Citation Nr: 1329791 Decision Date: 09/17/13 Archive Date: 09/25/13 DOCKET NO. 09-14 648 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to disability ratings higher than 0 percent from January 27, 2006, and 60 percent from February 12, 2013, for resection of uterine fibroid and removal of right ovary and fallopian tube with residual stress incontinence. 2. Entitlement to an initial disability rating higher than 10 percent for bipolar disorder. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from September 1986 to February 1987, from August 1994 to August 1995, from February 2003 to January 2006, and from January 2011 to January 2012. She also had service in the National Guard. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions by the Chicago, Illinois Regional Office (RO) of the United States Department of Veterans Affairs (VA). In an October 2006 rating decision the RO granted service connection for resection of uterine fibroid and removal of right ovary and fallopian tube with residual stress incontinence, and assigned a 0 percent disability rating. The RO granted service connection for bipolar disorder and assigned a 10 percent disability rating. The RO denied service connection for headaches, asthma, and a back disorder. In November 2012 the Board granted service connection for a back disorder. The Board remanded the issues of service connection for headaches and asthma and the issues of a higher rating for reproductive organ surgery residuals including incontinence, a higher rating for bipolar disorder, and service connection for headaches and asthma. In a June 2013 rating decision the RO granted service connected for migraine headaches and for asthma. The RO increased the rating for the reproductive organ surgery residuals including incontinence to 60 percent, effective February 12, 2013. Following RO and Board actions fully and partially granting some claims, the issues remaining on appeal are those listed in the issue section, above. The Board is satisfied that there has been substantial compliance with the remand directives. The Board will proceed with review. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has reviewed both the Veteran's paper claims file and the Veteran's file on the Virtual VA electronic file system, to ensure a total review of the evidence. In the November 2012 Board decision and remand, the Board noted that in October 2010 the Veteran submitted a statement regarding claimed post-traumatic stress disorder (PTSD) as a result of military sexual trauma. The Board found that the Veteran's statement constitutes a request to reopen a previously denied claim for service connection for PTSD. The Board referred that request to reopen the claim to the RO for further action. As of the Board's present review of the Veteran's case, the record contains no indication that the RO has taken action on the Veteran's request to reopen that claim. Therefore the Board again refers the Veteran's request to reopen a previously denied claim for service connection for PTSD to the RO for appropriate action. FINDINGS OF FACT 1. From January 27, 2006, resection of uterine fibroid and removal of right ovary and fallopian tube with residual stress incontinence has been manifested by iliac pain that does not require continuous treatment, and by urinary frequency with a daytime voiding interval of three to four hours and awakening to void one to two times per night. 2. Resection of uterine fibroid and removal of right ovary and fallopian tube with residual stress incontinence has required the wearing of absorbent materials that need changing multiple times per day, and has interfered with employment, but to a less than marked extent. 3. From January 27, 2006, bipolar disorder has produced occupational and social impairment with occasional decrease in work efficiency and intermittent lapses in ability to perform educational and occupational tasks, due to such symptoms as depressed mood, anxiety, chronic sleep impairment, and intermittent mild to moderate impairment of concentration, memory, and organization. CONCLUSIONS OF LAW 1. From January 27, 2006, resection of uterine fibroid and removal of right ovary and fallopian tube with residual stress incontinence has met the criteria for a 10 percent disability rating. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.115a, 4.116, Diagnostic Codes 7613, 7614, 7615, 7619 (2013). 2. Resection of uterine fibroid and removal of right ovary and fallopian tube with residual stress incontinence has not met the criteria for a disability rating higher than 60 percent. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 3.321(b)(1), Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.115a, 4.116, Diagnostic Codes 7613, 7614, 7615, 7619 (2013). 3. From January 27, 2006, bipolar disorder has met the criteria for a 30 percent disability rating. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Code 9432 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2011)) redefined VA's duty to assist a claimant in the development of a claim for VA benefits. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has stated that the requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). Insufficiency in the timing or content of VCAA notice is harmless, however, if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). The RO provided the Veteran with VCAA notice in letters issued in March 2006 and June 2006, before the initial decisions on the claims currently on appeal. In those letters the RO addressed the information and evidence necessary to substantiate claims for service connection. The RO informed the Veteran how VA assigns disability ratings and effective dates. The letters also addressed who was to provide the evidence. The Veteran's claim file (including information on paper and in electronic form) contains service treatment records, records of post-service treatment and examinations, and statements from the Veteran. The Veteran has had medical examinations performed by qualified clinicians who reviewed the Veteran's claims file. The examiners explained their findings and conclusions. The examinations and examination reports are adequate for the purpose of addressing the claims on appeal. Following the Board remand additional service records and post-service medical records have been added to the claims file and the Veteran has had additional VA medical examinations. The Board is satisfied that there has been substantial compliance with the remand directives, such that additional remand is not needed. See Stegall v. West, 11 Vet. App. 268 (1998). The Board finds that the Veteran was notified and aware of the evidence needed to substantiate her claims, as well as the avenues through which she might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran has actively participated in the claims process by providing evidence and argument. Thus, she was provided with a meaningful opportunity to participate in the claims process, and she has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication nor to have caused injury to the Veteran's interests. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless, and does not prohibit consideration of the claims on their merits. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Reproductive Organ Surgery Residuals Including Incontinence During the Veteran's 2003 to 2006 period of active service she underwent surgery that including resection of a uterine fibroid and removal of the right ovary and fallopian tube. After the surgery she experienced frequent urination and stress incontinence. The Veteran included residuals of the surgery in her 2006 claim for VA disability compensation. The RO established service connection, effective January 27, 2006, for resection of uterine fibroid and removal of right ovary and fallopian tube with residual stress incontinence. The RO assigned a 0 percent disability rating. The Veteran appealed that rating. In a June 2013 rating decision the RO increased the rating for that disability to 60 percent, effective February 12, 2013. The Veteran has continued her appeal of the ratings for that disability. In appealing the ratings of 0 percent from January 27, 2006, and 60 percent from February 12, 2013, the Veteran essentially contends that the residuals of reproductive organ surgery warrant higher ratings. VA assigns disability ratings by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.10. If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. The Court has held that, at the time of the assignment of an initial rating for a disability following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). As the Veteran appealed the initial rating that the RO assigned, the Board will consider the evidence for the entire period from January 27, 2006, the effective date of service connection for the reproductive organ and urinary function disability, and will consider whether for any parts of that period ratings higher than the ratings the RO assigned are warranted. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. The RO has evaluated the reproductive organ surgery residuals including urinary dysfunction under 38 C.F.R. §§ 4.115a and 4.116. Under 38 C.F.R. § 4.116, disease, injury, or adhesions of the female reproductive organs, including the uterus, fallopian tubes, and ovaries, are rated at 30 percent if there are symptoms that are not controlled by continuous treatment, 10 percent if there are symptoms that require continuous treatment, and 0 percent if there are symptoms that do not require continuous treatment. Removal of one ovary is rated at 100 percent for three months after the removal, and thereafter at 0 percent. 38 C.F.R. § 4.116, Diagnostic Code 7619. The RO granted the Veteran special monthly compensation for loss of use of a creative organ based on the removal of one ovary, in accordance with 38 U.S.C.A. § 1114(k) and 38 C.F.R. § 3.350. The rating schedule at 38 C.F.R. § 4.115a provides the following criteria for rating urinary frequency: Daytime voiding interval less than one hour, or; awakening to void five or more times per night ..................... 40 percent Daytime voiding interval between one and two hours, or; awakening to void three to four times per night .... 20 percent Daytime voiding interval between two and three hours, or; awakening to void two times per night .............. 10 percent The rating schedule at 38 C.F.R. § 4.115a provides the following criteria for rating urinary incontinence or stress incontinence: Requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day ........................................................... 60 percent Requiring the wearing of absorbent materials which must be changed 2 to 4 times per day ......................... 40 percent Requiring the wearing of absorbent materials which must be changed less than 2 times per day .................... 20 percent Medical records from the Veteran's 2003 to 2006 period of active service reflect surgery on the reproductive organs. Post-surgical records contain notations of urinary frequency and incontinence. Those service medical records do not indicate how frequently the Veteran urinated nor whether it was necessary to wear absorbent materials. Those records do not state whether the Veteran had any residual pain in the area of the surgery. On VA examination in April 2006 the Veteran related the history of surgical resection of a fibroid and removal of the right ovary and fallopian tube. She reported that she had irregular periods, cramps with periods, and abdominal cramps outside of periods. She stated that she had pain in the left iliac fossa. She reported a one year history of urine leakage with laughing, coughing, sneezing, carrying things, and climbing stairs. She also related having urge incontinence. She stated that she urinated four to five times during the day and one to two times at night. She indicated that a physical therapist prescribed Kegel exercises to help address the urge incontinence. The examiner found evidence of tenderness in the left iliac fossa, without any palpable masses. The examiner found that the Veteran's left iliac pain was residual to the fibroids and the reproductive organs surgery. The examiner concluded that the Veteran had stress urinary incontinence and occasional urge incontinence. Records of VA treatment from 2006 forward reflect an ongoing diagnosis of stress incontinence. In November 2009 the Veteran stated that the incontinence was increasing in severity. On VA examination in February 2013 the examiner reported having reviewed the Veteran's claims file. The examiner noted that the Veteran had urinary stress incontinence residual to the gynecological surgery she had during her 2003 to 2006 period of active service. The Veteran reported that she had frequent stress incontinence with laughing, coughing, or sneezing. She indicated that the incontinence required by changing pads six times daily. She stated that Kegel exercises did not provide much improvement in her urinary incontinence. She stated that her daytime voiding interval was between one and two hours, and that she awakened two times each night to void. The examiner noted that social embarrassment from the smell of urine, and the inconvenience of having to change the pads every couple of hours, presented obvious social and occupational impairment. The VA physician who examined the Veteran in April 2006 attributed the Veteran's left iliac pain to her reproductive organ surgery. It was not reported that the left iliac pain required continuous treatment, so that residual pain did not warrant a compensable rating under Diagnostic Code 7619. The Veteran's urinary frequency as reported in the 2006 examination was a daytime voiding interval of three to four hours and voiding one to two times at night. That frequency meets or very nearly meets the criteria for a 10 percent rating under 38 C.F.R. § 4.115a. Resolving reasonable doubt in the Veteran's favor, the Board grants an initial 10 percent rating for the urinary dysfunction residuals of the surgery. Prior to the February 2013 examination, the evidence did not show residuals and effects that warranted a rating higher than 10 percent. The surgery residuals, including urinary dysfunction, did not require continuous treatment. The Veteran did not have a daytime voiding interval of two hours or shorter and she did not awaken to void more than two times per night. While the Veteran reported in 2009 that the incontinence was worsening, there was no information before the 2013 examination that the incontinence required wearing absorbent materials. The RO granted a 60 percent rating effective from the February 12, 2013, VA examination. The 60 percent rating is the highest rating the rating schedule provides for urinary dysfunction. That rating adequately addresses the Veteran's urinary dysfunction, and the evidence does not tend to show that her surgery residuals including urinary dysfunction warrant a rating higher than 60 percent. When there is an exceptional disability picture, such that the rating schedule criteria do not reasonably describe a claimant's disability level and symptomatology, an RO may refer a case to the VA Under Secretary for Benefits or to the Director of the VA Compensation and Pension Service for consideration of an extraschedular rating. See 38 C.F.R. § 3.321(b)(1) (2012); see also Thun v. Peake, 22 Vet. App. 111, 115 (2008). Extraschedular ratings are limited to cases in which it is impractical to apply the regular standards of the rating schedule because there is an exceptional or unusual disability picture, with such related factors as frequent hospitalizations or marked interference with employment. 38 C.F.R. § 3.321(b)(1). The Veteran's urinary frequency and incontinence and other residuals of reproductive organ surgery have not required frequent hospitalizations. In the February 2013 VA examination the examiner expressed that the Veteran's urinary incontinence presents obvious social and occupational impairment. The record reflects, however, that the Veteran has continued to function in work and educational settings, and that her incontinence has not interfered with that functioning to an extent that rises to the level of marked. The rating criteria address the manifestations of the Veteran's condition, including symptoms such as pain and urinary dysfunction. The Board concludes that the regular rating criteria are adequate to evaluate the Veteran's reproductive organ and urinary function disability, and that it is not necessary to refer the rating of that disability for consideration of extraschedular ratings. The Board has considered whether the record raises the issue of unemployability, such that unemployability must be considered. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran's reproductive organ surgery residuals, including urinary frequency and incontinence, do produce some occupational impairment. Nonetheless, the Veteran has continued to function in educational and employment settings. The evidence does not raise a significant possibility that her urinary dysfunction makes her unable to secure or follow a substantially gainful occupation. Thus the record regarding that disability does not raise the issue of unemployability. Bipolar Disorder In February 2006 the Veteran filed a claim for service connection and compensation for multiple disabilities, including bipolar disorder. In the October 2006 rating decision the RO granted service connection, effective January 27, 2006, for bipolar disorder, and assigned a 10 percent disability rating. The Veteran appealed that rating. The Board will consider whether the effects of the Veteran's bipolar disorder has warranted higher ratings at any time from January 27, 2006, forward. The Veteran contends that the disorder produces impairment that warrants a rating or ratings higher than 10 percent. The rating schedule provides for evaluating mental disorders such as bipolar disorder under a General Rating Formula for Mental Disorders, which follows: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name .......................... 100 percent Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships ............................................. 70 percent Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships ........................... 50 percent Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) ..................................................... 30 percent Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication ............................. 10 percent A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication ................................ 0 percent 38 C.F.R. § 4.130. In treating and evaluating mental disorders, mental health professionals sometimes assign a Global Assessment of Functioning (GAF) score. The GAF scale is a scale of psychological, social, and occupational functioning a hypothetical continuum of mental health and illness. It is provided in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Assessments on the GAF scale are not to include impairment in functioning due to physical or environmental limitations. Clinicians have assigned the Veteran GAF scores of 49 through 70. GAF scores of 61 to 70 are for some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, having some meaningful interpersonal relationships. GAF scores of 51 to 60 are for moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores of 41 to 50 are for serious symptoms (e.g., suicidal ideation, severe obsessional rituals) or any serious impairment in social, occupation, or school functioning (e.g., no friends, unable to keep a job). DSM-IV. Medical records from the Veteran's 2003 to 2006 period of active service reflect her reports of stress, anxiety, heart palpitations, panic attacks, difficulty sleeping, and fatigue. She reportedly had behavioral health treatment, and antidepressant and antianxiety medications were prescribed. On VA examination in April 2006 the Veteran reported that during service in 2005 she experienced sleep difficulties, racing thoughts, and sadness. She stated that she was diagnosed with bipolar disorder and was treated with therapy and medication. She indicated that she continued on medication. She related that since her January 2006 separation from active service she had not yet returned to work as a home health worker. She reported current symptoms of anxiety, racing thoughts, insomnia, and anxiety. She stated that when not sleeping she felt that she had to engage in tasks such as cleaning. She related memory problems such as forgetting important things and forgetting directions to places. She indicated difficulty with concentration, such that she easily became sidetracked. She reported occasional periods of euphoria and hyperactivity. She expressed worry about her performance when she returned to work. The examiner found that the Veteran was oriented and had spontaneous speech and appropriate affect. There was no evidence of perceptual disordered thought. The examiner listed a diagnosis of bipolar disorder and assigned a GAF score of 62 to 65. The Veteran had VA outpatient mental health treatment from 2006 to 2008. Treatment included individual talk therapy and medications. During parts of that period she had therapy as frequently as weekly. In September 2006 the Veteran related having racing thoughts and problems sleeping. She reported that she was raped during service in 1994 and that periodically she relived that traumatic experience. She related that she was studying toward a nursing degree, and that she was single and raising her teenaged child. In November 2006 the Veteran reported that she ruminated about the 1994 rape. The treating clinician observed that the Veteran was nervous, anxious, and tearful. The clinician found that the Veteran was coherent and that her thought processes were logical. The clinician assigned a GAF score of 49. In December 2006 the Veteran reported that she was not doing well in her studies. The treating clinician observed that the Veteran's speech and thought processes were disorganized. In VA treatment in January 2007 the Veteran reported memory problems and inability to concentrate in her classes. She stated that she had failed some of her classes. The treating clinician noted that the Veteran had mildly disorganized thought processes and tangential speech. The clinician found that the Veteran had no psychotic symptoms. In February 2007 the clinician indicated that the Veteran had deficits in focus and organization. The clinician assigned a GAF score of 55. In March 2007 the Veteran reported that she had to wait to retake courses that she had failed, so she had resumed working in home healthcare. She related ongoing memory and concentration problems with manifestations such as forgetting routes while driving. In treatment in late 2007 the Veteran reported that she had recently married. A clinician assigned a GAF score of 50 in November 2007. On VA examination in November 2007 the Veteran reported that she was on medications for bipolar disorder, depression, and difficulty sleeping. She related depression, bad dreams, and difficulty concentrating. She reported having episodes of racing thoughts and difficulty sleeping. She stated that she was employed in home health care. She indicated that she had recently married and that the marital relationship was stressed. The examiner found that the Veteran was oriented and appeared to be depressed. The Veteran had clear speech, good memory, and a depressed mood, with tearfulness when describing traumatic and upsetting events. The Veteran denied delusion, hallucinations, or suicidal or homicidal thoughts. The examiner found that the Veteran had bipolar disorder with depression of moderate severity. The examiner noted that the Veteran lost a few hours from work due to bipolar disorder symptoms. The examiner assigned a GAF score of 60. In December 2007 a treating clinician began the Veteran in cognitive processing therapy to address ongoing effects of the traumatic experience of the rape. In January 2008 the Veteran reported feeling worse. A clinician assigned a GAF score of 50 in May 2008. Notes of general medical care in October 2009 reflect the Veteran's report that she had stopped mental health treatment because it had become too difficult, as she had experienced increased reliving of trauma. She indicated that presently she had flashbacks. She stated that she was working and studying toward a nursing degree. Notes of VA treatment in 2009 did not reflect that the Veteran was on any medication to address psychiatric issues. In 2011 and 2012 the Veteran argued, through her representative, that the effects of her mental disability on her occupational and social functioning warrant a rating higher than the assigned 10 percent rating. On VA examination in February 2013, the Veteran indicated that she was married and had an adult child and younger stepchildren. She indicated that she was unemployed since finishing a period of active service in November 2012. She reported that she had stopped outpatient mental health treatment in 2008 and had resumed treatment in July 2012 while experiencing difficulties with subordinates and superiors at work. She related having had no hypomanic episodes since December 2012. She stated that presently she felt exhausted but was trying to regroup. She reported that she felt tired almost all day about three days per week. She related having impaired concentration and being easily distracted. She reported having irritability, and stated that she overate and had gained weight. She indicated that she had difficulty returning to sleep after awakening to urinate. She stated that she was able to maintain daily activities, attend her children's activities, and seek employment. The examiner found that the Veteran was alert with an appropriate affect and impaired concentration but no distractibility. The examiner listed a diagnosis of bipolar disorder. The examiner indicated that the symptoms of the diagnosed mental disorder were not severe enough to interfere with occupational and social impairment or to require continuous medication. The examiner assigned a GAF score of 70. From 2006 forward treatment and examination records show that the Veteran's service-connected psychiatric disability, described as bipolar disorder, has been manifested by racing thoughts, difficulty sleeping, mood disturbances, and trouble with concentration, memory, and organization. The Veteran's bipolar disorder has resulted in at least occasional decrease in her efficiency in pursuing education and employment. The evidence shows a disability picture more consistent with the criteria for a 30 percent rating than with the criteria for a 10 percent rating. The Board therefore grants an initial 30 percent disability rating. The evidence does not tend to show that the Veteran's bipolar disorder has warranted a rating higher than 30 percent. Overall her occupational and social impairment has not risen to the level of reduced reliability and productivity. She has had difficulty in educational courses but has functioned more successfully in employment. On most observations her speech and thought processes have been normal or no more than slightly impaired. Her memory, concentration, and organization difficulties have affected her work and other functioning intermittently and mildly to moderately. The Board notes that the VA clinician who examined the Veteran in February 2013 selected the description of impairment consistent with a 0 percent rating. That finding, however appears to be somewhat inconsistent with symptoms reported at that time. The Veteran stated, for example, that she felt exhausted about three days each week, and she indicated that she had experienced hypomanic episodes a few months earlier. It is also significant that treating clinicians who saw the Veteran repeatedly observed a worse disability picture than did the clinician who saw the Veteran on one occasion for the 2013 examination. While the February 2013 examination report provides some evidence of diminished disability, the Board finds that the examination report does not provide a sufficiently informed and consistent picture of sustained improvement to warrant the assignment of a lower rating for a more recent period. The Veteran's bipolar disorder has not required frequent hospitalizations. The disability appears to have affected her educational endeavors more than it has affected her employment. Overall the effect on employment and related endeavors has not risen to the level of marked interference. The rating criteria address the effects of the Veteran's bipolar disorder, and provide for higher ratings for impairment greater than is present in this case. The regular rating criteria thus are adequate to evaluate the Veteran's bipolar disorder. It is not necessary to refer the rating of that disability for consideration of extraschedular ratings. The Board has considered whether the record with respect to the Veteran's bipolar disorder raises the issue of unemployability, such that unemployability must be considered. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran's bipolar disorder produces some occupational impairment, but she has continued to function in educational, employment, family, and social settings. The evidence does not tend to indicate that her bipolar disorder might make her unable to secure or follow a substantially gainful occupation. Thus the record regarding that disability does not raise the issue of unemployability. ORDER Entitlement to a 10 percent disability rating from January 27, 2006, for resection of uterine fibroid and removal of right ovary and fallopian tube with residual stress incontinence is granted, subject to the laws and regulations controlling the disbursement of monetary benefits. Entitlement to a disability rating higher than 60 percent for resection of uterine fibroid and removal of right ovary and fallopian tube with residual stress incontinence is denied. Entitlement to a 30 percent disability rating from January 27, 2006, for bipolar disorder is granted, subject to the laws and regulations controlling the disbursement of monetary benefits. ____________________________________________ MATTHEW D. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs