Citation Nr: 1307763 Decision Date: 03/08/13 Archive Date: 03/11/13 DOCKET NO. 10-39 412 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for systemic lupus erythematous, to include as due to service-connected Graves' disease. 2. Entitlement to service connection for asthma, to include as due to service-connected Graves' disease. 3. Entitlement to service connection for fibromyalgia, to include as due to service-connected Graves' disease. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran and E.Y. ATTORNEY FOR THE BOARD M. Katz, Counsel INTRODUCTION The Veteran served on active duty from February 1996 to November 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office in St. Petersburg, Florida. The claims file is currently in the jurisdiction of the VA Regional Office in Columbia, South Carolina (RO). In November 2012, the Veteran submitted additional evidence and argument with a waiver of her right to have her claims readjudicated by the RO with the additional evidence. See 38 C.F.R. § 20.1304(c) (2012). In November 2012, the Veteran filed a claim to reopen the issue of entitlement to service connection for a migraine headache disorder. That issue has not yet been adjudicated by the RO. Therefore, the Board does not have jurisdiction over it, and it is referred to the RO for appropriate action. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The probative evidence of record shows that systemic lupus erythematous (SLE) is not related to the Veteran's active duty service, to include as due to her service-connected Graves' disease. 2. The probative evidence of record shows that asthma is not related to the Veteran's active duty service, to include as due to her service-connected Graves' disease. 3. The probative evidence of record shows that fibromyalgia is not related to the Veteran's active duty service, to include as due to her service-connected Graves' disease. CONCLUSIONS OF LAW 1. SLE was not incurred in or aggravated by active military service, and is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. Asthma was not incurred in or aggravated by active military service, and is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 3. Fibromyalgia was not incurred in or aggravated by active military service, and is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims for entitlement to service connection for SLE, asthma, and fibromyalgia, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Prior to an August 2012 readjudication of the Veteran's claims, letters dated in December 2008 and August 2012 satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of her claims, to include the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007); Sanders v. Nicholson, 487 F.3d. 881, 887 (Fed. Circ. 2007), rev'd on other grounds, Sanders v. Shinseki, 556 U.S. 396 (2009). The Veteran's service treatment records, VA treatment records, Social Security Administration (SSA) records, and identified private treatment records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In addition, the Board obtained a VHA medical opinion, with supplemental opinions in March 2012 and April 2012, which addresses the etiology of the Veteran's SLE and fibromyalgia. Although the Veteran disagrees with the conclusions reached by the physician in the VHA opinions, the Veteran has not indicated that she found the opinions inadequate. Additionally, the Board finds the opinions provided by the VHA physician are adequate in this case, as they are based on a complete review of the evidence contained in the claims file and provide sufficient explanation and rationale to determine whether the Veteran's SLE and fibromyalgia are related to her active duty service or her service-connected Graves' disease. Although the Veteran submitted additional evidence in November 2012, which included private treatment records, the private medical records were duplicates of records already in the claims file and considered by the VHA physician in the March 2012 and April 2012 opinions. Thus, the Board finds the March 2012 and April 2012 opinions to be adequate in this case. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board did not obtain a VA opinion addressing the etiology of the Veteran's asthma. However, one was not required in this case, because there is no evidence suggesting a link between the Veteran's current asthma and her active duty service or her service-connected Graves' disease. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159; see McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). There is no indication in the record that any other additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran contends that service connection is warranted for her SLE, asthma, and fibromyalgia, and alleges that these disorders were caused by her active duty service or her service-connected Graves' disease. During an October 2011 hearing before the Board, the Veteran testified that believed that her SLE, asthma, and fibromyalgia were related to her service-connected Graves' disease because they were all autoimmune disorders. She stated that multiple physicians have told her that having an autoimmune disease, such as Graves' disease, made her more susceptible to developing other autoimmune diseases. She noted that her physicians also informed her that propylthiouracil (PTU), a medication used to treat her Graves' disease, was also linked with the development of other autoimmune diseases. The Veteran stated that her thyroid disease was first diagnosed in 1996, Graves' disease was diagnosed in 1998, SLE and asthma were diagnosed in 2004, and fibromyalgia was diagnosed in 2006. She noted that, although SLE was first diagnosed in 2004, she believes that she had symptoms of SLE, such as rash, depression, photosensitivity, and possibly weight loss before the official diagnosis, and even during active duty service. 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; 38 C.F.R. § 3.303(a). In addition, 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. 38 C.F.R. § 3.303(d). Additionally, service connection may be granted where a disability is determined to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran's service treatment records do not reflect diagnoses of SLE, asthma, or fibromyalgia during active duty service. However, they do show complaints of and treatment for depression, dermatitis, low thyroid stimulating hormone, headaches and migraines, dizziness, fatigue, weakness, lightheadedness, and tingling. In February 1996, the Veteran complained of dizziness, fatigue, and tingling in her right arm and legs with similar symptoms in the past. April 1996 records reflect that the Veteran complained of foot pain. A May 1996 record notes a diagnosis of possible sesamoiditis. A June 1996 record reveals that the Veteran reported dizziness, weakness, and lightheadedness when standing associated with stomach cramps and diarrhea. July 1996 records note diagnoses of adjustment disorder with depressed mood and major depressive disorder. Another July 1996 record reflects diagnoses of history of perineal dermatitis and low thyroid stimulating hormone (TSH). An August 1996 record reveals a diagnosis of probable major depressive disorder and indicates that the Veteran also had diagnoses of adjustment disorder and depressive mood. A September 1996 record notes a diagnosis of respiratory infection. In October 1996, the Veteran complained of a migraine headache for three days. An October 1996 medical assessment reveals that the Veteran reported depression and migraines. The first evidence of record reflecting a diagnosis of Graves' disease was in October 1998. In that regard, although there was evidence of hyperthyroidism prior to that date as far back as 1997, an October 1998 record shows that a 5 and 24 hour Iodine 123 uptake was significantly elevated and an enlarged homogeneous thyroid gland was shown on thyroid scan, compatible with Graves' disease. Thereafter, she was treated with PTU for about one year. She discontinued PTU in 2000 and went off all medications. VA treatment records from July 2001 indicate that the Veteran's Graves' disease was probably recurrent. Private treatment records beginning in 2004 reflect diagnoses of SLE. Records beginning in 2005 show diagnoses of fibromyalgia, and records beginning in 2002 reflect diagnoses of asthma. Private records from T. Tse, M.D. from October 1998 through May 2002 reveal diagnoses of and treatment for Graves' disease and asthma. They reflect that the Veteran took PTU from October 1998 to March 2000. May 2002 records reveal that the Veteran complained of itching skin, weight gain, depression and moodiness, hand tremors, and fatigue. The records also show a diagnosis of asthma, controlled, beginning in May 2002. An August 2002 statement from O.L., the Veteran's husband, noted that over the prior two years, the Veteran struggled with various conditions, including weight gain, itchy and dry skin, rashes, hair loss, body temperature fluctuations, irritability, and depression. A November 2002 private treatment records from M. B., M.D., reflects that the Veteran complained of joint pain mainly in her hands. She denied a history of skin rash, photosensitivity, and Raynaud's symptoms. She noted some dry skin and questionable ulcers. She denied any known family history of rheumatoid arthritis or lupus. The physician noted that, "[a]t this time I do not find any definitive evidence of lupus, but we will need to follow her." The diagnoses included history of Graves' disease, recent anemia, and positive antinuclear antibodies (ANA), which increased in titer. In January 2003, the Veteran reported muscle and joint pain. The diagnoses included positive ANA, polyarthritis, and Graves' disease. An April 2003 record reflects a diagnosis of fatigue, with complaints of joint pain in the feet, knees, and upper shoulder. A June 2003 record notes diagnoses of history of SLE and fatigue. Private records from Dr. S. from 2003 show diagnoses of and treatment for Graves' disease. Private records from V. J., M.D., reflect diagnoses of and treatment for SLE beginning in November 2004 and fibromyalgia as early as January 2005. In a November 2004 letter, Dr. J. stated that Graves' disease was diagnosed in 1998 and noted that the Veteran was on PTU at that time. He indicated that SLE was diagnosed in 2002. The Veteran's SLE criteria included photosensitivity, alopecia, positive ANA, anemia, and pleurisy times three in the last two years. In a May 2005 letter, R. R, M.D. noted that the Veteran's SLE symptoms had been present for about five years and indicated that the diagnosis of SLE was confirmed in February 2004. Dr. R. reported that the Veteran had a family history of Graves' disease, an aunt with scleroderma, and a sister with rheumatoid arthritis. Private records from C. C., M.D., from June 2006 through December 2007 reflect diagnoses of and treatment for SLE. In June 2006, the Veteran reported that Graves' disease was diagnosed in 1998. She noted that, for many years, she had chronic fatigue, joint pain, prolonged morning stiffness, and episodic swelling. She indicated that, in 2002 or 2004, SLE was diagnosed based on inflammatory arthritis, history of hives-like lesions with heat or sun exposure, thinning of the hair, and positive ANA. She noted a history of fatigue and difficulty sleeping due to pain. There was no history of Raynaud's disease, dry eyes, or dry mouth ulcers. She noted headaches in the past. She indicated that she developed episodes of numbness and tingling in the prior year. Diagnoses included SLE. In July 2007, she stated that she had shortness of breath and felt like she could not catch a good breath. She stated that she had asthma, and that she used inhalers. The diagnoses included SLE, with respiratory symptoms. VA treatment records from September 2008 to November 2011 reflect diagnoses of and treatment for SLE and fibromyalgia. A September 2008 record indicates that SLE was diagnosed in 2004. An October 2009 record notes that SLE was diagnosed in 2004 at the Tampa VA Medical Center. She reported a history of photosensitivity, arthritis, intermittent proteinuria, hemolytic anemia, and thrombocytopenia. An August 2010 record reflects complaints of generalized muscle aches in the upper back and neck and a diagnosis of fibromyalgia with a date of onset in 2006. In April 2011, the Veteran presented to the emergency department with complaints of pain in her whole body, specifically in the lower extremities and knees. An April 2011 record reflects that the Veteran complained of intractable pain in the neck, shoulders, back, and knees. She was referred to the pain clinic for evaluation and treatment. The diagnoses were chronic pain related to SLE, acute flare from SLE, and myofascial pain. A November 2011 record indicates that SLE was diagnosed in 2004, but that the Veteran presented with symptoms in 2002. The record reflects that her initial symptoms were arthralgias, headaches, genital ulcers, photosensitivity, and pleurisy. In a September 2011 lay statement, the Veteran's sister reported that the Veteran was in optimal health prior to service, and that, over the years, her health has become impaired due to Graves' disease, lupus, and fibromyalgia. In a September 2011 statement, the Veteran's son stated that the Veteran was very active prior to her military service and that, after service, her health declined significantly. In an October 2011 statement, M.S. and J.S. reported that, when they first met the Veteran, she was very energetic and active in her church, but that her energy and activity have decreased over the past several years, often times resulting in her being bedridden. In a March 2012, VA obtained a VHA opinion addressing the etiology of the Veteran's SLE, asthma, and fibromyalgia. After extensively reviewing the evidence in the Veteran's claims file, the examiner opined that it was "unlikely" that SLE or fibromyalgia were present during the Veteran's active duty service, as there was no documentation of SLE symptoms such as photosensitivity, malar rash, or peripheral joint pains in the service treatment records. The examiner noted the history of allergies to several drugs and perineal dermatitis in the service records, but explained that these symptoms are not related to SLE. The examiner also indicated that there were no fibromyalgia symptoms noted in the service records, such as widespread diffuse muscular pain or tender points. The examiner noted the Veteran's inservice symptoms of depression, plantar fasciitis, bronchitis, headaches and migraines, and diarrhea, but found that they were not known to be directly related to the development of SLE and were not criteria for a diagnosis of SLE. The examiner stated that the etiology for SLE and fibromyalgia are unknown, and that fibromyalgia is a diagnosis of exclusion. The examiner noted that fibromyalgia may be associated with the Veteran's inservice depression, but stated that "one does not directly cause the other." With regard to the Veteran's contention that her autoimmune Graves' disease put her at greater risk for developing another autoimmune disease, the examiner acknowledged that autoimmune diseases may occur together in the same patient, based on that patient's genetic susceptibility, but explained that "[a] specific autoimmune disease is not known to further increase the risk of another specific autoimmune disease beyond the individual's inherent risk; thus, Graves' disease is unlikely to further increase the risk of SLE." The examiner further noted that autoimmune diseases may cluster in families based on genetic susceptibility, and that there was a family history of autoimmune illnesses, which "points to a genetic susceptibility to autoimmune diseases in this Veteran." With regard to the Veteran's argument that the treatment of her Graves' disease with PTU put her at greater risk for developing another autoimmune disease, the examiner stated that this was unlikely. The examiner explained that, although there have been reports of drug-induced lupus with PTU, "the time course does not correlate and reported lupus symptoms did not resolve as would be expected once the drug was discontinued." Moreover, although the ANA was positive, antihistone antibody, which is classically seen in drug-induced lupus, was negative. Ultimately, the examiner concluded that it was "not likely that Graves' disease or its treatment contributed to and/or caused the development of SLE or fibromyalgia" and that it was "more likely" that the Veteran's genetic susceptibility contributed to SLE with her known family history of autoimmune disease. The examiner stated that there was "no known clear association between Graves' disease, PTU, and/or fibromyalgia; the etiology of the latter is unknown." In an April 2012 supplemental opinion, the VHA examiner who provided the March 2012 opinion provided clarification with regard to some of the opinions. With consideration of the Veteran's lay statements regarding her inservice symptoms of rash, depression, photosensitivity, and possible weight loss, which are not documented in the service treatment records, the examiner opined that determination of a definite diagnosis based on the Veteran's statements alone would require mere speculation. The examiner explained that SLE is a complex autoimmune disease, and may be classified based on 4 of 11 specific criteria: (1) malar rash; (2) discoid rash; (3) photosensitivity (which is not specific to lupus); (4) non-erosive peripheral arthritis of at least two joints; (5) oral ulcers observed by a physician; (6) serositis documented by a physician by hearing a rub or objectively on electrocardiogram; (7) renal disorder; (8) neurologic disorder (seizures and psychosis); (9) hematologic disorder of leucopenia/lymphopenia, hemolytic anemia, or thrombocytopenia; (10) immunologic disorder; and (11) ANA antibody. The examiner explained that, even with consideration of the Veteran's reported inservice symptoms which were not documented in the service records, there is not sufficient evidence to make a finding that SLE or fibromyalgia were present during active duty service. The examiner explained that it is not clear, based on the Veteran's records, when the first symptoms of fibromyalgia and SLE manifested. The examiner noted that the Veteran's reports of non-specific rash found in 1997 to be neurodermatitis, reported weight loss, and dry skin were likely related to thyroid dysfunction or depression, and that her drug allergies documented in 1996 and 1997 caused rashes. The examiner indicated that none of those findings support a diagnosis of fibromyalgia or SLE at that time. The examiner noted that the first ANA was found to be positive in 2002 and again in 2004, but indicated that this finding could have been related to the Veteran's thyroid disorder. Although there was evidence of mild lymphopenia once in 1997, it resolved and was not consistent with mild anemia attributed to heavy menses, as both rapidly normalized making it unlikely that they were related to SLE. The examiner explained that there was no proteinuria or renal dysfunction, and no pleuritis or pericarditis on chest x-ray or EKG. Neurological function was normal in 1998. There was still no evidence of proteinuria on urinalysis in 2001, and there was persistently normal renal function. The examiner concluded that there was no documentation of symptoms sufficient to make a definite diagnosis of SLE until 2004, and fibromyalgia until 2005. Thus, based on this review of the evidence, the examiner concluded that it was "unlikely that specific symptoms related to SLE and fibromyalgia, would have preceded this more definitive 2004 SLE diagnosis and 2005 fibromyalgia diagnosis by 8-9 years." Accordingly, the examiner found that "it is unlikely SLE or fibromyalgia were present during active duty service." In November 2012, the Veteran submitted medical treatises in support of her claims. These treatises include one summary of an article finding an increased frequency of autoimmune disease in patients with autoimmune thyroid pathologies; one article summary noting an increased prevalence of antithyroid antibodies in patients with SLE; one article summary stating that numerous autoimmune diseases have been shown to coexist frequently with thyroid autoimmune diseases; one article summary reporting that patients with SLE had a high prevalence of symptomatic and significantly more subclinical hypothyroidism and positive thyroid autoantibodies; and an email from the Lupus Foundation of America stating that fibromyalgia affects about 30 percent of people with lupus, that autoimmune diseases of the thyroid can coexist with SLE, that approximately 10 percent of people with lupus have thyroid antibodies, and that between 5 and 30 percent of people with lupus have overlapping symptoms characteristic of one or more connective tissue disease. The Veteran also submitted a November 2012 record from Dr. C., which notes that the Veteran was first seen in her office in June 2006, with an established diagnosis of both SLE and fibromyalgia. Dr. C. stated that, at the time of treatment, the Veteran met the criteria for SLE by positive ANA, photosensitivity, proteinuria, possible transient ischemic attacks, anemia, thrombocytopenia, immunological disorders with low C3 counts, and inflammatory arthritis in multiple joints. Dr. C. reported that she reviewed the Veteran's VA treatment records, as well as her military medical records, and that the Veteran's symptoms of "fatigue, weight loss, depression, muscle/joint pain (neck/back/shoulder pain), rashes, dry skin, photosensitivity and headaches/migraines experienced in 1996 could all indicate early onset of an autoimmune disease such as SLE or a rheumatic disease such as Fibromyalgia; however, without a diagnostic screening for SLE a diagnosis cannot be made." Dr. C. noted that review of the labs after 1996 show that the Veteran did meet the criteria with low C3 and high ESR. A November 2012 letter from Dr. J. states that Graves' disease was diagnosed in 1998 and SLE in 2004. Dr. J. noted the Veteran's reported symptoms as early as 1996. He stated that in November 2004, the Veteran met the SLE criteria due to photosensitivity, alopecia, positive ANA, anemia, pleurisy times three, and inflammatory arthritis. She soon developed widespread muscle pain and was diagnosed with fibromyalgia in February 2005. Dr. J. stated that, after reviewing the Veteran's medical records, he "cannot conclude if SLE and/or Fibromyalgia were present in 1996; however, patient did show active signs and symptoms" such as depression, anemia, photosensitivity, fatigue, widespread pain consistent with fibromyalgia, and unexplained rashes. He also noted that labs taken during her active duty service showed thrombocytopenia, another consistent finding in patients with active SLE. Dr. J. stated that he reviewed the VHA medical opinion and stated that genetic disposition is only one factor to consider when trying to find the cause of SLE and fibromyalgia. He stated that he could not conclude that the host of autoimmune and rheumatic disorders, including Graves' disease, SLE, asthma, fibromyalgia, rheumatoid arthritis, and celiac disease are contributed only by family history. After thorough review of the evidence of record, the Board concludes that the probative evidence of record does not show that entitlement to service connection for SLE, asthma, or fibromyalgia, to include as secondary to service-connected Graves' disease, is warranted. There are current diagnoses of SLE, asthma, and fibromyalgia. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). The service treatment records are negative for diagnoses of or treatment for SLE, asthma, or fibromyalgia; however they do show complaints of and treatment for depression, dermatitis, low thyroid stimulating hormone, headaches and migraines, dizziness, fatigue, weakness, lightheadedness, and tingling. The Veteran provided competent statements and testimony that she had rash, depression, photosensitivity, and possibly weight loss before her official diagnosis of SLE in 2004, and even during active duty service. The first medical diagnosis of SLE of record was in November 2004, over eight years after service discharge; the first medical diagnosis of asthma was in May 2002, over five years after service discharge; and the first medical diagnosis of fibromyalgia was in 2005, over eight years after service discharge. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of disorder). Further, the weight of the probative medical evidence of record does not reflect findings that the Veteran's SLE, asthma, or fibromyalgia are directly related to service, or that they are related to the Veteran's service-connected Graves' disease. The Board acknowledges the Veteran's argument that her service-connected Graves' disease made her more susceptible to developing other autoimmune diseases, including SLE, asthma, and fibromyalgia. However, the medical evidence of record does not reflect that the Veteran's current SLE, asthma, or fibromyalgia were caused or aggravated by her service-connected Graves' disease. In that regard, the only medical evidence of record addressing the relationship between the Veteran's Graves' disease and her SLE and fibromyalgia are the March 2012 and April 2012 VHA medical opinions, which concluded that, although autoimmune diseases may occur together in the same patient based on that patient's genetic susceptibility, "[a] specific autoimmune disease is not known to further increase the risk of another specific autoimmune disease beyond the individual's inherent risk; thus, Graves' disease is unlikely to further increase the risk of SLE." The examiner also stated that the PTU treatment for Graves' disease did not cause the Veteran's SLE in this instance, as the time course did not correlate with the reported lupus symptoms and antihistone antibody was negative. Ultimately, the examiner concluded that it was "not likely that Graves' disease or its treatment contributed to and/or caused the development of SLE or fibromyalgia." None of the other medical evidence of record addresses the relationship between the Veteran's Graves' disease and her SLE, fibromyalgia, or asthma. With regard to her asthma, there is no medical evidence of record suggesting a link between the Veteran's Graves' disease and asthma. The Board finds the March 2012 and April 2012 VHA opinions to be competent and entitled to probative weight, as they are based on a thorough review of the Veteran's claims file and provide supporting rationale for their conclusions. Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (holding that factors for assessing the probative value of a medical opinion include access to the claims file and the thoroughness and detail of the opinion); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (stating that the failure of the physician to provide a basis for an opinion goes to the weight or credibility of the evidence). The Board acknowledges the Veteran's lay statements and testimony that her SLE, asthma, and fibromyalgia were caused by her service-connected Graves' disease. However, as a layperson, the Veteran is unable to provide competent testimony as to matters which require medical expertise. Medical causation involves questions that are beyond the range of common experience and common knowledge and require the special knowledge and experience of a trained physician. Because the Veteran is not a physician, her statements are not competent evidence that her SLE, asthma, or fibromyalgia were caused by her service-connected Graves' disease. See Barr, 21 Vet. App. at 307. The Veteran has submitted several medical treatises regarding the relationship between autoimmune thyroid disease and other autoimmune diseases, including SLE and fibromyalgia. The Board notes that 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). Similarly, medical treatise evidence could "discuss [] generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least a plausible causality based upon objective facts." Mattern v. West, 12 Vet. App. 222, 229 (1999); Sacks v. West, 11 Vet. App. 314, 317 (1998), Libertine v. Brown, 9 Vet. App. 521 (1996); Beausoleil v. Brown, 8 Vet. App. 459 (1996). However, the medical treatise information submitted by the Veteran are of a general nature and do not contain any information or analysis specific to the Veteran's case. Moreover, the VHA examiner acknowledged that autoimmune diseases may occur together in the same patient based on that patient's genetic susceptibility, but concluded that having Graves' disease does not further increase the risk of developing SLE. As such, the treatise evidence submitted by the Veteran is of no probative value to establishing a link between her service-connected Graves' disease and her fibromyalgia or SLE. See generally Obert v. Brown, 5 Vet. App. 30, 33 (1993). Accordingly, the competent and probative evidence of record does not show that the Veteran's SLE, asthma, or fibromyalgia were caused or aggravated by her service-connected Graves' disease. The Veteran also contends that her SLE, asthma, and fibromyalgia are directly related to her active duty service. In that regard, she alleges that she experienced symptoms of SLE and fibromyalgia during service, prior to her official diagnosis, which have continued since that time. Due to the complicated nature of SLE and fibromyalgia, the Board solicited a VHA medical opinion to ascertain whether the Veteran's reported symptoms could support a finding that her SLE or fibromyalgia first manifested during service. However, after a careful review of the evidence of record, including the Veteran's lay statements as to symptomatology, the VHA examiner who provided the March 2012 and April 2012 opinions was unable to find that the symptoms noted in the service treatment records, including depression, plantar fasciitis, bronchitis, headaches and migraines, and diarrhea, as well as the symptoms that the Veteran testified that she began experiencing during service but which are not noted in the service records, such as rash, photosensitivity, and possible weight loss, were not sufficient to support a finding that the Veteran had SLE or fibromyalgia during service. The examiner explained the complicated process for establishing a diagnosis of SLE and fibromyalgia, and found that the evidence was insufficient to say that her inservice symptoms were early manifestations of SLE or fibromyalgia; thus, the examiner concluded that it was "unlikely SLE or fibromyalgia were present during active duty service." The Veteran did not report any specific symptoms of asthma during service or otherwise allege that she has experienced symptoms of asthma continuously since service discharge. The Board acknowledges the November 2012 opinions provided by Dr. C. and Dr. J. However, neither of these opinions is sufficient to support a finding that the Veteran's SLE or fibromyalgia are related to her active duty service. In that regard, Dr. C. concluded that, after reviewing the Veteran's VA treatment records and her service records, the Veteran's symptoms during service "could all indicate early onset of autoimmune disease such as SLE or a rheumatic disease such as Fibromyalgia; however, without a diagnostic screening for SLE a diagnosis cannot be made." (Emphasis added). Similarly, Dr. J. stated that he "cannot conclude if SLE and/or Fibromyalgia were present in 1996 . . . ." but noted that she did show signs and symptoms. Although Dr. J. disagreed with the rationale provided by the VHA examiner, Dr. J. did not provide a medical opinion linking the Veteran's SLE or fibromyalgia with her active duty service. Neither of these medical opinions were able to provide the definitive link between SLE or fibromyalgia and the Veteran's active duty service required for a medical opinion to be considered probative. Bloom v. West, 12 Vet. App. 185, 186-87 (1999) (treating physician's opinion that veteran's time as a prisoner of war "could" have precipitated the initial development of his lung condition found too speculative). Accordingly, the Board does not find them to be probative evidence of a link between the Veteran's SLE or fibromyalgia and her active duty service. The Veteran contends that she has had symptoms of SLE and fibromyalgia continuously since service discharge. While the Veteran's statements are competent evidence as to the symptoms that she experienced, her statements are not competent evidence sufficient to establish that those symptoms were SLE or fibromyalgia. See, e.g., Layno v. Brown, 6 Vet. App. 465, 469 (1994); see Barr, 21 Vet. App. at 307 (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions). Moreover, none of the physicians who reviewed the Veteran's claims file were able to conclude that she had SLE or fibromyalgia based on her reported inservice symptoms and those symptoms documented in her service records. Accordingly, as the competent and probative evidence of record does not relate the Veteran's SLE, asthma, or fibromyalgia to her service-connected Graves' disease or to her active duty service, service connection for SLE, asthma, and fibromyalgia is not warranted. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the probative evidence is against the Veteran's claims, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this, and in other cases, only independent medical evidence may be considered to support Board findings. The Board may not base a decision on its own unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). ORDER Service connection for SLE is denied. Service connection for fibromyalgia is denied. Service connection for asthma is denied. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs