Citation Nr: 1308548 Decision Date: 03/13/13 Archive Date: 03/20/13 DOCKET NO. 04-41 596A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for pelvic inflammatory disease. 2. Entitlement to service connection for abdominal cramps and vomiting. 3. Entitlement to service connection for residuals of a hysterectomy. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Mary E. Rude, Associate Counsel INTRODUCTION The appellant served on active duty for training from November 1974 to May 1975, and then evidently served in the reserve until 1978. These matters come to the Board of Veterans' Appeals (Board) on appeal from June 2004 and January 2007 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In August 2006 the appellant testified during a personal Decision Review Officer (DRO) hearing at the RO. In April 2009 she testified during a hearing at the RO before the undersigned Veterans Law Judge. Transcripts of both hearings are of record. In June 2009, February 2011, and August 2012 the Board remanded the case to the RO, via the Appeals Management Center (AMC) for further development. In March 2011 correspondence, the appellant raised the issues of entitlement to service connection for hot flashes, skin problems, hair loss, depression, weight gain, and decreased libido. These issues have not yet been adjudicated by the agency of original jurisdiction. Therefore, the Board does not have jurisdiction over them, and they are again referred to the agency of original jurisdiction for appropriate action. The Board notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the appellant's claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. There is no competent evidence of record which indicates that the claimant currently has pelvic inflammatory disease due to service. 2. There is no competent evidence of record which indicates that the claimant currently has abdominal cramps and vomiting due to service. 3. The preponderance of the probative evidence indicates that residuals of a hysterectomy are not related to an in-service disease or injury. CONCLUSIONS OF LAW 1. Pelvic inflammatory disease was not incurred or aggravated during active military service. 38 U.S.C.A. §§ 101(24), 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. A current disorder manifested by abdominal cramps and vomiting was not incurred in or aggravated during active military service. 38 U.S.C.A. §§ 101(24), 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 3. Residuals of a hysterectomy were not incurred in or aggravated during active military service. 38 U.S.C.A. §§ 101(24), 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the appellant in February and November 2004 of the information and evidence needed to substantiate and complete the claims, including notice of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain. Although the letters did not address either the rating criteria or effective date provisions that are pertinent to the appellant's claims, such error was harmless given that service connection is being denied for all three claims, and hence no rating or effective date will be assigned with respect to the claimed conditions. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA fulfilled its duty to assist the appellant in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. This case was remanded in June 2009, February 2011, and August 2012 for additional development, and the RO/AMC substantially complied with these remands. See Dyment v. West, 13 Vet. App. 141 (1999). There is no evidence that additional records have yet to be requested, or that additional examinations for these issues are in order. The Board has reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Relevant Laws and Regulations Service connection may be established for a disability resulting from disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). The term "active military service" includes active duty, any period of active duty for training during (ACDUTRA) which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status will not always constitute competent medical evidence. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997). To be present as a current disability, the claimed condition must be present at the time of the claim for benefits, as opposed to sometime in the distant past. Gilpin v. West, 155 F. 3d 1353 (Fed. Cir. 1998). The Gilpin requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Factual Background The appellant's claims entitlement to service connection for pelvic inflammatory disease, abdominal cramps and vomiting due to menses, and residuals of a hysterectomy. The appellant's service treatment records do show several complaints relating to the appellant's gynecological health. The appellant wrote in her April 1974 entrance examination that she had had an infection in one ovary followed by a unilateral oophorectomy in November 1973. The examining physician noted that history at enlistment. In a November 2012 addendum note by a VA examiner, however, the examiner noted that the appellant admitted that she was likely mistaken about the oophorectomy at the time of the entrance examination and that she currently still has both of her ovaries. The entrance examination also noted that the appellant had a caesarian section in 1969. In January 1975 the appellant reported spitting up blood, vomiting, abdominal tenderness, and severe abdominal cramps. She was hospitalized for five days, and after examination and testing, the appellant was diagnosed with pelvic inflammatory disease. The disorder was treated, and the claimant was placed on temporarily restricted duty. The appellant also reported oligomenorrhea (infrequent menstruation) and amenorrhea (no menstruation) in April and May 1975. In April 1975 the appellant was treated for vaginitis. The examiner noted on at the appellant's May 1975 separation examination that the appellant reported a two month history of no menses. The examiner commented that the appellant may be pregnant. The appellant's private records show that she had a second caesarian section delivery in 1982, a tubal ligation in 1988, and a total abdominal hysterectomy in December 2001. In November 1993, the appellant reported to a private physician a long history of irregular periods. The appellant's medical records from 1994 to 2001 show frequent complaints of irregular periods, heavy and prolonged bleeding during menses (menorrhagia), and menstrual pain (dysmenorrhea). In January 1994, a uterine fibroid was noted. In a January 1997 ultrasound report, two fibroids were found in the appellant's uterus. In September 2001, the appellant was treated at a VA hospital for excessive vaginal bleeding and dizziness. Later that month the appellant was treated by a private physician for prolonged bleeding and menorrhagia and was diagnosed with uterine fibroids. The appellant was diagnosed with bacterial vaginosis in September 2001. In October 2001, the appellant received an additional medical opinion from another physician, reported daily bleeding, and was again diagnosed with uterine fibroids. In December 2001 the appellant underwent a total abdominal hysterectomy and lysis of adhesions for treatment of fibroids and anemia. The appellant's entire uterus and cervix were removed. In 2003 the appellant began reporting menopausal symptoms to her private physician. In a September 2003 gynecological assessment, the appellant was found to be in a climacteric/menopausal state and diagnosed with atrophic vaginitis (vaginal dryness). The appellant's VA treatment records show numerous complaints in 2003 to 2004 of hot flashes and difficulty sleeping attributed to menopause, but contain no complaints or treatments for any abdominal pain or vomiting after December 2001. In February 2004 the appellant filed her claim of entitlement to service connection for pelvic inflammatory disease and for abdominal cramps and vomiting. In October 2004, the representative submitted a letter explaining that the appellant was actually claiming service connection for residuals of a hysterectomy, caused by pelvic inflammatory disease that led to abdominal cramps and vomiting. The RO interpreted this as a third, separate claim which is also now on appeal. A November 2004 signed statement from the physician stated that the pathology was consistent with leiomyomas and adenomyosis as well as mild chronic salpingitis. At an August 2006 hearing before a decision review officer the appellant provided additional information regarding her symptoms. She stated that while in the service she had dysmenorrhea, cramping, and pain, which led to her being hospitalized. She asserted that she continued to have pain, cramping, and heavy bleeding afterwards. The appellant stated that what she currently suffers from today was a hormonal imbalance, hot flashes, difficulty sleeping, and depression. She stated that she took hormones and pain medication. She also stated that she had infertility problems for years after service before they were resolved. She believed that her fertility problems were caused by her pelvic inflammatory disease in service. In an October 2007 signed statement, a VA physician's assistant noted her review of the appellant's active duty medical records, including the hospitalization for pelvic inflammatory disease. She noted that the appellant subsequently developed adhesions and, as a result of the adhesions, had chronic pelvic pain. The record review also showed bouts of dysmenorrhea with irregular bleeding. The appellant also testified at an April 2009 Board hearing. She stated that in service she had spent five days in the hospital and was treated with antibiotics for pelvic inflammatory disease in 1975. Afterwards she continued to experience dysmenorrhea. She said that postservice she was treated in 1976 for infections, but she could not remember the names of the doctors who treated her. The appellant indicated that her pelvic inflammatory disease led to chronic pain and nausea, which ultimately led to her hysterectomy as a means to control her pain and bleeding, although the fibroids also "helped with causing the heavy bleeding." The appellant stated that she continued to take Compazine for nausea and had occasional yeast infections. The representative asked the appellant if she continued to have nausea, vomiting, and bleeding, and she answered that it had been part of her menstrual cycle which she suffered from for years. When asked by the representative if she currently continued to experience abdominal cramps and vomiting, the appellant answered "I'm at my endpoint; I stopped having; I get nauseated now just because I have [inaudible] lupus ... So I take Compazine for that." The appellant also stated that she had earlier had an intrauterine device which caused her pain and scarring and made it more difficult for her to become pregnant. When asked whether physicians had indicated that her in-service pelvic inflammatory disease had caused her hysterectomy, she stated that the gynecologist who performed her hysterectomy had told her that fibroids were common in 80 to 90 percent of black females. In December 2009 the appellant was afforded a VA gynecological examination by a gynecologist who had access to and reviewed the claims file. The examiner stated that the appellant had had a total abdominal hysterectomy in 2001 and since then has been "well without abdominal pain or any abdominal complaints." The gynecologist opined that it was impossible for the appellant to have pelvic inflammatory disease without a uterus, and that any symptoms of abdominal discomfort or vomiting could therefore not be due to pelvic inflammatory disease. In March 2011 the same gynecologist added an addendum to opine that the appellant's hysterectomy was not in any way proximal to her inservice pelvic inflammatory disease. The gynecologist opined that the records showed that the hysterectomy had been due to menorrhagia caused by fibroids, and the record also noted a diagnosis of chronic salpingitis. In September 2012 the appellant received an additional gynecological examination from the same gynecologist. The examiner again reviewed the claims file and noted that the appellant had been hospitalized for pelvic inflammatory disease in 1975, began having heavy menstrual periods (menorrhagia) after her second caesarian section, and had a diagnosis of fibroid uterus which led to a hysterectomy in 2001. The examiner noted that the appellant did not currently have any symptoms related to a gynecological condition and did not currently require medication or treatment related to reproductive tract conditions. The examiner found no present conditions of the vulva, vagina, or cervix. The gynecologist noted that the appellant has gone through surgical menopause, had stress incontinence and a scar related to her gynecological conditions. The examiner opined that there was no evidence that residuals of the appellant's preservice caesarian section were aggravated beyond their natural course while she was on active duty for training. While on active duty for training she was diagnosed with pelvic inflammatory disease and recovered with no apparent residuals. Although infertility is a possible result of pelvic inflammatory disease, her subsequent pregnancy in 1982 evidenced that this was not a problem for the appellant. After a second caesarian postservice the appellant developed heavy menstrual periods, eventually resulting in a diagnosis of menorrhagia and fibroids and leading to her 2001 hysterectomy. The examiner stated that there was no relationship between the appellant's 1975 pelvic inflammatory disease, which is "a bacterial infection of the tubes and the uterine lining and in most instances after appropriate treatment is completely without symptomatology," and her uterine fibroids, which are "benign muscle tumors of the myometrium" which develop in approximately 30 percent of women and can result in significant uterine bleeding. Analysis A review of the evidence reveals that the preponderance of evidence weighs against a finding that the claimant currently has, or has had at any time during the pendency of this claim, pelvic inflammatory disease or a chronic disability manifested by abdominal cramping and vomiting. The appellant has clearly stated that she was diagnosed and treated for pelvic inflammatory disease only in January 1975. There is no evidence of record indicating that the appellant had pelvic inflammatory disease at any time other than in 1975, and the appellant has not claimed that she has. A claimed condition must be present at the time of the claim for benefits, as opposed to sometime in the distant past. Gilpin, 155 F. 3d 1353. In this case, the only incident of record of pelvic inflammatory disease occurred 29 years prior to the filing of the current claim. As the appellant has not presented any evidence or even claimed that she has had pelvic inflammatory disease during or since her February 2004 filing of a claim, service connection for pelvic inflammatory disease must be denied. Degmetich, 104 F. 3d at 1330. The record also preponderates against finding that the appellant has had a disorder manifested by abdominal cramping and vomiting at any time during the course of this claim. The appellant has stated that she experienced years of dysmenorrhea and menorrhagia, and this is supported by the numerous complaints in her private medical records up until her December 2001 hysterectomy. While the Board recognizes that she experienced many uncomfortable years of heavy bleeding, cramping, and nausea associated with her menstrual cycle, the appellant did not file a claim until February 2004, and she has failed to present any competent evidence that at any time since she has suffered from a disorder manifested by chronic abdominal cramping and vomiting. The appellant's postservice medical records do show that her complaints continued through September 2001, when her menstrual pain and bleeding became exceptionally problematic, and she was diagnosed with uterine fibroids. In December 2001 the appellant underwent a total abdominal hysterectomy, at which point her complaints of menstrual-related pain and nausea in her medical records abruptly stopped. At her December 2009 VA examination the appellant reported that she was doing well post-hysterectomy, without abdominal pain or any abdominal complaints. At the September 2012 VA examination the examiner found that the appellant did not currently have any symptoms related to a gynecological condition or require medication or treatment related to reproductive tract conditions. The appellant herself has stated that her menstrual-cycle related pain and nausea resolved after her 2001 hysterectomy. The appellant's primary contention throughout the claim has been that her menstrual-related pain and nausea was a chronic condition that that started in service and eventually led to her needing a hysterectomy in 2001. She has never averred that she continues to have these symptoms today. At the August 2006 hearing, the appellant raised new issues which she thought represented her then current pathology, but those issues are not currently before the Board. While the appellant mentioned currently having some "pain" at her August 2006 hearing, in light of her other statements and the medical evidence of record, it is highly unlikely that she was referring to the same menstrual pain that led to her hysterectomy. At no other time has the appellant reported having any pain related to her gynecological system since her 2001 hysterectomy, nor has she ever reported it to any VA examiner or her own treating medical professionals at VA. Therefore, the Board finds no credible and competent evidence that the appellant currently has, or has had at any time during or since her filing the February 2004 claim, a condition manifested by abdominal cramps or vomiting. Hence, the claim is denied. Regarding the appellant's claim for service connection for residuals of a hysterectomy, the appellant's medical records show that she underwent a hysterectomy in December 2001. While the appellant the appellant was treated for pelvic inflammatory disease while on active duty for training, and while she underwent the December 2001 hysterectomy, to grant service connection there must be evidence establishing a nexus between the appellant's current disability and that her in-service disease. 38 U.S.C.A. § 101(24), 1110, 1131. The appellant has insisted that the pelvic inflammatory disease she experienced in service led to chronic cramps and bleeding that ultimately led to her need for a hysterectomy. Though the appellant claims that her menstrual cramps were a chronic condition, the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic. See 38 C.F.R. § 3.309(a); Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). Pelvic inflammatory disease, dysmenorrhea, and menorrhagia are not chronic diseases under by 38 C.F.R. § 3.309(a), and cannot be the basis for establishing service connection due to the continuity of symptomatology since service. The VA gynecologist who examined the appellant in December 2009 and September 2012 reviewed her claims files and discussed history with the appellant. The gynecologist stated that the appellant's hysterectomy was not caused by or related to the pelvic inflammatory disease, dysmenorrhea, or menorrhagia she experienced during service. The gynecologist also stated that there had been no aggravation of any residual of a preservice caesarian section during her service. The examiner opined that the appellant's postservice hysterectomy had an entirely separate cause, i.e., uterine fibroids. The examiner further found that the appellant's pelvic inflammatory disease was a bacterial infection that had been treated and resolved at the time of service, with no residuals. None of the appellant's private or VA treatment records indicate that her in-service episode of pelvic inflammatory disease led to her hysterectomy. The appellant's gynecologist who performed the hysterectomy stated to her, as the claimant admitted at her April 2009 Board hearing, that the hysterectomy was conducted because of uterine fibroids. The first medical evidence of record showing that the appellant had uterine fibroids was in January 1994, many years after the appellant's service. The only opinion of record which supports the assertion that the appellant's hysterectomy was caused by pelvic inflammatory disease is her own opinion. The medical etiology of uterine fibroids and the need for a hysterectomy are not questions that are within the ken of a lay person. While the appellant, as a layperson, is competent to report on her history of menstrual pain or bleeding, she is not competent to etiologically link her hysterectomy to a disease experienced in service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Hence, her assertions in this regard do not constitute competent and persuasive evidence in support of the claim for service connection. There is no competent evidence of a medical nexus between any in-service symptoms or disease and the appellant's 2001 hysterectomy. In the absence of any competent medical evidence of a nexus between the appellant's current disability and service, service connection must be denied. For the foregoing reasons, the claim of entitlement to service connection for residuals of a hysterectomy must be denied. In reaching each of the foregoing decisions the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claims, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet.App. 49 (1990). ORDER Entitlement to service connection for pelvic inflammatory disease is denied. Entitlement to service connection for abdominal cramps and vomiting is denied. Entitlement to service connection for residuals of a hysterectomy is denied. ____________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs