Statement of Principles concerning malignant neoplasm of the endometrium (Balance of Probabilities) (No. 32 of 2025)

The instrument is built around several core legal and medical concepts. First, the condition itself: malignant neoplasm of the endometrium is defined as a primary malignant neoplasm arising from the cells of the mucous membrane that line the uterine cavity. It includes carcinoma in situ and carcinosarcoma (malignant mesodermal mixed tumour), but expressly excludes malignant neoplasm of the cervix, carcinoid tumour, soft tissue sarcoma of the uterus, non-Hodgkin's lymphoma, and Hodgkin's lymphoma. The ICD-10-AM code is C54.1, but the definition in subsection 7(2) controls. Death from the condition includes death from a terminal event (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function) that was contributed to by the person's malignant neoplasm.

Second, the standard of proof: "balance of probabilities" means that the decision-maker must be satisfied that it is more probable than not that the condition is connected to service. This is the standard used for claims under sections 120B of the VEA and 339 of the MRCA for relevant service, as defined. The instrument does not apply to operational service claims, which use a reasonable hypothesis standard.

Third, the factors. A factor is an event, circumstance, or medical condition that, on the evidence, can cause or contribute to the development or worsening of malignant neoplasm of the endometrium. The instrument lists nine exclusive factors. Each factor includes specific temporal conditions: the factor must exist before clinical onset (except factor 9(9) for clinical worsening), and often includes a cessation period during which onset must occur. For example, factor 9(2) requires using oestrogen-only hormone replacement therapy for at least six months before clinical onset, and if therapy ceased, onset must occur within 20 years of cessation. Factor 9(3) addresses cyclical combined hormone replacement therapy where oestrogen is combined with cyclical administration of progesterone for less than 15 days per cycle; it requires continuous use for at least five years before onset, with a five-year cessation period. Factor 9(4) applies only to post-menopausal females using tamoxifen for at least three months, with a 20-year cessation period. Factor 9(7) requires an inability to undertake physical activity greater than 3 METs for at least 10 years within the 30 years before clinical onset.

Fourth, "relevant service" is defined narrowly: eligible war service (other than operational service) under the VEA, defence service (other than hazardous service and British nuclear test defence service) under the VEA, or peacetime service under the MRCA. This means the instrument does not apply to service that is operational, hazardous, or British nuclear test defence service; a different SoP (made under subsection 196B(2)) applies to those.

Fifth, the concept of "clinical onset" is used throughout but not defined in the instrument. It is an established term in veterans' law, meaning the time when the condition first becomes clinically apparent. Similarly, "clinical worsening" is used only in factor 9(9). The instrument also provides that a factor referring to another disease (e.g., diabetes mellitus) may incorporate the factors from that disease's SoP under subsection 196B(3), on the basis that such SoPs apply as in force from time to time (section 11).

Sixth, the instrument uses physiological measures: BMI (weight in kilograms divided by height in metres squared), with "being overweight or obese" defined as a BMI of 25 or greater. MET (metabolic equivalent) is defined as 1 MET = 3.5 ml of oxygen per kilogram of body weight per minute, 1.0 kcal/kg per hour, or resting metabolic rate. "Oestrogen-only hormone replacement therapy" is defined as continuous, cyclical or intermittent administration of unopposed oestrogen, including diethylstilbestrol. "Tibolone" is not defined but is a known synthetic steroid hormone.

The primary persons affected are veterans and members of the Forces who have served in a capacity that qualifies as "relevant service" under the VEA or MRCA and who have been diagnosed with malignant neoplasm of the endometrium, or whose deaths are attributed to it. Because malignant neoplasm of the endometrium is specific to females (arising from the endometrium), the instrument applies only to female claimants. The factors are framed accordingly, with specific references to females aged over 35 years, post-menopausal females, and hormone therapies. The instrument does not address transgender veterans or intersex conditions; the term "female" is not defined, but in practice would be interpreted by reference to the person's sex at birth or legal gender depending on policy. The instrument also affects dependents who claim widow's or orphan's benefits based on a death from malignant neoplasm of the endometrium.

Second, the instrument affects decision-makers in the Department of Veterans' Affairs and the Military Rehabilitation and Compensation Commission. They must apply the SoP as a binding template for assessing any claim made under sections 120B of the VEA or 339 of the MRCA. The instrument narrows the range of acceptable causal reasoning: if a claimant can show one of the listed factors is present and related to service, the decision-maker must accept the connection. If no factor is met, the claim may still succeed on other medical evidence, but the instrument does not provide a safe harbour in that case. The instrument thus imposes a compliance burden on decision-makers to verify temporal windows and definitions precisely.

Third, the instrument affects medical practitioners who provide evidence in support of claims. They must be familiar with the definitions of BMI, MET, hormone therapy types, and the specific temporal requirements. For instance, a doctor's report stating the patient used "hormone replacement therapy" without specifying oestrogen-only versus cyclical combined, or without documenting the number of days of progesterone per cycle, may be insufficient. The instrument incentivises thorough documentation of risk factors over the patient's lifetime, particularly weight history, pregnancy history, and physical activity levels. This may involve obtaining records going back 20 to 30 years.

Fourth, the instrument affects the Repatriation Medical Authority itself. The RMA is required to keep the SoP under review and ensure it reflects sound medical-scientific evidence. By repealing the 2016 version, the RMA has concluded that the evidence now supports a different set of factors, temporal windows, or definitions. The new instrument may expand or contract the class of successful claimants compared to the previous version. For example, the addition of factor 9(8) for tibolone (a drug used for menopausal symptoms) suggests the RMA considered new evidence linking it to endometrial cancer. Conversely, the removal or modification of previous factors is not evident on the face of the instrument, but the repeal clause indicates a changed evidentiary basis.

Fifth, the instrument indirectly affects the Commonwealth as the ultimate funder of compensation, pensions, and medical treatment under the VEA and MRCA. Every factor that makes it easier for a claimant to establish connection expands the pool of potential liability. The instrument thus has fiscal implications: it may increase or decrease the number of accepted claims depending on whether the new factors are more or less inclusive. The instrument also affects private insurers, as veterans' compensation is a government scheme, but may set precedents for other compensation regimes.

The instrument does not itself create duties or rights, but it shapes the duties and rights that exist under the VEA and MRCA. The central right is the entitlement of a veteran or member to compensation or benefits for malignant neoplasm of the endometrium if the condition is determined to be service-related. The instrument provides a pathway to establish that relationship. If a person can show that at least one of the factors in section 9 exists and that the factor is related to their relevant service, the decision-maker must, on the balance of probabilities, find that the condition is connected to service. The factor must be related to service under section 10: the existence of the factor must be related to the relevant service the person rendered. For factor 9(9) (inability to obtain appropriate clinical management), there is an additional nuance: it applies only to material contribution to or aggravation of malignant neoplasm of the endometrium where the condition was suffered or contracted before or during (but did not arise out of) relevant service. This means that factor only helps establish worsening of a pre-existing condition, not initial onset.

The decision-maker has a duty to consider the instrument when assessing a claim that falls within its scope. They must apply the definitions strictly. For example, if a claimant relies on factor 9(5) (being overweight or obese), the decision-maker must verify that the BMI was 25 or greater for at least 10 years within the 20 years before clinical onset. The instrument does not give discretion to modify the temporal windows or to accept equivalent evidence that does not meet the precise definition. Similarly, the decision-maker must correctly classify the type of hormone replacement therapy: if a woman used oestrogen combined with progesterone for 15 or more days per cycle, factor 9(3) does not apply (it requires less than 15 days of progesterone per cycle), and they would need to rely on a different factor or other evidence.

The instrument also confers a right on claimants to rely on other Statements of Principles if a factor in section 9 refers to a disease that is itself covered by another SoP. Section 11 provides that if a factor refers to an injury or disease for which a SoP has been determined under subsection 196B(3), then the factors in that other SoP apply in accordance with its terms. For example, factor 9(6) requires having diabetes mellitus for at least 10 years before clinical onset. Diabetes mellitus is covered by its own SoP. Section 11 means that the decision-maker must apply the diabetes SoP factors to determine whether the diabetes is related to service. This creates a chain of causation: a claimant must first establish that the diabetes is service-related (under its SoP), and then the diabetes itself becomes a factor linking the endometrial cancer to service. This can simplify claims for veterans with conditions that are themselves presumptively service-related, but also adds layers of complexity for legal practitioners.

Claimants have no duty under the instrument itself, but must provide evidence to satisfy the decision-maker that a factor exists and is related to service. The burden of proof is on the balance of probabilities, meaning the claimant must produce evidence that makes it more likely than not that the factor exists and that it arose from service. The instrument does not prescribe the type of evidence, but in practice medical records, service records, and expert medical opinion are used.

This instrument does not contain any penalty provisions. It is not a criminal or regulatory instrument but an evidentiary standard for compensation claims. Enforcement in the traditional sense is not relevant. However, the instrument has indirect consequences for enforcement of the VEA and MRCA. If a claimant provides false or misleading information to support a factor under section 9, they may be subject to penalties under the Criminal Code or the VEA itself (for example, section 203 of the VEA deals with false statements). The instrument itself does not impose those penalties; they arise from the parent acts.

The instrument does provide a basis for review of decisions. If a decision-maker fails to apply the SoP correctly, the claimant can seek merits review by the Veterans' Review Board or the Administrative Appeals Tribunal, and judicial review by the Federal Court. The instrument can be challenged on grounds such as jurisdictional error (if the RMA acted beyond its power under s196B), procedural error (failure to consider sound medical-scientific evidence), or error of law (misinterpreting a factor). The instrument is a legislative instrument and is subject to disallowance by Parliament under the Legislation Act 2003, though this is rare for SoPs.

The instrument also imposes a kind of enforcement on the RMA itself: the RMA must ensure that a SoP is in force and that it is based on the best available evidence. The RMA is not subject to penalties but may be judicially reviewed if it fails to perform its statutory duty. The repeal of the 2016 instrument and replacement with the 2025 instrument suggests the RMA has actively reviewed the evidence and updated the factors accordingly. Failure to update could lead to claims that the SoP no longer reflects sound medical-scientific evidence, potentially exposing decisions to challenge.

The practical enforcement mechanism is the rejection of claims that do not meet the factors. The instrument thus enforces a strict causal framework. Claimants who cannot satisfy a factor will likely have their claim denied, unless they can advance alternative medical evidence that still meets the balance of probabilities standard. The instrument therefore operates as a gatekeeper: it reduces the decision-maker's discretion by specifying acceptable causal pathways, but it also provides a safe harbour for claimants who fit within those pathways.

The instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986. It operates within the broader veterans' compensation legislative framework. Section 120B of the VEA provides that the standard of proof for claims relating to service other than operational service is the balance of probabilities, and that the determination of whether an injury or disease is service-related must be made in accordance with a SoP determined under s196B(3) if such an SoP exists. Similarly, section 339 of the MRCA applies the same standard and refers to SoPs. This instrument therefore has the force of law for the purposes of those sections; decision-makers cannot ignore it.

The instrument interacts with other Statements of Principles for different conditions. Section 11 of the instrument expressly provides that if a factor refers to an injury or disease for which a SoP has been determined under s196B(3), then the factors in that other SoP apply. For example, factor 9(6) requires diabetes mellitus for at least 10 years before clinical onset. Diabetes mellitus is the subject of its own SoP (likely a separate instrument under s196B(3)). To rely on factor 9(6), the claimant must first establish that the diabetes is related to service under that diabetes SoP. The instrument thus creates a cascading application of multiple SoPs. This can be beneficial for claimants whose diabetes is already accepted as service-related, but adds complexity if the diabetes is not yet linked to service.

The instrument also interacts with the VEA's provisions for operational service. Claims for operational service use a reasonable hypothesis standard under s120 of the VEA, and are governed by SoPs made under s196B(2) (reasonable hypothesis) rather than s196B(3) (balance of probabilities). This instrument does not apply to operational service claims. However, a veteran may have a mixture of service types. The decision-maker must distinguish which periods of service are relevant and apply the correct SoP. If a veteran has both operational and non-operational service, the claim may need to be assessed under both standards, and the instrument only applies to the non-operational part.

The instrument interacts with the common law and other compensation schemes. It provides a statutory presumption, but it does not override the possibility of the veteran or member seeking damages from third parties (for example, if exposure to a carcinogen in the workplace contributed to the condition). The instrument is specific to military service and does not affect civil liability. It also interacts with state workers' compensation schemes, but only to the extent that a veteran may have dual entitlements, which are generally coordinated under the VEA.

The definitions in the schedule are legally binding. For example, the definition of "terminal event" in the schedule lists specific causes of death that can be attributed to the malignant neoplasm for the purpose of death claims. This interacts with coronial findings and death certificates. The ICD-10-AM code is referenced but not controlling; the meaning of malignant neoplasm of the endometrium is that given in subsection 7(2). This prevents reliance solely on coding.

The instrument also interacts with the Legislation Act 2003 regarding registration, tabling, and disallowance. As a legislative instrument, it must be registered on the Federal Register of Legislation and tabled in Parliament, and may be disallowed. That is a parliamentary oversight mechanism, but does not change its legal effect once made.

The instrument itself is a new instrument; it does not contain an amendment history. However, it explicitly repeals the previous instrument: the Statement of Principles concerning malignant neoplasm of the endometrium No. 12 of 2016 (F2016L00244) made under subsection 196B(3) and (8) of the VEA. That 2016 instrument was itself a replacement of earlier SoPs. The Repatriation Medical Authority reviews SoPs periodically as medical evidence evolves. The interval between 2016 and 2025 is approximately nine years, which is typical for SoPs: some are reviewed earlier if new evidence emerges, while others remain in force longer.

The repeal clause (section 4) means that any claim that is decided on or after the commencement date of this instrument (25 March 2025) must apply this new SoP, even if the condition manifested before that date. However, claims that were finally determined under the 2016 instrument are unaffected. Claims that are lodged after 25 March 2025 but relate to an earlier clinical onset will still be assessed under the new instrument. The transitional provisions of the VEA may affect how this operates, but no specific transitional provision is in this instrument.

The instrument does not provide a summary of changes from the 2016 version. To identify differences, one would need to compare the two instruments textually. The addition of factor 9(8) (tibolone) is a likely change; the 2016 instrument may or may not have included tibolone. The temporal windows may have been adjusted: for example, the 2016 instrument might have required a different duration for obesity or a different cessation period for oestrogen-only HRT. Without access to the 2016 instrument, we cannot be certain. The instrument's explanatory statement or accompanying documents would typically outline changes, but only the instrument itself is provided.

The authority for the RMA to make SoPs is subsection 196B(3) of the VEA. That subsection requires the RMA to be satisfied that the available sound medical-scientific evidence supports the determination. The repeal and replacement implies that the RMA has considered new evidence and concluded that the previous set of factors no longer reflects the current state of knowledge, or that additional factors have become supported. This process is ongoing; the RMA is required to keep SoPs under review. The instrument's long title includes the year 2025, indicating it is the 32nd SoP of that year, suggesting a busy schedule of reviews.

The instrument does not mention any interim amendments. SoPs are typically made as complete replacements rather than being amended piecemeal. However, note that section 11 of the instrument applies SoPs for other diseases "as in force from time to time", meaning that those other SoPs may be amended independently, and those amendments will automatically apply to this instrument without requiring an amendment to this instrument. This is an efficient mechanism to align multiple SoPs.

The instrument itself does not contain any litigation history. It is a new instrument commencing on 25 March 2025, and as of the date of this analysis, no court or tribunal decisions have yet been made interpreting it. However, previous SoPs for malignant neoplasm of the endometrium (including the 2016 version and earlier) have been the subject of litigation in the Administrative Appeals Tribunal and Federal Court. Typical arguments include: whether the RMA properly considered sound medical-scientific evidence; whether a factor is correctly interpreted (e.g., what constitutes "oestrogen-only hormone replacement therapy", whether "cyclical combined" includes continuous combined therapy with a progestogen-releasing IUD); whether the temporal windows are arbitrary; and whether the relationship to service is established (section 10). Claimants have also challenged decisions that failed to apply the SoP correctly or that misinterpreted the definitions.

The instrument is legislative in character, and the Federal Court has jurisdiction to review it for jurisdictional error, but such challenges are rare because the RMA has broad discretion to decide what factors to include based on the medical evidence. The High Court has considered the validity of SoPs in general, particularly regarding the requirement for "sound medical-scientific evidence". In Repatriation Commission v Gorton (2008) and similar cases, the courts have held that the RMA's decision is not amenable to merits review but can be challenged if it fails to take into account relevant considerations. However, no specific cases are named in this instrument.

Future litigation is likely to centre on the new factor 9(8) (tibolone) and whether it is supported by sound evidence, as well as the precise application of factor 9(3) regarding the number of days of progesterone per cycle. The instrument's definition of "oestrogen-only hormone replacement therapy" includes diethylstilbestrol, a drug no longer commonly used, which may raise issues of historical exposures. The factor 9(7) (inability to undertake physical activity greater than 3 METs) may be difficult to prove with service records; claimants may argue that service itself caused the inability, requiring interpretation of "related to service".

The instrument also adopts the standard for "balance of probabilities" SoPs, which are generally easier for claimants to meet than reasonable hypothesis ones, but the strict temporal windows still create fertile ground for disputes over dates of clinical onset and duration of factors. Litigation may also address the interplay with other SoPs under section 11, particularly whether the diabetes SoP's factors must be satisfied in full when diabetes is used as a factor for endometrial cancer.

Given that the instrument is only days old at the time of writing (commencing 25 March 2025, and this analysis is written after that date), there is no litigation history specific to it. The previous 2016 instrument has likely been litigated, but we cannot refer to those cases as they are not cited in the source. The absence of citation suggests the RMA did not intend to rely on any particular judicial interpretation.

Several provisions in the instrument can easily trap the unwary. First, factor 9(1) applies only to females aged over 35 years who have never been pregnant for more than 8 weeks. This excludes women under 35 and women who have had a pregnancy lasting more than 8 weeks at any point (even if they later miscarried or had an abortion after 8 weeks). The wording "never been pregnant for more than 8 weeks" is strict: a pregnancy that ended before 8 weeks does not count, but any pregnancy that reached 8 weeks and 1 day defeats the factor. This is a binary test with no allowance for the number of pregnancies.

Second, factor 9(2) (oestrogen-only hormone replacement therapy) requires use for at least 6 months before clinical onset, and if ceased, onset must occur within 20 years of cessation. Many women use oestrogen-only HRT for less than 6 months, or cease it and develop cancer more than 20 years later, so the window can easily be missed. The definition of oestrogen-only hormone replacement therapy includes diethylstilbestrol, which is used for other conditions (e.g., prostate cancer) but the instrument does not limit it to menopausal use. However, the condition is female-specific, so in practice that will not arise.

Third, factor 9(3) for cyclical combined HRT is particularly exacting. It requires that oestrogen be combined with cyclical administration of progesterone for less than 15 days during each treatment cycle, for a continuous period of at least 5 years before clinical onset. If the progesterone is given for 15 days or more per cycle, the factor does not apply. Many standard cyclical HRT regimens prescribe progesterone for 12 to 14 days per cycle, so they might satisfy this, but women using continuous combined HRT (where progesterone is given every day) or a progestogen-releasing IUD would not meet this factor because the administration is not cyclical. The cessation window is only 5 years, much shorter than the 20 years for oestrogen-only HRT.

Fourth, factor 9(4) (tamoxifen) applies only to post-menopausal females. Many women take tamoxifen for breast cancer, which may be pre-menopausal. The instrument does not define "post-menopausal"; it must be determined clinically. The factor requires treatment for at least 3 months before clinical onset, and if ceased, onset within 20 years of cessation. The short 3-month requirement seems generous, but the post-menopausal requirement is a key limitation.

Fifth, factor 9(5) (overweight or obese) uses a BMI threshold of 25 or greater. This is a relatively low threshold: a person with a BMI of 25 to 29.9 is overweight, and 30+ is obese. Many people fall into this range, but the factor requires the condition to have existed for at least 10 years within the 20 years before clinical onset. This requires longitudinal weight history, which may be difficult to prove from service records alone. The instrument does not allow for BMI fluctuations; it only requires that the person was overweight or obese for 10 years (not necessarily continuously, but presumably cumulative).

Sixth, factor 9(6) (diabetes mellitus for at least 10 years before clinical onset). Diabetes must be established by medical evidence, and the 10-year period is a minimum. If the diabetes was diagnosed less than 10 years before the endometrial cancer, the factor cannot be used.

Seventh, factor 9(7) (inability to undertake physical activity greater than 3 METs for at least 10 years within the 30 years before clinical onset). Three METs is a very low level of exertion: it equates to walking at about 3 km/h or light housework. Many people can undertake at least that much activity. The factor requires a demonstrated inability, not just a lack of interest. Service records showing a medical condition that limited mobility would be crucial. The 10-year period must be within the 30 years before onset, which is a wide window but hard to prove.

Eighth, factor 9(8) (tibolone) is a newer drug; the instrument requires at least 1 year of treatment before clinical onset, with a 10-year cessation window. Tibolone is used for menopausal symptoms and osteoporosis. Many clinicians may not document it clearly, and patients may not recall it.

Ninth, factor 9(9) is only for clinical worsening of a pre-existing condition. It cannot be used to establish initial onset. The wording requires "inability to obtain appropriate clinical management for malignant neoplasm of the endometrium". This seems to require that the veteran already had the condition and that the inability to obtain care worsened it. Proving both that the management was appropriate and that the inability was related to service will be difficult.

Tenth, the instrument applies only to "relevant service" as defined, which excludes operational service, hazardous service, and British nuclear test defence service. A veteran with a mixture of service types must ensure the claim is framed under the correct service. If the veteran served in a war zone (operational service), this SoP does not apply; a different SoP under s196B(2) would apply with a lower threshold of proof (reasonable hypothesis). Using this instrument for an operational service claim would be a complete error.

Eleventh, the definition of "terminal event" lists only five causes of death. If the veteran died from something not on the list (e.g., renal failure, sepsis), it may not be covered, even if the cancer contributed. The list is exclusive.

Twelfth, the instrument applies only to claims under section 120B of the VEA and section 339 of the MRCA. It does not apply to claims under the Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1988 or other schemes.

Thirteenth, the instrument's effective date is 25 March 2025. Any claim determined before that date must use the 2016 instrument. A decision-maker who issues a decision after 25 March 2025 must use the new instrument, even if the claim was lodged earlier. This may cause confusion during the transition.

Fourteenth, the instrument does not provide for multiple factors to be combined. At least one factor must exist. If a person has multiple weaker factors, they cannot be cumulated unless one individually meets the temporal and definitional requirements.

Fifteenth, the factor 9(5) for being overweight or obese does not require that the obesity itself be related to service, only that the factor exists and is related to service. This means the veteran could be obese due to non-service reasons, but if the obesity itself is related to service (e.g., service-induced diabetes leading to weight gain), then the factor applies. But if the obesity is unrelated to service, the factor cannot be used. This is a common misunderstanding: the factor must be related to service, not just the presence of the condition.

Compliance with this instrument is largely about evidence gathering and correct application by decision-makers. For a claimant seeking to establish that malignant neoplasm of the endometrium is connected to relevant service, the recommended steps are as follows.

First, determine the date of clinical onset of the malignant neoplasm. This is usually the date of first diagnosis (biopsy, imaging, or clinical presentation). The clinical onset date triggers all the temporal windows. If the onset is not clear, obtain a medical opinion. Second, identify which of the nine factors might apply based on the veteran's medical and personal history. For each candidate factor, gather documentary evidence to satisfy the temporal requirements. For example, for factor 9(5) (obesity), obtain medical records showing weight and height over the relevant period (at least 10 years within 20 years before onset). Calculate BMI using the formula. If records are incomplete, a retrospective medical report based on history may be used, but it must be credible.

Third, for hormone-related factors, obtain a complete history of hormone therapy including drug names, dosages, dates of use, and whether the therapy was oestrogen-only or combined. For cyclical combined HRT, the number of days of progesterone per cycle must be documented. Pharmacy records, prescribing records, and hospital charts are best. If the therapy was for menopausal symptoms, confirm that the veteran is post-menopausal for tamoxifen factor (9(4)). For tibolone (9(8)), ensure at least 1 year of use.

Fourth, for nulliparity (9(1)), obtain evidence of reproductive history: number of pregnancies and their durations. Medical records, birth certificates, or affidavits may suffice. A pregnancy lasting more than 8 weeks at any point disqualifies this factor.

Fifth, for diabetes (9(6)), obtain diagnosis dates and evidence that diabetes has been present for at least 10 years before clinical onset of the cancer.

Sixth, for physical inactivity (9(7)), obtain evidence of a medical or service-related condition that rendered the veteran unable to perform physical activity greater than 3 METs for at least 10 years within 30 years before onset. This might require occupational therapy assessments, medical reports about mobility limitations, or service records showing hospitalisation or discharge for a condition that caused limitation.

Seventh, for inability to obtain appropriate clinical management (9(9)), this factor applies only to worsening of a pre-existing condition. Document that the veteran had malignant neoplasm of the endometrium before or during service (but did not arise out of service). Then demonstrate that there was an inability to obtain appropriate clinical management for that condition, leading to clinical worsening. "Inability" must be related to service; for example, if the veteran was posted to a remote location with no access to oncologists. This factor is unlikely to be common.

Eighth, establish that the chosen factor is related to the veteran's relevant service. This requires linking the factor to a specific service event or condition. For example, if the factor is obesity, show that the weight gain resulted from a service-related injury that caused reduced mobility. If the factor is oestrogen-only HRT, show that the HRT was prescribed for a service-related menopausal condition (e.g., surgical menopause due to service injury). If the factor is nulliparity, show that the inability to become pregnant was caused by a service-related gynaecological condition. The relationship must be on the balance of probabilities.

Ninth, if the factor refers to another disease (e.g., diabetes), rely on the SoP for that disease to establish the service connection (section 11). Obtain a determination that the diabetes is service-related under its own SoP.

Tenth, present all evidence to the Department of Veterans' Affairs in support of the claim. The decision-maker will apply the instrument. If the decision-maker rejects the claim because a factor is not met, consider whether alternative factors apply or whether there is other medical evidence that could still establish connection on the balance of probabilities without relying on the instrument. The instrument does not preclude other evidence; it merely provides a presumptive pathway.

For decision-makers, compliance means applying the instrument strictly. Check each factor's temporal conditions and definitions. Do not substitute clinical judgment for the instrument's requirements. If the claimant relies on factor 9(3) but the evidence shows continuous combined HRT rather than cyclical, the factor is not met. If the claimant relies on factor 9(5) but BMI is 24.9, the factor is not met. Ensure that the dictionary definitions are applied, especially for "being overweight or obese" (BMI >=25) and "oestrogen-only hormone replacement therapy". When multiple factors are claimed, each must be assessed individually.

For legal practitioners, educate clients early about the need for accurate medical records. Advise on the difficulty of proving long-term weight and inactivity histories. Consider whether operational service claims might be easier under the reasonable hypothesis standard. Review the instrument alongside the previous version to understand changes in factors that may affect pending claims.

For medical practitioners, when treating female veterans with endometrial cancer, document all relevant risk factors systematically. Provide reports that explicitly address each temporal window. Use the instrument's language to avoid ambiguity. For example, state "the patient used oestrogen-only hormone replacement therapy from 1 January 2015 to 1 January 2018, a period of 3 years, which is more than 6 months. Clinical onset of endometrial cancer occurred in 2022, within 20 years of cessation. The therapy was prescribed for menopausal symptoms due to surgical menopause following a gynaecological injury sustained during service." Such specificity directly supports the factor.