Citation Nr: 1301872 Decision Date: 01/16/13 Archive Date: 01/23/13 DOCKET NO. 05-37 307 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for endometriosis. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C.A. Skow, Counsel INTRODUCTION The Veteran served on active duty from October 1986 to January 1993. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In December 2011, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims files. In February 2012, the Board remanded this case for further evidentiary development. The Board notes that, in addition to the paper claims files, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND The Veteran seeks service connection for endometriosis. Service treatment records (STRs) show complaints of abdominal and menstrual pain on multiple occasions. In August 1988, a cervical biopsy revealed severe acute and chronic inflammation of the cervix, and the Veteran subsequently underwent cryosurgery in October 1988. In June 1990, the Veteran complained of pelvic and abdominal pain as well as breakthrough bleeding. In September 1991, she complained of abdominal pain, and an ultrasound of the right upper quadrant revealed no evidence of hepatic mass lesions or intrahepatic biliary dilation. A March 1992 record noted continued abdominal pain. Report of medical history dated in August 1992 reflects menstrual pain. The Veteran testified at her December 2011 hearing that she had abdominal pain essentially throughout her military service. In February 2012, the Board remanded this case for additional evidentiary development to include a VA medical opinion. Report of VA examination dated in March 2012 reflects that: The veteran has had a long history of dysfunctional uterine bleeding, and pelvic pain documented in the STRs. In the early 2000's she was formally diagnosed with endometriosis by laproscopic surgery. Medical/hormone treatment failed to control her symptoms and veteran had complete hysterectomy in 9/03. With total relief of symptoms. The examiner opined that endometriosis was less likely than not incurred in or caused by in-service injury, event, or illness because "The veteran was not diagnosed with endometriosis until early 2000's." In an October 2012 addendum to that opinion, the examiner stated that it was less likely as not that the Veteran's in-service symptoms were related to endometriosis, or had any effect on the progression of the disease. Her rationale was as follows: Review of currently available medical records fails to document chronicity of claimed condition during service or after discharge from service. Veteran was seen four times during a six month period in 1990 (total service time 5 years 10/1986-01/1993) for complaints of irregular menses, breakthrough bleeding and pelvic pain. An appropriate GYN consult was placed for evaluation. A post service provider note documents no abdominal pain. The Veteran was not diagnosed with endometriosis until 2002. Having carefully reviewed the 2012 VA medical opinion and addendum, the Board finds that it is inadequate. The Veteran clearly believes that her in-service symptoms were early manifestations of later diagnosed endometriosis and has presented competent lay testimony regarding symptomatology including uterine bleeding and pelvic pain; however, the examiner does not explain why these symptoms are not early manifestations of endometriosis based on any history, clinical findings, or medical knowledge of the disease process. Rather, the examiner appears to base her opinion on the lack of diagnosed endometriosis in service with an initial diagnosis in 2002. The Board believes that the examiner's reasoning is inadequate as it is well-established that endometriosis was not diagnosed in service or until some years after service, and the seminal inquiry is whether the Veteran's in-service symptoms were as likely as not early manifestation of the later diagnosed endometriosis. Therefore, remand is necessary for an opinion by a physician with appropriate expertise. A medical opinion must support its conclusion with an analysis the Board can consider and weigh against other evidence in the record. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Furthermore, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). It is noted that a remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to insure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Additionally, remand is necessary because, following issuance of the most recent Supplemental Statement of the Case, the Board received pertinent web-based evidence from the Veteran's representative without a waiver of consideration by the originating agency. As such, the evidence must be returned to the originating agency for consideration in the first instance. 38 C.F.R. § 20.1304. Accordingly, the case is REMANDED for the following action: 1. The RO or the AMC should undertake appropriate development to obtain any outstanding, pertinent medical records. 2. Then, the claims files and any pertinent evidence in Virtual VA that is not included in the claims files should be made available to a physician with appropriate expertise for a gynecological medical opinion that has not previously examined the Veteran. The physician should express an opinion on the following: (a) Whether the Veteran's long history of dysfunctional uterine bleeding and pelvic pain in service are as likely as not (50 percent or more probability) early manifestations of endometriosis; and (b) Whether it is as likely as not that endometriosis was incurred in service although not formally diagnosed until after service. A complete rationale for all opinions is required. That is, the physician should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., that he/she relied upon in reaching his/her conclusions. Specifically, if the opinion is negative, the physician should explain the following: (1) Why he/she believes that the uterine bleeding and pelvic pain symptoms in service were not early manifestations of endometriosis; and (2) why he/she believes that endometriosis is unrelated to service (other than that it was not diagnosed until 2002). The physician must accept that the Veteran is credible or truthful, unless otherwise indicated, in her statements concerning onset of pain, treatment, and symptomatology. 3. The RO or the AMC should also undertake any other development it determines to be warranted. 4. Then, the AMC/RO should readjudicate the claim. If the benefit sought on appeal is not granted to the Veteran's satisfaction, she and her representative should be furnished a Supplemental Statement of the Case and given the requisite opportunity to respond before the case is returned to the Board for further appellate action. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).