Citation Nr: 1315567 Decision Date: 05/10/13 Archive Date: 05/15/13 DOCKET NO. 06-20 174 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for residual gynecological disabilities, to include endometriosis, status post hysterectomy with bilateral oophrectomy, to include as being due to medications prescribed for a skin disability. 2. Entitlement to service connection for a mouth disability, claimed as secondary to a skin disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Patrick J. Costello, Counsel INTRODUCTION The appellant served on active duty from June 1974 to June 1977. This case comes before the Board of Veterans' Appeals, hereinafter the Board, on appeal from a December 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada. In June 2006 the appellant requested a hearing before the Board via videoconference. However, in April 2007, prior to the hearing, she withdrew her request for the same. The Board thus finds that all due process has been satisfied with respect to the appellant's right to a hearing and will proceed on the matter based on the evidence contained in the claims folder. In November 2009, the Board remanded the case to the RO, via the Appeals Management Center (AMC), in Washington, DC, for further development and adjudicative action. A June 2011 Board Decision/Remand denied entitlement to service connection for posttraumatic stress disorder and again remanded the two issues shown on the front page of this action. The claims file has been returned to the Board for further appellate consideration. The claim was again remanded to the AMC in September 2012 to ensure that the appellant had been given due process. Upon reviewing the development that has occurred since September 2012, the Board finds there has been substantial compliance with its remand instructions. In this regard, the United States Court of Appeals for Veterans Claims, hereinafter the Court, has concluded that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination "more than substantially complied with the Board's remand order"). In this case, the record indicates that the AMC contacted the appellant to clarify whether she wished to continue with the prosecution of her appeal. Thereafter, a supplemental statement of the case was issued. Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its September 2012 Remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (finding that a remand by the Board confers on the appellant the right to compliance with the remand orders). Therefore, in light of the foregoing, the Board will proceed to review and decide the claim based on the evidence that is of record consistent with 38 C.F.R. § 3.655 (2012). The Board also notes that in the appellant's notice of disagreement, she seemed to aver that the medical treatment she received, to include the prescriptions prescribed for certain conditions, through the VA was deficient. This assertions has not been thoroughly explored or developed, as such, this item, which would be classified as entitlement to compensation under 38 U.S.C.A. § 1151 is referred back to the RO for further action. FINDINGS OF FACTS 1. The appellant is service-connected for a dermatological disorder for which she has been prescribed various medications both during and after service. 2. The appellant has suffered from endometriosis and has undergone a hysterectomy with bilateral oophrectomy. The medical evidence of record does not suggest or indicate that these disabilities were caused by or the result of the appellant's military service, a service-connected disability, or medications used to treat a service-connected disability. 3. The appellant has been diagnosed with eruptions in the mouth. The medical evidence of record does not suggest or indicate that this condition was caused by or the result of the appellant's military service, a service-connected disability, or medications used to treat a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for residuals of various gynecological disabilities, to include endometriosis, status post hysterectomy with bilateral oophrectomy, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for entitlement to service connection for a disability of the inside of the mouth have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all the evidence in the claims file. Although there is an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). Also, the Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, 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 a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act of 2000 (VCAA) - Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims, hereinafter the Court, held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Additionally, in Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, letters from the RO and the AMC advised the appellant of the evidence and information necessary to substantiate her service connection claim, as well as she and VA's respective responsibilities in obtaining such evidence and information. A December 2009 communication also informed the appellant of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Readjudication in March 2011 cured any timing deficiency. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Thus, no further development is necessary with respect to the duty to notify. The appellant was afforded VA examinations over the course of this appeal, the most recent in August of 2011. In all cases, the results from the examinations are of record. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The examinations and subsequent reports involved a review of the available medical records and the results of actual testing/examining of the appellant. The Board therefore finds that the medical information in toto is adequate for ratings purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Additionally, the Board notes that the appellant also has a Virtual VA paperless claims file, which is a highly secured electronic repository that is used to store and review documents involved in the claims process. Such evidence has been considered in deciding the instant appeal. Therefore, the Board will proceed with review of the appellant's claim based upon all relevant evidence. For the foregoing reasons, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the appellant in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). VA has satisfied its duty to inform and assist the appellant at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the appellant will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Laws and Regulations - Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110, 1131 (West 2002). For the showing of chronic disease (as defined under 38 C.F.R. § 3.309(a)) in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. See 38 C.F.R. § 3.303(b) (2012); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2012). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310(a) (2012); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). III. Facts and Analysis The appellant claims that service connection should be granted for residual gynecological disabilities and a disability of the inside of her mouth that she avers were caused by or the result of medications used to treat a skin disability. She has been granted service connection for a dermatological disorder and the Board observes that while in service, she did receive medications for the treatment of the skin disability. In-service treatment records dated in January 1976 and September 1976 reflect a diagnosis of gastroenteritis. A February 1977 in-service treatment record reflects complaints of abdominal pain and again indicates a diagnosis of probable gastroenteritis. The remainder of the service treatment records are silent for additional complaints or treatment referable to abdominal pain. In-service examinations reflect no stomach disabilities and no relevant complaints were raised in reports of medical history. The service treatment records reveal gynecological treatment basically throughout the appellant's period of active duty. Specifically, a November 1974 treatment note indicates that the appellant had irregular periods. A February 1975 OBGYN clinic note relates an excess of estrogen in the appellant. An April 1975 note indicates abdominal pain secondary to ovulation. A November 1975 cytology result indicates minimal dysplasia. A December 1975 provider's impression was one of rule out nonspecific vaginitis. A January 1976 OBGYN clinic note states the appellant mid-cycle break through bleeding. A March 1976 treatment note indicates severe menstrual cramping after missing two periods. A June 1976 treatment note indicates a vaginal infection with a watery yellow discharge. An October 1976 treatment note says the appellant had a vaginal discharge for two weeks. A December 1976 note from the OB/GYN emergency clinic indicates that the appellant wanted an IUD (inter-uterine device) inserted. A February 1977 note indicates that the IUD became displaced and half of it was expelled with the remaining portion of the device subsequently pulled out. A February 1977 treatment note indicates that the appellant had an adnexal mass on the right side of her uterus. A March 1977 lab report indicates that the appellant had a gonorrhea test which was negative. A March 1977 note indicates that the appellant had a foul smelling discharge with the impression being vaginitis. It is noted that none of these records indicated a chronic gynecological disability. Post-service, the record reveals a diagnosis of endometriosis in March 1999 following consistent complaints of abdominal pain. Other post-service treatment records show diagnoses of ovarian cysts and suspected small fibroid, and the appellant was eventually prescribed a hysterectomy to treat her endometriosis. Despite the medical records showing the development of endometriosis and eventual need for a hysterectomy, such evidence did not identify the cause of the gynecological symptoms and manifestations. To this end, the appellant was afforded a VA examination in March 2004 to determine the etiology of her endometriosis and hysterectomy; however, the examiner limited her discussion to the potential relationship between the appellant's problems and medications given to her by the San Francisco VA Medical Center (VAMC) Women's Clinic after service. While the examiner found no "legitimate claim" of endometriosis and hysterectomy due to medications provided by the VAMC Women's clinic after service, she did not address the appellant's contentions regarding the relationship between her gynecological problems and the in-service prescription and continued use of birth control pills and/or medication used to treat her service-connected skin disability. Moreover, she did not articulate any rationale for her conclusion, but instead noted that she had reviewed the claims folder and "research literature" in forming her opinion. Because the statements in the examination report were found to be inadequate, the Board ordered another examination, which was performed in April 2010. The examiner indicated that endometriosis is a condition which is due to a genetic predisposition and is not altered by environmental or occupational circumstances. The examiner provided appropriate citations to empirical evidence. However, the examiner did not consider the appellant's extensive treatment for gynecological problems in-service and whether the appellant's endometriosis and ovarian cysts, diagnosed post-service with a resultant hysterectomy, were related to in-service gynecological treatment and complaints. With respect to the appellant's mouth condition, the service treatment records reveal that the appellant was treated for "fever blisters," to include painful sores in the mouth and on the lips, with an assessment of herpes simplex. She was not diagnosed with any other dermatological disorder, disability, or disease. Subsequent to her discharge from service, and in conjunction with her claim for VA benefits, the appellant underwent examinations of the mouth in March 2004 and June 2007. On those occasions, the examiners reported intermittent papular lesions in the appellant's mouth; however, an etiological determination concerning those lesions or growths was not made. Likewise, when the appellant was examined in April 2010, the medical examiner did not proffer any type of opinion as to whether the appellant's claimed oral lesions were related to her in-service treatment for the oral herpes simplex virus. Subsequently, the claim was once again returned to the Board for review. It was concluded that the medical information contained in the claims was insufficient to make a determination on the appellant's claim and, as such, the claim was remanded to the AMC in June of 2011 to obtain a further medical opinion. Upon reviewing the claims folder and examining the appellant, the doctor in August 2011 provided the following opinion: DIAGNOSIS: Endometrioses S/P hysterectomy salpingo-oophrectomy PROBLEM ASSOCIATED WITH THE DIAGNOSIS: Endometriosis .... Is it likely that the veteran's residual GYM condition (endometriosis S/P hysterectomy) is due to or a result of "various gyn abnormalities found while she was on active duty" and or related to various medication[s] [taken] due to skin disorder - specifically to Depo-Provera provided by SFVA women's health. .... PERTINENT EVIDENCE: Medical literature pertaining to the etiology of endometriosis. .... Medical opinion is that: Her residual GYN condition (endometriosis S/P hysterectomy) is not caused by or a result of various gyn abnormalities found while she was on active duty and/or medications related to either GYN or skin disorder specifically Depo-Provera provided by SFVA women's health. RATIONALE FOR OPINION GIVEN: 1. 1974-1977 service medical records indicate treatment for menstrual cramps and irregularity. 2. Upon re-enlistment in 1978 veteran subjectively stated she had regular periods and the medical examiner stated she had been treated in the past for vaginitis. She reported being in good health without known allergies. On no medications. 3. According to current medical literature regarding women's health, the etiology of endometriosis is unknown (Up to Date - web based medical literature review). It can occur spontaneously or after Dilation and Curettage. There are hypothesis regarding an association to retrograde menstruation, autoimmune tendencies and genetic influences - however these are hypothetical. The veteran did not have record of these in service. 4. Her SMR and subsequent VA records do not include a history of Dilation and Curettage. 5. In regard to endometriosis, it is ironically treated with Depo-Prevera or pregnancy - both which the veteran had. Ironically Depo-Prevera is used to TREAT endometriosis, not cause it. 6. There is no clinical indication that there is a cause and effect relationship between: a. The listed medications found in her review of records (including Depo-Prevera) AND b. A diagnosis of vaginitis in the service and her subsequent diagnosis of endometriosis with S/P hysterectomy. The review of records and opinion provided by Dr. H. in her 2010 report is concise and medically sound. I concur with her medical opinion. The opinion regarding to the mouth claim, also obtained in August 2011, is provided below: Whether vet's mucosal lesions (intra-oral) are due to or a result of veteran's dermatological (non-mucosal) skin condition "eczema" "acne" 'granulomatous rosacea", and/or medications used to treat it, and/or to vet's history of herpes vesicles on lips. .... The condition mucosal lesions (intra-oral) are less likely as not (less than 50/50 probability) caused by or a result of vet's dermatological (non-mucosal) skin condition "eczema", "acne", "granulomatous rosacea", and/or medications used to treat it, and/or to vet's history of herpes vesicles on lips. RATIONALE: (a) Papulosquamous eruptions inside mouth, i.e. on mucous membrane, can occur under these conditions (ref UpToDate): Lichen Planus which vet has never been diagnosed with. (b) Search of online reference PubMed, in MESH mode, looking for connection between "recurrent mucosal papulosquamous lesions of mouth", with "drug allergy" (once drug is stopped) - no connection, according to PubMed literature search; similar search turns up no connection when dermatology condition of granulomatous rosacea is searched, and no connection when acne is searched, and no connection when eczema is searched. Nor does herpes of lips dive deep into mouth mucosa, without any involvement of lips. Nothing "fits" as cause of vet's claimed recurrent mucosal (intra-oral) papulosquamous lesions. In conclusion, vet's claimed mucosal (intra-oral) condition does not appear to be a progression of the SC skin disability, nor a reaction (allergic or otherwise) to medications used to treat the SC skin disability, nor an aggravation of something else by vet's medications, nor an "echo" of long ago herpes of lips. . . . No other medical evidence in the claims folder or on Virtual VA addresses the etiology of either disability now on appeal. To review, the claims folder contains the appellant's assertions that, but for the treatment she received for her service-connected skin disability, she would not now have disabilities of the mouth or residual gynecological disabilities. However, the medical evidence of record does not support her assertions. The Board must weigh the credibility and probative value of the medical opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)); see also Wensch v. Principi, 15 Vet. App. 362, 368 (2001) (it is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases for doing so). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-1 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997). In the case of Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), the Court held that a claims file review, as it pertains to obtaining an overview of a veteran's medical history, is not a requirement for private medical opinions. A review of the claims file by a VA examiner, without more, does not automatically render the VA examiner's opinion competent or persuasive since the claims file is a tool to assist in familiarity for the physician with the claims file, and conversely a private medical opinion may not be discounted solely because the opining clinician did not review the claims file as there are other means by which a physician can become aware of critical medical facts, such as a history of treating the veteran for an extended period of time and/or reviewing pertinent medical literature. The relevant focus is not on whether the clinician had access to the claims file, but instead on whether the clinician was "informed of the relevant facts" in rendering a medical opinion. Thus, when referring to facts obtained from review of the claims file as a basis for crediting one expert opinion over another, it is incumbent upon VA to point out those facts and explain why they were necessary or important in forming the appropriate medical judgment. Certainly, the particular medical information contained in a claims file may have significance to the process of formulating a medically valid and well-reasoned opinion. The Court further held that a medical opinion that contains only data and conclusions is not entitled to any weight and a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes is derived. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). In sum, in Nieves-Rodriguez, the Court indicated that it is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion. In this instance, the Board finds that the VA doctor's opinions of August 2011 concerning the gynecological disorders and the mouth disability were factually accurate. There are no medical opinions, either governmental or private, that support the appellant's assertions concerning either appealed disorder. The examiner pointed to established facts in the opinions. The Board further believes that the doctor provided sound reasoning in the analysis of the appellant's disabilities, the medications that were used over the years for treatment of miscellaneous disorders and disabilities, and her overall health status. In other words, the VA examiner reviewed in detail the pertinent medical records, discussed the salient facts, and provided complete rationale for all conclusions presented, as noted in the discussion above. The VA examiner supported his conclusions based on the objective evidence of record and sound medical principles. Additionally, the VA examiner's opinions were not equivocal. That examiner was very specific and direct in the opinions he provided. Based on the clarity and specificity provided in the VA opinions of 2011, the VA examiner's opinions do not appear speculative or based on information that is second-hand. See generally Bloom v. West, 12 Vet. App. 185 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). See also 38 C.F.R. § 3.102 (2012)(when considering application of the benefit- of-the-doubt doctrine, reasonable doubt is one within the range of probability, as distinguished from pure speculation or remote possibility). Accordingly, the Board attaches the most significant probative value to the VA opinions, as they are well reasoned, detailed, consistent with other evidence of record, and included an access to the accurate background of the appellant. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.) To support her claim for benefits, the appellant submitted excerpts obtained from the internet concerning the various medications that she has been prescribed for gynecological symptoms and dermatological manifestations. These articles contain a discussion of the various symptoms and manifestations produced by an individual who has received certain types of pharmaceutical treatment for a multitude of conditions. Yet, the excerpts themselves do not discuss the appellant's case history, they do not reference the appellant's case history as a member of a population upon which any of the excerpts are based thereon, and the author or authors of the excerpts never examined the appellant (or reviewed her records). Furthermore, the literature only provides generalized information concerning the drugs that the appellant has used over the years, along with some of their side-effects. Although there may be basic similarities to the medical history described in the article and the appellant's case, the highly probative VA doctor's opinions establish that the appellant's claimed conditions are not the result of those medications. Accordingly, the literature is too general and inconclusive, especially when considered in combination with the other evidence, to support the appellant's claim. The only remaining opinion addressing whether there is a link between the claimed disorders and the appellant's service, or a service-connected disability, or the medications used in the treatment of a service-connected disorder, is that of the appellant and endorsed by the accredited representative. The Board finds that the generalized statements provided by the appellant are too general in nature to provide, alone, the necessary evidence to show that the disabilities should be service-connected. See Sacks v. West, 11 Vet. App. 314, 316-17 (1998). Moreover, in the instant case, the question of etiology extends beyond that capable of lay observation and requires medical knowledge. As such, she is not competent as a lay person to offer such opinion and thus her statements in this regard do not constitute probative evidence. Barr v. Nicholson, 21 Vet. App. 303 (2007); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). In determining whether service connection is warranted, the VA must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case service connection must be denied. 38 U.S.C.A. § 5107 (West 2002 & Supp. 2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, competent and probative medical evidence that establishes the claims on appeal has not been presented. Therefore, after reviewing the appellant's claims folder, it is the conclusion of the Board that the preponderance of the evidence is against the appellant's claim. The evidence in this case is not so evenly balanced as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 3.102 (2012). (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for residual gynecological disabilities, to include endometriosis, status post hysterectomy with bilateral oophrectomy, to include as being due to medications prescribed for a skin disability, is denied. Entitlement to service connection for a mouth disability, claimed as secondary to a skin disability, is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs