Citation Nr: 1307665 Decision Date: 03/07/13 Archive Date: 03/11/13 DOCKET NO. 08-15 211 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for endometriosis with menorrhagia and dysmenorrhea, status post hysterectomy and bilateral oophorectomy. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Thomas H. O'Shay, Counsel INTRODUCTION The Veteran had active service from July 1979 to July 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a September 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified at a Board hearing held at the RO in May 2010. The Board remanded the claim in February 2011 for further development. FINDING OF FACT The Veteran's endometriosis with menorrhagia and dysmenorrhea, which resulted ultimately in hysterectomy and bilateral oophorectomy, is etiologically related to service. CONCLUSION OF LAW Endometriosis with menorrhagia and dysmenorrhea was incurred in service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Under 38 U.S.C.A. §§ 5103 and 5103A (West 2002 & Supp. 2012), VA has certain duties to notify and assist the Veteran in her appeal. However, given the favorable actions taken hereinbelow, further discussion explaining how VA complied with those laws is unnecessary. The Board trusts that the RO, in implementing the Board's decision, will provide the Veteran with any notice to which she is entitled under Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service treatment records show the Veteran complained in October 1979 of lower abdominal pain with her menstrual period; she was diagnosed as having dysmenorrhea. In April 1980 she reported a 10-day history of vaginal bleeding secondary to birth control pills. Following a pregnancy, she reported experiencing heavy bleeding in September 1981. Thereafter, she occasionally reported abnormalities in her menstruation. Post-service medical records on file document complaints through the years of abnormal vaginal bleeding. In November 1993, she underwent a laparoscopic bilateral tubal cauterization, at which time the physician did not mention any pathology present in the pelvis. In January 1996, she underwent laparoscopic right salpingectomy, which revealed significant scarring in the pelvis consistent with endometriosis. Based on the history of endometriosis, and the symptoms of dysmenorrhea and menorrhagia which were unresponsive to medical treatment, the Veteran underwent a total vaginal hysterectomy and bilateral oophorectomy in August 1998. The operative report noted no obvious fibroid on the uterus, but an endometrial implant on the left ovary. The Veteran was examined by VA in August 2006. She reported that while on active duty, she had experienced several occasions of excessive bleeding, and that after service she had experienced severe vaginal bleeding and pain until her hysterectomy. The examiner reviewed service treatment records documenting increased vaginal bleeding during menses, but observed that the treating clinician at the time felt it was a normal response to birth control pills. The examiner concluded that the Veteran had subjective increased vaginal bleeding during menses consistent with the use of birth control pills in service. She further concluded that the symptoms in service did not cause and were not related to the Veteran's subsequent gynecologic problems, and that the symptoms in service did not result in current residuals. The Veteran attended a second VA examination in March 2012. She reported a history of heavy bleeding with accompanying pain beginning in service and lasting through her hysterectomy in 1998. After reviewing the record and examining the Veteran, the examiner concluded that it was as likely as not that the Veteran's chronic dysmenorrhea was related to service. The examiner concluded that the Veteran's menorrhagia and endometriosis was unlikely to be related to service, as the service treatment records were silent for menorrhagia, and as the 1993 laparoscopic surgery did not document any endometriosis. In October 2012, the Board determined that a further medical opinion was necessary in the claim, and referred the claims file to a VA physician pursuant to its authority under 38 U.S.C.A. § 7109 (West 2002); 38 C.F.R. § 20.901 (2012). In November 2012, the requested opinion was provided by a VA nurse and a VA physician. The physician noted that the Veteran had dysmenorrhea in service, which resulted in treatment with various oral contraceptives. She noted that the surgeon who performed the first laparoscopic surgery for bilateral tubal ligation in 1993 may not have noted the endometriosis if it had been present, as it was not considered an exploratory procedure for diagnosing that disorder. The physician concluded that it therefore was as likely as not that the dysmenorrhea in service was caused by endometriosis, which ultimately ended in hysterectomy and bilateral oopherectomy in 1998. The evidence against the claim consists of the opinion of the August 2006 examiner, who apparently relied on the opinion of a service physician that the Veteran's problems in service were normal responses to the use of birth control pills, and who otherwise did not offer a rationale for the opinion that the symptoms in service did not cause and were not related to the Veteran's subsequent gynecologic problems. The lack of a rationale is particularly problematic given the Veteran's post-service history of experiencing the same or similar symptoms persistently since service. The evidence in favor of the claim consists of the March 2012 and November 2012 medical opinions. The latter opinion in particular provides a persuasive rationale linking the Veteran's endometriosis to service, in noting that the 1993 laparoscopic procedure, which was silent for any reference to endometriosis, was not for the purpose of assessing the presence of that disorder, and thus was not properly considered diagnostic for that disease. In other words, the 1993 laparoscopy was for the purpose of bilateral tubal cauterization, and not for exploring any particular gynecologic complaints at the time, and thus would not be expected to necessarily show endometriosis. Given the Veteran's documented complaints in service, and her post-service history of similar and persistent gynecologic complaints, the Board finds the favorable opinions in this case are better supported by the record than the opinion of the August 2006 examiner, and are thus entitled to greater evidentiary weight. The Board accordingly finds that the preponderance of the evidence is in favor of the claim, and the claim of service connection for endometriosis with menorrhagia and dysmenorrhea is granted. ORDER Service connection for endometriosis with menorrhagia and dysmenorrhea, status post hysterectomy and bilateral oophorectomy is granted. ____________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs