Citation Nr: 0608830	
Decision Date: 03/28/06    Archive Date: 04/04/06

DOCKET NO.  03-32 939	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Hartford, 
Connecticut


THE ISSUES

1.  Entitlement to service connection for hypothyroidism, to 
include as secondary to service connected bipolar illness.

2.  Entitlement to service connection for erectile 
dysfunction, to include as secondary to service connected 
bipolar illness.  


REPRESENTATION

Appellant represented by:	Disabled American Veterans


WITNESS AT HEARING ON APPEAL

Appellant

ATTORNEY FOR THE BOARD

M. Donovan, Associate Counsel


INTRODUCTION

The veteran served on active duty from October 1977 to May 
1978.  

This case comes before the Board of Veterans' Appeals (Board) 
on appeal from an April 2003 rating decision issued by the 
Department of Veterans Affairs (VA) Regional Office (RO) in 
Hartford, Connecticut which denied service connection for 
hypothyroidism and erectile dysfunction.  

In February 2004 the veteran testified before a Decision 
Review Officer at an RO hearing.  A transcript of that 
hearing is of record.  

The issue of entitlement to service connection for 
hypothyroidism is remanded to the RO via VA's Appeals 
Management Center.  The veteran and his representative will 
be notified if further action is required on their part.


FINDING OF FACT

Erectile dysfunction is as likely as not proximately caused 
by medications for the veteran's service connected bipolar 
illness.


CONCLUSIONS OF LAW

Erectile dysfunction is the proximate result of service 
connected bipolar illness.  38 U.S.C.A. § 1131; 38 C.F.R. 
§§ 3.303, 3.310.  


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

I.  Preliminary matters-The Veterans Claims Assistance Act 
of 2000 (VCAA)

The Veterans Claims Assistance Act of 2000 (VCAA) describes 
VA's duty to notify and assist claimants in substantiating a 
claim for VA benefits.  38 U.S.C.A. §§ 5100, 5102, 5103, 
5103A, 5107, 5126 (West 2002 & Supp. 2005); 38 C.F.R. 
§§ 3.102, 3.156(a), 3.159, 3.326(a) (2005).  

The VCAA is not applicable where further assistance would not 
aid the appellant in substantiating his claim.  Wensch v. 
Principi, 15 Vet App 362 (2001); see 38 U.S.C.A. § 
5103A(a)(2) (Secretary not required to provide assistance 
"if no reasonable possibility exists that such assistance 
would aid in substantiating the claim"); see also VAOPGCPREC 
5-2004; 69 Fed. Reg. 59989 (2004) (holding that the notice 
and duty to assist provisions of the VCAA do not apply to 
claims that could not be substantiated through such notice 
and assistance).  In view of the Board's favorable decision 
in regard to the erectile dysfunction, further assistance or 
notice (including that specified in Dingess v. Nicholson, No. 
01-1917 (U.S. Vet. App. March 3, 2006) is unnecessary to aid 
the veteran in substantiating his erectile dysfunction claim.  

II.  Factual Background

Service medical records are silent for complaints of or 
treatment for erectile dysfunction.  

The veteran is service connected for bipolar illness with 
acute manic episodes evaluated as 70 percent disabling.  

The veteran submitted with his claim medical articles from 
the Internet noting the potential for hypothyroidism as a 
result of using lithium carbonate, used to treat bipolar 
disorder.  

VA outpatient treatment records from February 1992 to October 
2003 do not include complaints of, or treatment for, erectile 
dysfunction.  

At VA examination in March 2003 the veteran complained of 
erectile dysfunction, which he attributed to his 
antipsychotic drug treatment.  The veteran reported that he 
was able to obtain, but not maintain, an erection.  He stated 
that he had had erectile dysfunction for the past 10 years 
but had been too embarrassed to discuss the problem with his 
psychiatric healthcare provider, who was a woman.  

The examiner noted that there were no observable 
abnormalities of the external genitalia.

The examiner included references to three medical articles 
which supported an association between chlorpromazine, which 
the veteran uses to treat bipolar disorder, and impotence.  
The examiner commented that the veteran's claim of erectile 
dysfunction was "purely subjective."  The examiner went on, 
however, to recommended treatment for erectile dysfunction.

At the February 2004 RO hearing the veteran reiterated his 
belief that medications for his bipolar disorder resulted in 
erectile dysfunction.  

III.  Legal Analysis

Service connection will be granted for disability resulting 
from personal injury suffered or disease contracted during 
active military service, or for aggravation of a pre-existing 
injury or disease during such service.  38 U.S.C.A. § 1131 
(West 2002); 38 C.F.R. § 3.303 (2005).  

Proof of direct service connection requires (1) medical 
evidence of a current disability, (2) medical evidence, or in 
certain circumstances lay testimony, of in-service incurrence 
or aggravation of an injury or disease, and (3) medical 
evidence of a nexus, or link, between the current disability 
and the in-service disease or injury.  Hickson v. West, 12 
Vet. App. 247, 253 (1999); Pond v. West, 12 Vet. App. 341, 
346 (1999).  

The determination as to whether these requirements are met is 
based on an analysis of all the evidence of record and the 
evaluation of its credibility and probative value.  Baldwin 
v. West, 13 Vet. App. 1, 8 (1999).

The veteran's complaints and the March 2003 VA examination 
provide competent evidence of current erectile dysfunction.  
While there is no evidence of erectile dysfunction in 
service, or of a direct link between current erectile 
dysfunction and service; the examiner's comments and the 
medical evidence provides competent evidence of a link 
between current erectile dysfunction and medication used to 
treat the service connected psychiatric disability.  
38 C.F.R. § 3.310(a).

The examiner did not firmly conclude that the veteran had 
current erectile dysfunction, or that current erectile 
dysfunction was the result of medications for the psychiatric 
disability.  The examiner apparently concluded, however, that 
it was as likely as not that the veteran had current erectile 
dysfunction as the result of medications taken for the 
service connected disability.  In this regard, the examiner 
recommended treatment, which he presumably would not have 
done if he had concluded that the condition was not present.  
The examiner only reported one potential cause of the 
erectile dysfunction, that being the medications taken for 
the psychiatric condition.  

Resolving reasonable doubt in the veteran's favor the Board 
concludes that service connection is warranted for erectile 
dysfunction as secondary to service connected bipolar 
disorder.  38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 
Vet. App. 49 (1990).


ORDER

Entitlement to service connection for erectile dysfunction as 
secondary to service connected bipolar illness, is granted.  


REMAND

Under the VCAA, VA is obliged to provide an examination or 
obtain a medical opinion when the record contains competent 
evidence that the claimant has a current disability or signs 
and symptoms of a current disability, the record indicates 
that the disability or signs and symptoms of disability may 
be associated with active service; and the record does not 
contain sufficient information to make a decision on the 
claim.  38 U.S.C.A. § 5103A(d) (West 2002).  The evidence of 
a link between current disability and service must be 
competent.  Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 
2003).

The veteran has submitted a medical article reporting that 
the use of lithium carbonate can cause hypothyroidism.  The 
veteran was prescribed lithium for bipolar disorder beginning 
with a VA hospitalization in July and August 1986.  

Thyroid disease has been variously reported as beginning some 
time between 1989 and 1992.  Initially, according to a 
February 1992 VA hospitalization report, hyperthyroidism was 
identified.  According to the 2003 VA examination, the 
veteran underwent removal of the thyroid and has required 
continuous medication for hypothyroidism since that time.

An examination is needed to obtain an opinion as to whether 
the veteran has current thyroid disease related to the use of 
lithium.

Accordingly, the case is remanded for the following:

1.  Afford the veteran an endocrine 
examination.  The examiner should review 
the claims folder, including a copy of 
this remand, and note such review in the 
examination report or an addendum to the 
report.  The examiner should express an 
opinion as to whether it is at least as 
likely as not (50 percent probability or 
more) that any current thyroid disease is 
the result of lithium use, or is 
otherwise the result of a disease or 
injury in service.  The examiner should 
provide a rationale for these opinions.

2.  After ensuring that all requested 
opinions and findings are of record, 
readjudicate the claim.  If the claim 
remains denied, issue a supplemental 
statement of the case before returning 
the case to the Board, if otherwise in 
order.

The appellant has the right to submit additional evidence and 
argument on the matter or matters the Board has remanded.  
Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment.  The law 
requires that all claims that are remanded by the Board of 
Veterans' Appeals or by the United States Court of Appeals 
for Veterans Claims for additional development or other 
appropriate action must be handled in an expeditious manner.  
See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2005).



____________________________________________
Mark D. Hindin
Veterans Law Judge, Board of Veterans' Appeals


 Department of Veterans Affairs