Diagnostic Assessment — Premenstrual Syndrome
Example 1 of 1 · fictitious patient (Veteran CV)
Diagnostic Assessment
Premenstrual Syndrome
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran CV, date of birth 11 May 1989, Royal Australian Navy, Combat Systems Operator, enlisted 21 January 2008, medically discharged 04 December 2021. Operational service: Middle East Area of Operations (maritime security), 15 February 2014 to 30 September 2014 (non-warlike); Middle East Area of Operations (maritime security), 05 March 2019 to 15 October 2019 (non-warlike).
Occupational History
Combat systems operators work in the operations rooms of warships and submarines, monitoring radar, sonar and electronic warfare systems. At sea the trade involves continuous watchkeeping on rotating rosters, such as six hours on and six hours off, for weeks or months at a time, with broken sleep, no natural daylight below decks and long periods in confined spaces. Sailors also take part in boarding operations, damage control and emergency drills.
Maritime security deployments involve boarding of suspect vessels, high operational tempo and prolonged separation from family and support. The shipboard culture of the period included high rates of smoking during breaks on the upper deck, and opportunities for exercise and fresh food are limited at sea. Specialist gynaecological and psychiatric care is not available on board.
History
Veteran CV, a combat systems operator in the Royal Australian Navy, developed premenstrual syndrome on 20 October 2015, after years of rotating watchkeeping and sleep disruption at sea, heavy smoking, weight gain, vitamin D deficiency from submarine service, and posttraumatic stress disorder and depression following the death of a shipmate in a boarding accident on non-warlike service in the Middle East in 2014. The diagnosis was confirmed on prospective symptom charting in February 2016, and the condition worsened on a second Middle East deployment in 2019.
Timeline
- 10 Mar 2011 — Periodic health examination at a naval base health centre. Menstrual cycles were regular at 28 days with mild dysmenorrhoea and no premenstrual mood or physical symptoms. She smoked about 15 cigarettes a day, having started during initial employment training in 2008. BMI 24.1. Mental state normal. "regular cycles, no PMS"
- 19 Aug 2013 — Routine review after 14 months of submarine service on six-on, six-off watch rotations with patrols of up to ten weeks. She reported fatigue and low mood at sea. Serum 25-hydroxy vitamin D was 31 nmol/L and vitamin D supplementation was prescribed, but supply at sea was intermittent. "vitamin D 31, watch rotations"
- 18 Jun 2014 — On non-warlike service in the Middle East, during a night boarding of a suspect vessel, a sea boat capsized alongside the ship. The veteran was on the boat deck assisting recovery and helped pull a shipmate from the water; he could not be revived and died on deck. She was involved in the resuscitation attempt for 40 minutes. "shipmate killed, boarding accident"
- 16 Mar 2015 — A psychiatrist diagnosed posttraumatic stress disorder and major depressive disorder related to the 2014 boarding accident. She had nightmares, hypervigilance, low mood and poor sleep, and had increased her smoking to 20 cigarettes a day. BMI 31.2, after weight gain of 18 kilograms since 2011. She was treated with trauma-focused psychological therapy and initially declined medication. "PTSD, MDD, BMI 31.2"
- 23 Nov 2015 — Presented to the medical officer with five weeks of cyclical symptoms beginning about 20 October 2015: irritability, mood swings, tearfulness, anxiety, food cravings, bloating, breast tenderness and headaches in the seven to ten days before each period, resolving within two to three days of menstruation. She had had two angry outbursts at work. She was asked to keep a prospective daily symptom record over two cycles. "cyclical mood, bloating, resolves menses"
- 17 Feb 2016 — Gynaecology consultation. Two cycles of prospective Daily Record of Severity of Problems charting showed marked luteal-phase symptoms with a clear symptom-free interval in the follicular phase and functional impairment at work. Thyroid function, iron studies and pelvic ultrasound were normal. The gynaecologist diagnosed premenstrual syndrome, advised a combined oral contraceptive and lifestyle measures and recommended against night watchkeeping. "PMS confirmed on prospective charting"
- 12 Aug 2019 — Seen by the ship's medical officer on non-warlike service in the Middle East. Her premenstrual symptoms had worsened markedly since 02 August 2019, with severe irritability, despair and passive suicidal thoughts in the luteal phase, and charting scores roughly double her 2016 scores. She had been on night watches for three months and her combined oral contraceptive supply had run out. No gynaecology or psychiatry review was available at sea. "PMS markedly worse, COCP ran out"
- 18 Nov 2019 — Gynaecology and psychiatry review on return to Australia. Premenstrual syndrome had worsened to a severe level. Continuous sertraline and a continuous combined oral contraceptive were commenced, with partial improvement over six months. She was referred for a medical employment classification review, leading to discharge in December 2021. "severe PMS, sertraline commenced"
Symptoms
At onset the veteran had irritability, mood swings, tearfulness, anxiety and a sense of being overwhelmed, with food cravings, bloating, breast tenderness, headaches and poor sleep, in the seven to ten days before each period. The symptoms resolved within two to three days of the start of menstruation, leaving her well in the follicular phase.
After the 2019 worsening the luteal-phase symptoms became severe, with despair, passive suicidal thoughts, angry outbursts and withdrawal from her shipmates, lasting up to twelve days each cycle. She now reports moderate premenstrual symptoms despite continuous treatment, with irritability, fatigue, bloating and breast pain, and plans her work and social commitments around her cycle.
Imaging
- 10 Feb 2016 — Pelvic ultrasound: "Normal uterus and ovaries. No endometrioma, fibroid or ovarian cyst."
Onset Date
The most likely date of onset of this condition is 20 Oct 2015.
At that date the veteran was serving full time on a frigate in Australian waters, on rotating watches, after more than three years of rotating watchkeeping including submarine service. She was being treated for posttraumatic stress disorder and depression arising from the death of a shipmate in a boarding accident in the Middle East on 18 June 2014, smoked about 20 cigarettes a day and had a BMI above 30. From about 20 October 2015 she developed cyclical premenstrual mood and physical symptoms.
This date is appropriate because her periodic health examination of 10 March 2011 recorded regular cycles with no premenstrual symptoms, and her psychiatric review of 16 March 2015 recorded no cyclical pattern to her mood. She first presented on 23 November 2015, reporting five weeks of cyclical symptoms, and the diagnosis was confirmed on two cycles of prospective charting on 17 February 2016.
For the shift work cause, the 12 months before onset run from 20 Oct 2014 to 20 Oct 2015; she worked rotating watches at sea throughout. For the smoking cause, the 5 years before onset run from 20 Oct 2010 to 20 Oct 2015, during which she smoked 15 to 20 cigarettes a day. For the stress, sleep and vitamin D causes, the 6 months before onset run from 20 Apr 2015 to 20 Oct 2015, during which she was undergoing treatment for posttraumatic stress disorder, averaged about five hours of sleep a night and her vitamin D remained below 50 nmol/L. Posttraumatic stress disorder, depressive disorder and obesity were each present on 20 Oct 2015.
For the worsening, documented on 12 Aug 2019 on non-warlike service in the Middle East, the 3 months before the worsening run from 12 May 2019 to 12 Aug 2019, during which she kept night watches, averaged about five hours of sleep and was under sustained operational stress. The 6 months before the worsening run from 12 Feb 2019 to 12 Aug 2019, during which she smoked about 20 cigarettes a day and had no reliable vitamin D supplementation.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Premenstrual Syndrome (ICD-10 N94.3). No Statement of Principles has been determined for this condition.
Premenstrual syndrome is a recurrent pattern of physical, emotional and behavioural symptoms that occur in the luteal phase of the menstrual cycle, in the one to two weeks before menstruation, and resolve within a few days of the onset of menses, with a symptom-free interval in the follicular phase. Typical symptoms are irritability, mood swings, anxiety, depressed mood, fatigue, food cravings, bloating, breast tenderness and headaches. It is thought to reflect an abnormal central nervous system sensitivity to normal cyclical changes in oestrogen and progesterone, involving serotonin and GABA pathways. Recognised risk factors include psychological trauma and stress, posttraumatic stress disorder, depression and anxiety, smoking, obesity, circadian disruption from shift work and low vitamin D. Diagnosis requires prospective daily symptom charting over at least two cycles.
The condition began on 20 October 2015, was confirmed on 17 February 2016 and worsened on non-warlike service in the Middle East in August 2019.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
20 October 2015.
When did the veteran first present to a health / medical provider for this condition?
23 November 2015.
When was the condition confirmed / formally diagnosed?
17 February 2016.
When did the veteran first present to you (or your practice) for this condition?
08 July 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on 17 February 2016 by a gynaecologist on the basis of two cycles of prospective Daily Record of Severity of Problems charting, which showed marked emotional and physical symptoms in the luteal phase, a clear symptom-free interval in the follicular phase, and impairment of work and relationships. This meets the accepted diagnostic criteria for premenstrual syndrome of the Royal College of Obstetricians and Gynaecologists and the International Society for Premenstrual Disorders.
Other causes were excluded: thyroid function, iron studies and full blood count were normal, pelvic ultrasound on 10 February 2016 showed no pelvic pathology, and the charting showed that her posttraumatic stress disorder and depression did not account for the cyclical pattern, as her mood was stable in the follicular phase. Repeat charting in August 2019 and specialist review on 18 November 2019 confirmed the worsening.
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.
Legislation: the clinical onset of this condition was on 20 October 2015, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. No Statement of Principles has been determined for premenstrual syndrome, so the claim is decided on the sound medical-scientific evidence of what causes and worsens the condition, without the limits a Statement of Principles would impose. The reasonable hypothesis standard applies to the veteran's non-warlike service in the Middle East in 2014 and 2019, and the balance of probabilities standard applies to her peacetime service. The recognised causes below are set out in Statement of Principles style.
Each factor must be related to the person's relevant 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 posttraumatic stress disorder at the time of the clinical onset of premenstrual syndrome; — MET
- A psychiatrist diagnosed posttraumatic stress disorder on 16 March 2015 arising from the boarding accident on non-warlike service in the Middle East on 18 June 2014, in which she helped recover a shipmate from the water and took part in his unsuccessful resuscitation. It was present at onset on 20 October 2015. Large cohort studies show that trauma exposure and posttraumatic stress disorder roughly double the risk of premenstrual syndrome.
Cause 2: having depressive disorder or anxiety disorder at the time of the clinical onset of premenstrual syndrome; — MET
- Major depressive disorder was diagnosed on 16 March 2015, related to the same service trauma, and was present at onset. Depressive and anxiety disorders share serotonergic vulnerability with premenstrual syndrome and are recognised as strong predictors of its development.
Cause 3: experiencing severe or sustained psychological stress for at least the 6 months before the clinical onset of premenstrual syndrome; — MET
- From 20 April 2015 to 20 October 2015 the veteran was undergoing trauma-focused therapy, attending the coronial inquiry into her shipmate's death and returning to sea on the same class of ship, as recorded by her psychologist. Sustained stress alters the hypothalamic-pituitary-adrenal axis and is an established risk factor for premenstrual syndrome.
Cause 4: smoking at least 15 cigarettes per day for at least the 5 years before the clinical onset of premenstrual syndrome; — MET
- The veteran began smoking during initial employment training in 2008 and smoked about 15 cigarettes a day, rising to 20 a day after the 2014 accident, throughout the 5 years before onset from 20 October 2010 to 20 October 2015. Smoking breaks on the upper deck were the main respite during long watches. Prospective cohort data show that smoking 15 or more cigarettes a day more than doubles the risk of premenstrual syndrome.
Cause 5: being obese, with a body mass index of 30 or more, at the time of the clinical onset of premenstrual syndrome; — MET
- Her BMI was 31.2 on 16 March 2015 and 31.6 in October 2015, after weight gain of 18 kilograms from 2011 attributed to submarine service with little opportunity for exercise, irregular shipboard meals and depression. Each 1 unit increase in BMI is associated with a higher risk of premenstrual syndrome, and obesity at least doubles it.
Cause 6: working rotating shifts or watches that include night work for at least the 12 months before the clinical onset of premenstrual syndrome; — MET
- The veteran kept rotating six-on, six-off and one-in-three watches at sea from 2012, including the whole of the 12 months before onset from 20 October 2014 to 20 October 2015, as shown on her ship's watch bills. Circadian disruption from shift work alters melatonin and reproductive hormone rhythms and is associated with menstrual disturbance and premenstrual symptoms.
Cause 7: having vitamin D deficiency, with a serum 25-hydroxy vitamin D level below 50 nanomoles per litre, for at least the 6 months before the clinical onset of premenstrual syndrome; — MET
- Her vitamin D was 31 nmol/L on 19 August 2013 after submarine patrols without daylight, and 38 nmol/L on 04 June 2015, as supplementation at sea was intermittent. Deficiency persisted throughout the 6 months before onset, from 20 April 2015 to 20 October 2015. Low vitamin D and calcium status are associated with a higher risk of premenstrual syndrome.
Cause 8: having chronic insufficient sleep, averaging less than 6 hours of sleep per night, for at least the 6 months before the clinical onset of premenstrual syndrome; — MET
- Watchkeeping and nightmares from posttraumatic stress disorder limited her sleep to about five hours a night from April 2015 to October 2015, as recorded in her psychology sleep diary. Sleep deprivation heightens emotional reactivity to hormonal fluctuation and is associated with the onset of premenstrual mood symptoms.
Worsening factors
Worsening 1: experiencing severe or sustained psychological stress for at least the 3 months before the clinical worsening of premenstrual syndrome; — MET
- On non-warlike service in the Middle East from March 2019 the veteran took part in repeated night boardings, which re-triggered memories of the 2014 accident, throughout the 3 months before the worsening from 12 May 2019 to 12 August 2019. Her charting scores roughly doubled compared with 2016.
Worsening 2: working night shifts or rotating shifts that include night work for at least the 3 months before the clinical worsening of premenstrual syndrome; — MET
- Despite the 2016 recommendation against night watchkeeping, she was rostered to the middle and morning watches on non-warlike service in the Middle East throughout the 3 months before the worsening, from 12 May 2019 to 12 August 2019, averaging about five hours of sleep a day.
Worsening 3: smoking at least 15 cigarettes per day for at least the 6 months before the clinical worsening of premenstrual syndrome; — MET
- She smoked about 20 cigarettes a day throughout the 6 months before the worsening, from 12 February 2019 to 12 August 2019, including on deployment.
Worsening 4: having vitamin D deficiency, with a serum 25-hydroxy vitamin D level below 50 nanomoles per litre, at the time of the clinical worsening of premenstrual syndrome; — MET
- Her vitamin D was 34 nmol/L on 14 August 2019, tested on board after the worsening, after months below decks in the operations room without supplementation.
Worsening 5: having posttraumatic stress disorder or depressive disorder at the time of the clinical worsening of premenstrual syndrome; — MET
- Posttraumatic stress disorder and major depressive disorder, arising from her 2014 non-warlike service, were active at the worsening, with a PCL-5 score of 48 recorded on 12 August 2019.
Worsening 6: inability to obtain appropriate clinical management for premenstrual syndrome. — MET
- On non-warlike service in the Middle East her combined oral contraceptive supply ran out in July 2019 and could not be replaced at sea, no gynaecology or psychiatry review was available, and her restriction from night watches was not applied. The condition worsened on 12 August 2019. 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 premenstrual syndrome has aggravated the veteran's accepted depressive disorder, with cyclical exacerbations of low mood and passive suicidal thoughts recorded by her psychiatrist in 2019. Recurrent premenstrual headaches have been treated as menstrually related migraine by her general practitioner since 2020.
Unintended Consequence
Met. Nausea, reduced libido and weight gain from continuous sertraline, and breakthrough bleeding from the continuous combined oral contraceptive, both prescribed for the premenstrual syndrome, are unintended consequences of treatment provided and paid for 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. On non-warlike service in the Middle East in 2019 the veteran's prescribed combined oral contraceptive ran out and could not be resupplied at sea, no gynaecological or psychiatric review was available, and the 2016 specialist recommendation against night watchkeeping was not applied. Her premenstrual syndrome worsened to a severe level with passive suicidal thoughts, and appropriate treatment was not started until 18 November 2019. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent prescribed treatment and recommended workplace restrictions amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 10 Mar 2011, Periodic health examination, Medical Officer, Naval base health centre
- 19 Aug 2013, Outpatient health record and pathology, Medical Officer
- 18 Jun 2014, Incident report and ship's medical record, Medical Officer, Middle East
- 16 Mar 2015, Psychiatric assessment, Consultant psychiatrist
- 04 Jun 2015, Pathology report, vitamin D
- 23 Nov 2015, Outpatient health record, Medical Officer
- 10 Feb 2016, Pelvic ultrasound, Radiologist
- 17 Feb 2016, Gynaecology consultation and symptom charting, Gynaecologist
- 12 Aug 2019, Ship's medical record, Medical Officer, Middle East
- 18 Nov 2019, Gynaecology and psychiatry review, Gynaecologist and Consultant psychiatrist
