Citation Nr: 1024914 Decision Date: 07/02/10 Archive Date: 07/09/10 DOCKET NO. 01-05 314 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for migraine headaches. 2. Entitlement to service connection for a gastrointestinal disorder. 3. Entitlement to service connection for a hiatal hernia. 4. Entitlement to service connection for a visual acuity disability. 5. Entitlement to service connection for scarring of the liver, bladder, and gallbladder. 6. Entitlement to service connection for a shortened cervix. 7. Entitlement to service connection for angioedema and urticaria. 8. Entitlement to service connection for hepatitis B. 9. Entitlement to service connection for fibromyalgia. 10. Entitlement to service connection for dysmenorrhea and amenorrhea. 11. Entitlement to service connection for galactorrhea. 12. Entitlement to service connection for hypertension. 13. Entitlement to service connection for a gynecological disorder other than dysmenorrhea, amenorrhea, or already service- connected gynecological disorders (hysterectomy, uterine fibroids, and left salpingo-oophorectomy). 14. Entitlement to an increased rating for lichen simplex of the left lower leg, currently evaluated as 10 percent disabling. 15. Entitlement to a determination of permanency of a total rating for the purpose of establishing entitlement to Dependents' Educational Assistance under Chapter 35 of the United States Code. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael Holincheck, Counsel INTRODUCTION The Veteran served on active duty from December 1976 to August 1981 and from May 1984 to October 1987 with additional service in the National Guard from August 1974 to December 1976. This matter comes before the Board on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. FINDINGS OF FACT 1. The Veteran does not experience a migraine headache disorder, a gastrointestinal disorder, a hiatal hernia, hepatitis B, or fibromyalgia that is attributable to her military service. 2. The Veteran has a shortened cervix as a result of a post- service hysterectomy. The medical evidence of record has not shown this to result in any additional disability related to service. 3. The medical evidence shows that the Veteran has refractive error, but does not relate any other visual acuity, or other eye disability to her military service. 4. The Veteran does not have disability due to scarring of the liver, bladder, or gallbladder. 5. The Veteran does not have angioedema or urticaria that is attributable to her military service. 6. The Veteran does not experience dysmenorrhea or amenorrhea as disabilities separate from her already service-connected gynecological disabilities. 7. The Veteran experienced galactorrhea in service and continues to experience it in the years after service. There is no medical evidence to demonstrate that the galactorrhea constitutes a disability. 8. The Veteran does not have a gynecological disability other than those already service connected. 9. The available record does not provide a basis for linking hypertension to service or for showing that a higher rating is warranted for lichen simplex; the Veteran failed to report for scheduled VA examinations without good cause. 10. The Veteran's 100 percent rating for service-connected PTSD has been in effect since October 20, 1989, a period of over 20 years and is a protected rating. As the disability rating has not been reduced during that period, and cannot be except in limited circumstances, it is reasonable to conclude that the rating will continue at that level during the Veteran's lifetime. Entitlement to DEA benefits is established. CONCLUSIONS OF LAW 1. Service connection is not warranted for a migraine headache disorder, gastrointestinal disorder, a hiatal hernia, visual acuity disability, scarring of the liver, bladder, or gallbladder, a shortened cervix, angioedema, urticaria, hepatitis B, fibromyalgia, dysmenorrhea, amenorrhea, galactorrhea, or other gynecological disorder. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2009). 2. Service connection for hypertension is denied by operation of law. 38 C.F.R. § 3.655 (2009); Kyhn v. Shinseki, 23 Vet. App. 335 (2010). 3. Entitlement to a disability rating in excess of 10 percent for lichen simplex of the left lower leg is denied by operation of law. 38 C.F.R. § 3.655; Kyhn v. Shinseki, 23 Vet. App. 335 (2010). 4. Basic eligibility requirements for entitlement to Dependents' Educational Assistance benefits under Chapter 35, Title 38, United States Code are met. 38 U.S.C.A. §§ 3500, 3501(a)(1), (11) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.807, 21.3021 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Background The Veteran served in the National Guard from August 1974 to December 1976. After that she served an initial period of active duty with the Air Force in an enlisted status from December 1976 to August 1981. She later attended a Reserve Officer Training Corps (ROTC) program from 1981 to 1984. The Veteran then served a second period of active duty in the Air Force as an officer from May 1984 to October 1987. The Veteran's service treat records (STRs) are associated with the claims folder and cover a period from July 1974 to October 1987. The Veteran reported having a child in 1968 on her original enlistment physical examination history in July 1974. The Veteran also reported a preexisting hay fever condition. A March 1975 allergy consultation provided an impression of allergic rhinitis. The STRs reflect that the Veteran was treated for allergic rhinitis and sinusitis on a number of occasions during her years of service. This also included complaints of headaches associated with her allergic condition. An entry dated in December 1976 reported a review of previously prescribed medications upon the Veteran's reporting at a new duty station. A prescription for Donnatal, used as an anti-spasmodic for the gastrointestinal (GI) tract, was not approved. The Veteran was approved for a drug used as an anti-sunburn filter, and Retin-A as an anti-acne medication. In regard to headaches, the STRs reflect that the Veteran complained of headaches in February 1977 when she said that she experienced headaches when she would type all day. A March 1977 entry noted that the Veteran gave an 8-year history of a milky discharge from her breasts (galactorrhea). This would coincide with a time period after her first child was born in 1968. A July 1976 obstetrics and gynecology (OB/GYN) visit noted that the Veteran reported an occasional irregularity in her menses. She also reported a discharge from her breasts. The Veteran's prescription for birth control pills (BCP) was renewed in August 1978. Her blood pressure was noted as 150/90 at the time. The entry further noted that her blood pressure was to be checked every three months and she was to discontinue taking her BCPs if her blood pressure exceeded 150/90. The Veteran's blood pressure was checked for five days during September 1978. It was still elevated in early September but a later entry on September 18 shows that she was normotensive, but also shows that the Veteran complained of headaches and dizziness at times. A June 1980 OB/GYN evaluation noted that the Veteran said that her discharge from her breasts was attributable to massive cystitis. Her blood pressure was 110/70. There were palpable masses of the adnexae. The Veteran was evaluated for a heart murmur in April 1981. An internal medicine consultation shows that there was no cardiac defect and that the Veteran was fit for worldwide duty. The Veteran was noted to be pregnant in July 1984. A Standard Form (SF 533), Prenatal and Pregnancy record documented blood pressure readings over six weeks during July and August 1984 with no evidence of an elevated blood pressure. The Veteran delivered a healthy baby by Caesarian section (C-section) in January 1985. The hospital operative report and discharge summary did not disclose any problems in the surgery or after care. The Veteran was noted to have experienced preeclampsia prior to her admission to the hospital. (Preeclampsia is defined as the development of hypertension with proteinuria or edema, or both, due to pregnancy or the influence of a recent pregnancy. STEDMAN'S MEDICAL DICTIONARY 1419 (26th Ed., 1995)) (hereinafter STEDMAN'S). The STRs reflect that the Veteran gave informed consent to a bilateral tubal ligation in September 1985. The surgery was performed in November 1985. Additional treatment records noted that the Veteran continued to complain of a discharge from her breasts. She was evaluated in April 1986 to include a bilateral mammogram and ultrasound of the left breast. Her Prolactin level was also checked and found to be normal. The Veteran was found to have an abnormal Pap smear in May 1986 with the presence of squamous metaplasia and inflammation noted. An October 1986 entry provided a diagnosis of galactorrhea of unknown etiology. The Veteran was treated for complaints of burning and drainage of the left eye for two days in October 1986. Her visual acuity was measured as 20/25 in the right eye, 20/20 in the left and 20/20 for both eyes. The assessment was of a corneal abrasion of the left eye. The Veteran was then treated for GI-related complaints in November 1986. An entry dated December 1, 1986, reported a nine-day history of upset stomach and diarrhea. The assessment was viral gastroenteritis versus cholecystitis. Additional treatment entries noted some improvement but the Veteran was treated again on December 16 for further complaints of stomach distress. In April 1987 the Veteran was treated for complaints of a rash on her face for the past two months. Physical examination reported hyperpigmented areas on the temples bilaterally. The assessment was tinea. The Veteran was also treated for conjunctivitis in April 1987. The Veteran was to have a GYN evaluation of her galactorrhea in September 1987 but there was insufficient time to complete the laboratory studies prior to her date of discharge. A review of physical examination reports dated in 1974, 1976, 1978, 1981, 1982, and 1987 are negative for any findings regarding migraine/tension headaches, a GI disorder, hiatal hernia, visual acuity problem or other eye disorder, scars of the liver, bladder and gallbladder, shortened cervix, angioedema and urticaria, hepatitis B, fibromyalgia, dysmenorrhea and amenorrhea. The September 1987 physical examination report did list a problem of galactorrhea. It also noted that the Veteran was under treatment for blotchy patches on her face that were treated with Lotrimin and Eldopaque Forte. The Veteran submitted her original claim for disability benefits in February 1988. Among the conditions listed for possible service connection was hypertension. She also submitted a list of treatment provided for several conditions. Pertinent to this claim were her notations of treatment for hypertension, fibroids and a skin condition. The Veteran was scheduled for a VA examination in July 1988 but was unable to make the appointments because she was an inpatient at the VA medical center (VAMC) in Tuscaloosa, Alabama, at the time. A discharge summary for a period of hospitalization from June 28, 1988, to July 29, 1988, reported that the Veteran was treated for psychiatric and dental conditions. The summary reported her blood pressure as 110/80 at the time. No treatment pertinent to the other issues on appeal was listed in the summary. Records were received from C. H. Smith, M.D., that reflect treatment of the Veteran in June and September 1988. The treatment was for the Veteran's psychiatric disorder. No pertinent information regarding the issues on appeal was provided in the records. The Veteran was afforded VA audiological and general medical examinations in October 1988. The results of the audiology examination provide no pertinent information regarding the issues on appeal. The general medical examination noted the Veteran's several instances of elevated blood pressure in service, to include preeclampsia. She said it had been monitored periodically and was borderline. The Veteran also reported continued problems with galactorrhea. Physical examination reported a blood pressure reading of 140/90. The Veteran was experiencing a sinus headache related to her allergies. No galactorrhea was present on examination. Pertinent diagnoses were borderline hypertension and galactorrhea, etiology undetermined. In a rating decision dated in December 1988, the Veteran was granted service connection for, inter alia, tinea corporis and uterine fibroids. She was assigned noncompensable evaluations for those disabilities. She was denied service connection for hypertension. No decision was made regarding her galactorrhea. The Veteran was notified of the rating decision in November 1988 and apprised of her appellate rights. A February 1989 VA psychiatric examination listed symptoms and findings relating to the Veteran's service-connected psychiatric disability. In March 1989, the RO proposed a finding of incompetence for the Veteran. The Veteran submitted a statement in March 1989 that requested that her mother be designated to serve as her fiduciary. In July 1989 the RO issued a rating decision that found the Veteran to be incompetent from July 14, 1989. Associated with the claims folder are VA outpatient treatment records for the period from August to October 1989. The Veteran was treated for a complaint of a rash on her skin in September 1989 and complaints of galactorrhea in October 1989. In June 1990 the Veteran advised the RO that she was hospitalized at the VAMC in Tuskegee, Alabama. She said that she was now having serious "pms" problems, which were related to her service-connected OB/GYN disorder. She did not elaborate on her problems. VA records show that the Veteran was inpatient at VAMC Montgomery, Alabama, from June 9, 1990, to June 12, 1990. Her primary complaint was urinary retention, burning and some hematuria. She was treated for this complaint and diagnosed with hemorraghic cystitis. She was later transferred to VAMC Tuskegee where she remained hospitalized until July 1990. Her primary diagnoses related to her psychiatric disability, migraine headaches and galactorrhea and amenorrhea syndrome. The summary did not elaborate on the Veteran's medical conditions. It was noted that she was on medications to treat her migraines (Sansert), and her galactorrhea (Parlodel). Treatment records associated with that hospitalization indicate that the Veteran complained of blurred vision, a rash on her face, twitching muscles and menstrual cramps on a nursing assessment dated June 17, 1990. The Veteran's blood pressure was not noted to be elevated and was measured as 136/70 upon her admission to VAMC Montgomery. The Veteran was afforded a VA social work field examination in October 1990. No pertinent physical symptoms were noted in the report. The Veteran was afforded a VA Aid and Attendance (A&A) examination in January 1991. The focus of the examination was the Veteran's mental health status. The Veteran was noted to complain of headaches as being almost constant. A December 1993 VA psychiatric examination related only to the Veteran's psychiatric disability and current symptoms. No physical complaints or disorders were identified. The Veteran underwent a total abdominal hysterectomy and left salpingo-oophorectomy in December 1994. (A salpingo-oophorectomy is the "surgical removal of uterine tube and ovary." Williams v. Brown, 8 Vet. App. 133, 134 (1995).) The discharge summary said that there were dense adhesions and scarring from possible old infection and inflammation and previous surgery. The discharge summary also noted that the Veteran had multiple dark spots on her legs and upper extremities. The summary noted that a previous GI series was consistent with probable gastritis as well as a hiatal hernia. Two of the Veteran's diagnoses prior to surgery were anemia and severe menometrorrhagia. (Menometrorrhagia is defined as irregular or excessive bleeding during menstruation and between menstrual periods. STEDMAN'S, 1089.) The December 1994 operative report noted excessive amounts of pelvic adhesions. Adhesions to the liver and gallbladder were noted. The uterus was noted to be hyperemic and boggy and enlarged. The report further noted that the bladder was abnormally adhered to the uterus secondary to previous surgery. The bladder was then dissected from the uterus and the upper part of the cervical neck. The report said that the cervix was found to be extremely long and that it curved under the bladder and was adhered to the bladder on the lower portion of the cervix as well. A large portion of the cervix was removed but the remainder was left in place because it was located too deep and was adhered to the bladder. The report indicated that the surgeon felt that the remaining portion of the cervix would not cause harm to the Veteran. A progress note entry, written postoperatively, reported that the surgery was complicated by an excessive amount of adhesions, an extremely long cervix, and an abnormally adhered bladder. A review of VA outpatient notes for the period from August 1990 to September 1999 reflect treatment primarily for the Veteran's psychiatric disability. There are a number of pertinent entries regarding several issues on appeal. The Veteran was noted to complain of headaches in entries dated in August and September 1990. The Veteran was noted to be taking Haldol for her headaches. An April 1992 neurology consult evaluated her for migraines with the Veteran claiming a 10-year history of headaches. No findings relating the condition to service were noted. Treatment entries in March 1993 reported a rash on the Veteran's left leg and back that was assessed as dermatitis. She was also noted to have menorrhagia and deep uterine bleeding (DUB). The Veteran was noted to be desirous of a hysterectomy to relieve her symptoms. It was noted that hysterectomy would be considered if medical therapy did not improve her symptomatology. The Veteran was treated for dermatitis of the back and left leg, and gastritis with refractive error noted in regard to complaints of blurry vision in July 1994. An optometry consultation at that time found no evidence of any problems other than refractive error. The Veteran was further evaluated for complaints of stomach pain with an upper GI series in October 1994. The results were interpreted to show increased gastric secretion within the stomach that was suggestive of probable gastritis. There was marked pyloric spasm. A routine optometry evaluation in March 1997 reported no major negative findings. The Veteran was diagnosed with presbyopia. The VA records contain the results of a blood serology evaluation performed at a civilian regional blood center in December 1997. The report indicated that the Veteran's blood was reactive for the presence of hepatitis B core antibody (HBcAb). Included with the results was an information sheet to explain the results of the blood test and that the results did not mean that the Veteran had hepatitis B, only that she had been exposed to the virus as some point in time. The Veteran requested VA laboratory tests in January 1998 to determine if she had hepatitis B. She also requested to be reevaluated for fibromyalgia. A February 1998 entry reported that the Veteran was treated for complaints related to reflux esophagitis and fibromyalgia. Additional entries dated in 1998 reported further treatment related to fibromyalgia. The Veteran submitted a claim for entitlement to service connection for several medical conditions to include migraine/tension headaches, GI disorder, vision/eye problems, angioedema and urticaria and hypertension in June 1999. She added a claim for service connection for hepatitis B, scarred liver, bladder and gall bladder, shortened cervix and hiatal hernia in September 1999. Associated with the claims folder are Reports of Contact with the Veteran, dated June 10, and June 11, 1999. The reports noted that the Veteran wanted to take the necessary steps to be found competent for VA purposes. The RO wrote to the Veteran in November 1999 and informed her of the requirements to submit a well-grounded claim. The Veteran was informed that she needed to submit evidence of a current disability that was related to her military service. Additional VA records for the period from July 1997 to December 1999 mostly related to treatment of the Veteran's service- connected psychiatric disability. An optometry entry, dated in November 1998, reported the Veteran's bilateral vision as 20/20. She was noted to have trichiasis, a condition involving the eyelashes growing toward the eye, and ametropia, a condition that represents a refractive error. Several entries in 1998 and 1999 noted her continued complaints regarding fibromyalgia. The Veteran was treated for dermatographism in November 1999. The Veteran was afforded a VA dermatology examination in June 2000. The examination report included color photographs of the Veteran's left calf area. The Veteran complained of having a rash. She said the rash on her left leg had increased in size from a dime to a quarter. She said it was dark and ashy. Physical examination reported a blood pressure of 173/79. The Veteran was noted to be uncomfortable during the examination and scratching all over her body. The rash on the left calf was described as approximately 11/2 inches in diameter and a darkened area with a fine rash. There was one small raised papular area on the inferior area. The examiner reported that they were unable to observe or palpate a rash on the Veteran's face due to her wearing make-up. The examiner noted that scrapings of the left calf area revealed fungal elements present. Photographs of the left calf showed the darkened area as described by the examiner in the report. The pertinent diagnosis was tinea corporis of the left leg and probably face. The Veteran's disability rating for tinea corporis was maintained at the noncompensable level by way of a rating decision dated in July 2000. A VA outpatient treatment record, dated in June 2000, noted that the Veteran continued to experience intermittent discharges from her breasts. A social and industrial survey was conducted in October 2000. The underlying purpose of the survey was to obtain evidence in order to assess the Veteran's request to be found competent. She informed the examiner that she felt that her diagnoses should be her psychiatric disorder, hiatal hernia, abrasion of the left cornea, scarred liver, hepatitis B, migraine headaches, fibromyalgia and a skin condition. A list of medications was provided that included medications to treat headaches, a skin condition, and high blood pressure. The Veteran was afforded a VA psychiatric examination in November 2000. The examiner noted that the Veteran related a history of hysterectomy, hypertension and migraine headaches. No findings regarding any physical symptoms were reported. The examiner opined that the Veteran was competent to handle her funds. In a rating decision dated in December 2000 the RO found the Veteran to be competent as of December 5, 2000. The RO also granted service connection for PTSD, secondary to sexual trauma. An effective date of June 10, 1999, was established for service connection of PTSD. The Veteran submitted a claim regarding several additional issues in January 2001. Her claim included an earlier effective date for service connection for PTSD, a permanent and total rating for her PTSD, an increased evaluation for her service-connected tinea corporis, and service connection for fibromyalgia, galactorrhea, a separate gynecological disability other than her hysterectomy and oophorectomy, and service connection for dysmenorrhea and amenorrhea prior to her December 1994 hysterectomy. She also requested a hearing at the RO. This request was later withdrawn in writing by the Veteran. The RO wrote to the Veteran in February 2001 and requested that she provide evidence to support her claim for an earlier effective date for service connection for PTSD as well as her claim for a permanent and total evaluation for PTSD. She was requested to provide evidence establishing a relationship between her diagnoses of fibromyalgia and galactorrhea and her military service. Finally, she was requested to provide further information regarding her claim for other gynecological disability. She was specifically requested to identify the disability or disabilities involved and to provide medical evidence of a current diagnosis. The Veteran was advised in all instances that if she wanted assistance in obtaining records from a private facility or physician, she should submit the necessary authorization. Associated with the claims folder are VA outpatient psychiatric treatment records for the period from April to August 2000. The records noted that the Veteran was competent and able to manage her own funds. They also noted that she was desirous of obtaining additional training through VA. Her Global Assessment of Functioning (GAF) scores ranged from 50 to 70. The Veteran was afforded a VA psychiatric examination in February 2001 for the purpose of evaluating the appropriate diagnosis for her psychiatric disability. The examiner addressed only psychiatric symptoms in concluding that the Veteran's diagnosis should be PTSD secondary to sexual trauma. A second VA examination was conducted, by a vocational and rehabilitation psychologist, also in February 2001. The psychologist concluded that symptoms related to PTSD were not clinically prominent prior to 1999. A VA field examination was conducted in February 2001. The examiner noted the Veteran's several diagnoses but made no comment regarding any current physical problems or symptoms. The examiner did state that they concurred with the decision to find the Veteran competent as she was able to pay her bills in a timely manner. Associated with the claims folder are pharmacy records listing a number of medications prescribed to the Veteran. Some of the listings describe the purpose of the medications to include treating skin problems on the face and legs, and to control itching, joint pain, headaches, and hypertension. Because of the prior differing opinions as to the Veteran's proper psychiatric diagnosis, a review of the Veteran's claims folder was conducted by a different VA examiner in March 2001. The examiner concluded that the Veteran's proper diagnosis was PTSD. The examiner assigned a current GAF score of 60. The Veteran was afforded a VA dermatology examination in March 2001. The examiner noted positive evidence of dermographism on the Veteran's arms. There were also scattered urticarial plaques on the upper torso, and hypertrophic lichen-like lesions, which were hyperpigmented, on the left lateral leg. There was vague erythema identified on the Veteran's cheeks. The examiner's assessment was post-inflammatory hyperpigmentation, versus melasma of the face; lichen simplex of the left lower leg; and, urticaria plus dermographism. No opinion was expressed as to the etiology of the Veteran's urticaria/dermographism. In May 2001, the RO established an effective date of June 28, 1988, as the effective date for the grant of service connection for PTSD. The Veteran's disability rating for lichen simplex of the left lower leg, previously rated as tinea corporis, was increased to 10 percent. The remaining issues claimed in January 2001 were denied. A May 2001 letter from the RO informed the Veteran that the May 2001 rating decision was corrected to include service connection for residuals of her C-section scar, evaluated as 10 percent disabling from May 11, 2000. The Veteran submitted a notice of disagreement with the May 2001 rating action that same month. In regard to the additional gynecological disability claimed, she disagreed with the rating decision denying her benefits. She did not elaborate on the condition(s) claimed or identify any source of evidence. The Veteran submitted her substantive appeal with respect to several of the issues on appeal in June 2001. She included a VA outpatient psychiatric treatment record in support of her claim. The record reflected treatment provided in May 2001. The entry stated that the Veteran's correct psychiatric diagnosis was PTSD, delayed onset, chronic and severe. The Veteran was noted to have co-morbid intense anxiety and depression and associated somatization, generalized anxiety, depressive and hypomanic-like symptoms which have complicated her clinical picture. The Veteran was noted to be a high functioning and motivated patient that would benefit from vocational rehabilitation opportunities and going back to school. The Veteran testified at a Board hearing in July 2001. She said that she had migraine headaches in service. She continued to have headaches and used medication for relief. She stated that her migraine headaches differed from her sinus headaches. The Veteran also testified that she first had GI problems in Korea and that it was believed to be gastritis or colitis. She continued to have problems after service and she now has gastric reflux and heartburn, controlled with medication. She said that she experienced eye problems while typing in service. She said that she did a lot of reading and this strained her eyes. The Veteran said that she continued to have problems with her eyes and would see double without her glasses. The Veteran said that she first experienced high blood pressure in 1978. She said her OB/GYN physician noticed her high blood pressure and referred her for a week of readings. She said she was taking medication for hypertension. She said she was not given medication for hypertension in service. The Veteran recounted her difficulties while pregnant in 1984-1985 and how she experienced edema and preeclampsia. The Veteran also stated that she found out that she had the antigen to the antibody for hepatitis B when she tried to donate blood. She believed that it was due to surgeries at the VA, in service, or while a military dependent; however, she never had a blood transfusion. She said she had been told that she had a scarred liver. She received medical follow-up every 6 months and managed her diet. In regard to her claim involving a scarred liver, bladder and gall bladder, the Veteran complained of no current symptomatology at her hearing. She recounted how her VA surgeon told her in 1994 that she had had extensive adhesions related to previous surgeries and that she had had to suffer from pain from those adhesions. The Veteran also did not contend that she suffered from any current disability due to the shortened cervix. She said that she developed a hiatal hernia after her 1994 surgery. She would experience her food coming up causing her to choke, cough and gag. She was on a new medication that seemed to provide relief. The Veteran testified that the urticaria/dermatographism started a few years earlier. She first noticed it in 1996 and did not have it in service. She felt the condition was related to stress she experienced. She also testified that she experienced pain in service but that she did not complain. She was initially evaluated after service by a rheumatologist that put her on a diet. The diet did not help. She thereafter was diagnosed with fibromyalgia by another physician in 1996 and she used pain medication. No physician had related her present diagnosis of fibromyalgia to her symptoms in service. The Veteran testified that she had atypical bleeding prior to her hysterectomy but that it had essentially stopped. In regard to her assertion that her disability should be rated permanent and total the Veteran said that the underlying events that caused her PTSD could not be undone and that she would always be affected by them. Therefore, her disability rating for PTSD should be permanent with no future examination of the disability. Finally, in regard to her lichen simplex the Veteran said that she first developed this on her return from her assignment in Korea. She would scratch the spot on her leg and it would ooze. She was told that scratching the spot would make it worse as the skin would thicken and toughen. She was given a number of medications to treat the problem. She said she would dress so as to cover the spot on her leg. The Veteran submitted additional evidence, consisting of medical and other evidence, after her Board hearing. Some of the evidence was duplicative of evidence already of record. Much of the evidence consisted of the hospitalization records associated with the Veteran's initial period of hospitalization with VA in June 1988. In that regard the records noted several higher blood pressure readings but then a majority of readings that would not be considered as indicative of hypertension. No diagnosis of hypertension was made. The Veteran indicated not ever having high blood pressure or hepatitis when she answered a dental questionnaire. An entry, dated July 21, 1988, noted that the Veteran reported having a fungus of her facial skin and had been treated for that in the past. She also reported galactorrhea since the birth of her baby in January 1985. Included in the evidence submitted by the Veteran was an annotated (by the Veteran) copy of a vocational and rehabilitation counseling report dated in April 2000. The report noted that the Veteran had been determined to be competent but also provided a detailed analysis of what the counselor felt were reasons why she would not be a candidate for further training. The counselor's opinion was that the Veteran was, as of that time, "infeasible for vocational rehabilitation purposes." The Veteran also included a letter from J. M. Badry, Ph.D., dated in June 2000. The Veteran had asserted that she was evaluated by Dr. Badry on several occasions in the mid-1990's but that the records from those evaluations were missing. Dr. Badry said that she had seen the Veteran in the spring of 1995; however, there were no notes or records available of those evaluations. Dr. Badry stated that her recollection was that the Veteran showed no signs of schizophrenia and no signs of being incompetent. Associated with the claims folder is a copy of a statement of the case (SOC) from the RO's Vocational Rehabilitation and Employment Officer dated in August 2001. The SOC addressed the issue of the Veteran's entitlement to vocational rehabilitation training under Chapter 31 of Title 38, United States Code. Most of the evidence related to that claim is not associated with the claims folder as it pertains to a claim not under the Board's jurisdiction at this time. The SOC indicated that the Veteran was afforded another review in assessing her desire to receive training benefits. The SOC reported that a February 2001 evaluation found the Veteran to be infeasible for vocational rehabilitation counseling due to her severe disability and her refusal to complete an Extended Evaluation to determine her feasibility for employment due to her long absence from any productive employment or schooling. The Veteran was provided a copy of the transcript for her July 2001 Board hearing in March 2002. She then submitted several pages of corrections to the transcript. The changes were received at the Board and an Interlocutory Order issued in April 2002 incorporating most of the Veteran's requested changes. The Board originally denied the Veteran's claims for service connection and for a permanent and total disability rating by way of a decision dated in May 2002. The Veteran's claim for an increased rating for her service-connected lichen simplex was denied. The Board also found that there was new and material evidence to reopen a claim for service connection for hypertension and remanded that issue for further development. In July 2003, the Veteran's then attorney representative and the VA's General Counsel filed a joint motion to vacate the Board's May 2002 decision, except for the decision to reopen the claim of service connection for hypertension, and remand the case for further action consistent with the joint motion. In August 2003, the Court granted the motion and remanded the case to the Board for readjudication. The Board remanded the case to comply with the joint motion in April 2004. The remand required that the Veteran be afforded notice as required by the Veterans Claims Assistance Act of 2000 (VCAA). Further, the adjudication of an increased rating for service-connected lichen simplex required consideration of a change in VA regulations used to evaluate skin disabilities. Finally, VA examinations were to be provided to evaluate the service-connected lichen simplex and to obtain opinions regarding any possible nexus between the Veteran's several other claimed disabilities and her military service. The Appeals Management Center (AMC) arranged for the Veteran to undergo VA examinations in December 2004 and January 2005. The AMC wrote to the Veteran in December 2004 to advise her that she would receive notice of the scheduled examinations. The Veteran was also informed that 38 C.F.R. § 3.655 (2009) provides that when a claimant fails to report for a VA examination, without good cause, the claim will be adjudicated based on the evidence of record. The Veteran was informed of examples of good cause to include illness of the veteran. An entry in the claims folder indicates that the Veteran's daughter called to cancel the Veteran's appointments for examinations scheduled in December 2004 and January 2005. The daughter said that the Veteran was ill and unable to report for the examinations. No documentation of illness was provided. The AMC again wrote to the Veteran about an upcoming examination in February 2005. She was provided the same notice as the December 2004 letter. The Veteran was scheduled for another examination in March 2005. She failed to report for the examination. The Veteran submitted a statement that was received at the AMC in May 2005. The Veteran said that she was unable to work on her claim because of her health. She requested "an extension of time as allowed by law." She also indicated that her daughter had called to cancel appointments for VA examinations. The Veteran said that she had been unable to keep those appointments because of poor health. Again, no documentary evidence attesting to her health status was submitted by the Veteran to support her contention that her health kept her from making her scheduled examination appointments. The Veteran's request for additional time was received by the AMC within 60 days after a supplemental statement of the case (SSOC) was issued in March 2005. The Board finds that the request was timely. Further, the Veteran stated that she required the extra time because her health affected her ability to work on her appeal. The Veteran provided no evidence, other than her own statements, that her health had affected her ability to report for the examinations or to work on her appeal. Nevertheless, in affording the Veteran every benefit of the doubt at that time, the Board found that she had demonstrated good cause for an extension of time to respond to the SSOC. See 38 C.F.R. § 20.303 (2009). The Board further found that she had demonstrated good cause for having the examinations rescheduled. The Board remanded the case again in November 2005. The Veteran was to be asked to identify any additional source of treatment so that the records could be obtained. She was also to be afforded the same VA examinations as directed in the remand of April 2004. The Veteran was to be given notice, as per 38 C.F.R. § 3.655, regarding any failure to report for a VA examination. Finally, the notice was to also advise the Veteran that, if she claimed she was unable to report for an examination due to her health, she was to provide evidence of that inability by way of a statement from a medical professional. The AMC wrote to the Veteran in November 2005. The letter asked the Veteran to identify any sources of treatment and to submit the records or authorize the AMC to obtain them on her behalf. She was asked to submit any evidence in her possession. The letter was sent to the Veteran at her address in Houston, Texas. The Veteran responded in January 2006. She said she had received treatment from VAMCs in Nashville, Tennessee, Montgomery, Alabama, Tuscaloosa, Alabama, Tuskegee, Alabama, and Atlanta, Georgia. She could not remember the dates of treatment and said the treatment related to illness and surgery. She listed her address as the same one used by the AMC in its letter of November 2005. The AMC wrote to the Veteran at her Houston address in March 2006. She was informed that she was going to be scheduled for a VA examination at the VA facility nearest to her. She was advised to contact the facility if she would be unable to keep her appointment in order to reschedule. She was further advised that her failure to report for an examination, without good cause, could result in her claim being decided based on the evidence of record. The letter also provided examples of good cause such as illness or hospitalization of the Veteran, or death of a family member. The letter was returned as undeliverable as addressed in March 2006. Associated with the claims folder is a C&P (Compensation & Pension) exam detail printout dated March 23, 2006. The detail was printed out by someone at the Tennessee Valley Health Care System (HCS). It showed that several VA examinations were requested by the AMC on March 23, 2006. The detail also listed an address for the Veteran in Antioch, Tennessee. Also associated with the claims folder is an e-mail from an AMC employee to several employees at the VAMC in Nashville. The e- mail noted that the examinations were cancelled due to the Veteran's failure to report. The e-mail asked that a copy of the examination notice letters provided to the Veteran be sent to the AMC for inclusion in the claims folder. The e-mail reported that the Board's remand required this. (The Board notes the remand of November 2005 did not impose this requirement). Another e-mail in the claims folder, from one AMC employee to another, noted that the RO had an address for the Veteran in Houston while the VAMC had an address for the Veteran in Antioch. Copies of the examination notice letters were faxed to the AMC in August 2006. The letters were addressed to the Veteran at her address in Antioch, Tennessee. Also associated with the claims folder is a VA examination report for mental disorders/eating disorders dated in April 2006. The examiner reviewed the claims folder and questioned the need for an eating disorder examination and stated that an examination for PTSD would be more appropriate. The examiner referenced the Veteran's psychiatric history and that a VA examiner had determined that the Veteran's diagnosis was most appropriately classified as PTSD as secondary to sexual trauma in service in March 2001. The examiner also stated that a May 2001 rating decision granted a 100 percent rating for PTSD from June 28, 1988. The examiner stated that she was unable to locate any additional psychiatric treatment records in the claims folder dated after May 2001. The Board notes that the examiner's statement of the facts are not correct. The Veteran was originally granted service connection for schizo-affective disorder by way of a rating decision dated in December 1988. The effective date for the grant of service connection was established as June 28, 1988. The Veteran received a temporary 100 percent rating at that time under 38 C.F.R. § 4.29, based on a period of hospitalization. Her disability rating was established as 30 percent from August 1, 1988, upon completion of the temporary total rating period. The Veteran's psychiatric disability rating was increased to 70 percent by way of a rating decision dated in March 1989. The disability was re-characterized as schizophrenia, paranoid type. The effective date of the increase, and change in diagnosis, was established as August 1, 1988. The Veteran's psychiatric disability rating was increased to 100 percent in April 1991. The effective date for the increased rating was October 20, 1989. The Veteran's disability rating remained at the 100 percent from that time. The Veteran sought entitlement to service connection for PTSD in June 1999. Service connection for PTSD was granted in December 2000. The disability was rated at the 100 percent level. The effective date for the grant of service connection, and the 100 percent rating, was June 10, 1999. As noted by the VA examiner, the Veteran's psychiatric disability was re-characterized as PTSD by way of a rating decision dated in May 2001. The Veteran was also granted an earlier effective date for the grant of service connection for her PTSD as June 28, 1988, with the same temporary 100 percent rating applicable for her psychiatric hospitalization. A 70 percent rating was in effect from August 1, 1988, to October 20, 1989, at which time the disability rating increased to 100 percent. This represents the current status of the Veteran's psychiatric disability. Associated with the claims folder is a deferred rating decision dated in July 2007. The decision noted that the Master Record showed a new address for the Veteran in Montgomery, Alabama. The decision asked that the Veteran be scheduled for VA examinations at the VAMC in her area. The AMC wrote to the Veteran at an address in Montgomery in August 2007. She was advised that she would be scheduled for VA examinations. She was given the same notice as before regarding any failure to report for her examinations without good cause. The Veteran was scheduled for a number of VA examinations in August 2007. She failed to report for the examinations. A review of the C&P Exam Detail shows that the VAMC had a different address for the Veteran in Montgomery than the AMC. However, there was no indication that any notice to the Veteran was returned. The AMC wrote to the Veteran at the same address used by the VAMC in October 2007. The AMC noted that the Veteran had failed to report for her scheduled examinations. She was asked to contact the AMC within 30 days to reschedule the examinations. A response was received in December 2007. The response was from the Veteran and written on a copied page from the AMC letter. She said that her mother was terminally ill and assigned to hospice. She asked that her appointments be postponed during this time. The Veteran did not provide any evidence of her mother's medical condition. Of note, the return address was the same as on file with the VAMC and used by the AMC in October 2007. The AMC wrote to the Veteran in August 2008. She was asked if she was able to report for examinations. She was also informed she could submit information relevant to her appeal. The Veteran responded in September 2008. She noted that she had asked that her claim be postponed due to her mother being gravely ill. She again asked that she be given an extension due to a recent death in the immediate family (the individual was not identified and the relationship to the Veteran was not reported) with burial occurring in August 2008. She also referenced her mother's illness as another reason to give her an extension. The AMC obtained copies of VA medical records from four VAMCs in December 2008. The records encompassed a period from June 2000 to December 2008. Records from VAMC Tuscaloosa and VAMC Nashville were duplicates of examination reports dated in March 2001 and April 2006, respectively. Records from VAMC Atlanta covered a period from December 2001 to December 2002. The Veteran was seen on a number of occasions for routine medical care. She was seen in the emergency department on several occasions. In December 2001, she was seen in the emergency department for complaints of bilateral knee and ankle pain. She told the physician she had been diagnosed with fibromyalgia seven years earlier. No obvious problems were noted on examination. The diagnostic impression was chronic knee and ankle pain bilaterally. The Veteran was seen in the emergency department in February 2002 for complaints of left eye pain and sudden changes in visual acuity. She said her symptoms occurred several times a day and could skip days. She reported she had seen an optometrist and was diagnosed with astigmatism. The Veteran said she noticed a ring around the edge of her corneas and decreased visual acuity while driving in the rain at night. The examiner said the diagnostic impression was uncertain. The Veteran was noted to have numerous ongoing medical concerns and a likely diagnosis that could explain headache with symptoms was a migraine equivalent. He also said there may be cataracts. The Veteran was diagnosed with viral conjunctivitis of both eyes in March 2002. Additional entries noted that the Veteran had not had a PAP smear in over three years as she was afraid of the examination. A Women's Wellness clinic entry from May 2002 reported a normal pelvic and breast examination for the Veteran. The Veteran was seen in the same clinic in August 2002 and asked for an estrogen patch to treat symptoms of menopause. The Veteran was given an abdominal ultrasound due to complaints of pelvic pain in September 2002. A clinic entry from October 2002 noted that the Veteran disputed the results of the ultrasound as it reportedly said she had no ovaries and she maintained that she had one ovary. A social work entry from October 2002 noted that the Veteran was seeking a VA physician to sign paperwork relating to a claim for Social Security Administration (SSA) benefits. She was upset with the process required and said that she would have a civilian doctor sign the papers. Records from VAMC Montgomery were from June 2000 to December 2008. The records actually show outpatient treatment from June 2000 to November 2003 and then outpatient dental treatment in 2008. An optometry clinic visit from November 2000 provided an assessment of compound hypermetropic astigmatism/presbyopia in both eyes, early pterygium in the left eye, and normal fundus in both eyes. Another clinical entry from November 2001 noted that the Veteran was given a hepatitis A vaccination. An entry from May 30, 2002, noted that the Veteran had questions about a 2nd dose of vaccine. She was going to be traveling out of the country. The nurse noted that the Veteran only required a 2nd dose of the hepatitis A vaccine. The Veteran was noted to have hepatitis B antibodies. An entry from October 2002 noted that the Veteran reported she was now living in Atlanta and wanted to receive her treatment there. Finally, the records show multiple visits to VAMC Montgomery for dental treatment during the period from February 2008 to December 2008. The records reflect that the Veteran was seen for treatment in every month except October. There was one appointment where she was recorded as a "no show" otherwise she was present for her many appointments. The AMC wrote to the Veteran in December 2008. The letter listed the 15 issues on appeal. She was informed that the VA medical facility near her had been asked to schedule her for VA examinations. The Veteran was advised that it was important for her to report for the examination. The letter further advised that, without the evidence from the examinations, the AMC would decide her case based on the evidence of record and may have to deny her claim. She was informed to contact the medical facility if she was unable to keep her appointment. The Veteran was scheduled for VA examinations in March 2009. The VAMC C&P Exam Detail recorded that she failed to report for her examinations. The address listed was the same Montgomery address used by VA and the Veteran since October 2007. There is no indication in the claims folder of the return of any correspondence sent to the Veteran at that address. The AMC re-adjudicated the Veteran's claims in April 2009. The claims were denied and she was issued a supplemental statement of the case (SSOC) at that time. The Veteran responded to the SSOC in May 2009. She noted that she had notified several VA sources and her representative that she had asked that all of her appointments be canceled and that her case postponed due to her current family crisis. She said her mother was terminally ill and totally helpless. She then said that when she is scheduled for appointments, she asked that they be in the afternoon in Montgomery. Associated with the claims folder is a Report of Contact with the Veteran dated May 15, 2009. The report was completed by a VA employee at the National Call Center (NCC) and recorded the Veteran's statement that she was taking care of her dying mother and would like that any examinations be re-scheduled. She would like the examinations in the afternoon and, if possible, in the Montgomery area. II. Analysis A. Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2009). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In the alternative, the chronicity provisions of 38 C.F.R. § 3.303(b) are applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service, or during an applicable presumptive period, and still has such condition. Such evidence must be medical unless it relates to a condition as to which under case law of the Court, lay observation is competent. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). Generally, 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 between the current disability and the in-service disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999); accord Caluza v. Brown, 7 Vet. App. 498 (1995). As noted, the Board previously denied the Veteran's claim by way of a decision dated in May 2002. The Court vacated that decision and remanded the case to the Board. The Court's action was based on a joint motion that asked for such an outcome. The joint motion challenged the Board's determination regarding several of the Veteran's claimed disorders as not rising to the level of a disability. The Board remanded the case for appropriate medical examinations to provide medical opinions in that regard. The case was remanded in April 2004 and the examinations were scheduled. The Veteran failed to report for any of the examinations. Her daughter reported that the Veteran was too ill. Later, the Veteran informed the RO that she was too ill to work on her claims. Although the Veteran submitted no evidence to support her statements, she was afforded the benefit of the doubt. The Board remanded the case again in November 2005. The Veteran was again scheduled for examinations but she failed to report for them. She initially reported that she was unable to report for her examinations because her mother was terminally ill. After missing further appointments, she said she had had a death in the family in addition to her mother's illness. The Board notes that VA outpatient records reflect that the Veteran was able to attend multiple dental appointments throughout most of 2008. The evidence demonstrates that the Veteran could have attended a VA examination that would have been expected to have provided relevant evidence in the development of her claim. Her failure to report for her VA examinations, following the remand of November 2005, was not for good cause. Thus, her service connection issues will be adjudicated based on the evidence of record as required by 38 C.F.R. § 3.655. The Board notes that lay evidence in the form of statements or testimony of the Veteran is competent to establish evidence of symptomatology where symptoms are capable of lay observation. See Charles v. Principi, 16 Vet. App. 370, 374 (2002); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Also the absence of contemporaneous treatment records is not dispositive. See Buchanan v. Nicholson, 451 F.3d. 1331 (Fed. Cir. 2006). In some cases, under 38 U.S.C.A. § 1154(a) (West 2002), lay evidence can be sufficient to establish diagnosis of a condition. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In particular, the Federal Circuit stated that: We have consistently held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d. at 1316 (citing Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir 2007). In Jandreau, the Federal Circuit held that a layperson may provide competent evidence to establish a diagnosis where the lay person is "competent to identify the medical condition." 492 F.3d at 1377. When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Headaches The STRs document several instances of complaints of headaches, either associated with eye strain or related to sinus and allergy complaints. There are no entries in any military treatment record or on any of the several physical examination reports that document any complaints or treatment for migraine headaches. An October 1988 VA examination was negative for any findings relating to migraine headaches. The first evidence of a diagnosis of migraine headaches is contained in the June to July 1990 VA hospital summary. Later VA records contain further evidence of treatment for migraines, to include prescription medication. However, there is no medical evidence linking the Veteran's migraine headaches to service. The STRs show treatment for headaches unrelated to migraines, headaches attributable to eye strain and allergies. The Veteran did tell a VA provider that she had a 10-year history of headaches. However, she also testified in 2001 that her migraine headaches were different than the headaches she had in service. The Board finds her testimony, and other statements in the treatment records to show that there was not a continuity of symptoms since service. Further, as noted there is no medical evidence to link her migraines to her military service. The Board finds that there is no basis to establish service connection for migraine headaches. GI Disorder/Hiatal Hernia The Veteran's STRs record an instance in 1976 where a medical review of medications indicated that a prescription for Donnatal was not approved. The records are silent for any further reporting of a GI-related entry until November and December 1986. The Veteran was treated for an upset stomach and diarrhea. The assessment was viral gastroenteritis versus cholecystitis. The Veteran's September 1987 separation physical examination was negative for any GI-related complaints. She testified to having her symptoms in Korea. After service, the first evidence of any GI-related complaints were in October 1994 with the results of an upper GI series documenting probable gastritis and marked pyloric spasm. The Veteran was first diagnosed with a hiatal hernia at the time of her December 1994 hysterectomy. The Veteran confirmed this timeline in her testimony in 2001. The Veteran has also been diagnosed with esophageal reflux and gastritis. There is no medical evidence to link any GI disorder or hiatal hernia to any incident of service. The STRs show several widely spaced GI- related events that were acute and transitory in nature. The first evidence after service of any GI disorder is approximately seven years later. The Veteran has not alleged a continuity of symptomatology and the medical evidence of record does not relate the later diagnosed GI disorders to her military service. Service connection for a GI disorder, to include a hiatal hernia, is denied. Visual Acuity In regard to the Veteran's claim regarding a visual acuity disability, the STRs are negative for any indication of any type of long-term eye problem or complaints. The Veteran was noted to complain that her vision was blurry or that her eyes burned on a couple of occasions. These complaints were noted to be related to eye strain or associated with the Veteran's rhinitis and allergies. She was also treated for conjunctivitis on several occasions and for a left corneal abrasion in October 1986. The Veteran wore reading glasses in service. The several military physical examination reports listed no eye-related problems, to include at the time of discharge. Her distant and near vision were reported as 20/15 in each eye in September 1987. The Veteran did not complain of any type of eye problem when she submitted her original claim for disability benefits in February 1988. The June-July 1988 VA discharge summary provided no findings regarding any eye disorder or problem, although treatment records from that hospitalization indicate that she complained of blurred vision. The October 1988 VA examination report was also negative for any findings of an eye-related problem. A July 1994 outpatient entry noted that the Veteran complained of blurry vision. This was attributed to a refractive error. A March 1997 optometry entry provided an assessment of arterial narrowing-hypertensive cardiovascular disease and presbyopia of both eyes. A November 1998 optometry note reported that the Veteran was reviewed for a vision assessment. She was noted to have ametropia (a refractive error) and trichiasis (a condition where the eyelashes curve toward the eye). Her bilateral vision was measured as 20/20. A November 2000 optometry clinic entry provided an assessment of compound hypermetropic astigmatism/presbyopia in both eyes, early pterygium in the left eye and normal fundus in both eyes. Refractive error of the eyes is not considered a disease or injury as defined by law to warrant service connection for disability compensation. See 38 C.F.R. §§ 3.303(c), 4.9 (2009); see also Veterans Benefits Administration Adjudication Manual M21-1, Part III, Subpart iv, 4.B.10 (Astigmatism, myopia, hyperopia and presbyopia as examples of refractive errors). There is no evidence of any type of chronic eye problem in service. There were several instances of acute and transitory conjunctivitis. She had an abrasion of her left cornea with no documented residuals. Her tested visual acuity was recorded as 20/15 at the time of her September 1987 physical examination. The later VA records show visual acuity complaints, to include blurry vision. To the extent the Veteran had any continuity of symptoms, they were related to blurry vision or decreased visual acuity while driving at night. The VA records do not relate any type of eye disorder to the Veteran's period of service and there is no other medical evidence of record identifying an eye disorder that is related to service. Thus there is no basis to find an entitlement to service connection for a visual acuity disorder. Scarring of the Liver, Bladder and Gallbladder The Veteran has alleged that she suffers from a disability as a result of scarring of the liver, bladder and gallbladder. The Veteran underwent surgery in January 1985 for the birth of a child by C-section. She later had laparoscopic surgery for a tubal ligation in November 1985. There is no indication in the STRs of any residual problems from either of these surgeries. The operative report from the Veteran's December 1994 VA hysterectomy did note multiple adhesions in the pelvic cavity involving the liver, bladder and gallbladder. The bladder was noted to be abnormally adhered to the uterus secondary to prior surgery. Adhesions, in general, are not uncommon from surgery. In this case, while there certainly is documentation of adhesions, even extensive adhesions attributed to surgeries prior to 1994, there is no evidence of any residual scarring causing disability as a result of the adhesions. The operative report noted that the pelvic adhesions involving the liver, bladder, and gallbladder were dissected. There is no evidence of record to show any defect of or damage to the liver, gallbladder or bladder as a result of the adhesions. There is no doubt that the Veteran had the adhesions but they were corrected as a result of the surgery in December 1994. The Veteran is not competent to provide a diagnosis of any condition related to her liver, gallbladder, or bladder. See Woehlart v. Nicholson 21 Vet. App. 456, 462 (2007) (distinguishing the decisions in Barr and Jandreau as to what conditions are capable of a lay diagnosis). These are internal organs and not subject to outwardly observable defects or conditions. In the absence of any competent evidence of record to demonstrate any current disability involving the liver, gallbladder, and bladder, the claim must be denied. Shortened Cervix The Veteran's claim regarding her shortened cervix relates only to residuals from post-service surgery in 1994. The Veteran's cervix was found to be abnormally long at the time of her 1994 hysterectomy. The VA operation report indicated that a large portion of the cervix was removed as part of the hysterectomy but that a portion of the cervix was left in place because it was located too deep and adhered to the bladder. The fact that the cervix was thus shortened in no way represents any type of a disability that is related to service. The surgery occurred after service and was not found to be related to any condition identified in service. Moreover, there is no evidence of record, to include statements from the Veteran prior to the surgery, that there was any problems related to the cervix. The Veteran has pointed to no evidence of record that her shortened cervix is related to her military service and she is not competent to make such an assertion as a lay person. Angioedema and Urticaria The Veteran testified that she first experienced problems with angioedema and urticaria after service. (Transcript p. 30). Her STRs document a diagnosis of tinea corporis that is already service-connected and rated as lichen simplex. There is no evidence of any additional skin condition in service. Tinea was also diagnosed at the time of the October 1988 VA examination. The VA treatment records after service note diagnoses of urticaria and dermatographism several years after the Veteran's discharge in 1987. There is no medical evidence of record that provides any nexus between the Veteran's later diagnoses of angioedema, urticaria or dermatographism and any incident of service. Nor is there credible evidence of any continuity of symptomatolgy as the Veteran's own statements, and the objective evidence of record demonstrate that the two disorders were manifested after service. There is no basis to establish service connection for either angioedema or urticaria. Hepatitis B The Veteran alleges that she was infected with hepatitis B as a result of her surgeries in service. She provided a copy of test results performed by a regional blood center dated in December 1997. The results reported that her sample was reactive to the hepatitis B core antibody (HbcAb). The accompanying fact sheet clearly stated that this did not mean that she had hepatitis B, only that she had been exposed to the virus at some point in the past and had developed an antibody. The fact sheet also stated that there were "countless" ways of becoming exposed to the virus. Further, the fact that she had developed the antibody made the chances good that she had eliminated the virus from her system. There is no evidence of record to show that the Veteran suffers from any ill effects from her exposure to the virus for hepatitis B. The many treatment records, VA examination reports and assessments of the Veteran's overall health make no mention of any problems associated with hepatitis B. Later VA records note that the Veteran was given a hepatitis A vaccination in November 2001 in preparation to traveling out of the country. In May 2002, the Veteran was noted to have hepatitis B antibodies but there was no diagnosis of hepatitis B and no diagnosis of any disorder associated with her prior exposure to hepatitis B. Further, the Veteran has presented no evidence to show that her exposure to hepatitis B was related to any event in service. As the fact sheet stated, there are countless ways to be exposed. The Veteran's exposure was first documented in 1997, some 10 years after service. Finally, there is no competent evidence of record to show that she has hepatitis B. As a layperson, the Veteran is not competent to provide a diagnosis. See Woehlaert, supra. Accordingly, service connection for hepatitis B is denied. Fibromyalgia The Veteran also desires entitlement to service connection for fibromyalgia. The STRs are negative for any diagnosis of fibromyalgia. They do not reflect any ongoing treatment of complaints of fatigue and/or vague muscle and/or joint pain. The Veteran testified that her legs hurt in service but that she did not complain. There were no complaints of fatigue, joint or muscle pain at the time of the Veteran's hospitalization in June 1988 or at the time of her October 1988 VA examination. The Veteran was referred for a rheumatology consultation with a provisional diagnosis of fibromyalgia in December 1997, approximately 10 years after service. The Veteran was diagnosed with fibromyalgia and treated on a number occasions in 1998 and beyond. VA records from December 2000 to December 2001 show additional joint pain complaints and the Veteran reporting her prior diagnoses of fibromyalgia; however, there are no entries that relate the disorder to her military service. There is no objective competent evidence to indicate that the Veteran's fibromyalgia had its onset in service or that her current diagnosis is related to any incident of service. Service connection is denied. Dysmenorrhea and Amenorrhea The Veteran was treated for several OB/GYN complaints during service. She was provided birth control pills as a means of regulating her menses at one time. She now seeks to establish service connection for dysmenorrhea and amenorrhea. The Board notes that dysmenorrhea is defined as a difficult or painful menstruation. STEDMAN'S, 532. Amenorrhea is defined as the absence or abnormal cessation of the menses. STEDMAN'S, 57. No complaints related to abnormal or chronic uterine bleeding were noted at the time of the Veteran's hospitalization in June 1988 or at the time of the October 1988 VA examination. The Veteran was treated for hemorrhagic cystitis in June 1990 but this was related to a temporary bladder infection. The VA outpatient records do show that the Veteran began to experience episodes of DUB in 1993 and 1994. She was evaluated and treated for this on a number of occasions. There is no evidence of an absence of the Veteran's menses. Ultimately, the Veteran underwent the hysterectomy and left salpingo-oophorectomy in December 1994 to ameliorate her bleeding problems. The December 1994 discharge summary noted her complaints of bleeding and pelvic pain as leading to the surgery. A natural result of this surgery was the cessation of her menses. Post-surgical treatment records do not report any ongoing residual or chronic problem associated with continued bleeding. The Veteran testified in July 2001 that the bleeding had essentially stopped since her surgery. (Transcript p. 38). The Veteran did not submit a claim for service connection for dysmenorrhea and amenorrhea until January 2001. This was almost seven years after her hysterectomy in 1994 which lead to a cessation of her symptoms. The Veteran has said that she wanted benefits for the period prior to her surgery; however, that is not possible. She cannot be service connected for a disability prior to her submitting a claim for such benefits. See generally, 38 U.S.C.A. § 5510 (West 2002); 38 C.F.R. § 3.400 (2009). The Veteran has not alleged, and there is no evidence of record to indicate that any claim for benefits for these claimed disorders was submitted prior to December 1994. Absent such a claim, she cannot receive benefits. The Veteran's contentions are an admission that there is no current disability involving dysmenorrhea . Further, there is no evidence of record, either by way of a lay statement from the Veteran or medical records, that the absence of her menses causes any residual defect or disorder. Thus, the Veteran's claim for service connection is denied. Galactorrhea The Veteran also seeks service connection for galactorrhea. The Veteran was clearly diagnosed with galactorrhea while on active duty. She has continued to receive multiple diagnoses for the condition since service. Significantly, there is no medical evidence to indicate that this diagnosis represents any type of a disability. Galactorrhea, by itself, represents a discharge from the breasts. Unless there is an underlying cause that is identified as something medically significant, or evidence that the discharge is such that it causes problems for the Veteran such as requiring her to change clothes constantly, there is no disability involved. Although the Veteran continues to have a diagnosis of galactorrhea years after service, there is no evidence that it constitutes a disability that would warrant entitlement to service connection. The Veteran has been evaluated for traditional causes of galactorrhea to include thyroid evaluations and other laboratory tests. No evidence has been presented, and no diagnosis provided that identifies the galactorrhea as a symptom of any other disorder. The Board notes that the joint motion objected to this characterization in the Board's decision of May 2002. However, despite efforts to develop evidence to address this disorder, no additional relevant evidence has been developed. The Veteran failed to report for her scheduled examinations where the matter would have been discussed and an opinion provided. She has not provided, or identified additional medical evidence pertinent to the issue. Absent competent evidence to establish galactorrhea as a disability, there is no basis to establish service connection. Unspecified OB/GYN Disorders The Board notes that the Veteran also submitted a claim for service connection for unspecified OB/GYN disabilities. The RO wrote to her in February 2001 and requested that she specify what disability or disabilities were represented by this claim. The Veteran has not identified any disabilities in response to the RO's request. The Board finds that the Veteran's OB/GYN disabilities have been rated under the residuals for her hysterectomy and left salpingo-oophorectomy. The Board has adjudicated issues relating to claimed residuals from prior pelvic surgeries, as well as dysmenorrhea and amenorrhea. The medical evidence of record does not show any additional OB/GYN disabilities related to service or as a consequence of her December 1994 surgery. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Board is unable to identify a reasonable basis for granting service connection for the several claimed disorders. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2009). B. Reopened Claim - Hypertension The Veteran was previously denied service connection for hypertension by way of a rating decision dated in November 1988. She failed to perfect an appeal of that decision and it became final. The Veteran later sought to reopen her claim and the Board found that new and material evidence had been received to reopen the claim in May 2002. The issue underwent development at the Board in keeping with procedural practices in place at the time. When the other issues were returned to the Board from the Court, they were remanded for development in April 2004. The issue of hypertension was also remanded at that time, by way of a separate remand. As noted in the discussion in the section regarding the service connection issues, several VA examinations were scheduled for the Veteran but she failed to report. Also previously discussed, the Board resolved reasonable doubt in favor of the Veteran for her missing the examinations due to good cause and remanded the case again in November 2005. The Veteran failed to report for several examinations. The Board has determined that the Veteran did not have good cause for her failure to report. In particular, she clearly attended multiple VA outpatient appointments for dental care in 2008 despite informing VA she could not attend a VA examination appointment due to personal issues involving the health of her mother and the death of an immediate family member. The Board notes that 38 C.F.R. § 3.655(a) (2009) provides that, when entitlement to a benefit cannot be established without a current VA examination and a claimant, without good cause, fails to report for the examination, action shall be taken in accordance with 38 C.F.R. § 3.655 (b), (c), as appropriate. The Board notes that 38 C.F.R. § 3.655 (c) relates to running awards. However, 38 C.F.R. § 3.655(b) provides that, when a claimant fails to report for an examination scheduled in conjunction with a reopened claim for a benefit which was previously disallowed, the claim shall be denied. (emphasis added). The Court addressed this particular fact pattern in Kyhn v. Shinseki, 23 Vet. App. 335 (2010). There, the veteran's claim for service connection for tinnitus was reopened by the Board and remanded for a VA examination. The claimant failed to report for the examination. The Board adjudicated the claim on the merits. The Court found that VA should not have adjudicated the claimant's reopened claim on the merits but should have denied the claim as required by 38 C.F.R. § 3.655(b). He had failed to report for a VA examination, without good cause, in a reopened claim. See Kyhn, 23 Vet. App. 342-43. The same fact pattern is present in this case. The Veteran's claim for service connection was reopened and remanded for a VA examination. She failed to report for her examination without good cause. In light of the mandate of 38 C.F.R. § 3.655, and the Court's application of that provision, the Veteran's claim for service connection must be denied. (There was no link established by the available record between hypertension and the Veteran's period of military service, so an examination was required to establish entitlement to the benefit sought.) C. Increased Rating The Veteran's claim for an increased rating for her service- connected lichen simplex was remanded for VA examinations in April 2004 and November 2005. As noted the second remand resulted from a determination by the Board that the Veteran had good cause for failing to report for her earlier scheduled examination. As already established, the Veteran did not have good cause for her failure to report for VA examinations scheduled as a result of the remand in November 2005. The same regulatory provision, 38 C.F.R. § 3.655(b), provides that when a claimant fails to report for an examination scheduled in conjunction with a claim for an increased rating, the claim shall be denied. Thus, given that the Veteran failed to report for her scheduled examinations, without good cause, following the remand of November 2005, her claim for an increased rating must be denied. (The available record did not show symptoms such that an increase above 10 percent could be granted without the evidence than an examination may have provided-the record only shows itching in the area of a 11/2 inch lesion on the left lower leg. 38 C.F.R. § 4.118.) D. Permanent and Total Rating The Veteran is rated at 100 percent for her service-connected PTSD disability. This rating has been in effect since October 20, 1989. The Veteran wants the disability rating to declared permanent and total so that she would not have to submit to future VA examinations to assess the current level of her disability and to be eligible for Dependents' Educational Assistance (DEA) benefits under 38 U.S.C.A. Chapter 35. The child of a person who, as a result of qualifying service has a total disability permanent in nature resulting from service- connected disability, is a person eligible for such benefits. See 38 U.S.C.A. § 3501(a)(1)(ii) (West Supp. 2010). The term total disability permanent in nature is defined as any disability that is rated as total for disability compensation and is based upon an impairment reasonably certain to continue throughout the life of the disabled person. See 38 U.S.C.A. § 3501(a)(11) (West 2002); 38 C.F.R. §§ 3.807, 21.3021 (2009). The Board previously denied entitlement to DEA benefits in May 2002 because the Veteran's 100 percent disability rating was not considered to be a permanent and total disability. However, due the period of time that has elapsed during the pendency of the current appeal, the Veteran's 100 percent rating has now been in effect for over 20 years. As a result, the 100 percent rating is now protected and cannot be reduced except for a showing that such rating was based on fraud. See 38 U.S.C.A. § 110 (West 2002); see also 38 C.F.R. § 3.951(b) (2009). There is no evidence that the 100 percent rating is the result of fraud. The provisions of the statue and regulations do not address circumstances where a 100 percent rating has been effect for 20 years or more without having previously been found to be permanent and total. However, the facts of this case demonstrate that the Veteran's PTSD disability has not improved and she has a total disability rating. Because the time that has passed, it is likely that her level of disability is permanent. The Board concludes that the evidence of record now establishes that the Veteran satisfies the criteria to be considered to have a total disability permanent in nature. Eligibility for DEA benefits is established. Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp 2009)), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2009), provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. (The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008. See 73 Fed. Reg. 23353-56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the veteran to provide any evidence in the veteran's possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1).) The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was deemed incompetent for VA fiduciary purposes at the outset of her claim. Initial correspondence was sent to the Veteran through her custodian. Several of the issues on appeal were received as claims prior to the enactment of the VCAA in 1999 and the remainder shortly thereafter in 2001. The RO wrote to her, through her custodian, in November 1999. Although the letter advised the Veteran on what she needed to submit for a well grounded claim, the requirement for such was eliminated by the VCAA, the Veteran was still informed of the requirement for a current disability, evidence to link the disability to service, and evidence of a disability in service. She was informed that the RO would obtain her STRs and any VA records where she was treated. She was also asked to identify any private treatment she had received and to provide the RO with the necessary authorization to obtain any relevant records. The letter further provided several paragraphs addressing the specific type of evidence required to well ground her claim. The Veteran responded by submitting personnel records in December 1999. Her claim for service connection for migraine headaches, GI disorder, eye problems, hypertension, hepatitis B, scarred liver, bladder and gallbladder, shortened cervix, hiatal hernia, and angioedema and urticaria were denied in May 2000. She submitted her NOD that same month. The RO wrote to the Veteran in May 2000. The letter addressed several additional issues she had raised. The letter noted five separate issues and listed specific information as to each issue. The Veteran was asked to submit evidence in accordance with the letter. In July 2000 the Veteran was issued a statement of the case (SOC) in regard to the issues denied in May 2000. The Veteran perfected her appeal in July 2000. She included a detailed statement that addressed her specific reasons for her appeal. The Veteran asked for a complete copy of her claims folder in October 2000. A copy was provided in February 2001. In December 2000, the RO found the Veteran to be competent to manage her personal affairs. The Veteran's claim for an increased rating for her service- connected lichen complex was increased to 10 percent in May 2001. Her claim for service connection for fibromyalgia, galactorrhea, dysmenorrhea and amenorrhea, and gynecological problems were denied at that time. The Veteran submitted her NOD with the rating actions that same month. The RO issued a SOC for the issues listed in the May 2001 decision that same month. The Veteran perfected her appeal in June 2001. The Veteran testified at a Travel Board hearing in July 2001. She submitted a substantial amount of evidence in support of her claim at the hearing. The Veteran was provided a copy of the transcript of the hearing in January 2002. She provided a number of requested changes to the transcript. The Board issued an Interlocutory Order to implement most of those changes in April 2002. The Board originally denied her claim for the issues on appeal, except for reopening her claim for service connection for hypertension, in May 2002. As previously discussed, the Veteran appealed the Board's decision. The Court vacated the decision and the case was returned to the Board. The Board notified the Veteran of the Court's actions and provided her an opportunity to provide additional argument or evidence in September 2003. Her representative submitted additional argument in February 2004. The Board remanded the case for additional development in April 2004. The hypertension issue was remanded separately that same month. The AMC wrote to the Veteran in April 2004. The issues on appeal were identified. The Veteran was advised of the evidence required to substantiate her claim for service connection. She was further advised of the information required from her to enable VA to obtain evidence on her behalf, the assistance that VA would provide to obtain evidence on her behalf, and that she should submit such evidence or provide VA with the information necessary for VA to obtain such evidence on her behalf. The RO informed the Veteran on the types of evidence she could submit that would support her claim for service connection. She was asked to submit any medical evidence that she had. The letter informed the Veteran of the evidence of record. The AMC again wrote to the Veteran in December 2004. She was informed she would be scheduled for an examination and advised in regard to the provisions of 38 C.F.R. § 3.655. The AMC wrote separately to the Veteran to inform her of the evidence necessary to substantiate her claim for service connection for hypertension in February 2005. The Veteran was advised of the information required from her to enable VA to obtain evidence on her behalf, the assistance that VA would provide to obtain evidence on her behalf, and that she should submit such evidence or provide VA with the information necessary for VA to obtain such evidence on her behalf. The AMC again wrote to the Veteran to inform her she would be scheduled for VA examinations in February 2005. The letter also included an advisement of the provisions of 38 C.F.R. § 3.655. The Veteran failed to report for the scheduled examinations. The AMC re-adjudicated the claim in March 2005. The issues remained denied and the AMC issued a supplemental statement of the case (SSOC) that addressed the evidence added to the record and the basis for the continued denial of the claim. The Veteran responded to the SSOC in May 2005. She said that she had not missed any appointments. She also said that she was too ill to work on her claim. Her case was returned to the Board. The Board remanded the case again in an attempt to obtain the needed VA examinations in November 2005. The AMC wrote to her in November 2005. She was informed that additional development would be conducted in her case. She was asked to provide information on any additional treatment and to provide releases for records she wanted VA to obtain. The Veteran responded in January 2006. She listed treatment at several VAMCs. The AMC wrote to her in March 2006. She was informed that she would be scheduled for a VA examination. She was also informed that if she failed to report, without good cause, her claim could be denied. The letter was returned as undeliverable. However, the Veteran was still scheduled for VA examinations at the VAMC in Nashville, as reflected by the copies of the notice letters provided in the claims folder. Those letters were sent to a different address and not returned. The Veteran failed to report for her examinations. The AMC again informed her she would be scheduled for VA examinations in August 2007. The Veteran was again informed of the possible consequences for failure to report without good cause. She failed to report for her examinations. The AMC wrote to her in October 2007 to ask her to contact the AMC within 30 days. The Veteran responded in December 2007 and reported her mother was terminally ill and asked that her appointments be postponed during this time. The AMC wrote to the Veteran in August 2008. She was asked if she was able to attend an examination. She was also provided with a form to use if she wanted to submit additional information. She responded in September 2008 that her mother was still ill and there had been a death in the immediate family. The AMC obtained the VA medical records discussed supra, in December 2008. They showed the Veteran's attendance at multiple dental appointments in 2008. The AMC wrote to the Veteran in December 2008. She was informed that a VA examination would be scheduled. As before, the letter also informed the Veteran her claim could be denied if she failed to report without good cause. She failed to report for examinations scheduled in March 2009. The AMC re-adjudicated her claim in April 2009. The Veteran's claim remained denied and she was issued a SSOC that same month. She responded to the SSOC in May 2009. She said she had notified VA, via several sources, of her personal circumstances and that she had asked for her appointments to be canceled due to her mother's terminal illness. The case was returned to the Board. The Veteran has not disputed the contents of the VCAA notice in this case. She was afforded a meaningful opportunity to participate in the development of her claim. Although initial correspondence to her preceded the enactment of the VCAA the Veteran was given notice on how to substantiate her claim for service connection. She responded to those letters with the information and/or evidence she wanted to submit. She presented specific argument in support of her claim. The Board finds that the Veteran had actual knowledge of what was required to establish service connection for the several service connection issues. Thus, the Board is satisfied that the duty to notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied. The Board notes that the Veteran was not provided notice in regard to her claim for an increased rating. However, this lack of notice did not prejudice the Veteran as her claim was denied because she failed to report for her scheduled VA examinations. (The provisions of 38 C.F.R. § 3.655 require that this claim be denied.) The Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate her claims. All available evidence pertaining to the Veteran's claims has been obtained. As noted, her STRs and some military personnel records were obtained or of record. VA records were associated with the claims folder and private records in the claims folder were reviewed. The Veteran was afforded a Travel Board hearing. The AMC made multiple attempts to afford the Veteran examinations; however, she failed to report for any of them. The Board remanded her case once, after giving her the benefit of the doubt for her failure to report for examinations. She continued to not report for the examinations or call the VAMC to re-schedule. She said that she was unable to attend the examinations because of personal reasons, primarily her mother's ill health. However, she attended multiple dental appointments throughout 2008. Thus, it was clear that she could have reported for a VA examination despite her contentions. Other than reporting her treatment at several VAMCs in January 2006, she has not identified any other evidence to be obtained in this case. The Board notes that a VA outpatient entry from October 2002 recorded that the Veteran was looking for a physician to sign papers related to a SSA disability. The Veteran has not provided any information or evidence that she is in receipt of SSA disability benefits. She has received several letters from VA requesting that she identify evidence pertinent to her case beginning with the remand of April 2004. She has communicated with VA but has not stated that there are any relevant SSA records in her case. Absent any indication from the Veteran that there are any outstanding records, VA has no additional duty in this regard. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Finally, the Board notes that corresponding to VA's duty to assist the Veteran in obtaining information is a duty on the part of the Veteran to cooperate with VA in developing a claim. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (noting that "[t]he duty to assist is not always a one-way street"); see also 38 C.F.R. § 3.159 (c)(2)(i) (2009). VA's duty must be understood as a duty to assist the Veteran in developing her claim, rather than a duty on the part of VA to develop the entire claim with the Veteran performing a passive role. Turk v. Peake, 21 Vet. App. 565, 568 (2008) (citing to Woods, 1 Vet. App. at 193). The Veteran has failed to cooperate with VA's efforts to develop her claims. The Board finds that there is no benefit to remand the case again to obtain VA examinations in light of the Veteran's actions over the course of two prior remands. ORDER Service connection for migraine headaches, a gastrointestinal disorder, a hiatal hernia, a visual acuity disability, scarring of the liver, bladder, or gallbladder, a shortened cervix, angioedema, urticaria, hepatitis B, fibromyalgia, dysmenorrhea, amenorrhea, galactorrhea, hypertension, and other gynecological disorder is denied. Entitlement to a rating in excess of 10 percent for service- connected lichen simplex of the left lower leg is denied. The Veteran's 100 percent rating for service-connected PTSD is total and permanent in nature; basic eligibility to DEA benefits is granted. _____________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs