Citation Nr: 1323432 Decision Date: 07/23/13 Archive Date: 08/01/13 DOCKET NO. 07-14 795 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for dysmenorrhea. 2. Entitlement to service connection for hysterectomy, to include post-operative residuals. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Tresa M. Schlecht, Counsel INTRODUCTION The Veteran served on active duty from October 1987 to April 1990. This appeal initially came before the Board of Veterans' Appeals (Board) from a June 2006 rating decision of the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for dysmenorrhea and hysterectomy. The Board Remanded the appeal in December 2008 and in February 2012. The Board has recharacterized the Veteran's claim for service connection for hysterectomy to more accurately reflect the Veteran's contention on appeal. In December 2007, the Veteran testified before a Veterans Law Judge (VLJ) at a Travel Board hearing at the RO. In December 2010, the Board sent the Veteran a letter informing her that the VLJ who conducted the December 2007 Travel Board hearing was no longer employed by the Board. The Veteran was offered the opportunity to testify at another hearing. See 38 C.F.R. § 20.717 (2012). In February 2011, she requested another Travel Board hearing. In March 2011, she withdrew her Travel Board request. FINDINGS OF FACT 1. Abnormal uterine bleeding began during and was causally related to the Veteran's service. 2. The Veteran's pelvic pain and dysmenorrhea began prior to the Veteran's service, but were aggravated during service. 3. The medical evidence establishes that it is as likely as not that the Veteran would have required a hysterectomy for treatment of abnormal bleeding and dysmenorrhea that began or was permanently aggravated during service, even without the development of fibroids following service. CONCLUSIONS OF LAW 1. Dysmenorrhea was incurred or aggravated during the Veteran's active service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The criteria for service connection for a hysterectomy, to include residuals, are met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Generally, service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Direct service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247 (1999). Service treatment records reflect that the Veteran was treated for gynecologic complaints during service. She was seen as early as June 1988 for complaints of pelvic pain. Following another visit for pelvic pain in January 1989, the Veteran underwent a laparoscopy, which yielded no diagnosis. The Veteran also sought evaluations for abdominal pain in April 1989, May 1989, and September 1989 and, in each instances, no diagnosis of a reproductive system disorder was assigned. The Veteran's pelvic examination was described as normal on separation examination in March 1990, and no history or complaint of a pelvic disorder was noted. Lengthy post-service VA and private clinical records have been obtained. At least 500 pages of clinical records are included in the four volumes of the claims files. Treatment notes dated in 1991 and 1992 reflect that the Veteran complained of recurring pelvic pain and symptomatology when she was treated for dysmenorrhea beginning about a year following her service discharge. The provider who rendered an August 2010 VA medical opinion concluded that fibroids present at the time of a 2005 hysterectomy were not likely present in service, since pelvic examinations in 1992 and 1994 were negative for fibroids. The examiner did not address whether complaints of dysmenorrhea and pelvic pain which were treated in service were chronic. The Veteran submitted a private opinion dated in May 2013 in support of her appeal. The 2013 opinion states that the disorder which required the Veteran to undergo hysterectomy in 2005 was adenomyosis, which might have developed during service, rather than fibroids which developed after service. The provider opined that adenomyosis was present during the Veteran's service and thereafter. However, this favorable opinion did not discuss the service treatment records or post-service treatment records with specificity. In June 2013, the Board requested a medical opinion from the Veterans Health Administration (VHA) in accordance with 38 C.F.R. § 20.901(a). The requested opinion has been provided and associated with the Veteran's VA claims folder. Although the June 2013 VHA opinion has not yet been provided to the Veteran, it would be adverse to the Veteran's interest to undertake this procedural process rather than issue this decision, as the Board is granting in full the benefit sought on appeal, based on the findings set forth in the VHA opinion. 38 C.F.R. § 20.903. The reviewer who provided the June 2013 VAH opinion concluded that the Veteran's service treatment records disclose that the Veteran sought treatment for dysmenorrhea and abnormal bleeding soon after her entry into service. Reference was also made to an August 1988 treatment note that indicated that the Veteran's menstrual cycles were regular prior to service. Based on this treatment note, and in light of her clinical experience and knowledge, the reviewer concluded that it was likely that the Veteran's abnormal bleeding began during service and was even possibly caused by the stress of service. The reviewer noted that the Veteran was seen for dysmenorrhea multiple times in service. The reviewer provided a lengthy discussion of the basis for the conclusion that, although it was reasonable to conclude that the Veteran's pelvic pain and dysmenorrhea began prior to her service, the disorder or disorders underlying that pain were permanently aggravated during service. In this regard, the question of whether the dysmenorrhea preexisted was not addressed under the corrected evidentiary standard. However, whether the dysmenorrhea had its initial onset in service or preexisted and was aggravated by service is relatively immaterial. The fact remains that the examiner essentially determined that the Veteran's dysmenorrhea was related to her active service. The criteria for service connection for dysmenorrhea are met. The June 2013 VHA examiner also agreed with the opinion of the VA examiner who provided the 2010 opinion to the extent that the examiner concluded that fibroids present at the time of the Veteran's 2005 hysterectomy were not present during the Veteran's service. These opinions address the Veteran's contention that her hysterectomy was required because of fibroids, which the Veteran asserts developed during or as a result of her service. However, in essence, the Veteran is seeking service connection for a hysterectomy and the residuals thereof, rather than the fibroids present at the time of the hysterectomy. As to the claim for service connection for the hysterectomy, the June 2013 VHA examiner concluded that it was possible that the Veteran would have undergone hysterectomy for her persistent pain and bleeding even if fibroids had not developed post-service. The Board interprets the reviewer's conclusion and the rationale underlying that conclusion as a medical determination that the evidence is at least in equipoise to warrant a finding that the Veteran's hysterectomy was required as a result of the gynecologic symptoms and disorders which developed or were aggravated in service. The 2013 VHA opinion is favorable to the Veteran's claim that her hysterectomy resulted from disabilities incurred in or aggravated by service. Indeed, despite some ambiguities in the June 2013 opinion, the examiner ultimately concluded that the Veteran's hysterectomy was necessary for unresolved bleeding and pain symptoms that began either in service or worsened during/by service. The criteria for service connection are met. Finally, in light of the fully favorable determination in this case, discussion of compliance with VA's duty to notify and assist is not deemed necessary. ORDER The appeal for service connection for dysmenorrhea is granted. The appeal for service connection for hysterectomy, to include post-operative residuals, is granted. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs