Citation Nr: 1019751 Decision Date: 05/27/10 Archive Date: 06/09/10 DOCKET NO. 96-22 754 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a gynecological disability, with residuals of tubal reconstruction, to include ovarian cysts, abdominal cramps and adhesions, and a total hysterectomy. 3. Entitlement to an increased initial rating for hives (cold urticaria), currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and father ATTORNEY FOR THE BOARD Jennifer Hwa, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1979 to January 1982. This matter comes before the Board of Veterans' Appeals (Board) from an August 1995 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) that denied service connection for an acquired psychiatric disorder, to include PTSD, and a gynecological disability, and granted service connection and awarded a 10 percent disability rating for hives, effective February 10, 1995. The Veteran testified before the Board in October 2005. The Board remanded these claims for additional development in October 2004 and January 2006. FINDINGS OF FACT 1. The Veteran's PTSD is at least as likely as not the result of her period of active service. 2. The Veteran's gynecological disability, with residuals of tubal reconstruction, to include ovarian cysts, abdominal cramps and adhesions, and a total hysterectomy, is unrelated to her period of service or to any incident therein. 3. Since February 10, 1995, the effective date of service connection, the Veteran's cold urticaria has been manifested by itchy and dry papular rashes and fatigue. The disability is productive of no more than mild impairment, with attacks without laryngeal involvement occurring four times a month but lasting only four hours. The recurrent episodes of hives occurred at least four times during the past 12-month period and responded to treatment with antihistamines. CONCLUSIONS OF LAW 1. The Veteran's current PTSD was incurred in or aggravated by her active service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2009). 2. The Veteran's current gynecological disability, with residuals of tubal reconstruction, to include ovarian cysts, abdominal cramps and adhesions, and a total hysterectomy, was not incurred in or aggravated by her active service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306 (2009). 3. The criteria for an initial rating in excess of 10 percent for hives have not been met since February 10, 1995. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code (DC) 7118 (as in effect both prior to and as of Jan. 12, 1998); 38 C.F.R. § 4.118, DC 7825 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2009). Disability which is proximately due to or the result of a disease or injury incurred in or aggravated by service will also be service-connected. 38 C.F.R. § 3.310 (2009). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Degmetich v. Brown, 104 F.3d 1328 (1997); Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection for certain chronic diseases, like psychoses, will be rebuttably presumed if they are manifest to a compensable degree within one year following active service. The Veteran's gynecological disabilities, however, are not disabilities subject to presumptive service connection. 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. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without them. 38 C.F.R. § 3.303(d) (2009). For the showing of chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2009). Service connection may also be granted for a 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. § 3.30(d) (2009). 1. Acquired Psychiatric Disorder, to Include PTSD Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., under the criteria of DSM-IV), a link, established by medical evidence, between current symptoms and an in-service stressor, and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 4.125 (2009). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2009); 38 U.S.C.A. § 1154(b) (West 2002). The provisions of 38 U.S.C.A. § 1154(b) are only applicable in cases where a Veteran is shown to have actually served in combat with the enemy. For application of 38 U.S.C.A. § 1154(b), it is not sufficient that a Veteran be shown to have served during a period of war or to have served in a theater of combat operations or in a combat zone. To gain the benefit of a relaxed standard for proof of service incurrence of an injury or disease, 38 U.S.C. § 1154(b) requires that the veteran have actually participated in combat with the enemy. VAOPGCPREC 12-99 (October 18, 1999); 65 Fed. Reg. 6257 (2000). When the evidence does not establish that a Veteran is a combat Veteran, any assertions of service stressors are not sufficient to establish the occurrence of such events. Rather, the alleged service stressors must be established by official service record or other credible supporting evidence. 38 C.F.R. § 3.304(f) (2009); Pentecost v. Principi, 16 Vet. App. 124 (2002); Fossie v. West, 12 Vet. App. 1 (1998); Cohen v. Brown, 10 Vet. App. 128 (1997); Doran v. Brown, 6 Vet. App. 283 (1994). If a posttraumatic stress disorder claim is based on in- service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a post-traumatic stress disorder claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304(f)(4) (2009). Because the Veteran is alleging sexual abuse, the special provisions of VA Adjudication Procedure Manual M21-1 (M21-1), Part III (Feb. 20, 1996), regarding personal assault must also be considered. The Manual identifies alternative sources for developing evidence of personal assault, such as private medical records, civilian police reports, reports from crisis intervention centers, testimonial statements from confidants such as family members, roommates, fellow service members, or clergy, and personal diaries or journals. M21-1, Part III, 5.14c(4)(a). When there is no indication in the military record that a personal assault occurred, alternative evidence, such as behavior changes that occurred at the time of the incident, might still establish that an in-service stressor incident occurred. Examples of behavior changes that might indicate a stressor include (but are not limited to): visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment; sudden requests that a military occupational series or duty assignment be changed without other justification; lay statements indicating increased use or abuse of leave without apparent reason; changes in performance or performance evaluations; lay statements describing episodes of depression, panic attacks or anxiety with no identifiable reasons for the episodes; increased or decreased use of prescription medication; evidence of substance abuse; obsessive behavior such as overeating or under-eating; pregnancy tests around the time of the incident; increased interest in tests for HIV or sexually transmitted diseases; unexplained economic or social behavior changes; treatment for physical injuries around the time of the claimed trauma but not reported as a result of the trauma; or breakup of a primary relationship. M21-1, Part III, 5.14c(7) (a)-(o). Subparagraph (9) provides that "[r]ating boards may rely on the preponderance of evidence to support their conclusions even if the record does not contain direct contemporary evidence. In personal assault claims, secondary evidence which documents such behavior changes may require interpretation in relationship to the medical diagnosis by a VA neuropsychiatric physician." Patton v. West, 12 Vet. App. 272 (1999); YR v. West, 11 Vet. App. 393 (1998). This is the approach that was codified at 38 C.F.R. § 3.304(f)(4) (2009). VA will not deny a PTSD claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the Veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304(f)(4) (2009). It is the Board's principal responsibility to assess the credibility, and therefore the probative value of proffered evidence of record in its whole. Owens v. Brown, 7 Vet. App. 429 (1995); Elkins v. Gober, 229 F.3d 1369 (Fed. Cir. 2000); Madden v. Gober, 125 F. 3d 1477 (Fed. Cir. 1997); Guimond v. Brown, 6 Vet. App. 69 (1993); Hensley v. Brown, 5 Vet. App. 155 (1993). In determining whether documents submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant's uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). The Veteran contends that her PTSD is due to in-service sexual assaults, harassment, physical abuse, racism, and an automobile accident. The record reflects that in July 2009, a VA physician evaluated the Veteran's psychiatric symptoms and found that they met the DSM-IV criteria for PTSD. As a result of that examination, the Veteran was diagnosed with PTSD. Accordingly, the remaining question before the Board is whether the Veteran's PTSD diagnosis is based upon a verified stressor. The Veteran's service personnel records reveal that she served in the Army as a stock control specialist and a military policeman. She received the Good Conduct Medal. The Veteran's award is consistent with service, but it is not indicative of combat. The Board has reviewed the record, including the Veteran's service medical and personnel records, and there is no evidence of combat duty in those records. As the Veteran does not have a confirmed history of engaging in combat with the enemy during service, her alleged stressors must be verified. The Board notes that in April 2006, the RO notified and requested from the Veteran the types of evidence described in M21-1 and 38 C.F.R. § 3.304(f)(4). In reply, the Veteran has submitted statements regarding the stresses of service, but did not submit any other additional evidence. The Board therefore has relied on the available evidence in determining if the alleged stressors can be corroborated. Service medical records are negative for any complaints of or treatment for any psychiatric disability. The records show that the Veteran was involved in an automobile accident on August 30, 1981. She received eight stitches in her forehead due to a laceration and lost consciousness for about 10 minutes. She vomited once. A closed head injury was ruled out, and the Veteran was diagnosed with a contusion to her back and a forehead laceration with no artery or nerve involvement. The first post-service evidence of an acquired psychiatric disorder is a September 1985 VA medical report where the Veteran was found to have situational depression due to marital problems. Post-service VA and private medical records dated from January 1994 to January 2010 show that the Veteran received intermittent treatment for agoraphobia, anxiety disorder, panic disorder, major depressive disorder, and PTSD. The Veteran testified before a Decision Review Officer in September 1996 and at a video conference hearing with her father before the Board in October 2005. Testimony revealed that during her period of service, the Veteran endured sexual harassment by being called "Dolly Parton" because of her large breasts, by being repeatedly asked by her drill sergeants to date them, and by having her underwear stolen by male soldiers to be hung in their barracks. She stated that she also witnessed female soldiers having sex with the drill sergeants as well as female soldiers being raped. The Veteran testified that after she met and married a black man, she was called a mud shark, had mud thrown on the door of her house, and was prohibited from living with her husband and from living off post. She reported that she was called into her commander's office with her husband and told that she had committed a sin, which provoked her husband into attacking the commander. She stated that she had headaches and depression in the military due to the constant harassment she received. She testified that she had episodes of crying that lasted for hours at a time. She reported that a Congressional investigation was held behind closed doors regarding the unfair treatment towards the Veteran and her husband and that although 25 soldiers admitted that she had been harassed and treated unfairly, she and her husband were shipped to a new assignment. She stated that the racial harassment continued at her new assignment, and her husband began to beat her. She also testified that in August 1980 when she was assigned to escort a soldier to a plant because he had a load for shipment, he grabbed her breasts while they were driving and ejaculated in front of her in the truck. She stated that this soldier received a dishonorable discharge and served six months in prison for the incident. The Veteran asserted that she was also raped by a NCO after he had given her two beers. The Veteran reported not seeking much treatment for her anxiety and depression for fear of being blamed for it. She stated that she attempted suicide by overdosing on sleeping pills and was then involved in a car accident a few weeks afterwards. She reported that she currently experienced nightmares, distrust of other people, depression, and loneliness. The Veteran's father testified that the Veteran currently suffered from severe depression when she thought about all the things that happened to her during her period of service. On VA examination in June 1995, the Veteran reported being called insulting names in service and receiving discriminatory treatment because she had married a black man. She stated that her husband began beating her. She asserted that she felt that the military hated her and that her family hated her due to her marital behavior, so she took an overdose of sleeping pills one day. She complained that because she felt in the middle between her husband and the military, she suffered periods of uncontrollable crying, nervous feelings, and an inability to breathe during her period of service. She reported going to the military infirmary many times for her symptoms but stated that she was never given any psychological treatment. She complained that she was not treated fairly by the military when she divorced her husband in 1986 because he ended up getting everything. She asserted that her anxiety symptoms were already present in service, but nobody had paid any attention to her back then. Examination revealed that the Veteran was well-oriented, relaxed, friendly, and at ease. She had coherent and relevant conversation and appeared to be sad at times with tears in her eyes when describing the incidents in service. She was depressed, and her affect was appropriate to her mood. Thought content revealed anger and depression problems regarding her time in service. There was no psychotic deviation found. She had good memory and superficial insight and her judgment seemed to be okay. The examiner diagnosed the Veteran with generalized anxiety disorder with panic attacks. At an April 2002 VA examination, the Veteran reported that she suffered from panic attacks, depression, anxiety, and PTSD. The examiner found deficiencies of concentration, episodes of deterioration or decompensation in a work place, and failure to complete tasks. The Veteran was diagnosed with major depressive disorder, chronic panic disorder, and PTSD. An April 2003 Social Security Administration decision granted disability benefits to the Veteran due to her severe impairments of fibromyalgia, degenerative disc disease of the lumbar spine, irritable bowel syndrome, bilateral carpal tunnel syndrome, migraine headaches, bilateral refractory lateral epicondylitis, anxiety disorder with panic attacks, and depression. On VA examination in July 2009, the Veteran reported being sexually assaulted by soldiers in 1979 to 1980 and in 1981 and being involved in a motor vehicle accident during service. She stated that she was currently married to her fifth husband and had three children, one of which was deceased. She asserted that she got along okay with her current husband but was a loner in general. She reported a history of suicide attempts. She described her leisure activities as swimming, going to the beach, and riding a bike. Examination revealed a cooperative attitude, anxious and dysphoric mood, and constricted affect. The Veteran's attention and memory were intact, and she was oriented in three spheres. She had unremarkable thought process and content and good impulse control. She understood the outcome of behavior and the fact that she had a problem. There was no evidence of delusions, hallucinations, suicidal or homicidal behavior, or episodes of violence. The Veteran had sleep impairment, panic attacks, and inappropriate behavior where she bit and tore off her fingernails and toenails until they bled. The Veteran had constricted affect, diminished interest in activities, feelings of detachment from others, sleep disturbance leading to daytime fatigue, irritability, hypervigilance, and exaggerated startle response. She persistently re-experienced her traumatic events in service and persistently avoided stimuli associated with the trauma. The examiner diagnosed the Veteran with chronic PTSD based on the stressors of pre-military physical and sexual assault, military automobile accident and sexual assault (if verified), and a post-military automobile accident. The examiner noted that the Veteran's panic disorder and depression were part of the PTSD-associated symptom complex. The examiner also stated that the Veteran's early childhood physical and sexual trauma predisposed her to the later development of PTSD subsequent to trauma exposure. The examiner opined that it was at least as likely as not that the Veteran's PTSD was caused by or a result of her military sexual assault and motor vehicle accident. The rationale was that the Veteran's symptoms, psychosocial impairment, and occupational impairment were consistent with PTSD and fit a typical pattern of PTSD. The examiner also noted that the trauma to which the Veteran was exposed was known to cause PTSD. At a September 2009 VA examination, the examiner was asked to opine as to the etiology of the Veteran's PTSD because the Veteran's stressor of a motor vehicle accident in service had been verified since the last examination but there were questions about the veracity of her alleged stressors. The Veteran reported that in the motor vehicle accident, she lost consciousness for an unknown period of time, was traumatized by the sudden violent nature of the crash and her and others' injuries, and was hospitalized to assure that her serious head injury did not result in a condition which would require a life-saving neurosurgical procedure. The examiner explained that the Veteran had developed initial PTSD symptoms following her 1979 sexual assault, including nightmares, traumatic memories, hypervigilance, hyperarousal, social anxiety, and problems with trust. The examiner stated that the Veteran's symptoms became more accentuated following her second unwanted sexual contact in 1981, and that the content of her nightmares and intrusive memories changed after her car accident to include vivid accidents in which she and others were harmed. The Veteran also developed unprecedented fears of riding in cars and planes and going over bridges and through tunnels. She complained that her accident nightmares and distressing memories became aggravated by being in traffic either as a passenger or driver, by news accounts and other references to transportation accidents, and by action movies portraying fast driving and crashes. The Veteran reported weekly recurrent dreams of being harmed by various means and of her attempts to save others from harm and stated that these dreams caused her to wake up and prevent her from readily returning to sleep. She complained of being very anxious, feeling unsafe in her house, constantly checking that her car doors were unlocked and that she had an escape tool to break the windows and sever the seatbelt, and being hypervigilant when she was alone. Examination of the Veteran revealed no changes from the July 2009 VA examination. The examiner opined that it could be reasonably clinically concluded that it was at least as likely as not that the Veteran's confirmed PTSD was directly due to both the two alleged sexual assaults in service and to the confirmed motor vehicle accident while on active duty. The examiner noted that the Veteran had provided consistent and credible clinical information leading to the independent psychiatric conclusion because her reports and witnessed symptoms were consistent with those of other individuals who were commonly evaluated and treated with PTSD. The examiner also noted that while the Veteran had been diagnosed with a number of different psychiatric disorders, like depressive disorder, anxiety neurosis, and panic disorder, he concurred with the July 2009 examiner that the Veteran's sole diagnosis was that of PTSD. The Veteran submitted several lay statements from her family and former spouse in support of her claim. Those statements report that the Veteran experienced rape, mental abuse, and physical abuse during active duty and that she had suffered from bad nerves since the military. The Veteran's family members state that the military had informed them in 1981 that she had taken an overdose of sleeping pills and that several weeks later, she had called them to tell them that she had been in a car accident. They assert that she currently suffered from panic attacks and depression. The Board finds that the evidence in the Veteran's service medical records documents her August 30, 1981, automobile accident and subsequent medical treatment. Therefore, the Veteran's cited stressor of an automobile accident during her period of active service is corroborated. Although there are inconsistencies concerning the details of the automobile accident such as the length of time that the Veteran had lost consciousness or whether the Veteran had sustained injuries to her ribs and knees, the Board acknowledges the circumstances at the time of the accident, such as head injury, and resolves all doubt in favor of the Veteran in finding that her stressor is verified. With regard to the Veteran's claim for service connection for the PTSD with which she has been diagnosed, the Board finds that service connection is warranted. An evaluation of the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467 (1993). The Board finds that the July 2009 and September 2009 VA medical opinions relating the Veteran's chronic PTSD to her military experiences is probative based on the examiners' thorough and detailed examinations of the Veteran as well as the adequate rationale for the opinions. In addition, there are no contrary competent medical opinions of record. Accordingly, the Board finds that service connection for the Veteran's PTSD is warranted. Because the Veteran's PTSD diagnosis was based on a corroborated stressor, the Board finds that service connection for PTSD is warranted. All reasonable doubt has been resolved in favor of the Veteran in making this decision. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Gynecological Disability Service medical records show that the Veteran received treatment throughout active duty for various gynecological conditions, including nonspecific vaginitis, irregular and absent menstrual periods, abdominal cramping, and anovulatory cycles/bleeding. The Veteran reported in various treatment records that she had undergone a tubal ligation prior to service in 1977, but there were no records available regarding the tubal ligation. She underwent a tubal reanastomosis in October 1980. Post-service VA medical records dated from November 1982 to January 2010 show that the Veteran received intermittent treatment for gynecological disabilities. She suffered from anovulatory bleeding, secondary infertility, hormonal imbalance, irregular menstrual periods, uterine fibroids, dysmenorrhea, dysfunctional uterine bleeding, PAP smear with atypical squamous cell of undetermined significance, acute and chronic cervicitis, bilateral unilocular ovarian cysts, multiple nabothian cysts in the cervix, slightly enlarged uterine fundus, menorrhagia, metorrhagia, abdominal pain, vulvitis, atrophic vaginitis, and urinary tract infections. The Veteran underwent an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and Marshall Marchetti Kranz procedure in August 2002. On VA examination in June 1993, the Veteran reported having a tubal ligation in 1978 and a tubal reanastomosis in 1980. She complained of problems with scar tissue and painful adhesion. She stated that she had experienced abdominal pain since 1980 and reported suffering from irregular, heavy menses with clotting. Examination revealed an enlarged uterus and a laparotomy scar at umbilicus. The diagnoses were mildly enlarged uterus and metorrhagia. The Veteran testified before a Decision Review Officer in September 1996 and then testified before the Board with her father at a video conference hearing in October 2005. Testimony revealed that the Veteran had several vaginal infections during service that she was told were due to long hours of field exercises in the heat and dirt for basic training. She testified that she also began having irregular menstrual problems due to the physical training she went through. She reported that she decided to have a tubal reanastomosis in service and that after the procedure, she incurred a lot of scar tissue and adhesions that did not heal and caused her pain and discomfort that had persisted through the years. She stated that a doctor had informed her that her uterus had become enlarged after the surgery. She also testified that she had cysts on her uterus after the surgery. She asserted that despite undergoing the renastomosis, she never got pregnant again. The Veteran testified that she suffered from severe cramps and bleeding in service that sometimes prevented her from going out and marching. She reported that she underwent a total hysterectomy in 2002 for her bleeding, scar tissue, and cysts. She stated that the hysterectomy had cleared up some of her previous gynecological problems such as cramping and cysts. On VA examination in September 2006, the Veteran reported having a tubal ligation in 1977, two laparoscopies in 1979 for her female problems, and tubal reconstruction in 1980. She stated that she could not remember when her uterine fibroids were diagnosed but that her abdominal adhesions and cramping started in service while her ovarian cysts were diagnosed after service. She asserted that she began having abnormal PAP smears in 1995 with chronic cervicitis. The Veteran complained of surgical abdominal scars from the hysterectomy and tubal reconstruction. She reported that her past problems of menstruation with severe cramping and heavy bleeding and adhesions with abdominal pain and cramping that had started in the service had resolved with the hysterectomy. Since the 2002 hysterectomy, she was not menstruating. Examination revealed vulva without skin lesions, absent uterus from hysterectomy, and absent cervix. There was no inflammation of Bartholin's glands or yellow or green vaginal discharge. The adenexa was not palpable. The surgical scars from the hysterectomy and the tubal reconstruction were light, flat, and nontender. The scars had no ulcers or adhesions and did not cause any functional loss. The examiner found that the Veteran had a residual nontender umbilical scar from the in-service tubal reanastomosis. Regarding the Veteran's residual nontender abdominal scar from her total hysterectomy, the examiner opined that the scar was not due to military service because the Veteran's enlarged boggy uterus with fibroids had to be removed in August 2002 because of her heavy and prolonged periods and abnormal PAP in February 2002. The examiner explained that the Veteran did not have an enlarged uterus or abnormal PAP in service and that she only began having an abnormal PAP in 1995. The examiner opined that the Veteran's past uterine fibroids that had been removed with abdominal hysterectomy were not due to service because she did not have any examinations showing a fibroid uterus in service. The first documentation of the Veteran's enlarged uterus was in 1993, which was more than 10 years after discharge from service. With respect to the past ovarian cysts that had been removed with total abdominal hysterectomy, the examiner was unable to offer a nexus opinion because any opinion would be speculation. The examiner was unable to make a direct connection between the cysts and service because the Veteran did not have any tests documenting ovarian cysts until March 1996. Regarding the Veteran's past adhesions with abdominal pain and cramping that had been resolved with total abdominal hysterectomy, the examiner could not offer any nexus opinion because any opinion would be speculation. The examiner was unable to make a direct connection between the adhesions with abdominal pain and cramping and service because the Veteran had undergone a tubal ligation prior to service which might have caused the adhesions. Additionally, the Veteran had reported abdominal problems prior to her in-service tubal reconstruction. At an October 2009 VA examination, the Veteran complained of a residual feeling of bladder dropping and urinary incontinence when sneezing, leaning over, exercising, and having intercourse. She reported using an incontinence pad if she was sick or going some place far. She stated that she had incontinence at least once a day. She also reported vaginal dryness and residual pain with intercourse. Examination revealed vulva without skin lesions, but there was atrophic skin. A slight cystocele was noted. Regarding the total abdominal hysterectomy with residuals and the slight cystocele with intermittent urinary incontinence, the examiner found that those conditions were not related to the in-service tubal reconstruction. The examiner was unable to make any direct connections. With respect to the Veteran's past uterine fibroids, past ovarian cysts, and past abdominal cramping that were all resolved with the hysterectomy, the examiner found that those conditions were not related to the Veteran's in-service tubal reanastomosis. The examiner was unable to make any direct connections. As for the Veteran's abdominal adhesions, the examiner could not offer any nexus opinion because such knowledge was not available in the medical literature and any opinion would be speculation. The examiner was unable to directly connect the abdominal adhesions to the in-service tubal reconstruction. The examiner explained that because the Veteran had also undergone a tubal ligation prior to service and a hysterectomy with removal of the ovaries after service, any of those surgeries could have caused her adhesions. The examiner was additionally unable to tell without speculation if the Veteran's adhesions were aggravated by the in-service tubal reconstruction. An evaluation of the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Regarding the Veteran's residual nontender abdominal scar from her total hysterectomy, the Board concludes that the September 2006 VA medical opinion finding no relation between the abdominal scar and service is probative and persuasive based on the examiner's thorough and detailed examination of the Veteran as well as the adequate rationale for the opinion. The examiner found that the hysterectomy had to be undertaken due to the Veteran's enlarged uterus with fibroids and abnormal PAP, which were conditions that occurred after service. In addition, there are no contrary competent medical opinions of record. With respect to the Veteran's total abdominal hysterectomy with residuals and the slight cystocele with intermittent urinary incontinence, the Board concludes that the October 2009 VA medical opinions finding no relation between the hysterectomy and cystocele and service are probative and persuasive. While no rationale has been offered for the opinions, the examiner did conduct a thorough and detailed examination of the Veteran, and there are no contrary competent medical opinions of record. As for the Veteran's past uterine fibroids that had been removed with abdominal hysterectomy, the Board concludes that the September 2006 and October 2009 VA medical opinions finding no relation between the uterine fibroids and service are probative and persuasive based on the examiners' thorough and detailed examinations of the Veteran as well as the adequate rationales for the opinions. The examiners found that the Veteran did not have a fibroid uterus in service and that the first documentation of her enlarged uterus was in 1993, which was more than 10 years after discharge from service. In addition, there are no contrary competent medical opinions of record. Regarding the Veteran's past ovarian cysts and past adhesions with abdominal pain and cramping that had been resolved with total hysterectomy, the Board concludes that the September 2006 and October 2009 VA medical opinions are probative and persuasive. Although the examiners were unable to offer any nexus opinions about the ovarian cysts and adhesions because any nexus opinions would be speculative, an examiner's conclusion that a diagnosis or etiology opinion is not possible without resort to speculation is considered to be a medical conclusion just as much as a firm diagnosis or a conclusive opinion. The Board may rely on such a conclusion if the examiner explains the basis for such an opinion, bases the opinion on sufficient facts or data, and clearly identifies precisely what facts cannot be determined. Additionally, the examiner may have an obligation to conduct research in the medical literature depending on the evidence in the record at the time of the examination. Jones v. Shinseki, 23 Vet. App. 382 (2010). In the present cases, the examiners explained that a nexus opinion for the ovarian cysts would be speculative because the Veteran did not have any tests documenting ovarian cysts until March 1996. They also explained that because the Veteran had undergone a tubal ligation prior to service as well as a hysterectomy after service, any of those surgeries could have caused the Veteran's adhesions, and therefore, they were unable to tell without speculation whether the adhesions were directly related to or aggravated by the in-service tubal reconstruction. Furthermore, the VA examiners noted that such knowledge regarding the relation of the adhesions to service was not available in the medical literature. Therefore, the opinions indicate that the phrase without resort to speculation reflects the limitations of knowledge in the medical community at large and not those of the particular examiner. The Board thus finds that the Veteran's past ovarian cysts and abdominal adhesions with pain and cramping are not related to her period of service. The Board also finds that the adhesions could be due to any of three surgeries, only one of which occurred during the Veteran's service. Therefore, the Board finds that it is not at least as likely as not that the adhesions were the result of the inservice surgery. With respect to the Veteran's residual nontender umbilical scar from the in-service tubal reanastomosis, the usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, including postoperative scars, absent or poorly functioning parts or organs, will not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1) (2009). In this case, the Veteran's in-service tubal reconstruction had the effect of ameliorating her pre-service tubal ligation, and the residual umbilical scar is considered to be a usual effect of the surgical treatment. The competent evidence of record does not show that the Veteran's residual gynecological conditions from the in-service tubal reanastomosis were aggravated by service. Therefore, service connection for a residual nontender umbilical scar from in- service tubal reanastomosis is not warranted. Service connection may be granted when all the evidence establishes a medical nexus between military service and current complaints. Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). In this case, the Board finds that the evidence is against a finding of a nexus between military service and the Veteran's current gynecological disability because the evidence does not show that this disability is due to the Veteran's service in any way. The Veteran and her father contend that her current gynecological disability is related to her active service. However, as laypersons, they are not competent to give a medical opinion on diagnosis, causation, or aggravation of a medical condition. Bostain v. West, 11 Vet. App. 124 (1998); Routen v. West, 142 F.3d. 1434 (Fed. Cir. 1998); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The Board acknowledges that the Veteran and her father are competent to give evidence about what they experienced. Layno v. Brown, 6 Vet. App. 465 (1994). Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67 (1997). Therefore, the Veteran and her father can testify to that which they are competent to observe, such as abdominal pain or abnormal bleeding, but they are not competent to provide a medical diagnosis for any gynecological disability or to relate any gynecological disability medically to her service. The Board finds that the preponderance of the medical evidence weighs against a finding that the Veteran's gynecological disability developed in service. Therefore, the Board concludes that the gynecological disability was not incurred in or aggravated by service. As the preponderance of the evidence is against the claim for service connection, the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Ratings for service-connected disabilities are determined by comparing the symptoms the Veteran is presently experiencing with criteria set forth in VA's Schedule for Rating Disabilities which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2009). Separate diagnostic codes identify the various disabilities. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2009). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2009). Also, when making determinations as to the appropriate rating to be assigned, VA must take into account the Veteran's entire medical history and circumstances. 38 C.F.R. § 4.1 (2009); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran has been diagnosed with cold urticaria, or cold hives. The Board notes that where the Veteran's diagnosed condition does not match any of the diagnostic codes contained in the rating schedule, it is permissible to rate the condition under a closely related disease or injury, in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. 38 C.F.R. § 4.20 (2009). One diagnostic code may be more appropriate than another based upon factors such as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. The RO rated the Veteran's cold urticaria by analogy using the criteria found in Diagnostic Code 7118, which contemplates disability due to angioneurotic edema. 38 C.F.R. § 4.104, Diagnostic Code 7118. Because of the the nature of the Veteran's disability, the Board finds that the rating criteria applied by the RO are appropriate. Pernorio v. Derwinski, 2 Vet. App. 625 (1992); 38 C.F.R. §§ 4.20, 4.21 (2009). The Board notes that a new diagnostic code contemplating urticaria, Diagnostic Code 7825, was created when the criteria used to evaluate disabilities involving the skin were amended in August 2002. See 67 Fed. Reg. 49,590-49,599 (Jul. 31, 2002). The Board finds that the Veteran's disability can also be rated under 38 C.F.R. § 4.118, Diagnostic Code 7825 (2009). The Board can identify no more appropriate diagnostic codes and the Veteran has not identified any. Butts v. Brown, 5 Vet. App. 532 (1993). Accordingly, the Board will proceed with an analysis of the Veteran's disability under these diagnostic codes. When a law or regulation changes during the pendency of a Veteran's appeal, the version most favorable to the Veteran applies, absent congressional intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). By regulatory amendment effective January 12, 1998, substantive changes were made to the schedular criteria for evaluating the cardiovascular system, including the criteria for evaluating angioneurotic edema. 62 Fed. Reg. 65207-65224 (1997). The criteria used to evaluate disabilities involving the skin were also amended in August 2002. 67 Fed. Reg. 49,590-49,599 (Jul. 31, 2002). The Board will proceed with consideration of this appeal, applying the version of the criteria which is more favorable to the Veteran, subject to the effective date limitations, such that previous criteria can be used during the entire rating period while amended criteria can only be used from their effective date. VAOPGCPREC 3-2000 (Apr. 10, 2000), 65 Fed. Reg. 33,421 (2000); Bernard v. Brown, 4 Vet. App. 384 (1993). The Board notes that the criteria for rating skin disabilities were revised again, effective October 23, 2008. Those amendments only apply to applications for benefits received on or after October 23, 2008, or where the Veteran specifically requests review under those regulations. 73 Fed. Reg. 54, 708 (Sept. 23, 2008). While the Veteran can request a review under the new criteria, the Veteran has not requested such a review. Therefore, the amended skin regulations effective October 23, 2008, are not for application in this appeal. According to rating criteria in effect prior to January 12, 1998, for angioneurotic edema, mild infrequent attacks of moderate extent and duration warrant a 10 percent rating. Frequent attacks of moderate extent and duration warrant a 20 percent rating. A severe condition with frequent attacks of prolonged duration and with severe manifestations warrants a 40 percent rating. 38 C.F.R. § 4.104, Diagnostic Code 7118 (1997). Under the new rating criteria for angioneurotic edema, a 10 percent rating is warranted if there are attacks without laryngeal involvement lasting one to seven days and occurring two to four times a year. A 20 percent rating is warranted if there are attacks without laryngeal involvement lasting one to seven days and occurring five to eight times a year, or; attacks with laryngeal involvement of any duration occurring once or twice a year. A 40 percent rating is warranted where there are attacks without laryngeal involvement lasting one to seven days or longer and occurring more than eight times a year, or; attacks with laryngeal involvement of any duration occurring more than twice a year. 38 C.F.R. § 4.104, Diagnostic Code 7118 (2009). Under Diagnostic Code 7825, a 10 percent rating is warranted where there is evidence of recurrent episodes occurring at least four times during the past 12-month period, and; responding to treatment with antihistamines or sympathomimetics. A 30 percent rating is warranted where there is evidence of recurrent debilitating episodes occurring at least four times during the past 12-month period, and; requiring intermittent systemic immunosuppressive therapy for control. A maximum 60 percent rating is warranted where there is evidence of recurrent debilitating episodes occurring at least four times during the past 12-month period despite continuous immunosuppressive therapy. 38 C.F.R. § 4.118, Diagnostic Code 7825 (2009). Post-service VA and private medical records dated from June 1982 to February 2010 show that the Veteran received intermittent treatment for her hives. She suffered from such symptoms as itchy and dry papular rashes and fatigue associated with her hives. She treated her hives daily with antihistamines such as Benadryl, Periactin, Loratidine, and Hydroxyzine. On VA examination in May 1995, the Veteran complained of breaking out in large welts when she was exposed to cold weather. The examiner diagnosed her with hives. At a September 2006 VA examination, the Veteran complained of her hives occurring about once or twice a week and lasting about 1.5 to 2 hours. She reported that they occurred on the face, arms, hands, stomach, knees, and ankles. She stated that they were red raised blotches that itched. She also reported that she hyperventilated in cold weather and turned color. The examiner noted that the Veteran took Benadryl orally about twice a week to treat her disability. The Veteran complained that she had to live in a warm climate, avoid low air conditioning, avoid cold water in pools, avoid traveling to cold areas for long periods of time, and take a sweater or jacket to movies and restaurants. Examination revealed no scars related to the Veteran's skin disease. The Veteran had no hives on examination with 0 percent of exposed areas affected and 0 percent of the entire body affected. There was no disfigurement from the skin disability. On VA examination in October 2009, the Veteran reported that her hives occurred about four times a month and lasted about four hours. She stated that they occurred on her face, arms, hands, stomach, knees, and ankles. She described the hives as being red raised blotches that itched. She reported last having hives two weeks previously and complained of getting hives in the previous two years when she became too hot. The Veteran complained of having to avoid low air conditioning, cold water in pools, traveling to cold areas for long periods of time, and having to take a sweater or jacket to movies and restaurants. The examiner noted that the Veteran had been treated daily with the oral antihistamines Loratidine and Hydroxyzine. Examination revealed no scars related to the Veteran's skin disease. The Veteran had no hives on examination with 0 percent of exposed areas affected and 0 percent of the entire body affected. There was no disfigurement from the skin disability. The Board finds that a rating in excess of 10 percent for cold urticaria is not warranted under Diagnostic Code 7118. Under the criteria in effect prior to January 12, 1998, a 20 percent rating was only warranted for frequent attacks of moderate extent and duration. However, the Board finds that the Veteran's cold urticaria is productive of no more than mild, infrequent attacks of mild extent and duration. The medical evidence of record indicates that the Veteran's cold urticaria occurred intermittently at about four times a month, and each episode lasted only four hours. The Veteran's disability also fails to meet the criteria under Diagnostic Code 7118 in effect after January 12, 1998. There is no evidence of attacks without laryngeal involvement lasting one to seven days and occurring five to eight times a year. Although the Veteran experiences attacks without laryngeal involvement about four times a month, each episode only lasts four hours. Furthermore, the Veteran does not suffer from attacks of cold urticaria with laryngeal involvement. Therefore, the Board finds that an increased initial rating for hives is not warranted under Diagnostic Code 7118. Similarly, an increased initial rating for the Veteran's hives is not warranted under the rating criteria for urticaria in Diagnostic Code 7825. Under that diagnostic code, a 30 percent rating is warranted for recurrent debilitating episodes occurring at least four times during the past 12-month period and the requirement of intermittent systemic immunosuppressive therapy for control. On the Veteran's VA examinations in September 2006 and October 2009, the Veteran was found to require the use of systemic antihistamines. She had attacks of hives about 4 times a month that lasted four hours at the most. The hives were red raised blotches that itched and could occur on her face, arms, hands, stomach, knees, and ankles. There was no evidence of disfigurement or scars relating to her hives. Other than having to avoid or take preventive measures against cold temperatures and water, the Veteran's urticaria did not affect her daily activities. Although the Veteran had attacks of hives four times a month, the evidence does not show that the attacks were debilitating in any way. Furthermore, the Veteran's cold urticaria was controlled by oral antihistamines and did not require the use of immunosuppressive therapy. Therefore, the Board finds that an increased initial rating for hives is not warranted under Diagnostic Code 7825. In sum, the weight of the credible evidence demonstrates that the Veteran's cold urticaria does not warrant an initial rating in excess of 10 percent under Diagnostic Codes 7118 and 7825 for all periods under consideration since service connection was established. As the preponderance of the evidence is against the claim for an increased rating, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board finds no evidence that the Veteran's service-connected cold urticaria disability presents such an unusual or exceptional disability picture at any time so as to require consideration of an extra-schedular rating. 38 C.F.R. § 3.321(b)(1) (2009). The objective medical evidence of record shows that manifestations of the Veteran's service-connected hives do not result in a marked functional impairment to a degree other than that addressed by VA's Rating Schedule. The schedular rating criteria are designed to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155 (West 2002). Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2009). The Board finds that the evidence does not show frequent hospitalization due to the cold urticaria or that the disability causes marked interference with employment beyond that envisions by the schedular rating already assigned. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008); Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996). Duties to Notify and Assist the Appellant Upon receipt of a complete or substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. This notice requires VA to indicate which portion of that information and evidence is to be provided by the claimant and which portion VA will attempt to obtain on the claimant's behalf. See 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. § 3.159 (2009). The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the RO sent correspondence in May 2001 and April 2006; rating decisions in August 1995 and December 2002; a statement of the case in March 1996; and supplemental statements of the case in November 1996, February 1997, December 2002, March 2003, January 2004, and July 2005. These documents discussed specific evidence, the particular legal requirements applicable to the claims, the evidence considered, the pertinent laws and regulations, and the reasons for the decisions. VA made all efforts to notify and to assist the appellant with regard to the evidence obtained, the evidence needed, the responsibilities of the parties in obtaining the evidence, and the general notice of the need for any evidence in the appellant's possession. The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claims with an adjudication of the claims by the RO subsequent to receipt of the required notice. There has been no prejudice to the appellant, and any defect in the timing or content of the notices has not affected the fairness of the adjudication. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) (specifically declining to address harmless error doctrine); see also Dingess v. Nicholson, 19 Vet. App. 473 (2006). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the final adjudication in the November 2009 supplemental statement of the case. In addition, all relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has also obtained medical examinations in relation to these claims. Thus, the Board finds that VA has satisfied both the notice and duty to assist provisions of the law. ORDER Service connection for PTSD is granted. Service connection for a gynecological disability is denied. An initial rating in excess of 10 percent for hives is denied. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs