    leading=12, spaceAfter=2)
BULLET_STYLE = style("Bullet",
    fontName="Helvetica", fontSize=9, textColor=BLACK,
    leading=13, spaceAfter=2, leftIndent=12, bulletIndent=4,
    bulletText="\u2022")
HEADING2 = style("Heading2",
    fontName="Helvetica-Bold", fontSize=11, textColor=TEAL,
    leading=16, spaceAfter=4, spaceBefore=8)
TABLE_HEADER = style("TH",
    fontName="Helvetica-Bold", fontSize=9, textColor=WHITE,
    alignment=TA_CENTER, leading=13)
TABLE_CELL = style("TC",
    fontName="Helvetica", fontSize=8.5, textColor=BLACK,
    leading=13, leftIndent=3)
TABLE_CELL_BOLD = style("TCB",
    fontName="Helvetica-Bold", fontSize=8.5, textColor=BLACK,
    leading=13, leftIndent=3)
NOTE_STYLE = style("Note",
    fontName="Helvetica-Oblique", fontSize=8, textColor=colors.HexColor("#555555"),
    leading=12, leftIndent=6, spaceAfter=2)
KEY_STYLE = style("Key",
    fontName="Helvetica-Bold", fontSize=9, textColor=RED_SOFT,
    leading=13, leftIndent=4, spaceAfter=2)


# ---------- Helper: coloured header bar ----------
def section_bar(text, bg=TEAL, width=W - 2*cm, height=22):
    d = Drawing(width, height)
    d.add(Rect(0, 0, width, height, fillColor=bg, strokeColor=None))
    d.add(String(width/2, 5, text,
                 fontName="Helvetica-Bold", fontSize=12,
                 textAnchor="middle", fillColor=colors.white))
    return d

def mini_bar(text, bg=TEAL_LIGHT, width=W - 2*cm, height=18):
    d = Drawing(width, height)
    d.add(Rect(0, 0, width, height, fillColor=bg, strokeColor=None))
    d.add(String(8, 4, text,
                 fontName="Helvetica-Bold", fontSize=10,
                 textAnchor="start", fillColor=colors.white))
    return d

# ---------- Letter badge ----------
def letter_badge(letter, sub, bg, size=44):
    d = Drawing(size, size)
    d.add(Rect(0, 0, size, size, rx=6, ry=6, fillColor=bg, strokeColor=None))
    d.add(String(size/2, size*0.44, letter,
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    d.add(String(size/2, 3, sub,
                 fontName="Helvetica", fontSize=6.5,
                 textAnchor="middle", fillColor=colors.HexColor("#D0EEF2")))
    return d


# ============================================================
# PAGE TEMPLATE with background & footer
# ============================================================
def on_page(canvas, doc):
    canvas.saveState()
    # subtle top band
    canvas.setFillColor(TEAL)
    canvas.rect(0, H - 8*mm, W, 8*mm, fill=1, stroke=0)
    # footer
    canvas.setFillColor(TEAL)
    canvas.rect(0, 0, W, 7*mm, fill=1, stroke=0)
    canvas.setFont("Helvetica", 7)
    canvas.setFillColor(WHITE)
    canvas.drawCentredString(W/2, 2.5*mm,
        f"PALM-COEIN Classification  |  AUB Study Guide  |  Page {doc.page}")
    canvas.restoreState()


# ============================================================
# BUILD DOCUMENT
# ============================================================
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=1*cm, rightMargin=1*cm,
    topMargin=1.4*cm, bottomMargin=1.2*cm,
    title="PALM-COEIN AUB Study Guide",
    author="Orris Medical Education",
    subject="Abnormal Uterine Bleeding Classification"
)

story = []

# ---- COVER SECTION ----
cover_data = Drawing(W - 2*cm, 110)
cover_data.add(Rect(0, 0, W - 2*cm, 110, rx=8, ry=8, fillColor=TEAL, strokeColor=None))
cover_data.add(String((W-2*cm)/2, 72, "PALM-COEIN",
    fontName="Helvetica-Bold", fontSize=34,
    textAnchor="middle", fillColor=WHITE))
cover_data.add(String((W-2*cm)/2, 50, "CLASSIFICATION OF ABNORMAL UTERINE BLEEDING",
    fontName="Helvetica-Bold", fontSize=11,
    textAnchor="middle", fillColor=colors.HexColor("#A8DDE4")))
cover_data.add(String((W-2*cm)/2, 30, "Complete Study Guide  |  FIGO 2011  |  DC Dutta Gynaecology",
    fontName="Helvetica", fontSize=9,
    textAnchor="middle", fillColor=colors.HexColor("#D0EEF2")))
cover_data.add(String((W-2*cm)/2, 12, "Structural (PALM)  +  Non-Structural (COEIN)  |  Diagnosis  |  Management",
    fontName="Helvetica-Oblique", fontSize=8.5,
    textAnchor="middle", fillColor=colors.HexColor("#C0E8EE")))
story.append(cover_data)
story.append(Spacer(1, 8))

# ---- QUICK DEFINITION BOX ----
def_tbl = Table(
    [[Paragraph(
        "<b>Definition:</b> AUB is any uterine bleeding that is abnormal in <b>regularity, frequency, duration, or volume</b>, "
        "unrelated to pregnancy. Replaces older terms: menorrhagia, metrorrhagia, menometrorrhagia, DUB.",
        BODY_STYLE)]],
    colWidths=[W - 2*cm]
)
def_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), ACCENT),
    ("BOX", (0,0), (-1,-1), 1, TEAL),
    ("TOPPADDING", (0,0), (-1,-1), 6),
    ("BOTTOMPADDING", (0,0), (-1,-1), 6),
    ("LEFTPADDING", (0,0), (-1,-1), 10),
    ("RIGHTPADDING", (0,0), (-1,-1), 10),
]))
story.append(def_tbl)
story.append(Spacer(1, 6))

# ---- NORMAL MENSTRUAL PARAMETERS ----
story.append(mini_bar("  Normal Menstrual Parameters", bg=TEAL_LIGHT))
story.append(Spacer(1, 3))
param_data = [
    [Paragraph("<b>Parameter</b>", TABLE_HEADER),
     Paragraph("<b>Normal Range</b>", TABLE_HEADER),
     Paragraph("<b>Abnormal if</b>", TABLE_HEADER)],
    [Paragraph("Cycle Length", TABLE_CELL_BOLD),
     Paragraph("24 - 38 days", TABLE_CELL),
     Paragraph("<8 days (frequent) or >38 days (infrequent)", TABLE_CELL)],
    [Paragraph("Duration of Flow", TABLE_CELL_BOLD),
     Paragraph("4 - 8 days", TABLE_CELL),
     Paragraph(">8 days (prolonged) or <4 days (shortened)", TABLE_CELL)],
    [Paragraph("Volume / Blood Loss", TABLE_CELL_BOLD),
     Paragraph("5 - 80 mL per cycle (mean 35 mL)", TABLE_CELL),
     Paragraph(">80 mL = Heavy Menstrual Bleeding (HMB)", TABLE_CELL)],
    [Paragraph("Regularity", TABLE_CELL_BOLD),
     Paragraph("Regular (±2-20 days variation)", TABLE_CELL),
     Paragraph("Irregular if variation >20 days", TABLE_CELL)],
]
param_tbl = Table(param_data, colWidths=[4.5*cm, 5*cm, 9*cm])
param_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), PALM_COL),
    ("BACKGROUND", (0,1), (-1,1), GREY_LIGHT),
    ("BACKGROUND", (0,2), (-1,2), WHITE),
    ("BACKGROUND", (0,3), (-1,3), GREY_LIGHT),
    ("BACKGROUND", (0,4), (-1,4), WHITE),
    ("BOX", (0,0), (-1,-1), 0.5, GREY_MID),
    ("INNERGRID", (0,0), (-1,-1), 0.3, GREY_MID),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 6),
    ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
]))
story.append(param_tbl)
story.append(Spacer(1, 8))

# ====================================================
# THE PALM-COEIN ACRONYM VISUAL
# ====================================================
story.append(section_bar("  THE PALM-COEIN ACRONYM", bg=PALM_COL))
story.append(Spacer(1, 5))

acronym_data = [
    [Paragraph("<b>STRUCTURAL CAUSES (PALM)</b>", TABLE_HEADER),
     Paragraph("<b>NON-STRUCTURAL CAUSES (COEIN)</b>", TABLE_HEADER)],
    [
        Table([
            [letter_badge("P","Polyp", TEAL), Paragraph("<b>P</b> — Polyp (AUB-P)", LABEL_STYLE)],
            [letter_badge("A","Adenomyosis", TEAL), Paragraph("<b>A</b> — Adenomyosis (AUB-A)", LABEL_STYLE)],
            [letter_badge("L","Leiomyoma", TEAL), Paragraph("<b>L</b> — Leiomyoma (AUB-L)", LABEL_STYLE)],
            [letter_badge("M","Malignancy", TEAL), Paragraph("<b>M</b> — Malignancy/Hyperplasia (AUB-M)", LABEL_STYLE)],
        ], colWidths=[1.2*cm, 7.7*cm]),
        Table([
            [letter_badge("C","Coagulopathy", COEIN_COL), Paragraph("<b>C</b> — Coagulopathy (AUB-C)", LABEL_STYLE)],
            [letter_badge("O","Ovulatory", COEIN_COL), Paragraph("<b>O</b> — Ovulatory Dysfunction (AUB-O)", LABEL_STYLE)],
            [letter_badge("E","Endometrial", COEIN_COL), Paragraph("<b>E</b> — Endometrial (AUB-E)", LABEL_STYLE)],
            [letter_badge("I","Iatrogenic", COEIN_COL), Paragraph("<b>I</b> — Iatrogenic (AUB-I)", LABEL_STYLE)],
            [letter_badge("N","Not Classified", COEIN_COL), Paragraph("<b>N</b> — Not Otherwise Classified (AUB-N)", LABEL_STYLE)],
        ], colWidths=[1.2*cm, 7.7*cm]),
    ]
]
acronym_tbl = Table(acronym_data, colWidths=[(W-2*cm)/2, (W-2*cm)/2])
acronym_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (0,0), PALM_COL),
    ("BACKGROUND", (1,0), (1,0), COEIN_COL),
    ("BOX", (0,0), (-1,-1), 0.5, GREY_MID),
    ("INNERGRID", (0,0), (-1,-1), 0.3, GREY_MID),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    ("TOPPADDING", (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("RIGHTPADDING", (0,0), (-1,-1), 5),
]))
story.append(acronym_tbl)
story.append(Spacer(1, 8))

# ====================================================
# PALM - DETAILED TABLE
# ====================================================
story.append(section_bar("  PALM — STRUCTURAL CAUSES (Diagnosed by Imaging / Histology)", bg=PALM_COL))
story.append(Spacer(1, 4))

palm_data = [
    [Paragraph("<b>Category</b>", TABLE_HEADER),
     Paragraph("<b>Definition</b>", TABLE_HEADER),
     Paragraph("<b>Clinical Features</b>", TABLE_HEADER),
     Paragraph("<b>Key Points</b>", TABLE_HEADER)],

    [Paragraph("AUB-P\nPolyp", TABLE_CELL_BOLD),
     Paragraph("Benign overgrowth of endometrial glands + stroma; sessile or pedunculated", TABLE_CELL),
     Paragraph("IMB, PCB, heavy periods; often asymptomatic; diagnosed by TVS/hysteroscopy", TABLE_CELL),
     Paragraph("Up to 5% malignant transformation\nAssociated with tamoxifen, obesity, PCOS", TABLE_CELL)],

    [Paragraph("AUB-A\nAdenomyosis", TABLE_CELL_BOLD),
     Paragraph("Endometrial glands & stroma within myometrium (>2.5 mm from basalis)", TABLE_CELL),
     Paragraph("Bulky, tender, globular uterus; progressive dysmenorrhoea; HMB; secondary dysmenorrhoea", TABLE_CELL),
     Paragraph("Definitive Dx: histology post-hysterectomy\nMRI best imaging modality", TABLE_CELL)],

    [Paragraph("AUB-L\nLeiomyoma\n(Fibroids)", TABLE_CELL_BOLD),
     Paragraph("Benign smooth muscle tumours from myometrium\nType 0-8 (FIGO fibroid classification)", TABLE_CELL),
     Paragraph("Most common benign GU tumor (70% by age 50)\nSubmucosal (Type 0-2) → most likely to bleed", TABLE_CELL),
     Paragraph("Predominantly in Black women\nRx: Mirena, GnRH agonist, myomectomy, UAE, hysterectomy", TABLE_CELL)],

    [Paragraph("AUB-M\nMalignancy /\nHyperplasia", TABLE_CELL_BOLD),
     Paragraph("Endometrial hyperplasia (simple/complex, with/without atypia) or carcinoma", TABLE_CELL),
     Paragraph("90% of endometrial Ca presents with AUB/PMB\nRisk: obesity, PCOS, unopposed estrogen, Lynch syndrome", TABLE_CELL),
     Paragraph("MUST EXCLUDE in women >45 or with risk factors\nEndometrial biopsy mandatory", TABLE_CELL)],
]
palm_tbl = Table(palm_data, colWidths=[2.3*cm, 4.8*cm, 5.5*cm, 5.9*cm])
palm_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), PALM_COL),
    ("BACKGROUND", (0,1), (-1,1), GREY_LIGHT),
    ("BACKGROUND", (0,2), (-1,2), WHITE),
    ("BACKGROUND", (0,3), (-1,3), GREY_LIGHT),
    ("BACKGROUND", (0,4), (-1,4), WHITE),
    ("BOX", (0,0), (-1,-1), 0.5, GREY_MID),
    ("INNERGRID", (0,0), (-1,-1), 0.3, GREY_MID),
    ("TOPPADDING", (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("RIGHTPADDING", (0,0), (-1,-1), 5),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    ("FONTNAME", (0,1), (0,-1), "Helvetica-Bold"),
    ("TEXTCOLOR", (0,1), (0,-1), PALM_COL),
]))
story.append(palm_tbl)
story.append(Spacer(1, 8))

# ====================================================
# COEIN - DETAILED TABLE
# ====================================================
story.append(section_bar("  COEIN — NON-STRUCTURAL CAUSES (Medical / Hormonal)", bg=COEIN_COL))
story.append(Spacer(1, 4))

coein_data = [
    [Paragraph("<b>Category</b>", TABLE_HEADER),
     Paragraph("<b>Definition</b>", TABLE_HEADER),
     Paragraph("<b>Clinical Features / Examples</b>", TABLE_HEADER),
     Paragraph("<b>Key Points</b>", TABLE_HEADER)],

    [Paragraph("AUB-C\nCoagulopathy", TABLE_CELL_BOLD),
     Paragraph("Systemic disorder of haemostasis causing HMB", TABLE_CELL),
     Paragraph("von Willebrand disease (most common)\nITP, haemophilia carrier, liver disease, anticoagulants", TABLE_CELL),
     Paragraph("5-20% of HMB cases\nRed flag: HMB since menarche\nScreen: CBC, PT, aPTT, VWF Ag + activity", TABLE_CELL)],

    [Paragraph("AUB-O\nOvulatory\nDysfunction", TABLE_CELL_BOLD),
     Paragraph("Absent/abnormal ovulation → no progesterone → unopposed estrogen → irregular endometrial shedding", TABLE_CELL),
     Paragraph("PCOS, hypothyroidism, hyperprolactinaemia\nHypothalamic dysfunction, POI, obesity\nCommon at extremes of reproductive life", TABLE_CELL),
     Paragraph("Most common cause in reproductive age\nEstrogen breakthrough bleeding mechanism\nAmenorrhoea → acute heavy bleed pattern", TABLE_CELL)],

    [Paragraph("AUB-E\nEndometrial", TABLE_CELL_BOLD),
     Paragraph("Primary endometrial haemostatic defect despite normal ovulation and no structural pathology", TABLE_CELL),
     Paragraph("Regular but heavy periods (HMB)\nAbnormal prostaglandin / fibrinolytic balance\nExcess PGE2 / prostacyclin (vasodilators)", TABLE_CELL),
     Paragraph("Diagnosis of EXCLUSION\nNormal endometrial biopsy\nRx: tranexamic acid, NSAIDs", TABLE_CELL)],

    [Paragraph("AUB-I\nIatrogenic", TABLE_CELL_BOLD),
     Paragraph("Bleeding attributable to exogenous hormonal / pharmacological agents or devices", TABLE_CELL),
     Paragraph("OCPs / Progestins: breakthrough bleeding\nAnticoagulants (warfarin, DOAC)\nAntipsychotics → hyperprolactinaemia\nCopper/LNG-IUD\nTamoxifen", TABLE_CELL),
     Paragraph("Always take a thorough drug history\nChlamydia screen if irregular OCP bleeding\nAdjust/stop offending agent if possible", TABLE_CELL)],

    [Paragraph("AUB-N\nNot Otherwise\nClassified", TABLE_CELL_BOLD),
     Paragraph("Rare / poorly understood causes not fitting other categories", TABLE_CELL),
     Paragraph("Arteriovenous malformations (AVM)\nMyometrial hypertrophy\nCervicitis, endometritis", TABLE_CELL),
     Paragraph("Rare but important to consider\nAVM diagnosed on Doppler USS / MRI\nRx: uterine artery embolisation", TABLE_CELL)],
]
coein_tbl = Table(coein_data, colWidths=[2.3*cm, 4.5*cm, 5.7*cm, 6*cm])
coein_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), COEIN_COL),
    ("BACKGROUND", (0,1), (-1,1), GREY_LIGHT),
    ("BACKGROUND", (0,2), (-1,2), WHITE),
    ("BACKGROUND", (0,3), (-1,3), GREY_LIGHT),
    ("BACKGROUND", (0,4), (-1,4), WHITE),
    ("BACKGROUND", (0,5), (-1,5), GREY_LIGHT),
    ("BOX", (0,0), (-1,-1), 0.5, GREY_MID),
    ("INNERGRID", (0,0), (-1,-1), 0.3, GREY_MID),
    ("TOPPADDING", (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("RIGHTPADDING", (0,0), (-1,-1), 5),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    ("FONTNAME", (0,1), (0,-1), "Helvetica-Bold"),
    ("TEXTCOLOR", (0,1), (0,-1), COEIN_COL),
]))
story.append(coein_tbl)
story.append(Spacer(1, 8))

# ====================================================
# CAUSES BY AGE + MECHANISM OF ANOVULATORY BLEEDING
# ====================================================
story.append(section_bar("  CAUSES BY AGE GROUP", bg=TEAL))
story.append(Spacer(1, 4))

age_data = [
    [Paragraph("<b>Age Group</b>", TABLE_HEADER),
     Paragraph("<b>Common Causes</b>", TABLE_HEADER),
     Paragraph("<b>Priority Concern</b>", TABLE_HEADER)],
    [Paragraph("Neonatal / Infancy", TABLE_CELL_BOLD),
     Paragraph("Maternal estrogen withdrawal", TABLE_CELL),
     Paragraph("Physiological; self-limiting", TABLE_CELL)],
    [Paragraph("Prepubertal", TABLE_CELL_BOLD),
     Paragraph("Vulvovaginitis, foreign body, precocious puberty, tumor", TABLE_CELL),
     Paragraph("Rule out abuse / tumor", TABLE_CELL)],
    [Paragraph("Adolescent", TABLE_CELL_BOLD),
     Paragraph("Anovulation (most common), coagulopathy (vWD), pregnancy, exogenous hormones", TABLE_CELL),
     Paragraph("HMB since menarche → screen coagulopathy", TABLE_CELL)],
    [Paragraph("Reproductive Age", TABLE_CELL_BOLD),
     Paragraph("Pregnancy, anovulation, fibroids, polyps, thyroid, PCOS, exogenous hormones", TABLE_CELL),
     Paragraph("Always exclude pregnancy first", TABLE_CELL)],
    [Paragraph("Perimenopausal", TABLE_CELL_BOLD),
     Paragraph("Anovulation, fibroids, polyps, thyroid dysfunction", TABLE_CELL),
     Paragraph("Endometrial biopsy if ≥45 yrs", TABLE_CELL)],
    [Paragraph("Postmenopausal", TABLE_CELL_BOLD),
     Paragraph("Atrophy (most common), polyps, HRT, endometrial cancer", TABLE_CELL),
     Paragraph("ALL PMB = abnormal → biopsy if ET >4 mm", TABLE_CELL)],
]
age_tbl = Table(age_data, colWidths=[3.5*cm, 8*cm, 7*cm])
age_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), TEAL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [GREY_LIGHT, WHITE]),
    ("BOX", (0,0), (-1,-1), 0.5, GREY_MID),
    ("INNERGRID", (0,0), (-1,-1), 0.3, GREY_MID),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 6),
    ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
]))
story.append(age_tbl)
story.append(Spacer(1, 8))

# ====================================================
# MECHANISM OF ANOVULATORY DUB
# ====================================================
story.append(mini_bar("  Mechanism of Anovulatory Bleeding (AUB-O)", bg=TEAL))
story.append(Spacer(1, 4))

mech_data = [
    [Paragraph(
        "<b>No Ovulation</b> → <b>No Corpus Luteum</b> → <b>No Progesterone</b> → "
        "<b>Unopposed Estrogen</b> → <b>Endometrial Proliferation</b> → "
        "<b>Irregular / Fragile Shedding</b>",
        style("Mech", fontName="Helvetica-Bold", fontSize=9, textColor=TEAL,
              leading=16, alignment=TA_CENTER)
    )]
]
mech_tbl = Table(mech_data, colWidths=[W - 2*cm])
mech_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), ACCENT),
    ("BOX", (0,0), (-1,-1), 1, TEAL_LIGHT),
    ("TOPPADDING", (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("LEFTPADDING", (0,0), (-1,-1), 12),
    ("RIGHTPADDING", (0,0), (-1,-1), 12),
]))
story.append(mech_tbl)
story.append(Spacer(1, 4))

detail_mech = [
    [Paragraph("Low estrogen levels:", BODY_BOLD),
     Paragraph("Irregular prolonged spotting", BODY_STYLE)],
    [Paragraph("High sustained estrogen:", BODY_BOLD),
     Paragraph("Amenorrhoea followed by sudden, acute heavy bleeding", BODY_STYLE)],
    [Paragraph("Ovulatory DUB (20%):", BODY_BOLD),
     Paragraph("Normal cycles but excess PGE2/prostacyclin → impaired platelet plug → HMB", BODY_STYLE)],
]
dm_tbl = Table(detail_mech, colWidths=[5*cm, 13.5*cm])
dm_tbl.setStyle(TableStyle([
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    ("TOPPADDING", (0,0), (-1,-1), 2),
    ("BOTTOMPADDING", (0,0), (-1,-1), 2),
]))
story.append(dm_tbl)
story.append(Spacer(1, 8))

# ====================================================
# PAGE 2 - INVESTIGATIONS & MANAGEMENT
# ====================================================
story.append(PageBreak())

story.append(section_bar("  INVESTIGATIONS — STEP-BY-STEP APPROACH", bg=PALM_COL))
story.append(Spacer(1, 5))

inv_data = [
    [Paragraph("<b>Step</b>", TABLE_HEADER),
     Paragraph("<b>Investigation</b>", TABLE_HEADER),
     Paragraph("<b>Rationale</b>", TABLE_HEADER)],
    [Paragraph("1 (Always First)", TABLE_CELL_BOLD),
     Paragraph("Urine / serum beta-hCG (Pregnancy Test)", TABLE_CELL),
     Paragraph("Exclude ectopic pregnancy, abortion, GTD before all else", TABLE_CELL)],
    [Paragraph("2 (Haematology)", TABLE_CELL_BOLD),
     Paragraph("CBC (Hb, platelets, WBC)", TABLE_CELL),
     Paragraph("Detect anaemia from HMB; thrombocytopenia (ITP)", TABLE_CELL)],
    [Paragraph("3 (Endocrine)", TABLE_CELL_BOLD),
     Paragraph("TSH, Prolactin, LH/FSH, AMH (if indicated)", TABLE_CELL),
     Paragraph("Thyroid dysfunction, hyperprolactinaemia, POI, PCOS evaluation", TABLE_CELL)],
    [Paragraph("4 (Coagulation)", TABLE_CELL_BOLD),
     Paragraph("PT, aPTT, VWF antigen + activity, Factor VIII, fibrinogen", TABLE_CELL),
     Paragraph("If HMB since menarche, family Hx bleeding, easy bruising, epistaxis", TABLE_CELL)],
    [Paragraph("5 (Infection)", TABLE_CELL_BOLD),
     Paragraph("Cervical swab / NAAT for Chlamydia, gonorrhoea; Pap smear", TABLE_CELL),
     Paragraph("Exclude cervicitis, endometritis, cervical cancer", TABLE_CELL)],
    [Paragraph("6 (Imaging)", TABLE_CELL_BOLD),
     Paragraph("Transvaginal USS (TVS) — first-line imaging", TABLE_CELL),
     Paragraph("Assess endometrial thickness, fibroids, polyps, adnexa; ET >4 mm PMB → biopsy", TABLE_CELL)],
    [Paragraph("7 (Specialised)", TABLE_CELL_BOLD),
     Paragraph("Sonohysterography / Saline Infusion Sonography (SIS)", TABLE_CELL),
     Paragraph("Best for intracavitary lesions (polyps, submucosal fibroids)", TABLE_CELL)],
    [Paragraph("8 (Histology)", TABLE_CELL_BOLD),
     Paragraph("Endometrial biopsy (Pipelle) / Hysteroscopy + D&C", TABLE_CELL),
     Paragraph("Mandatory: age ≥45; <45 with obesity, PCOS, persistent AUB, Lynch syndrome risk", TABLE_CELL)],
    [Paragraph("9 (Imaging Plus)", TABLE_CELL_BOLD),
     Paragraph("MRI pelvis (if USS inconclusive)", TABLE_CELL),
     Paragraph("Best for adenomyosis characterisation; fibroid mapping pre-surgery", TABLE_CELL)],
]
inv_tbl = Table(inv_data, colWidths=[3.2*cm, 6.5*cm, 8.8*cm])
inv_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), PALM_COL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [GREY_LIGHT, WHITE]),
    ("BOX", (0,0), (-1,-1), 0.5, GREY_MID),
    ("INNERGRID", (0,0), (-1,-1), 0.3, GREY_MID),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("RIGHTPADDING", (0,0), (-1,-1), 5),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(inv_tbl)
story.append(Spacer(1, 8))

# ====================================================
# MANAGEMENT
# ====================================================
story.append(section_bar("  MANAGEMENT OF AUB", bg=COEIN_COL))
story.append(Spacer(1, 5))

# Medical
story.append(mini_bar("  Medical Treatment", bg=TEAL_LIGHT))
story.append(Spacer(1, 3))

med_data = [
    [Paragraph("<b>Drug / Intervention</b>", TABLE_HEADER),
     Paragraph("<b>Mechanism</b>", TABLE_HEADER),
     Paragraph("<b>Efficacy / Notes</b>", TABLE_HEADER)],
    [Paragraph("Levonorgestrel IUS (Mirena)", TABLE_CELL_BOLD),
     Paragraph("Local progestin → endometrial atrophy", TABLE_CELL),
     Paragraph("Reduces HMB by up to 90%; first-line for HMB; also contraception", TABLE_CELL)],
    [Paragraph("Tranexamic Acid", TABLE_CELL_BOLD),
     Paragraph("Antifibrinolytic → stabilises clot", TABLE_CELL),
     Paragraph("Reduces HMB by 40-50%; non-hormonal; take during menses only", TABLE_CELL)],
    [Paragraph("NSAIDs (Mefenamic acid, Ibuprofen)", TABLE_CELL_BOLD),
     Paragraph("PG synthetase inhibitor → reduces PGE2/prostacyclin", TABLE_CELL),
     Paragraph("Reduces HMB by 20-50%; also treats dysmenorrhoea", TABLE_CELL)],
    [Paragraph("Combined OCP (COCP)", TABLE_CELL_BOLD),
     Paragraph("Suppress HPO axis → regular withdrawal bleeds", TABLE_CELL),
     Paragraph("Reduces HMB by 40-50%; regulates cycle; also contraception", TABLE_CELL)],
    [Paragraph("Progestins (Norethisterone, MPA, Dydrogesterone)", TABLE_CELL_BOLD),
     Paragraph("Oppose estrogen → stabilise endometrium", TABLE_CELL),
     Paragraph("Oral: D5-D26 for anovulatory AUB; less effective than Mirena for HMB", TABLE_CELL)],
    [Paragraph("GnRH Agonists (Leuprolide, Goserelin)", TABLE_CELL_BOLD),
     Paragraph("Down-regulate HPO → hypo-oestrogenic state → amenorrhoea", TABLE_CELL),
     Paragraph("Short-term (3-6 months); pre-op fibroid shrinkage; add-back HRT needed", TABLE_CELL)],
    [Paragraph("Danazol", TABLE_CELL_BOLD),
     Paragraph("Androgen; suppresses FSH/LH; androgenic endometrium", TABLE_CELL),
     Paragraph("Effective but androgenic SE (acne, hirsutism); reserved for resistant cases", TABLE_CELL)],
]
med_tbl = Table(med_data, colWidths=[4.5*cm, 5.5*cm, 8.5*cm])
med_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), COEIN_COL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [GREY_LIGHT, WHITE]),
    ("BOX", (0,0), (-1,-1), 0.5, GREY_MID),
    ("INNERGRID", (0,0), (-1,-1), 0.3, GREY_MID),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("RIGHTPADDING", (0,0), (-1,-1), 5),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(med_tbl)
story.append(Spacer(1, 6))

# Surgical
story.append(mini_bar("  Surgical Treatment", bg=TEAL))
story.append(Spacer(1, 3))

surg_data = [
    [Paragraph("<b>Procedure</b>", TABLE_HEADER),
     Paragraph("<b>Indication</b>", TABLE_HEADER),
     Paragraph("<b>Notes</b>", TABLE_HEADER)],
    [Paragraph("Endometrial Ablation", TABLE_CELL_BOLD),
     Paragraph("HMB with failed medical Rx; family complete", TABLE_CELL),
     Paragraph("Destroys endometrium; 80% amenorrhoea/hypomenorrhoea; day procedure", TABLE_CELL)],
    [Paragraph("Hysteroscopic Polypectomy", TABLE_CELL_BOLD),
     Paragraph("Endometrial / endocervical polyps", TABLE_CELL),
     Paragraph("Outpatient; resectoscope; send polyp for histology", TABLE_CELL)],
    [Paragraph("Myomectomy", TABLE_CELL_BOLD),
     Paragraph("Symptomatic fibroids, fertility desired", TABLE_CELL),
     Paragraph("Abdominal / laparoscopic / hysteroscopic (Type 0-2 fibroids)", TABLE_CELL)],
    [Paragraph("Uterine Artery Embolisation (UAE)", TABLE_CELL_BOLD),
     Paragraph("Symptomatic fibroids / AVM; uterus preservation desired", TABLE_CELL),
     Paragraph("Interventional radiology; 85-90% symptom improvement", TABLE_CELL)],
    [Paragraph("Hysterectomy", TABLE_CELL_BOLD),
     Paragraph("Definitive; failed conservative Rx; malignancy", TABLE_CELL),
     Paragraph("Total / subtotal; abdominal, laparoscopic or vaginal approach", TABLE_CELL)],
]
surg_tbl = Table(surg_data, colWidths=[4.5*cm, 5.5*cm, 8.5*cm])
surg_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), TEAL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [GREY_LIGHT, WHITE]),
    ("BOX", (0,0), (-1,-1), 0.5, GREY_MID),
    ("INNERGRID", (0,0), (-1,-1), 0.3, GREY_MID),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("RIGHTPADDING", (0,0), (-1,-1), 5),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(surg_tbl)
story.append(Spacer(1, 8))

# ====================================================
# PAGE 3 - HIGH YIELD EXAM NOTES
# ====================================================
story.append(PageBreak())

story.append(section_bar("  HIGH-YIELD EXAM POINTS", bg=colors.HexColor("#8B0000")))
story.append(Spacer(1, 5))

# Two column layout
left_col = []
right_col = []

left_col.append(Paragraph("Classic DC Dutta exam facts:", HEADING2))
left_items = [
    ("DUB definition", "Abnormal uterine bleeding with NO organic, systemic, or iatrogenic cause — diagnosis of exclusion"),
    ("DUB most common type", "Anovulatory (80%); common at extremes of reproductive life"),
    ("Most common cause HMB", "Uterine fibroids (leiomyoma) in reproductive age"),
    ("Most common cause PMB", "Endometrial atrophy"),
    ("Most common coagulopathy", "von Willebrand Disease (5-20% of HMB)"),
    ("Estrogen breakthrough", "Low estrogen → irregular spotting; High estrogen → sudden heavy bleed"),
    ("Hormone in anovulatory DUB", "No progesterone; unopposed estrogen"),
    ("PALM-COEIN origin", "FIGO 2011; replaced all old terminology"),
    ("Term now abandoned", "DUB, menorrhagia, metrorrhagia, menometrorrhagia"),
    ("HMB definition", ">80 mL/cycle or soaking a pad/tampon every hour for 2+ consecutive hours"),
    ("Most effective medical Rx", "LNG-IUS (Mirena) — reduces flow up to 90%"),
    ("Best initial imaging", "Transvaginal Ultrasound (TVS)"),
    ("Biopsy mandatory in", "Women ≥45 yrs with AUB; ANY postmenopausal bleeding with ET >4 mm"),
]
for title, fact in left_items:
    left_col.append(Table(
        [[Paragraph(title, TABLE_CELL_BOLD), Paragraph(fact, TABLE_CELL)]],
        colWidths=[4.5*cm, 5.5*cm]
    ))

right_col.append(Paragraph("Quick mnemonics & differentials:", HEADING2))
right_col.append(Table(
    [[Paragraph(
        "<b>PALM</b> = Structural (seen on imaging/histology)<br/>"
        "<b>COEIN</b> = Non-structural (medical/hormonal)<br/><br/>"
        "<b>P</b>olyp → Pedunculated or sessile; feeder vessel on Doppler<br/>"
        "<b>A</b>denomyosis → Boggy, tender, enlarged uterus<br/>"
        "<b>L</b>eiomyoma → Submucosal bleeds most<br/>"
        "<b>M</b>alignancy → Must always exclude!<br/><br/>"
        "<b>C</b>oagulopathy → vWD, ITP, liver disease<br/>"
        "<b>O</b>vulatory dysfunction → PCOS, thyroid, prolactin<br/>"
        "<b>E</b>ndometrial → excess PGE2, fibrinolysis<br/>"
        "<b>I</b>atrogenic → OCP, warfarin, antipsychotics, IUD<br/>"
        "<b>N</b>ot classified → AVM, myometrial hypertrophy",
        style("Mnemo", fontName="Helvetica", fontSize=8.5, textColor=BLACK,
              leading=15, leftIndent=5)
    )]],
    colWidths=[10*cm]
))
right_col.append(Spacer(1, 8))
right_col.append(Paragraph("Postmenopausal Bleeding - Key Rules:", HEADING2))
right_col.append(Table(
    [[Paragraph(
        "1. ANY PMB must be investigated<br/>"
        "2. Most common cause: ATROPHY<br/>"
        "3. Most feared cause: ENDOMETRIAL CANCER<br/>"
        "   (90% of Ca endometrium presents with PMB)<br/>"
        "4. ET ≤4 mm on TVS → biopsy may be avoided<br/>"
        "5. ET >4 mm → endometrial biopsy MANDATORY<br/>"
        "6. Caution: 4 mm cutoff may miss Ca in Black patients<br/>"
        "7. Persistent bleeding despite normal USS → biopsy",
        style("PMB", fontName="Helvetica", fontSize=8.5, textColor=BLACK,
              leading=15, leftIndent=5)
    )]],
    colWidths=[10*cm]
))
right_col[-1].setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), colors.HexColor("#FFF3F3")),
    ("BOX", (0,0), (-1,-1), 0.8, RED_SOFT),
    ("TOPPADDING", (0,0), (-1,-1), 6),
    ("BOTTOMPADDING", (0,0), (-1,-1), 6),
    ("LEFTPADDING", (0,0), (-1,-1), 8),
]))

for item in left_items:
    pass

# Rebuild left column as a single table
left_table_data = [[Paragraph("<b>Topic</b>", TABLE_HEADER), Paragraph("<b>Key Point</b>", TABLE_HEADER)]]
for title, fact in left_items:
    left_table_data.append([Paragraph(title, TABLE_CELL_BOLD), Paragraph(fact, TABLE_CELL)])
left_table = Table(left_table_data, colWidths=[4.5*cm, 5.5*cm])
left_table.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#8B0000")),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [GREY_LIGHT, WHITE]),
    ("BOX", (0,0), (-1,-1), 0.5, GREY_MID),
    ("INNERGRID", (0,0), (-1,-1), 0.3, GREY_MID),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("RIGHTPADDING", (0,0), (-1,-1), 5),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))

right_mnemo = Table([[Paragraph(
    "<b>PALM</b> = Structural (seen on imaging/histology)<br/>"
    "<b>COEIN</b> = Non-structural (medical/hormonal)<br/><br/>"
    "<b>P</b>olyp → Pedunculated or sessile; feeder vessel on Doppler<br/>"
    "<b>A</b>denomyosis → Boggy, tender, globular uterus<br/>"
    "<b>L</b>eiomyoma → Submucosal type bleeds most<br/>"
    "<b>M</b>alignancy → Must ALWAYS be excluded!<br/><br/>"
    "<b>C</b>oagulopathy → vWD (most common), ITP, liver Dx<br/>"
    "<b>O</b>vulatory dysfunction → PCOS, thyroid, prolactin, POI<br/>"
    "<b>E</b>ndometrial → abnormal PGE2/fibrinolytic activity<br/>"
    "<b>I</b>atrogenic → OCP, warfarin, antipsychotics, IUD, tamoxifen<br/>"
    "<b>N</b>ot classified → AVM, myometrial hypertrophy",
    style("Mnemo2", fontName="Helvetica", fontSize=8.5, textColor=BLACK, leading=15, leftIndent=5)
)]], colWidths=[9.5*cm])
right_mnemo.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), ACCENT),
    ("BOX", (0,0), (-1,-1), 0.8, TEAL),
    ("TOPPADDING", (0,0), (-1,-1), 7),
    ("BOTTOMPADDING", (0,0), (-1,-1), 7),
    ("LEFTPADDING", (0,0), (-1,-1), 8),
]))

right_pmb = Table([[Paragraph(
    "<b>Postmenopausal Bleeding Rules:</b><br/>"
    "1. ANY PMB = abnormal; MUST investigate<br/>"
    "2. Most common cause: ENDOMETRIAL ATROPHY<br/>"
    "3. Most feared: ENDOMETRIAL CANCER (90% present with AUB)<br/>"
    "4. TVS ET ≤4 mm → biopsy may be deferred<br/>"
    "5. TVS ET >4 mm OR persistent bleeding → BIOPSY mandatory<br/>"
    "6. Note: 4 mm cutoff may under-diagnose Ca in Black patients",
    style("PMB2", fontName="Helvetica", fontSize=8.5, textColor=BLACK, leading=15, leftIndent=5)
)]], colWidths=[9.5*cm])
right_pmb.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), colors.HexColor("#FFF3F3")),
    ("BOX", (0,0), (-1,-1), 0.8, RED_SOFT),
    ("TOPPADDING", (0,0), (-1,-1), 7),
    ("BOTTOMPADDING", (0,0), (-1,-1), 7),
    ("LEFTPADDING", (0,0), (-1,-1), 8),
]))

two_col = Table(
    [[
        Table([[Paragraph("Classic Exam Facts:", HEADING2)], [left_table]], colWidths=[10.5*cm]),
        Table([
            [Paragraph("Quick Mnemonics:", HEADING2)],
            [right_mnemo],
            [Spacer(1, 6)],
            [Paragraph("Postmenopausal Bleeding:", HEADING2)],
            [right_pmb],
        ], colWidths=[9.5*cm])
    ]],
    colWidths=[10.5*cm, 9.5*cm]
)
two_col.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),
    ("COLPADDING", (0,0), (-1,-1), 4),
]))
story.append(two_col)
story.append(Spacer(1, 8))

# ====================================================
# OLD TERMINOLOGY TABLE
# ====================================================
story.append(mini_bar("  Old Terminology (Now Replaced by PALM-COEIN)", bg=TEAL))
story.append(Spacer(1, 4))

old_data = [
    [Paragraph("<b>Old Term</b>", TABLE_HEADER),
     Paragraph("<b>Meaning</b>", TABLE_HEADER),
     Paragraph("<b>Status</b>", TABLE_HEADER)],
    [Paragraph("Menorrhagia", TABLE_CELL_BOLD),
     Paragraph("Regular cycle, excessive flow (>80 mL) or duration (>7 days)", TABLE_CELL),
     Paragraph("Replaced by 'Heavy Menstrual Bleeding (HMB)'", TABLE_CELL)],
    [Paragraph("Metrorrhagia", TABLE_CELL_BOLD),
     Paragraph("Irregular bleeding between periods", TABLE_CELL),
     Paragraph("Replaced by 'Intermenstrual Bleeding (IMB)'", TABLE_CELL)],
    [Paragraph("Menometrorrhagia", TABLE_CELL_BOLD),
     Paragraph("Irregular, excessive, prolonged bleeding", TABLE_CELL),
     Paragraph("Abandoned; describe by FIGO parameters", TABLE_CELL)],
    [Paragraph("Polymenorrhoea", TABLE_CELL_BOLD),
     Paragraph("Cycle interval <21 days", TABLE_CELL),
     Paragraph("Replaced by 'Frequent menstruation'", TABLE_CELL)],
    [Paragraph("Oligomenorrhoea", TABLE_CELL_BOLD),
     Paragraph("Cycle interval >35 days", TABLE_CELL),
     Paragraph("Replaced by 'Infrequent menstruation'", TABLE_CELL)],
    [Paragraph("Dysfunctional Uterine Bleeding (DUB)", TABLE_CELL_BOLD),
     Paragraph("AUB with no structural/systemic cause; diagnosis of exclusion", TABLE_CELL),
     Paragraph("ABANDONED — covered by AUB-O, AUB-E in PALM-COEIN", TABLE_CELL)],
    [Paragraph("Postcoital Bleeding (PCB)", TABLE_CELL_BOLD),
     Paragraph("Bleeding after intercourse", TABLE_CELL),
     Paragraph("Still used; evaluate cervix (polyp, cervicitis, Ca cervix)", TABLE_CELL)],
]
old_tbl = Table(old_data, colWidths=[4*cm, 7*cm, 7.5*cm])
old_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), TEAL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [GREY_LIGHT, WHITE]),
    ("BOX", (0,0), (-1,-1), 0.5, GREY_MID),
    ("INNERGRID", (0,0), (-1,-1), 0.3, GREY_MID),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("RIGHTPADDING", (0,0), (-1,-1), 5),
    ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
    ("TEXTCOLOR", (2,7), (2,7), colors.HexColor("#555555")),
]))
story.append(old_tbl)
story.append(Spacer(1, 8))

# ====================================================
# QUICK REFERENCE FOOTER BOX
# ====================================================
footer_box = Table([[Paragraph(
    "<b>Source:</b> Berek &amp; Novak's Gynecology | DC Dutta's Textbook of Gynaecology | "
    "Sabiston Textbook of Surgery | FIGO Working Group on Menstrual Disorders (2011)  |  "
    "<b>Classification valid for non-pregnant, reproductive-age women</b>",
    style("Footer", fontName="Helvetica-Oblique", fontSize=7.5, textColor=colors.HexColor("#444"),
          leading=12, alignment=TA_CENTER)
)]], colWidths=[W - 2*cm])
footer_box.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), GREY_LIGHT),
    ("BOX", (0,0), (-1,-1), 0.5, GREY_MID),
    ("TOPPADDING", (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING", (0,0), (-1,-1), 8),
]))
story.append(footer_box)

# ====================================================
# BUILD
# ====================================================
doc.build(story, onFirstPage=on_page, onLaterPages=on_page)
print(f"PDF created: {OUTPUT}")

Running Command

cd /home/daytona/workspace/palm-coein-guide && python3 generate_pdf.py 2>&1

Running Command

ls -lh /home/daytona/workspace/palm-coein-guide/PALM_COEIN_Study_Guide.pdf

Your study guide PDF is ready!

PALM COEIN Study Guide

PDF Document · PDF

The 3-page PDF includes:

Page 1

Cover banner with title and subtitle
Normal menstrual parameters table (cycle length, duration, volume, regularity)
Full PALM-COEIN acronym visual with colour-coded letter badges (teal for PALM, dark teal for COEIN)
PALM structural causes - detailed table (Polyp, Adenomyosis, Leiomyoma, Malignancy)
COEIN non-structural causes - detailed table (all 5 categories with mechanisms)
Causes by age group (neonatal → postmenopausal)
Mechanism of anovulatory bleeding flowchart

Page 2

Step-by-step investigations (9 steps, pregnancy test through MRI)
Medical management table (LNG-IUS, tranexamic acid, NSAIDs, OCP, progestins, GnRH agonists, danazol)
Surgical management table (ablation, polypectomy, myomectomy, UAE, hysterectomy)

Page 3

High-yield exam facts (DC Dutta style)
Quick mnemonics for each letter
Postmenopausal bleeding rules (highlighted red)
Old terminology comparison table (all deprecated terms vs their replacements)
Source attribution footer

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