Citation Nr: 1027864 Decision Date: 07/26/10 Archive Date: 08/10/10 DOCKET NO. 03-10 032 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for carcinoma in situ of the exocervix. 2. Entitlement to service connection for a gynecological disorder other than carcinoma in situ of the exocervix. (The issue of entitlement to reimbursement of unauthorized medical expenses is the subject of a separate decision.) REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Zawadzki, Associate Counsel INTRODUCTION The Veteran served in the Army National Guard from April 1988 to April 1996 with multiple periods of inactive duty for training (INADT) and active duty for training (ADT), to specifically include active duty from July 1990 to October 1990 and from January 1992 to February 1993. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2002 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, in which the RO denied service connection for carcinoma in situ of the exocervix. In July 2004, the Veteran testified during a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. In December 2004 and April 2006, the Board remanded the claim for service connection for carcinoma in situ of the exocervix for further development. Thereafter, in July 2008, the Board sought an independent medical opinion (IME) regarding the claim for service connection for carcinoma in situ of the exocervix. In February 2009 the Board denied the Veteran's claim for service connection for carcinoma in situ of the exocervix. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2010 Joint Motion to Vacate and Remand, the Secretary of Veterans Affairs (VA) and the Veteran, through her representative, moved that the February 2009 decision be vacated and remanded. The Court granted the motion by Order in March 2010. In the Joint Motion, the parties found that the Board did not provide adequate reasons and bases as to why it did not consider whether pelvic inflammatory disease (PID) is related to service, noting that the record showed that the Veteran had been diagnosed with PID since 1992 and that service department records revealed that she acquired PID in service. The Joint Motion included citation to Clemons v. Shinseki. See Joint Motion, at p. 2. In that case, the Court held that claims for service connection are properly viewed as claims for service connection for a disability manifested by claimed symptomatology. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In light of the evidence of record, and the Joint Motion, the Board finds that the Veteran's claim for service connection for carcinoma in situ of the exocervix included a claim for service connection for PID. Accordingly, the Board has recharacterized the matters on appeal as reflected on the title page. As will be discussed in the remand below, further development is required regarding the claim for service connection for a gynecological disorder other than carcinoma in situ of the exocervix. The Board, however, can find no reason why it should not adjudicate the narrow issue of service connection for carcinoma in situ of the exocervix, which has been fully developed, and will do so in the decision that follows, with the assurance that the broader issue of service connection for a gynecological disorder other than carcinoma in situ of the exocervix will be fully developed and adjudicated upon remand. To not adjudicate the claim for service connection for carcinoma in situ of the exocervix at this time would require that it be remanded to the agency of original jurisdiction (AOJ), an exercise that would serve no useful purpose because that issue is already fully developed. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands that would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). The Board notes that the claim for service connection for carcinoma in situ of the exocervix was most recently addressed in a June 2007 supplemental statement of the case (SSOC). Additional VA and private treatment records have been associated with the claims file subsequent to issuance of that SSOC. This evidence was not accompanied by a waiver of review by the AOJ. See 38 C.F.R. § 20.1304 (2009). However, this evidence is negative for complaints regarding or treatment for carcinoma in situ of the exocervix and, as such, is not pertinent to the claim herein decided. Thus, while the Veteran has not waived RO consideration of the evidence received since issuance of the SSOC, a remand for such consideration is unnecessary. See 38 C.F.R. § 20.1304. The issue of entitlement to service connection for a gynecological disorder other than carcinoma in situ of the exocervix is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim herein decided has been accomplished. 2. Competent and persuasive evidence of record does not demonstrate that carcinoma in situ of the exocervix was manifested during active service, was manifested within the first post-service year, or was developed as a result of an established event, injury, or disease during active service. CONCLUSION OF LAW Carcinoma in situ of the exocervix was not incurred in or aggravated by during active military service, nor may in-service incurrence of a malignant tumor be presumed. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1116, 1137, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the Court have been fulfilled. In this case, the Veteran's claim for service connection for carcinoma in situ of the exocervix was received in January 2002. Thereafter, she was notified of the general provisions of the VCAA by the RO and the AMC in correspondence dated in March 2002, February 2005, and July 2006. These letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing her claim, identified the Veteran's duties in obtaining information and evidence to substantiate her claim, and provided other pertinent information regarding the VCAA. Thereafter, the claim was reviewed and an SSOC was issued in June 2007. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006), Mayfield v. Nicholson (Mayfield III), 499 F.3d 1317 (Fed. Cir. 2007). During the pendency of this appeal, the Court, in Dingess v. Nicholson, 19 Vet. App. 473 (2006), found that the VCAA notice requirements applied to all elements of a claim. Notice as to this matter was provided in July 2006. The Veteran has been made aware of the information and evidence necessary to substantiate her claim and has been provided opportunities to submit such evidence. A review of the claims file shows that VA has conducted reasonable efforts to assist her in obtaining evidence necessary to substantiate her claim during the course of this appeal. Her service treatment records, service personnel records, and all relevant VA and private treatment records pertaining to her claim have been obtained and associated with her claims file. The Veteran has also been provided with a VA medical examination as well as an independent medical opinion to assess the nature and etiology of her claimed carcinoma in situ of the exocervix. The Board has considered the fact that the record reflects that the Veteran is in receipt of Social Security disability benefits. The Social Security Administration (SSA) decision is not of record; however, a January 2007 VA examination report reflects that the Veteran was awarded SSA benefits for PTSD. There is no indication that the Veteran is in receipt of SSA benefits for carcinoma in situ of the exocervix. There has been no argument that the SSA records are pertinent to the claim being adjudicated in this decision as to require that additional adjudication resources be expended to obtain these records. See 38 U.S.C.A. § 5103A(b),(c); Baker v. West, 11 Vet. App. 163, 169 (1998); Grivois v. Brown, 6 Vet. App. 136, 139 (1994); Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992). Similarly, the record reflects that the Veteran is in receipt of state disability benefits for PTSD and has received therapy at the Vet Center. While neither the state disability retirement benefit records, nor Vet Center counseling records have been associated with the claims file, the record reflects that such records pertain to service-connected PTSD, as opposed to carcinoma in situ of the exocervix. Therefore, these records are not pertinent to the claim herein decided, and a remand to obtain these records would impose unnecessary additional burdens on adjudication resources, with no benefit flowing to the Veteran, and is, thus, unnecessary. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). The Board acknowledges that the claim for service connection for a gynecological disorder other than carcinoma in situ of the exocervix is being remanded, in part, to attempt to obtain the report of a private laparoscopy performed in April 2003. There is no indication that this report includes a finding of carcinoma in situ of the exocervix; rather, the Veteran's private physician stated that this laparoscopy revealed residual adhesive disease in the pelvis. Based on the foregoing, the Board finds that this report is not pertinent to the claim herein decided, and a remand to obtain this record would impose unnecessary additional burdens on adjudication resources, with no benefit flowing to the Veteran, and is, thus, also unnecessary. See Soyini, 1 Vet. App. at 546. Furthermore, the Veteran has not identified any additional, relevant evidence that has not been requested or obtained. The Veteran has been notified of the evidence and information necessary to substantiate her claim, and she has been notified of VA's efforts to assist her. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating her claim. Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. See 38 C.F.R. § 3.303(d). Service connection shall be granted to a veteran if the veteran served 90 days or more during a war period or after December 31, 1946 or had peacetime service on or after January 1, 1947, and a malignant tumor, although not otherwise established as incurred in or aggravated by service, is manifested to a compensable degree within one year following the requisite service. See 38 C.F.R. §§ 3.307, 3.309. As a general matter, service connection for a disability on the basis of the merits of such claim is focused upon (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. See Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Active duty includes any period of ADT during which the individual concerned was disabled from a disease or injury incurred or aggravated in line of duty, and any period of INADT during which the individual concerned was disabled from an injury incurred or aggravated in line of duty. 38 C.F.R. § 3.6 Accordingly, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ADT or from injury incurred or aggravated while performing INADT. See 38 U.S.C.A. §§ 101(24), 106, 1110. Factual Background Service treatment records are negative for treatment for carcinoma in situ of the cervix or cervical cancer. A physical examination performed on entrance to active duty in July 1990 noted that a June 1990 vaginal pelvic examination was normal. In association with the physical examination, the Veteran also provided a Report of Medical History in July 1990, in which she indicated that she had been previously treated for irregular periods and had experienced a change in her menstrual cycle. No further explanation was provided. The record reveals that the Veteran was hospitalized and treated for PID in May 1992. A physical examination performed while on active duty in November 1992 included a vaginal pelvic examination which was normal. The record reflects that the Veteran received gynecological care from private physicians during her period of active duty service. These records reflect that in July 1992, she was diagnosed by D.B., M.D., with anemia, etiology uncertain, during a breast and pelvic examination. Additional private treatment records show that she received gynecological care from M.A.C., M.D. from 1992 to 1997, to include during her period of active duty service. A July 1992 Pap smear was class II; atypical, without evidence of malignancy or squamous atypia; possibly dysplastic, of indeterminate significance. A December 1992 treatment record noted that the Veteran was hospitalized in May 1992 for dehydration and had a diagnosis of PID. A repeat Pap smear in December 1992 was abnormal, class III. A December 1992 pathology report noted that a cervical biopsy showed slight to moderate nonkeratinizing dysplasia with condylomatous atypia. A December 1992 colposcopy examination showed mild dysplasia and possible HPV. A December 1992 pelvic ultrasound was normal. A May 1993 Pap smear performed at Raleigh Pathology showed a high grade squamous intraepithelial lesion; moderate to severe dysplasia; and cellular changes associated with human papilloma virus (HPV). A May 1993 pathology report from the cervical biopsy identified condylomatous atypia and severe dysplasia (CIN 3). Endocervical currettings revealed endocervical columnar epithelium negative for dysplasia and condyloma. A Wake Medical Center June 1993 operative report reflects that the Veteran underwent laser vaporization of the exocervix. The pre-operative and post-operative diagnoses were carcinoma in situ of the cervix. An October 1993 Pap smear showed benign cellular changes, without atypical or malignant cells; Class I. A February 1994 operative report from Wake Medical Center reflects that the Veteran underwent a diagnostic laparoscopy to determine the origin of her chronic pelvic pain, status post laser vaporization (ablation) of the cervix. The test showed normal fallopian tubes, ovaries and uterus and the postoperative diagnosis was normal pelvis. Pap smears dated in February 1994, May 1994, September 1994, January 1995, and June 1995 showed only benign cellular changes, without atypical or malignant cells present; Class I. A clinical record dated in October 1995 from F.C.H., M.D., shows that after complaints of left pelvic pain, the appellant was diagnosed with a left ovarian cyst. An October 1995 transabdominal and endovaginal pelvic ultrasound examination demonstrated a small right ovarian follicle. An April 1996 Pap smear revealed squamous cellular changes, associated with a benign reactive/reparative process; Class I. Emergency room records dated in June 1996 from Rex Healthcare noted a medical history of left ovarian cyst and noted complaints of left lower quadrant pain. The diagnosis was ruptured ovarian cyst. A February 1997 Pap smear was within normal limits, with no atypical or malignant cells present; Class I. During an August 1997 VA psychiatric examination, the Veteran complained of pelvic pain attacks one or two times a month. During VA treatment in December 2001, the Veteran indicated that she had a private October 2001 Pap smear and routine gynecological examination with normal findings. A January 2002 report from Wake Radiology reflects that transabdominal and endovaginal pelvic ultrasound examination revealed normal pelvic findings. Private treatment records dated from September to November 2002 from Cary Obstetrics and Gynecology reflect complaints of left lower quadrant pain and chronic pelvic pain. An October 2002 cytopathology report revealed findings negative for intraepithelial lesion or malignancy. The Veteran underwent laparoscopy and bilateral tubal ligation in November 2002 at Western Wake Medical Center. The procedure revealed normal uterus, tubes, and ovaries bilaterally. She did have an adhesion of the omentum to the anterior peritoneum from the prior laparoscopic surgery. No other abnormalities were noted. In a May 2003 letter, G.K.S., M.D., of Cary Obstetrics and Gynecology noted that the Veteran had a long history of significant pelvic pain. The physician detailed that his letter was to clarify the relationship of some of the Veteran's recurrent problems to her prior in-service diagnosis of PID. It was noted that PID has long been known to be closely associated to abnormal Pap smears through the mechanism of the human papilloma virus and to cause significant pelvic adhesions which can result in pelvic pain for prolonged periods of time. The physician indicated that the Veteran had had a persistent, significant chronic pelvic pain over the last several years while being followed at his practice. He added that a laparoscopy performed over the last month revealed some residual adhesive disease in the pelvis, the etiology of which may in fact be from PID. During her July 2004 hearing, the Veteran complained of breakthrough bleeding, abnormal menstrual disturbances, back pain, leg pain, cramping, pelvic pain, vomiting, diarrhea, and PTSD. She also submitted medical treatise information concerning risk factors, symptoms, and treatment options of cervical cancer as well as PID and HPV. In a written opinion dated in August 2004, C. N. B., M.D., a neuro-radiologist, indicated that he had reviewed the appellant's service medical records, post-service medical records, imaging reports, other medical opinions, medical literature; and also conducted a patient interview. He opined that the appellant's lower abdominal symptoms of bloating, pain, irregular bleeding/periods/infections and diarrhea/constipation which had all been occurring since 1992 were all likely due to her service- acquired PID or its sequela and/or secondary to her 1994 laparoscopy. He further wrote that without a current cervical evaluation her [the appellant's] biopsy-proven "...mild to moderate dysplasia with condylomatous atypia...HPV... carcinoma in situ..." could be contributing to her current symptomatology. Dr. C.N.B. stated that his opinion was based upon these specific reasons: 1) the Veteran has PID; 2) PID is well known to cause pelvic pain and complications with adjacent organs and many of the appellant's symptoms correspond to complications of this disease; 3) she had a laparoscope in 1994, which is well known to cause pelvic inflammation and scarring and bowel and/or bladder complaints; 4) the literature supports associations between PID and other pelvic complications; and 5) the medical record does not include other diagnoses to account for her symptoms. During VA treatment in November 2004, the Veteran indicated that she had a private April 2004 Pap smear which was normal. The Veteran underwent a VA examination in March 2005, at which time the claims file was reviewed. The VA obstetrician/gynecologist discussed the Veteran's detailed past obstetric history. A 1992 Pap smear was class II with repeat December 1992 Pap smear revealing abnormal findings. Thereafter, she underwent colposcopy and biopsies. A pathology report showed condylomatous atypia with slight to moderate dysplasia. This was treated with cryosurgery therapy. Follow-up May 1993 pathology report revealed class III Pap smear consistent with severe dysplasia. She underwent repeat colposcopy and biopsies with the pathology report showing condylomatous atypia and severe dysplasia of the cervix. Endocervical currettings were also noted to be negative. She underwent laser conization in June 1993. The examiner pointed out that while the pathology diagnosis was severe dysplasia-her gynecological surgeon used the term "carcinoma in situ of the cervix" as an operative diagnosis at the time of her laser therapy. It was further noted by the VA physician that the Veteran had undergone numerous normal Pap smears since then. The Veteran also reported a history of chronic problems of pelvic pain, abdominal bloating, especially in the left lower quadrant, and irregular vaginal bleeding. She was noted to have extensive workups for these symptoms including numerous ultrasounds and other diagnostic tests. She also underwent a diagnostic laparoscopy in 1994 that revealed completely normal pelvic organs. She again underwent a diagnostic laparoscopy in November 2002 and also had a tubal ligation carried out at that time. The only finding being that the operative procedure was one band of adhesion from omentum to anterior abdominal wall, which was thought to be from her previous laparoscopy. This was easily lysed. The uterus, tubes, and ovaries were all reported otherwise as completely normal. The examiner further noted that while there had been a question in the past of a diagnosis of pelvic inflammatory disease, both of her laparoscopic examinations are noted to have been completely unremarkable. The Veteran indicated that she had a Pap smear two weeks earlier which was normal. In his March 2005 examination report, the VA examiner noted that he had reviewed the Veteran's claims file, interviewed the Veteran, and indicated that a pelvic examination was denied by the Veteran due to her prior psychologic history and aversion to male gynecologists. However, his diagnoses included: history of severe dysplasia of the cervix, treated with laser conization with long-term negative follow-up; and history of recurrent pelvic pain, irregular bleeding, and associated pelvic symptoms with two completely negative laparoscopic examinations. In response to specific questioning as to whether carcinoma in situ in the cervix is a malignancy, the examiner emphasized that most gynecologists and pathologists still make a distinction between "dysplasia of the cervix," which is a pre-cancerous lesion and "carcinoma in situ in the cervix," which is the very early stage of cervical carcinoma/cancer. In most cases the diagnosis and treatment may be altered based upon the distinction between the two, which may be subtle in some cases; but it is still a widely accepted approach in terms of diagnosis and treatment. The gynecologist also questioned the qualifications of the neuro-radiologist who rendered the August 2004 opinion to offer such an opinion. During VA treatment in May 2005, the Veteran indicated that she had a private February 2005 Pap smear and routine gynecological examination with normal findings. In an additional statement dated in July 2005, Dr. C. N. B. indicated that he had reviewed the VA examiner's March 2005 report and did not see anything to make him change his previous opinion. In an April 2006 statement, a Chief in the Personal Affairs/Line of Duty Branch from the Department of the Army determined that the Veteran acquired PID and HPV due to a 1989 sexual assault while attending Reserve Officer Training Camp and that this subsequently placed her in a very high risk of acquiring cervical dysplasia and cervical cancer. The Veteran was found to be in the line of duty for PID and HPV. The Chief indicated in her statement that she had not received any communication from the Office of the Surgeon General, and that she had read medical research material and arrived at the decision based on her review. It should be noted that the Chief is a lay person and not a medical authority. During VA treatment in August 2006 and April 2007, the Veteran indicated that she had normal private Pap smears around April 2006 and December 2006, respectively. In July 2008, the Board sought an independent medical opinion (IME) to answer the following inquiries: 1) Is there any evidence that the Veteran had carcinoma in situ of the exocervix during service or within one year thereafter? 2) If the response is negative, is there evidence that the Veteran had carcinoma in situ of the exocervix at any time after service which, based on the evidence of record can be related to service based on continuity of symptomatology? and 3) If it is determined that the Veteran had carcinoma in situ of the exocervix which can be related to service, does she have a present identifiable disability as a result of that cancer, and if so, what is the disability? Thereafter, the Board obtained an August 2008 opinion from an Associate Professor in the Department of Obstetrics and Gynecology at the University of Alabama-Birmingham School of Medicine. This physician made findings based on his review of the record but did not examine the Veteran. In his conclusions, he indicated that there was no evidence that the Veteran had carcinoma in situ of the exocervix during service or within one year thereafter. The physician noted that while the 1993 physician's operative note used the preoperative and postoperative diagnosis of carcinoma in situ, the supporting pathology reports do not support that assertion. It was further noted that the May 1993 Pap smear revealed moderate to severe dysplasia and the subsequent May 1993 colposcopic biopsies revealed severe dysplasia and condylomatous atypia. However, the pathologist did not describe any evidence of carcinoma in situ. The physician then detailed that laser conization of the cervix does not result in a pathologic specimen for evaluation and that all subsequent cervical cytology (Pap smears) had been normal. The physician further indicated that there was no evidence that the Veteran had carcinoma in situ of the exocervix at any time after service that could be related to service based on continuity of symptomatology. It was noted that available records described normal cervical cytology from October 21, 1993 to September 2002. Finally, the physician clearly opined that the Veteran had no pathologic evidence of carcinoma in situ. Analysis As discussed in the introduction, the claim for service connection for a gynecological disorder other than carcinoma in situ of the exocervix is being remanded for further development. Accordingly, the Board's decision herein is limited to consideration of entitlement to service connection for carcinoma in situ of the exocervix. Considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection is not warranted. Service treatment records are negative for findings of carcinoma in situ of the exocervix. As described above, extensive post- service testing has been conducted due to the Veteran's reported problems with chronic pelvic pain. The Board has considered the fact that the May 2003 private gynecologist's statement and the August 2004 private neuro- radiologist's opinions note findings of residual adhesive disease in the pelvis and PID, respectively; however, neither of these physicians makes reference to a current diagnosis of carcinoma in situ of the exocervix. In this regard, while, in his August 2004 statement, Dr. C.N.B. indicated that the PID "could" be contributing to the Veteran's current symptomatology, he did not specifically identify carcinoma in situ of the exocervix; in fact, he concluded his August 2004 statement this way, "It is my opinion that this patient's lower abdominal symptoms of bloating, pain, irregular bleeding/periods/infections, diarrhea/constipation which have all been occurring since 1992 are likely due to her service acquired PID or its sequella and/or secondary to her 1994 laparoscope." Rather, the only medical opinion which addresses the question of whether the Veteran has carcinoma in situ of the exocervix related to service is that rendered by the physician who provided the August 2008 IME opinion. The Board recognizes that a June 1993 operative report clearly reflects pre-operative and post-operative diagnoses of carcinoma in situ of the cervix; however, the August 2008 medical opinion was prepared by a physician with a specialty in gynecology and provided consistent and detailed findings to support the conclusion that the Veteran did not have carcinoma in situ of the exocervix at any time during or after service. Further, the August 2008 IME specialist provided comprehensive findings, supported by clearly-stated rationale, after reviewing the extensive service and post-service records. The Board finds this opinion dispositive of the question of whether the Veteran has carcinoma in situ of the exocervix which was incurred in or aggravated by service, as the physician's findings were based on a review of the claims file and consideration of the Veteran's history. In addition, the physician provided a rationale for his opinion. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470- 71 (1993) (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). Thus, the only competent, probative (persuasive) opinion on the specific question of whether the Veteran has carcinoma in situ of the exocervix that is etiologically related to service weighs against the claim for service connection. As such, the Veteran is not entitled to service connection for a right or left shoulder disability. Moreover, the Board points out that, despite the pre and post- operative diagnoses rendered in June 1993, the August 2008 IME specialist specifically opined that the Veteran did not have carcinoma in situ of the exocervix during service or within one year thereafter. He specifically discussed the diagnoses in the 1993 operative note, but indicated that the contemporaneous pathology reports did not support such diagnoses. The IME specialist clearly stated that there was no pathologic evidence of carcinoma in situ. This specialist's opinion is supported by the opinion of the March 2005 VA examiner, who indicated that most gynecologists and pathologists still make a distinction between dysplasia of the cervix and carcinoma in situ of the cervix and commented that, while the gynecologic surgeon used the term carcinoma in situ of the cervix as an operative diagnosis, the pathology diagnosis was severe dysplasia. Based on the foregoing, the Board finds that the weight of the medical evidence is against the rebuttable presumption of service incurrence afforded to certain chronic diseases, to include malignant tumors. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The Board has also considered the medical articles submitted by the Veteran in support of her claim. Medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). However, the Court has held that medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Here, the treatise evidence which has been submitted by the Veteran is general in nature and does not specifically relate to the facts and circumstances surrounding her particular case. The Board has determined that competent and persuasive medical evidence indicates that the Veteran does not have carcinoma in situ of the exocervix. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110; 1131. Hence, in the absence of proof of carcinoma in situ of the exocervix (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 143-144 (1992). In addition to the medical evidence, in adjudicating this claim, the Board has considered the Veteran's and her representative's assertions; however, none of this evidence provides a basis for allowance of the claim. Laypersons, such as the Veteran and her representative, are generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). See also Bostain v. West, 11 Vet. App. 124, 127 (1998) citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Lay testimony is competent, however, to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). While the Veteran may report on the symptoms of her claimed disability; the evidence of record does not contain a current diagnosis of carcinoma in situ of the exocervix. For the foregoing reasons, the claim for service connection for carcinoma in situ of the exocervix must be denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53- 56 (1990). ORDER Entitlement to service connection for carcinoma in situ of the exocervix is denied. REMAND The Board's review of the claims file reveals that further action on the claim remaining on appeal is warranted. As an initial matter, while the March 2002, February 2005, and July 2006 VCAA letters advised the Veteran of the information and evidence necessary to substantiate her claim for service connection for carcinoma in situ of the exocervix, in light of the broadening of the claim to include a claim for service connection for a gynecological disorder other than carcinoma in situ of the exocervix, she should be furnished VCAA notice regarding the expanded claim. In addition, VA has a duty to obtain relevant records of treatment reported by private physicians. Massey v. Brown, 7 Vet. App. 204 (1994). In his May 2003 letter, Dr. G.K.S. stated that the Veteran had a laparoscopy performed over the last month which revealed some residual adhesive disease in the pelvis. No record of an April 2003 laparoscopy is associated with the claims file. While it is unclear whether the Veteran actually underwent laparoscopy in April 2003, in light of her July 2004 testimony that she had undergone two laparoscopies (the reports of February 1994 and November 2002 laparoscopies are currently associated with the claims file), the May 2003 letter from Dr. G.K.S. nevertheless suggests that she did, in fact, have a more recent laparoscopy. Moreover, while records of VA treatment as recently as April 2008 reflect normal findings on private Pap smears, the actual records of the Veteran's recent private gynecological treatment have not been associated with the claims file. The Board highlights that an October 2008 report of private neurological treatment indicated that the Veteran underwent endometrial ablation in September 2008. The most recent records of private gynecological treatment currently associated with the claims file are dated in November 2002. Accordingly, on remand, the AMC/RO should attempt to obtain all outstanding records of private gynecological treatment. VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C.A. § 5103A(d)(2) (West 2002 & Supp. 2009); 38 C.F.R. § 3.159(c)(4)(i) (2009); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon, 20 Vet. App. at 83. As discussed above, the Veteran was diagnosed with PID in May 1992. In August 2004, Dr. C.N.B. opined that the Veteran had PID and that her lower abdominal symptoms, which had been occurring since service, were all likely due to her service acquired PID. He added that she had adhesions removed during a laparoscope procedure in 2002 and that it was likely that such adhesions were due to a 1994 laparoscopic procedure for PID. Despite his opinion, in March 2005, the VA examiner indicated that, while there had been a question of a diagnosis of PID in the past, the Veteran's laparoscopic examinations in 1994 and 2002 were completely unremarkable. Dr. C.N.B. did not examine the Veteran and the March 2005 VA examiner did not perform a pelvic examination, although both reviewed the medical records. Dr. G.K.S. indicated in May 2003 that the Veteran had some residual adhesive disease in the pelvis, and that the etiology of this might be from PID. While this opinion suggests that the Veteran may have a current gynecological disorder related to service, it is simply too speculative to establish a nexus. See Bostain v. West, 11 Vet. App. 124, 127-28 (1998), quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a medical nexus). Given the above-described evidence, the Board finds that VA examination and medical opinion as to the relationship, if any, between any current gynecological disorder other than carcinoma in situ of the exocervix and service, based on full consideration of the Veteran's documented medical history and assertions, and supported by stated rationale, is needed to resolve the claim remaining on appeal. See 38 U.S.C.A. § 5103A. Considering the Veteran's March 2005 refusal of pelvic examination in light of her psychologic history and aversion to male gynecologists, the examination should be performed by a female physician, if possible. Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should provide the Veteran a VCAA notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), that advises her of the information and evidence necessary to substantiate her claim for service connection for a gynecological disorder other than carcinoma in situ of the exocervix. This notice should include an explanation as to the information or evidence needed to establish a disability rating and effective date, as outlined by the Court in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). 2. The AMC/RO should contact the Veteran and obtain the names and addresses of all medical care providers, VA and non-VA, which treated her for a gynecological disorder other than carcinoma in situ of the exocervix. Of particular interest are records of private gynecological treatment since November 2002, to include the report of any laparoscopy performed around April 2003. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. All attempts to procure records should be documented in the file. If the AMC/RO cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran and her representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 3. The Veteran should be afforded a VA examination to determine the etiology of any gynecological disorder other than carcinoma in situ of the exocervix. The examination should be performed by a female physician. All indicated tests and studies are to be performed. Prior to the examination, the claims folder must be made available to the physician for review of the case. A notation to the effect that this record review took place should be included in the report of the physician. Following examination of the Veteran and a review of the record, the examiner should identify any current gynecological disorder other than carcinoma in situ of the exocervix. In regard to any such diagnosed disorder, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's current gynecological disorder was incurred or aggravated as a result of active service. The examiner should review the claims file prior to the evaluation. A notation to the effect that this record review took place should be included in the report of the examiner. All examination findings, along with the complete rationale for all opinions expressed, should be set forth in the examination report. 4. The Veteran must be given adequate notice of the date and place of any requested examination. A copy of all notifications, including the address where the notice was sent must be associated with the claims folder. The Veteran is to be advised that failure to report for a scheduled VA examination without good cause shown may have adverse effects on her claim. 5. After ensuring that the development is complete, re-adjudicate the claim. If not fully granted, issue a supplemental statement of the case before returning the claim to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs