Citation Nr: 0201263 Decision Date: 02/07/02 Archive Date: 02/11/02 DOCKET NO. 01-09 788 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama THE ISSUE Entitlement to service connection for endometriosis. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs ATTORNEY FOR THE BOARD G. Zills, Associate Counsel INTRODUCTION The veteran served on active duty from July 1974 to December 1984. This case comes before the Board of Veterans' Appeals (Board) from a July 2001 RO decision which denied the veteran's claim for service connection for endometriosis (including residuals such as a hysterectomy). FINDINGS OF FACT The veteran's endometriosis and its residuals (including hysterectomy, bilateral salpingo-oophorectomy, colon resection, and appendectomy) began following service and were not caused by any incident of service. CONCLUSION OF LAW Endometriosis and its residuals were not incurred in or aggravated by active military service. 38 U.S.C.A. § 1131 (West 1991 & Supp. 2001); 38 C.F.R. § 3.303 (2001). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background The veteran served on active duty in the Army from July 1974 to December 1984. Her service medical records show routine gynecological care, and at times abnormalities were noted, such as bleeding from cervicitis which was treated with cryo therapy in early 1982. Endometriosis was not confirmed by various studies. A 1983 routine gynecological examination noted all structures were within normal limits, as was a pap smear. The 1984 service separation examination contains no evidence of endometriosis. Service medical records show the veteran was treated for other physical ailments, including low back pain/strain which was associated with activity, hemorrhoids, and complaints of urinary stress incontinence. In December 1984, the veteran filed a claim for service connection for various conditions, but not for a gynecological disorder. On a VA general medical examination in January 1985, the veteran's genitourinary system was noted to be within normal limits, with a rectal examination showing external and internal hemorrhoids, and her stool testing guaiac negative. At the time of the examination, she was diagnosed with benign functional heart murmur, intermittent low back pain (by history), hemorrhoids, and urinary incontinence (by history). In March 1985, the RO granted service connection for a low back disorder and hemorrhoids. There is no medical evidence of endometriosis for a number of years after service. In February 1989, the veteran was admitted to Humana Hospital after recent studies related to rectal symptoms. She gave a history which included bleeding at the time of menses for the past several years. She was suspected of having endometriosis of the cul-de-sac of the uterus with rectal invasion. She underwent surgery which confirmed endometriosis of various pelvic structures including the uterus, ovaries, rectosigmoid colon, and appendix. She underwent a colon resection with low anterior anastamosis, total abdominal hysterectomy with bilateral salpingo- oophorectomy, and appendectomy. Treatment records from 1991 show the veteran being seen for urinary problems. The veteran submitted her claim for service connection for endometriosis in October 2000. She essentially asserted that symptoms during service and thereafter, which had been attributed to her service-connected low back pain and hemorrhoids, actually represented undiagnosed endometriosis which started in service. The veteran submitted an October 2000 statement from her gynecologist, Dr. Thomas C. Pitman. The doctor related that the veteran gave a history of low back pain for quite some time before the 1989 surgery for endometriosis, and that the sigmoid involvement of her endometriosis would be the etiology of her back pain, especially since the pain resolved after the sigmoid resection. Dr. Pitman further stated that there was no way to know when the veteran's endometriosis began, but that her back symptoms were consistent with the surgical findings. The veteran was admitted to Huntsville Hospital in November 2000. She recently had been experiencing symptoms of irritable bowel syndrome, and a computerized tomography (CT) scan showed a lesion in the area of the cecum. During the admission she underwent an exploratory laparotomy and right hemicolectomy with anastomosis. Final diagnosis included a sessile villous adenoma of the cecum, and a history of endometriosis. In December 2000, the veteran was seen at The Orthopaedic Center in connection with pain and numbness in her back and hips. An impression of trochanteric bursitis was made, and her past history of endometriosis was noted. In March 2001, the veteran was given a VA spine examination. The examiner noted that the veteran's low back pain was initially attributed to endometriosis but had persisted following her total abdominal hysterectomy and partial colectomy for endometriosis. Following examination, diagnoses were mild degenerative joint disease of the lumbosacral spine, and mild degenerative joint disease of the right hip. In April 2001, the veteran was given a VA gynecological examination. The examiner noted the veteran's history of back pain since 1982 and rectal bleeding with menses beginning in 1985. Reportedly following her hysterectomy in 1989, rectal bleeding had stopped but her back pain had not completely resolved. The examiner also noted the veteran's urinary history of stress incontinence since 1982, which initially improved following her hysterectomy but was now recurring upon coughing, exercise, and laughing. Following examination, the impression was a history of severe endometriosis, status post total hysterectomy with bilateral salpingo-oophorectomy with sigmoid resection, currently asymptomatic, chronic low back pain thought to be musculoskeletal, and mild to moderate stress urinary incontinence. In a rating decision dated in July 2001, the RO denied the veteran's claim for service connection for endometriosis. Analysis The file shows that in correspondence, rating decisions, and the statement of the case, the RO has notified the veteran of the evidence necessary to substantiate her claim for service connection for endometriosis. Identified relevant medical records which have been obtained, and she has been given a VA examination. The Board finds that the notice and duty to assist provisions of the law have been satisfied. 38 U.S.C.A. §§ 5103, 5103A (West Supp. 2001); 66 Fed.Reg. 45,620, 45,630 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. § 3.159). Service connection may be granted for disability due to disease or injury which was incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. The veteran's service medical records from her 1974-1984 active duty show various ailments but do not show endometriosis. A VA examination in 1985, shortly after her separation from service, contains no findings endometriosis. The first medical evidence of endometriosis is from 1989, several years following service. The veteran was found to have severe pelvic endometriosis, and such required a total abdominal hysterectomy, bilateral salpingo-oophorectomy, resection of part of the colon, and removal of the appendix. An October 2000 letter by the veteran's gynecologist opines that the endometriosis was the etiology of the back pain the veteran reportedly experienced in the 1980s, prior to the 1989 surgery for endometriosis, but further states that there is no way to determine when the veteran's endometriosis began. The Board finds this opinion has little probative value in connecting the endometriosis to service. For one, the doctor essentially concedes that it would be impossible to pinpoint when the endometriosis began. Additionally, the medical records from during and after service show an orthopedic low back condition (which has been service connected) independent of any endometriosis. Given the extent of the endometriosis which was found on surgery in 1989, the condition obviously had existed for some time before then. Yet it would require resort to speculation, which is beyond the reasonable doubt doctrine, to find that the endometriosis started in service which ended in 1984. In light of the available medical records from during service and the years immediately following, it does not appear that there is sufficient information for a doctor to provide a competent medical opinion which could reasonably link the condition to service. The veteran asserts that her endometriosis began while she was in service; however, as a layman, whe has no competence to give a medical opinion on diagnosis or etiology of a disorder. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The weight of the credible evidence establishes that endometriosis (and its residuals) started after service and was not caused by any incident of service. The Board finds that the condition was not incurred in or aggravated by service. As the preponderance of the evidence is against the claim for service connection for endometriosis, the benefit- of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for endometriosis is denied. L. W. TOBIN Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.