Reference Determination Content
Suggested draft · fictitious patient
Secondary Amenorrhoea
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 August 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 August 2025;
- A psychiatric assessment by the consultant psychiatrist, dated 14 March 2014;
- A hospital admission and CT report by the emergency physician and radiologist, dated 22 June 2015;
- An operation report by the gynaecologist, dated 12 August 2015;
- A pre-deployment medical and pathology by the medical officer, dated 28 October 2015;
- A mental health record by the deployed psychologist, Iraq, dated 20 January 2016;
- A dietetic assessment by the deployed dietitian, Iraq, dated 22 February 2016;
- A role 2 health record by the medical officer, Iraq, dated 14 June 2016;
- An endocrinology consultation and MRI pituitary report by the endocrinologist and radiologist, dated 5 July 2016;
- A hysteroscopy report by the gynaecologist, dated 8 September 2016;
- An endocrinology review and pathology by the endocrinologist, dated 14 August 2017;
- A bone densitometry report by the radiologist, dated 21 August 2017;
- A repatriation Medical Authority: no Statement of Principles determined for secondary amenorrhoea; causes drawn from the sound medical-scientific evidence.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
6 February 2011 and 15 November 2019
Secondary Amenorrhoea
You have stated that your condition was caused by:
- undertaking strenuous physical activity with low energy availability, being an energy intake of less than 30 kilocalories per kilogram of fat-free mass per day after exercise energy expenditure, for at least the 3 months before the clinical onset of secondary amenorrhoea
- losing at least 10 per cent of body weight within the 6 months before the clinical onset of secondary amenorrhoea
- experiencing a severe psychological stressor within the 6 months before the clinical onset of secondary amenorrhoea
- taking a drug which causes hyperprolactinaemia, including risperidone, for at least the 4 weeks before the clinical onset of secondary amenorrhoea
- having a traumatic brain injury within the 12 months before the clinical onset of secondary amenorrhoea
- having hypothyroidism at the time of the clinical onset of secondary amenorrhoea
- receiving an injection of depot medroxyprogesterone acetate within the 12 months before the clinical onset of secondary amenorrhoea
- taking opioid medication daily for at least the 3 months before the clinical onset of secondary amenorrhoea
- having intrauterine surgery, including curettage of the endometrium, within the 12 months before the clinical onset of secondary amenorrhoea
Diagnosis: Secondary Amenorrhoea
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 22 August 2025, and is supported by an endocrinology consultation and MRI pituitary report by the endocrinologist and radiologist, dated 5 July 2016.
I am satisfied this is the appropriate diagnosis.
There is no Statement of Principles (SOP) for this condition. In determining your claim for this condition, I have therefore considered the available evidence, applying the standard of proof:
Reasonable Hypothesis - no Statement of Principles determined for this condition
which requires the evidence to connect the condition with service.
I am satisfied that the evidence establishes the following link to your service:
- undertaking strenuous physical activity with low energy availability, being an energy intake of less than 30 kilocalories per kilogram of fat-free mass per day after exercise energy expenditure, for at least the 3 months before the clinical onset of secondary amenorrhoea
- losing at least 10 per cent of body weight within the 6 months before the clinical onset of secondary amenorrhoea
- experiencing a severe psychological stressor within the 6 months before the clinical onset of secondary amenorrhoea
- taking a drug which causes hyperprolactinaemia, including risperidone, for at least the 4 weeks before the clinical onset of secondary amenorrhoea
- having a traumatic brain injury within the 12 months before the clinical onset of secondary amenorrhoea
- having hypothyroidism at the time of the clinical onset of secondary amenorrhoea
- receiving an injection of depot medroxyprogesterone acetate within the 12 months before the clinical onset of secondary amenorrhoea
- taking opioid medication daily for at least the 3 months before the clinical onset of secondary amenorrhoea
- having intrauterine surgery, including curettage of the endometrium, within the 12 months before the clinical onset of secondary amenorrhoea
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with no menstrual period since early February 2016, with hot flushes, poor sleep and fatigue on 14 June 2016.
The diagnosis was confirmed by an endocrinologist on 5 July 2016: you had had no menses for four months after previously regular cycles, pregnancy was excluded, and investigations showed low gonadotrophins, a low oestradiol, hyperprolactinaemia and central hypothyroidism, with a normal pituitary MRI and no polycystic ovarian morphology. This establishes secondary amenorrhoea of hypothalamic and pituitary origin. Hysteroscopy on 8 September 2016 showed minor adhesions that did not account for the amenorrhoea alone.
This has then led to further investigations and the diagnosis of your condition of Secondary Amenorrhoea. I have accepted your condition of Secondary Amenorrhoea.
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that this condition is related to your wartime service.
I have therefore accepted that this condition is related to your service with effect from 2 March 2016.
Secondary Amenorrhoea (Worsening)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 August 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 August 2025;
- A psychiatric assessment by the consultant psychiatrist, dated 14 March 2014;
- A hospital admission and CT report by the emergency physician and radiologist, dated 22 June 2015;
- An operation report by the gynaecologist, dated 12 August 2015;
- A pre-deployment medical and pathology by the medical officer, dated 28 October 2015;
- A mental health record by the deployed psychologist, Iraq, dated 20 January 2016;
- A dietetic assessment by the deployed dietitian, Iraq, dated 22 February 2016;
- A role 2 health record by the medical officer, Iraq, dated 14 June 2016;
- An endocrinology consultation and MRI pituitary report by the endocrinologist and radiologist, dated 5 July 2016;
- A hysteroscopy report by the gynaecologist, dated 8 September 2016;
- An endocrinology review and pathology by the endocrinologist, dated 14 August 2017;
- A bone densitometry report by the radiologist, dated 21 August 2017;
- A repatriation Medical Authority: no Statement of Principles determined for secondary amenorrhoea; causes drawn from the sound medical-scientific evidence.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
6 February 2011 and 15 November 2019
Secondary Amenorrhoea (Worsening)
You have stated that the worsening of your condition was caused by:
- undertaking strenuous physical activity with low energy availability for at least the 3 months before the clinical worsening of secondary amenorrhoea
- losing at least 5 per cent of body weight within the 6 months before the clinical worsening of secondary amenorrhoea
- taking a drug which causes hyperprolactinaemia, including risperidone, for at least the 4 weeks before the clinical worsening of secondary amenorrhoea
- inability to obtain appropriate clinical management for secondary amenorrhoea
Diagnosis: Secondary Amenorrhoea (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 22 August 2025, and is supported by an endocrinology consultation and MRI pituitary report by the endocrinologist and radiologist, dated 5 July 2016.
I am satisfied this is the appropriate diagnosis.
There is no Statement of Principles (SOP) for this condition. In determining your claim for this condition, I have therefore considered the available evidence, applying the standard of proof:
Balance of Probabilities (reasonable satisfaction) - no Statement of Principles determined for this condition
which requires the evidence to connect the condition with service.
I am satisfied that the evidence establishes the following link to your service:
- undertaking strenuous physical activity with low energy availability for at least the 3 months before the clinical worsening of secondary amenorrhoea
- losing at least 5 per cent of body weight within the 6 months before the clinical worsening of secondary amenorrhoea
- taking a drug which causes hyperprolactinaemia, including risperidone, for at least the 4 weeks before the clinical worsening of secondary amenorrhoea
- inability to obtain appropriate clinical management for secondary amenorrhoea
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with no menstrual period since early February 2016, with hot flushes, poor sleep and fatigue on 14 June 2016.
The diagnosis was confirmed by an endocrinologist on 5 July 2016: you had had no menses for four months after previously regular cycles, pregnancy was excluded, and investigations showed low gonadotrophins, a low oestradiol, hyperprolactinaemia and central hypothyroidism, with a normal pituitary MRI and no polycystic ovarian morphology. This establishes secondary amenorrhoea of hypothalamic and pituitary origin. Hysteroscopy on 8 September 2016 showed minor adhesions that did not account for the amenorrhoea alone.
After the condition arose, it was worsened during your service. From April 2017 you trained for a physically demanding selection course, running 70 kilometres a week and completing loaded marches, and a sports dietitian on 31 July 2017 calculated your energy availability at about 20 kilocalories per kilogram of fat-free mass per day. Your weight fell from 56.0 kg on 20 February 2017 to 52.5 kg on 14 August 2017, a loss of 6.3 per cent within the 6 months before the worsening, from 14 February 2017 to 14 August 2017, with you BMI falling to 18.6. Risperidone was increased to 4 mg at night on 6 March 2017 for worsening posttraumatic stress disorder and was taken every night throughout the months before the worsening. Your low free T4 in October 2015 was not followed up before deployment, and in theatre there was no gynaecology or endocrinology service, so the amenorrhoea was not investigated until July 2016.
This has then led to further investigations and the diagnosis of your condition of Secondary Amenorrhoea (Worsening). I have accepted your condition of Secondary Amenorrhoea (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that the worsening of this condition is related to your peacetime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 14 August 2017.
