Reference Determination Content
Suggested draft · fictitious patient
Vulvovaginal Candidiasis
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 30 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 30 April 2025;
- An outpatient health record by the medical officer, Garrison health centre, dated 18 January 2016;
- A pre-deployment medical examination by the medical officer, dated 22 April 2016;
- A role 2 treatment record by the medical officer, Iraq, dated 12 June 2016;
- A role 2 treatment record by the medical officer, Iraq, dated 30 July 2016;
- A role 2 treatment record and vaginal microscopy by the medical officer, Iraq, dated 17 August 2016;
- A microbiology culture report by the coalition laboratory, dated 24 August 2016;
- A sexual health consultation by the sexual health physician, dated 8 March 2017;
- A field health record and microbiology culture with susceptibilities by the medical officer and microbiologist, dated 24 July 2017;
- Recognised causes of vulvovaginal candidiasis (infectious diseases, sexual health and gynaecology literature (no Statement of Principles)).
Your service
I have identified that you have the following service:
Australian Defence Force service between :
9 March 1998 and 14 December 2020
Vulvovaginal Candidiasis
You have stated that your condition was caused by:
- taking a systemic broad-spectrum antibiotic within the 4 weeks before the clinical onset of vulvovaginal candidiasis
- taking a systemic corticosteroid for at least 7 days within the 3 months before the clinical onset of vulvovaginal candidiasis
- having diabetes mellitus with an HbA1c of 8 per cent or more at the time of the clinical onset of vulvovaginal candidiasis
- taking a sodium-glucose co-transporter 2 inhibitor for at least the 4 weeks before the clinical onset of vulvovaginal candidiasis
- taking an oestrogen-containing hormonal contraceptive for at least the 3 months before the clinical onset of vulvovaginal candidiasis
- living or working in a hot climate, with daily maximum temperatures of at least 30 degrees Celsius, for at least the 4 weeks before the clinical onset of vulvovaginal candidiasis
- wearing occlusive, non-breathable clothing over the genital area for at least 8 hours a day for at least the 4 weeks before the clinical onset of vulvovaginal candidiasis
- having restricted access to bathing and laundry facilities for at least the 2 weeks before the clinical onset of vulvovaginal candidiasis
Diagnosis: Vulvovaginal Candidiasis
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 30 April 2025, and is supported by a microbiology culture report by the coalition laboratory, dated 24 August 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:
- taking a systemic broad-spectrum antibiotic within the 4 weeks before the clinical onset of vulvovaginal candidiasis
- taking a systemic corticosteroid for at least 7 days within the 3 months before the clinical onset of vulvovaginal candidiasis
- having diabetes mellitus with an HbA1c of 8 per cent or more at the time of the clinical onset of vulvovaginal candidiasis
- taking a sodium-glucose co-transporter 2 inhibitor for at least the 4 weeks before the clinical onset of vulvovaginal candidiasis
- taking an oestrogen-containing hormonal contraceptive for at least the 3 months before the clinical onset of vulvovaginal candidiasis
- living or working in a hot climate, with daily maximum temperatures of at least 30 degrees Celsius, for at least the 4 weeks before the clinical onset of vulvovaginal candidiasis
- wearing occlusive, non-breathable clothing over the genital area for at least 8 hours a day for at least the 4 weeks before the clinical onset of vulvovaginal candidiasis
- having restricted access to bathing and laundry facilities for at least the 2 weeks before the clinical onset of vulvovaginal candidiasis
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 intense vulval itch, burning and soreness, pain on passing urine and on sitting, and a thick white discharge, with vulval redness, swelling and fissuring on examination.After onset the symptoms recurred at least four times within twelve months and, from July 2017, became persistent despite weekly fluconazole on 17 August 2016.
The diagnosis was confirmed on 17 August 2016 by typical symptoms and signs, vaginal pH of 4.2 and microscopy showing budding yeasts and pseudohyphae, and on 24 August 2016 by culture growing Candida albicans. Bacterial vaginosis and trichomoniasis were excluded by the normal pH and microscopy.
This has then led to further investigations and the diagnosis of your condition of Vulvovaginal Candidiasis. I have accepted your condition of Vulvovaginal Candidiasis.
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 14 August 2016.
Vulvovaginal Candidiasis (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 30 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 30 April 2025;
- An outpatient health record by the medical officer, Garrison health centre, dated 18 January 2016;
- A pre-deployment medical examination by the medical officer, dated 22 April 2016;
- A role 2 treatment record by the medical officer, Iraq, dated 12 June 2016;
- A role 2 treatment record by the medical officer, Iraq, dated 30 July 2016;
- A role 2 treatment record and vaginal microscopy by the medical officer, Iraq, dated 17 August 2016;
- A microbiology culture report by the coalition laboratory, dated 24 August 2016;
- A sexual health consultation by the sexual health physician, dated 8 March 2017;
- A field health record and microbiology culture with susceptibilities by the medical officer and microbiologist, dated 24 July 2017;
- Recognised causes of vulvovaginal candidiasis (infectious diseases, sexual health and gynaecology literature (no Statement of Principles)).
Your service
I have identified that you have the following service:
Australian Defence Force service between :
9 March 1998 and 14 December 2020
Vulvovaginal Candidiasis (Worsening)
You have stated that the worsening of your condition was caused by:
- taking a systemic broad-spectrum antibiotic within the 4 weeks before the clinical worsening of vulvovaginal candidiasis
- taking a systemic corticosteroid within the 3 months before the clinical worsening of vulvovaginal candidiasis
- having diabetes mellitus with an HbA1c of 8 per cent or more, or taking a sodium-glucose co-transporter 2 inhibitor, at the time of the clinical worsening of vulvovaginal candidiasis
- living or working in hot or humid conditions with restricted access to bathing facilities for at least 2 weeks within the 4 weeks before the clinical worsening of vulvovaginal candidiasis
- inability to obtain appropriate clinical management for vulvovaginal candidiasis
Diagnosis: Vulvovaginal Candidiasis (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 30 April 2025, and is supported by a microbiology culture report by the coalition laboratory, dated 24 August 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:
- taking a systemic broad-spectrum antibiotic within the 4 weeks before the clinical worsening of vulvovaginal candidiasis
- taking a systemic corticosteroid within the 3 months before the clinical worsening of vulvovaginal candidiasis
- having diabetes mellitus with an HbA1c of 8 per cent or more, or taking a sodium-glucose co-transporter 2 inhibitor, at the time of the clinical worsening of vulvovaginal candidiasis
- living or working in hot or humid conditions with restricted access to bathing facilities for at least 2 weeks within the 4 weeks before the clinical worsening of vulvovaginal candidiasis
- inability to obtain appropriate clinical management for vulvovaginal candidiasis
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 intense vulval itch, burning and soreness, pain on passing urine and on sitting, and a thick white discharge, with vulval redness, swelling and fissuring on examination.After onset the symptoms recurred at least four times within twelve months and, from July 2017, became persistent despite weekly fluconazole on 17 August 2016.
The diagnosis was confirmed on 17 August 2016 by typical symptoms and signs, vaginal pH of 4.2 and microscopy showing budding yeasts and pseudohyphae, and on 24 August 2016 by culture growing Candida albicans. Bacterial vaginosis and trichomoniasis were excluded by the normal pH and microscopy.
After the condition arose, it was worsened during your service. During a field exercise in northern Queensland you took doxycycline for 14 days for infected insect bites, within the 4 weeks before the documented worsening on 24 July 2017, when severe symptoms persisted despite maintenance fluconazole and culture grew fluconazole-resistant Candida glabrata. You took a five-day course of prednisolone for asthma during the exercise, within the 3 months before the worsening, from 24 April to 24 July 2017. Your HbA1c was 8.9 per cent in 2017 and you continued daily empagliflozin up to and at the worsening. You spent four weeks in the field in heat and humidity in northern Queensland, in combat uniform with showering limited to twice weekly, from late June 2017 to the worsening on 24 July 2017. On deployment in Iraq your recurrences were treated empirically with single-dose fluconazole because no culture, susceptibility testing or specialist review was available, and after your return the first gynaecology appointment was five months away.
This has then led to further investigations and the diagnosis of your condition of Vulvovaginal Candidiasis (Worsening). I have accepted your condition of Vulvovaginal Candidiasis (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 24 July 2017.
