Diagnostic Assessment — Polycystic Ovary Syndrome
Example 1 of 1 · fictitious patient (Veteran CU)
Diagnostic Assessment
Polycystic Ovary Syndrome
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran CU, date of birth 05 February 1988, Royal Australian Air Force, Aircraft Technician (Avionics), enlisted 12 January 2007, medically discharged 14 March 2016. Operational service: Afghanistan, Kandahar Airfield, 10 January 2010 to 15 July 2010 (warlike); Middle East Area of Operations, 01 February 2012 to 30 August 2012 (warlike).
Occupational History
As an avionics technician the veteran maintained aircraft electrical, navigation and communication systems on a flight line that operated around the clock. Flight line maintenance involves rotating day and night shifts, extended hours to meet flying programs, irregular meals reliant on vending and mess food, and long periods of disrupted sleep. These conditions are recognised to disturb circadian rhythm and to promote weight gain and metabolic disturbance.
Deployed air bases in Afghanistan and the Middle East were subject to indirect rocket and mortar fire, exposing personnel to blast injury, traumatic events and sustained threat. Access to specialist medical care, including gynaecology and endocrinology, is limited on deployment, and changes to medication can affect a member's deployability.
Shift workers on deployed flight lines commonly rely on high-energy convenience foods during night shifts and have limited opportunity for regular exercise, and medications that cause weight gain are often continued unchanged on deployment to avoid compromising a member's fitness to deploy.
History
Veteran CU, an avionics technician in the Royal Australian Air Force, developed polycystic ovary syndrome on 15 August 2011 after a traumatic brain injury in a rocket attack at Kandahar Airfield in May 2010, which led to post-traumatic epilepsy treated with sodium valproate and to posttraumatic stress disorder treated with olanzapine, with a weight gain of 21 kg, insulin resistance and prolonged night shift work. The condition was confirmed on the Rotterdam criteria on 20 December 2011 and worsened during her 2012 deployment.
Timeline
- 18 May 2010 — During warlike service at Kandahar Airfield a rocket struck near the flight line workshop where the veteran was working a night shift. She was thrown against a steel container and was unconscious for about 35 minutes, with a Glasgow Coma Scale score of 11 at the role 3 hospital and a small right frontal contusion on CT. She returned to night shift duties after three weeks. The deployed psychologist recorded nightmares, hypervigilance and avoidance on 20 June 2010. "moderate TBI, frontal contusion"
- 06 Sep 2010 — After her return to Australia she had a generalised tonic-clonic seizure at home on 02 September 2010. A neurologist diagnosed post-traumatic epilepsy related to the frontal contusion and commenced sodium valproate 500 mg twice daily, which she continued without interruption to 2013. Weight was 70 kg, up from 62 kg (BMI 22.8) at her pre-deployment medical in December 2009. "post-traumatic epilepsy, valproate commenced"
- 14 Feb 2011 — A consultant psychiatrist diagnosed posttraumatic stress disorder arising from the rocket attack, with symptoms meeting criteria from July 2010. Olanzapine 10 mg at night was commenced for severe insomnia, nightmares and agitation, and psychological therapy was arranged. She continued rotating day and night shifts on the flight line. "PTSD, olanzapine 10 mg nocte"
- 24 Mar 2011 — Her periodic health examination recorded regular 28-day menstrual cycles, no acne or excess hair growth, weight 78 kg and BMI 28.7. On 20 June 2011 a fasting insulin of 24 mU/L, HOMA-IR of 5.0 and acanthosis nigricans of the neck were recorded, and insulin resistance was diagnosed. "regular cycles, no hirsutism"
- 12 Oct 2011 — She presented to the medical officer reporting that her period due on 15 August 2011 had not come, with only one period since, new coarse hair on the chin and upper lip, acne on the jaw and continued weight gain. Weight was 85 kg, BMI 31.2. A pregnancy test was negative. "oligomenorrhoea, new hirsutism, BMI 31.2"
- 20 Dec 2011 — A gynaecologist confirmed polycystic ovary syndrome on the Rotterdam criteria: oligomenorrhoea, clinical hyperandrogenism with a modified Ferriman-Gallwey score of 10 and raised total testosterone, and polycystic ovarian morphology on transvaginal ultrasound. Thyroid function, prolactin and 17-hydroxyprogesterone were normal. Metformin was commenced. The neurologist recommended changing valproate to levetiracetam, but this was deferred because a change of antiepileptic would have made her unfit for her planned deployment. "PCOS confirmed, Rotterdam criteria"
- 15 May 2012 — On warlike service in the Middle East her three-month supply of metformin ran out and the deployed medical facility could not obtain more. She was working a fixed night shift roster on the flight line and reported increased snacking on night shifts and further weight gain. No gynaecology or endocrinology advice was available in theatre, and her valproate and olanzapine were continued. "metformin unavailable, night roster"
- 15 Oct 2012 — After seven months of night shifts in the Middle East, where her metformin supply ran out in May 2012 and no gynaecology review was available, she reported six months of amenorrhoea and worsening facial hair. The modified Ferriman-Gallwey score was 19, total testosterone had risen further, HbA1c was 6.3 per cent and weight was 94 kg, BMI 34.5. The gynaecologist recorded clear worsening of the polycystic ovary syndrome. "amenorrhoea 6 months, mFG 19"
Symptoms
At onset the veteran had missed and infrequent periods, new coarse hair on the chin and upper lip, acne along the jaw and continued weight gain. After onset her periods became absent for months at a time, the hair growth spread to the neck and abdomen and she developed thinning of the scalp hair.
She now reports irregular periods, persistent facial and body hair requiring laser treatment, difficulty losing weight, fatigue and distress about her appearance. She has been told she has prediabetes and has been advised that she may have difficulty conceiving.
She reports that the weight gain and hair growth that began after her injury and medication changes have affected her confidence and her relationships, and that she avoided social activities on deployment because of her appearance.
Imaging
- 18 May 2010 — CT head: "Small right frontal haemorrhagic contusion. No skull fracture. No mass effect."
- 20 Dec 2011 — Transvaginal pelvic ultrasound: "Both ovaries enlarged, right 12.4 mL and left 11.8 mL, each with more than 20 peripheral follicles of 2 to 9 mm, consistent with polycystic ovarian morphology. Normal uterus and endometrium."
- 15 Oct 2012 — Transvaginal pelvic ultrasound: "Persisting polycystic ovarian morphology with increased ovarian volumes, right 14.1 mL and left 13.6 mL. Endometrial thickness 11 mm in the setting of prolonged amenorrhoea."
Onset Date
The most likely date of onset of this condition is 15 Aug 2011.
At that date the veteran was serving full time as an avionics technician at an RAAF base in Australia, working rotating day and night shifts on the flight line. She was taking sodium valproate for post-traumatic epilepsy and olanzapine for posttraumatic stress disorder, both arising from the rocket attack at Kandahar Airfield in May 2010, had gained about 21 kg since January 2010, was obese and had insulin resistance.
This date is appropriate because her periodic health examination of 24 March 2011 recorded regular cycles and no hyperandrogenic features, and her period due on 15 August 2011 failed to occur, followed by new hirsutism and acne, with her first presentation on 12 October 2011. It falls within uninterrupted full-time service.
For the valproate cause, the 6 months before onset run from 15 Feb 2011 to 15 Aug 2011; she took valproate continuously from 06 Sep 2010. For the antipsychotic cause, the 3 months before onset run from 15 May 2011 to 15 Aug 2011; she took olanzapine continuously from 14 Feb 2011. For the weight gain and night shift causes, the 2 years before onset run from 15 Aug 2009 to 15 Aug 2011, during which her weight rose from 62 kg to 83 kg and she worked rotating night shifts from January 2010 onwards, more than 12 months in total. For the posttraumatic stress disorder cause, the 1 year before onset runs from 15 Aug 2010 to 15 Aug 2011, and the disorder met criteria from July 2010. Obesity and insulin resistance were present on 15 Aug 2011.
For the worsening causes, the documented worsening was on 15 Oct 2012. The 1 year before the worsening runs from 15 Oct 2011 to 15 Oct 2012, during which her weight rose from 85 kg to 94 kg. Valproate and olanzapine were continued throughout this period, and her metformin was unavailable on deployment from May 2012.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Polycystic Ovary Syndrome (ICD-10-AM E28.2). No Statement of Principles has been determined for polycystic ovary syndrome.
Polycystic ovary syndrome is a common endocrine and metabolic disorder of women characterised by irregular or absent ovulation, excess androgen production causing hirsutism, acne and scalp hair loss, and polycystic-appearing ovaries. Insulin resistance and the compensatory high insulin levels drive ovarian androgen production and are central to the condition, so weight gain, obesity and drugs that cause them can bring on or worsen the syndrome. Sodium valproate is a recognised cause of the syndrome. Long-term consequences include infertility, type 2 diabetes, dyslipidaemia, endometrial hyperplasia and cancer, sleep apnoea, depression and cardiovascular disease.
The diagnosis followed a service-related traumatic brain injury and posttraumatic stress disorder, treatment with valproate and olanzapine, marked weight gain with insulin resistance, and prolonged night shift work. It began on 15 August 2011, was confirmed on 20 December 2011 and worsened during her 2012 deployment.
In this veteran the syndrome arose in adulthood, after a normal menstrual history, in direct temporal relationship to valproate and olanzapine treatment and rapid weight gain, which distinguishes it from the constitutional form that begins around puberty.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
15 August 2011.
When did the veteran first present to a health / medical provider for this condition?
12 October 2011.
When was the condition confirmed / formally diagnosed?
20 December 2011.
When did the veteran first present to you (or your practice) for this condition?
26 May 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by a gynaecologist on 20 December 2011 on the Rotterdam criteria, which require two of the following three features: oligo-ovulation or anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology. All three were present: oligomenorrhoea from August 2011, hirsutism with a modified Ferriman-Gallwey score of 10 and raised total testosterone, and more than 20 follicles in each ovary on transvaginal ultrasound.
Other causes were excluded, with normal thyroid function, prolactin and 17-hydroxyprogesterone and a negative pregnancy test. The diagnosis was supported by insulin resistance with a HOMA-IR of 5.0 and acanthosis nigricans. Review on 15 October 2012 confirmed worsening, with six months of amenorrhoea, a Ferriman-Gallwey score of 19, a higher testosterone and an HbA1c of 6.3 per cent.
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 for polycystic ovary syndrome. The claim is therefore decided on the sound medical-scientific evidence of what causes the condition, without the limits a Statement of Principles would impose, and the recognised causes below are drawn from the endocrinology, gynaecology and pharmacology literature.
Legislation: the clinical onset of this condition was on 15 August 2011, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The reasonable hypothesis standard applies to her warlike service in Afghanistan in 2010, where the rocket attack caused her traumatic brain injury and posttraumatic stress disorder and her night shift work began, and in the Middle East in 2012, where the condition worsened. The balance of probabilities standard applies to her peacetime service, including her shift work and treatment in Australia. Each cause must be related to 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: taking sodium valproate for a continuous period of at least the 6 months before the clinical onset of polycystic ovary syndrome; — MET
- A neurologist commenced sodium valproate 500 mg twice daily on 06 September 2010 for post-traumatic epilepsy caused by the frontal contusion sustained in the rocket attack at Kandahar Airfield on 18 May 2010. She took it continuously throughout the 6 months before onset, from 15 February 2011 to 15 August 2011. Valproate raises androgen levels and causes weight gain and insulin resistance, and is a recognised cause of polycystic ovary syndrome.
Cause 2: taking an atypical antipsychotic drug for a continuous period of at least the 3 months before the clinical onset of polycystic ovary syndrome; — MET
- A consultant psychiatrist commenced olanzapine 10 mg at night on 14 February 2011 for posttraumatic stress disorder arising from the rocket attack. She took it continuously throughout the 3 months before onset, from 15 May 2011 to 15 August 2011. Olanzapine causes marked weight gain and insulin resistance, which drive ovarian androgen excess.
Cause 3: gaining at least 10 kilograms in body weight within the 2 years before the clinical onset of polycystic ovary syndrome; — MET
- The veteran weighed 62 kg (BMI 22.8) at her pre-deployment medical in December 2009, 70 kg on 06 September 2010, 78 kg on 24 March 2011 and about 83 kg in August 2011, a gain of 21 kg within the 2 years before onset, from 15 August 2009 to 15 August 2011. The gain followed her service-related injury, valproate and olanzapine treatment and night shift work.
Cause 4: being obese, with a body mass index of 30 or more, at the time of the clinical onset of polycystic ovary syndrome; — MET
- Her BMI was 28.7 on 24 March 2011, about 30.5 in August 2011 and 31.2 on 12 October 2011, so she was obese at onset on 15 August 2011. The obesity was the result of the service-related weight gain described above.
Cause 5: having insulin resistance or hyperinsulinaemia at the time of the clinical onset of polycystic ovary syndrome; — MET
- On 20 June 2011 her fasting insulin was 24 mU/L with a HOMA-IR of 5.0, and acanthosis nigricans of the neck was recorded, confirming insulin resistance, which was present at onset on 15 August 2011. The insulin resistance followed the service-related weight gain and olanzapine and valproate treatment. High insulin levels stimulate ovarian theca cells to produce androgens and suppress sex hormone binding globulin.
Cause 6: undertaking night shift work for a cumulative period of at least 6 months within the 2 years before the clinical onset of polycystic ovary syndrome; — MET
- From January 2010 the veteran worked rotating flight line shifts, about half of them night shifts, at Kandahar Airfield on warlike service and then at her home squadron in Australia. Her night shift work totalled more than 12 months within the 2 years before onset, from 15 August 2009 to 15 August 2011. Circadian disruption from night work is associated with menstrual irregularity, insulin resistance and polycystic ovary syndrome.
Cause 7: having posttraumatic stress disorder for at least the 1 year before the clinical onset of polycystic ovary syndrome; — MET
- Posttraumatic stress disorder arose from the rocket attack at Kandahar Airfield on warlike service on 18 May 2010, with symptoms recorded by the deployed psychologist on 20 June 2010 and meeting criteria from July 2010, and was formally diagnosed on 14 February 2011. It was present throughout the 1 year before onset, from 15 August 2010 to 15 August 2011. Posttraumatic stress disorder is associated with an increased risk of polycystic ovary syndrome in women veterans, through chronic stress hormone activation and metabolic disturbance.
Worsening factors
Worsening 1: gaining at least 5 kilograms in body weight within the 1 year before the clinical worsening of polycystic ovary syndrome; — MET
- Her weight rose from 85 kg on 12 October 2011 to 94 kg on 15 October 2012, a gain of 9 kg within the 1 year before the worsening, from 15 October 2011 to 15 October 2012, much of it during night shift work on warlike service in the Middle East.
Worsening 2: taking sodium valproate at the time of the clinical worsening of polycystic ovary syndrome; — MET
- Sodium valproate for her service-related post-traumatic epilepsy was continued at the worsening on 15 October 2012, because the recommended change to levetiracetam in December 2011 was deferred to keep her fit for deployment.
Worsening 3: taking an atypical antipsychotic drug at the time of the clinical worsening of polycystic ovary syndrome; — MET
- Olanzapine 10 mg at night for her service-related posttraumatic stress disorder was continued throughout her 2012 deployment and at the worsening on 15 October 2012.
Worsening 4: inability to obtain appropriate clinical management for polycystic ovary syndrome. — MET
- The neurologist's recommendation in December 2011 to replace valproate with levetiracetam was deferred because a change of antiepileptic would have made her unfit to deploy. On warlike service in the Middle East her metformin supply ran out in May 2012 and could not be replaced, and no gynaecology or endocrinology review was available. The condition worsened, with the Ferriman-Gallwey score rising from 10 to 19 and six months of amenorrhoea. 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
The polycystic ovary syndrome is a sequela of the veteran's accepted conditions: the post-traumatic epilepsy treated with sodium valproate and the posttraumatic stress disorder treated with olanzapine, both arising from the traumatic brain injury in the 2010 rocket attack, and the resulting weight gain and insulin resistance. The syndrome has in turn led to prediabetes, endometrial thickening from prolonged amenorrhoea, and reduced fertility.
Unintended Consequence
Met. The polycystic ovary syndrome is an unintended consequence of sodium valproate and olanzapine, prescribed and paid for by the Commonwealth while the veteran was serving for her service-related epilepsy and posttraumatic stress disorder (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. The recommended change from valproate to levetiracetam was deferred in December 2011 so that she would remain deployable, her metformin ran out on warlike service in the Middle East in May 2012 and could not be replaced, and no gynaecology or endocrinology care was available in theatre. During that time she gained 9 kg, became amenorrhoeic for six months and her hirsutism score almost doubled. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), deferral of recommended treatment for deployability and the unavailability of prescribed medication and specialist care on deployment amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- Dec 2009, Pre-deployment medical examination, Medical Officer
- 18 May 2010, Trauma admission and CT head report, Role 3 hospital, Kandahar Airfield
- 20 Jun 2010, Deployed mental health record, Psychologist
- 06 Sep 2010, Neurology consultation, Neurologist
- 14 Feb 2011, Psychiatric assessment, Consultant psychiatrist
- 24 Mar 2011, Periodic health examination, Medical Officer, RAAF base health centre
- 20 Jun 2011, Pathology report, fasting insulin and glucose
- 12 Oct 2011, Outpatient health record, Medical Officer
- 20 Dec 2011, Gynaecology consultation and pelvic ultrasound, Gynaecologist
- Dec 2011, Neurology review, Neurologist
- 15 May 2012, Deployed health record, Medical Officer, Middle East Area of Operations
- 15 Oct 2012, Gynaecology review, pelvic ultrasound and pathology, Gynaecologist
