Dysmenorrhoea — DVA claim example

Diagnostic Assessment — Dysmenorrhoea

Example 1 of 1 · fictitious patient (Veteran CS)

Diagnostic Assessment

Dysmenorrhoea

No Statement of Principles applies to this condition (non-SOP claim).

ADF History

Veteran CS, date of birth 08 August 1988, Australian Army, Signaller (Royal Australian Corps of Signals), enlisted 20 February 2007, medically discharged 11 December 2020. Operational service: Afghanistan, 10 January 2011 to 25 August 2011 (warlike); Middle East Area of Operations (Iraq), 05 November 2015 to 30 May 2016 (warlike).

Occupational History

As a signaller the veteran installed, operated and maintained radio and satellite communications in headquarters, vehicles and field sites, worked long shifts and night duty in communications centres, carried radio equipment and batteries on foot, and lived in field conditions on exercises and deployments for weeks at a time.

Female members on deployment and in the field faced limited privacy and sanitation for menstrual care, restricted access to gynaecological review, imaging and specialist treatment, and practical barriers to obtaining and maintaining contraception and menstrual suppression. Deployments to Afghanistan and Iraq involved indirect fire, prolonged hypervigilance and separation from family, and a smoking culture was common in deployed and garrison units of the period.

History

Veteran CS, a signaller in the Australian Army, developed secondary dysmenorrhoea on 14 September 2012, after warlike service in Afghanistan, on a background of endometriosis, adenomyosis, a submucosal fibroid, a copper intrauterine device inserted in service, pelvic inflammatory disease, cervical stenosis after a cervical excision procedure, smoking and posttraumatic stress disorder. The condition worsened markedly on warlike service in Iraq on 12 March 2016, after her levonorgestrel intrauterine system was expelled and could not be replaced in theatre.

Timeline

• 09 Nov 2011 — Routine cervical screening after the veteran's return from Afghanistan showed a high-grade squamous intraepithelial lesion, and colposcopic biopsy confirmed cervical intraepithelial neoplasia grade 2. A gynaecologist performed a large loop excision of the transformation zone, removing a 14 mm deep cone of cervix. Her periodic health examination of 03 August 2011 had recorded regular, painless periods. "LLETZ for CIN2, 14 mm"
• 20 Jan 2012 — A psychiatrist diagnosed posttraumatic stress disorder arising from repeated rocket attacks on her base in Afghanistan in 2011, including an impact 30 metres from her communications centre. She reported nightmares, hypervigilance and poor sleep and had increased her smoking to 15 cigarettes a day. Sertraline and trauma-focused psychological therapy were commenced. "PTSD, smoking 15 per day"
• 22 Mar 2012 — The veteran presented with lower abdominal pain, fever and abnormal discharge. Examination showed cervical motion and adnexal tenderness, and a cervical swab was positive for Chlamydia trachomatis. The medical officer diagnosed pelvic inflammatory disease and treated her with ceftriaxone, doxycycline and metronidazole. "PID, Chlamydia trachomatis positive"
• 18 Jun 2012 — Because she had developed migraine with aura, her combined oral contraceptive, taken since 2007, was stopped as contraindicated. A Defence medical officer inserted a copper intrauterine device. Insertion was difficult because of a tight cervical os and required dilatation. "copper IUD inserted, tight os"
• 17 Sep 2012 — The veteran presented with severe cramping lower abdominal and back pain with each period since 14 September 2012, pain scores of 8 out of 10, nausea and vomiting, deep dyspareunia and heavier bleeding. She had missed two days of duty. The medical officer prescribed mefenamic acid and referred her to a gynaecologist. "severe period pain 8/10"
• 06 Mar 2013 — A gynaecologist confirmed secondary dysmenorrhoea. Transvaginal ultrasound and MRI showed adenomyosis, a 25 mm submucosal fibroid and a 22 mm left ovarian endometrioma. At removal of the copper device the cervical canal was stenosed and admitted only a fine dilator. Laparoscopy on 15 May 2013 confirmed stage III endometriosis, which was excised, the cervix was dilated and a levonorgestrel intrauterine system was inserted. "secondary dysmenorrhoea, endometriosis, adenomyosis"
• 12 Mar 2016 — On warlike service in Iraq the veteran collapsed with pain on the first day of her period. Her levonorgestrel intrauterine system had been expelled in January 2016 and no gynaecological care was available in theatre to replace it. Pain scores were 10 out of 10, she missed three to four days of duty each month, and she required intramuscular opioid analgesia at the deployed health facility. "collapsed with pain, IUS expelled"
• 20 Jul 2016 — After her return to Australia, MRI and repeat laparoscopy showed progression to stage IV endometriosis with a deep infiltrating rectovaginal nodule and a 41 mm endometrioma, and an increase in the adenomyotic junctional zone from 14 to 18 mm. The gynaecologist excised the disease and inserted a new levonorgestrel intrauterine system. She was medically discharged on 11 December 2020. "stage IV endometriosis, progression"

Symptoms

At onset the veteran had severe cramping lower abdominal pain beginning a day before each period and lasting four to five days, radiating to the lower back and thighs, with nausea, vomiting, diarrhoea, heavy bleeding with clots, deep dyspareunia and fatigue. The pain did not respond to over-the-counter analgesia and kept her from duty for one to two days a month.

After the 2016 worsening the pain was constant for most of each cycle, with severe flares at menstruation, painful defaecation and pelvic pain on exertion, and she missed three to four days a month. She now reports monthly pain of 7 to 9 out of 10 despite treatment, chronic pelvic pain between periods, fatigue and low mood, and she has restricted her work and social activities around her cycle.

Imaging

• 06 Mar 2013 — Transvaginal ultrasound: "Bulky uterus with heterogeneous myometrium and subendometrial cysts consistent with adenomyosis. 25 mm submucosal fibroid. 22 mm left ovarian endometrioma. Copper intrauterine device in situ."
• 06 Mar 2013 — MRI pelvis: "Thickened junctional zone of 14 mm consistent with adenomyosis. Submucosal fibroid. Left ovarian endometrioma. Narrowed cervical canal."
• 20 Jul 2016 — MRI pelvis: "Junctional zone 18 mm. 41 mm left ovarian endometrioma. 18 mm deep infiltrating nodule of the rectovaginal septum. Progression since 2013."

Onset Date

The most likely date of onset of this condition is 14 Sep 2012.

At that date the veteran was serving full time with a signal regiment in Australia, a year after returning from warlike service in Afghanistan. She was being treated for posttraumatic stress disorder, was smoking 15 cigarettes a day, had recently been treated for pelvic inflammatory disease and had had a copper intrauterine device inserted three months earlier. On 14 September 2012 her period began with severe cramping pain, and the pain recurred with every subsequent period.

This date is appropriate because her periodic health examination of 03 August 2011 and the gynaecological history taken before her cervical procedure on 09 November 2011 recorded regular, painless periods, and she presented with new severe period pain on 17 September 2012, giving 14 September 2012 as the first day of that period. A gynaecologist confirmed secondary dysmenorrhoea on 06 March 2013. It falls within continuous full-time service.

For the pelvic inflammatory disease cause, the 2 years before onset run from 14 Sep 2010 to 14 Sep 2012, and the infection was diagnosed on 22 Mar 2012. For the smoking cause, the 1 year before onset runs from 14 Sep 2011 to 14 Sep 2012, during which she smoked 10 to 15 cigarettes a day. For the mental disorder cause, the 6 months before onset run from 14 Mar 2012 to 14 Sep 2012, during which she had posttraumatic stress disorder, diagnosed on 20 Jan 2012. The cervical excision of 09 Nov 2011 and the copper device inserted on 18 Jun 2012 preceded onset. Endometriosis, adenomyosis and the submucosal fibroid were present at onset, confirmed on imaging on 06 Mar 2013 and at laparoscopy on 15 May 2013.

For the worsening factors, the documented worsening is 12 Mar 2016, on warlike service in Iraq, confirmed by pain scores of 10 out of 10, three to four days of lost duty a month and, on 20 July 2016, imaging and laparoscopic progression of the endometriosis and adenomyosis. The 6 months before the worsening run from 12 Sep 2015 to 12 Mar 2016, during which her posttraumatic stress disorder relapsed under indirect fire in Iraq, and the 1 year before it runs from 12 Mar 2015 to 12 Mar 2016, during which she smoked 10 to 15 cigarettes a day. The intrauterine system was expelled in January 2016, within 3 months before the worsening.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is secondary dysmenorrhoea (ICD-10 N94.5), due to endometriosis and adenomyosis with contributing uterine and cervical pathology. No Statement of Principles has been determined for this condition.

Dysmenorrhoea is painful menstruation. Primary dysmenorrhoea is menstrual pain without pelvic pathology, beginning in adolescence. Secondary dysmenorrhoea is menstrual pain caused by pelvic disease, usually beginning later in life after a period of painless menstruation. Its causes include endometriosis, adenomyosis, uterine fibroids, intrauterine devices, pelvic inflammatory disease and obstruction to menstrual outflow. The pain results from excessive prostaglandin release, uterine contraction and ischaemia, and inflammation from ectopic endometrial tissue, and it is often accompanied by heavy bleeding, gastrointestinal symptoms, dyspareunia and chronic pelvic pain.

In this veteran the dysmenorrhoea began on 14 September 2012 after years of painless periods, in the presence of several recognised causes that arose during service. It was confirmed on 06 March 2013 and worsened on warlike service in Iraq on 12 March 2016.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

14 September 2012.

When did the veteran first present to a health / medical provider for this condition?

17 September 2012.

When was the condition confirmed / formally diagnosed?

06 March 2013.

When did the veteran first present to you (or your practice) for this condition?

25 February 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was made by a gynaecologist on 06 March 2013 on a history of new, severe, cyclical pelvic pain with menstruation from 14 September 2012 after previously painless periods, with associated heavy bleeding and dyspareunia, and pelvic pathology on transvaginal ultrasound and MRI: adenomyosis with a junctional zone of 14 mm, a 25 mm submucosal fibroid and a left ovarian endometrioma. Laparoscopy on 15 May 2013 confirmed stage III endometriosis histologically. Painful menstruation with identified pelvic pathology meets the accepted definition of secondary dysmenorrhoea.

The worsening was confirmed by an increase in pain from 8 to 10 out of 10 with three to four days of lost duty a month from March 2016, the need for parenteral opioid analgesia in theatre, and MRI and laparoscopy on 20 July 2016 showing progression to stage IV endometriosis with a deep infiltrating nodule, a larger endometrioma and an increase in adenomyosis.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

No Statement of Principles has been determined by the Repatriation Medical Authority for dysmenorrhoea. The claim is therefore decided on the sound medical-scientific evidence of what causes and worsens the condition, without the limits a Statement of Principles would impose. The recognised causes below are drawn from the gynaecological literature, and each is addressed against the veteran's service and clinical history.

Legislation: the clinical onset of this condition was on 14 September 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. Where a Statement of Principles exists, the Reasonable Hypothesis instrument applies to operational service and the Balance of Probabilities instrument to peacetime service; here the condition arose in peacetime service after warlike service in Afghanistan, and it worsened on warlike service in Iraq. Each cause must be related to the person's service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Recognised causes on the medical-scientific evidence (no Statement of Principles)

Causative factors

Cause 1: having endometriosis at the time of the clinical onset of dysmenorrhoea; — MET

- A 22 mm left ovarian endometrioma was shown on ultrasound and MRI on 06 March 2013, and laparoscopy on 15 May 2013 confirmed stage III endometriosis of the pouch of Douglas, uterosacral ligaments and left ovary, with histology showing endometrial glands and stroma. Disease of this extent develops over years and was present at onset on 14 September 2012. Endometriosis is the commonest cause of secondary dysmenorrhoea. It was diagnosed and treated during service.

Cause 2: having adenomyosis at the time of the clinical onset of dysmenorrhoea; — MET

- Ultrasound and MRI on 06 March 2013 showed a bulky uterus with subendometrial cysts and a junctional zone thickness of 14 mm, diagnostic of adenomyosis, present at onset. Adenomyosis causes heavy, painful periods through myometrial bleeding and inflammation.

Cause 3: having a submucosal or intramural uterine fibroid at the time of the clinical onset of dysmenorrhoea; — MET

- A 25 mm submucosal fibroid distorting the endometrial cavity was shown on ultrasound and MRI on 06 March 2013 and confirmed at hysteroscopy on 15 May 2013. A fibroid of this size was present at onset. Submucosal fibroids increase menstrual blood loss and uterine contractility and cause cramping pain.

Cause 4: having a copper intrauterine device in place at the time of the clinical onset of dysmenorrhoea; — MET

- A Defence medical officer inserted a copper intrauterine device on 18 June 2012, after the veteran's combined oral contraceptive was stopped because of migraine with aura, and it remained in place at onset on 14 September 2012, three months later. Copper devices increase endometrial prostaglandin production and are a well-recognised cause of new or increased dysmenorrhoea and heavy bleeding. The device was inserted and paid for by Defence.

Cause 5: having pelvic inflammatory disease within the 2 years before the clinical onset of dysmenorrhoea; — MET

- Pelvic inflammatory disease due to Chlamydia trachomatis was diagnosed on 22 March 2012, with cervical motion and adnexal tenderness, fever and a positive cervical swab, six months before onset. Pelvic infection causes adhesions and chronic inflammation of the pelvic organs, and is a recognised cause of secondary dysmenorrhoea and chronic pelvic pain. It was diagnosed and treated by Defence medical staff.

Cause 6: having cervical stenosis following an excisional procedure of the cervix before the clinical onset of dysmenorrhoea; — MET

- A large loop excision of the transformation zone removing a 14 mm deep cone of cervix was performed on 09 November 2011 for cervical intraepithelial neoplasia found on routine Defence screening. A tight os was recorded at insertion of the copper device on 18 June 2012, and on 06 March 2013 the canal was stenosed and admitted only a fine dilator, with a narrowed canal on MRI. Cervical stenosis after deep excision obstructs menstrual outflow and causes obstructive dysmenorrhoea and retrograde menstruation.

Cause 7: smoking an average of at least 10 cigarettes per day for at least the 1 year before the clinical onset of dysmenorrhoea; — MET

- The veteran took up smoking during initial training in 2007 and smoked about 10 cigarettes a day, increasing to 15 a day on warlike service in Afghanistan in 2011 and after her return, as recorded on 20 January 2012 and at each subsequent review. She smoked at least 10 a day throughout the 1 year before onset, from 14 September 2011 to 14 September 2012. Smoking causes uterine vasoconstriction and is consistently associated with more frequent and more severe dysmenorrhoea.

Cause 8: having a clinically significant psychiatric disorder, including posttraumatic stress disorder, depression or an anxiety disorder, for at least the 6 months before the clinical onset of dysmenorrhoea; — MET

- A psychiatrist diagnosed posttraumatic stress disorder on 20 January 2012, arising from repeated rocket attacks on warlike service in Afghanistan in 2011, and it was active and under treatment throughout the 6 months before onset, from 14 March 2012 to 14 September 2012. Psychological distress, anxiety and depression are associated with a higher prevalence and severity of dysmenorrhoea, through altered pain processing and stress hormone effects.

Worsening factors

Worsening 1: having progression of endometriosis or adenomyosis at the time of the clinical worsening of dysmenorrhoea; — MET

- MRI and laparoscopy on 20 July 2016 showed progression from stage III to stage IV endometriosis, with a new 18 mm deep infiltrating rectovaginal nodule and enlargement of the endometrioma from 22 to 41 mm, and an increase in the adenomyotic junctional zone from 14 to 18 mm. The progression occurred over the months in which her menstrual suppression lapsed on warlike service and was present at the worsening on 12 March 2016.

Worsening 2: having a clinically significant psychiatric disorder, including posttraumatic stress disorder, depression or an anxiety disorder, for at least the 6 months before the clinical worsening of dysmenorrhoea; — MET

- The veteran's posttraumatic stress disorder relapsed on warlike service in Iraq from November 2015, with nightmares and hypervigilance after repeated indirect fire alarms, recorded by the deployed psychologist, and it was active throughout the 6 months before the worsening, from 12 September 2015 to 12 March 2016.

Worsening 3: smoking an average of at least 10 cigarettes per day for at least the 1 year before the clinical worsening of dysmenorrhoea; — MET

- The veteran smoked 10 to 15 cigarettes a day throughout the 1 year before the worsening, from 12 March 2015 to 12 March 2016, increasing on warlike service in Iraq, as recorded at her pre-deployment and deployed health reviews.

Worsening 4: inability to obtain appropriate clinical management for dysmenorrhoea. — MET

- The levonorgestrel intrauterine system that controlled her endometriosis and dysmenorrhoea was expelled in January 2016 on warlike service in Iraq. No gynaecologist or replacement device was available in theatre, and continuous hormonal suppression was not arranged, so she was without effective treatment for four months until she returned to Australia. The dysmenorrhoea worsened on 12 March 2016 and the disease progressed. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

The % contribution of the causes is 100% and significant.

Sequelae

Met. The dysmenorrhoea is a manifestation of endometriosis and adenomyosis that developed and progressed during service. It has led to chronic pelvic pain between periods, deep dyspareunia and painful defaecation from the rectovaginal nodule, iron deficiency from heavy bleeding, and a depressive adjustment to chronic pain, which should be considered for separate claims.

Unintended Consequence

Met. The copper intrauterine device that contributed to onset was inserted by a Defence medical officer on 18 June 2012, and the cervical stenosis followed the excisional cervical procedure performed on 09 November 2011 for a lesion found on Defence screening, both provided by the Commonwealth while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. The veteran's levonorgestrel intrauterine system was expelled on warlike service in Iraq in January 2016. There was no gynaecological service or replacement device in theatre and no continuous hormonal suppression was arranged, so she was untreated for about four months, during which the dysmenorrhoea worsened on 12 March 2016 and the endometriosis progressed to stage IV. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the absence of specialist women's health care in the operational setting amounts to an inability to obtain appropriate clinical management. The six-month delay between first presentation in September 2012 and specialist imaging in March 2013 is also indicative of barriers to care.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 03 Aug 2011, Periodic health examination, Medical Officer, Garrison health centre
2. 09 Nov 2011, Colposcopy and operation report, Gynaecologist
3. 20 Jan 2012, Psychiatric assessment, Consultant psychiatrist
4. 22 Mar 2012, Outpatient health record and pathology, Medical Officer, Garrison health centre
5. 18 Jun 2012, Procedure record, intrauterine device insertion, Medical Officer
6. 17 Sep 2012, Outpatient health record, Medical Officer, Garrison health centre
7. 06 Mar 2013, Ultrasound and MRI pelvis reports and gynaecology consultation, Gynaecologist
8. 15 May 2013, Operation and histopathology reports, Gynaecologist
9. 12 Mar 2016, Deployed health record, Medical Officer, Middle East Area of Operations
10. 20 Jul 2016, MRI pelvis and operation reports, Gynaecologist