Citation Nr: 1331092 Decision Date: 09/26/13 Archive Date: 09/30/13 DOCKET NO. 08-21 887 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUE Entitlement to service connection for a chronic disability manifested by abnormal blood chemistry and/or endocrine dysfunction, currently claimed as hirsutism. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran served on active duty from March 1980 to March 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. The Veteran appealed the decision. Jurisdiction over this appeal may have transferred to another RO. The latest information in the Board's Veterans Appeals Control and Locator System (VACOLS) indicates that the Veteran has moved to Pennsylvania. In February 2009, the Veteran testified before the undersigned Veterans Law Judge at the VA Central Office in Washington, D.C. In March 2010, the Board remanded this matter for further development. After the case was returned to the Board, it denied the Veteran's claim in a December 2011 decision. The Veteran appealed the December 2011 decision to the United States Court of Appeals for Veterans Claims (Court). In a November 2012 Joint Motion for Remand (JMR), both the appellant and the VA Secretary (hereinafter "the parties") requested that the Board decision denying service connection be vacated and the issue remanded for compliance with the terms of the JMR. The Court issued an order granting the Joint Motion later in November 2012. In March 2013, the Board remanded this matter for further development in accordance with the instructions of the JMR. The appeal has now been returned to the Board for adjudication. The following determination is based on review of the Veteran's claims file in addition to her Virtual VA "eFolder." FINDING OF FACT Resolving all reasonable doubt in the Veteran's favor, the evidence of record indicates that her hirsutism is likely related to her period of active service. CONCLUSION OF LAW Hirsutism was incurred during the Veteran's active military service. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The provisions of the VCAA are codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) and interpreted by the Court. (See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 20 Vet. App. 473 (2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006)). Given the determination reached in this decision, the Board is satisfied that adequate development has taken place and that there is a sound evidentiary basis for resolution of the claim for service connection for a chronic disability manifested by abnormal blood chemistry and/or endocrine dysfunction, claimed as hirsutism, without detriment to the due process rights of the Veteran. Service Connection - Laws and Regulations Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Generally, in order to prevail on the issue of service connection on the merits, 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) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). The United States Court of Appeals for the Federal Circuit has held that a veteran seeking disability benefits must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). A veteran is presumed to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrated that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). If the disorder was not noted upon entry, the presumption of soundness may be rebutted by a showing, by clear and unmistakable evidence, both that a disease or injury existed prior to service and that the disease or injury was not aggravated by service. 38 U.S.C.A. § 1111; VAOPGCPREC 3-2003 (July 16, 2003); see also Cotant v. Principi, 17 Vet. App. 116, 123-30 (2003). Such clear and unmistakable evidence includes medical facts and principles that may be considered to determine whether the increase is due to the natural progression of the condition. The Federal Circuit has rejected the view that competent medical evidence is required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. Under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d. 1313 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). The Board must assess the credibility and weight of all the 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 claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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. Factual Background and Analysis The Veteran seeks service connection for a chronic disability manifested by abnormal blood chemistry and/or endocrine dysfunction, currently claimed as hirsutism. In her written submissions and Board testimony, the Veteran contends that she began to experience excessive facial and chest hair during service. The Veteran's service enlistment examination in January 1980 noted no abnormalities of her blood or endocrine system, or any condition of hirsutism. A June 1981 service treatment record noted a diagnosis of mild hirsutism for excessive facial hair and that the Veteran's command structure requested that something be done. Service treatment records reflect that in 1982 and for the remainder of her service she received treatment for hirsutism manifested by excessive hair growth on her face and chest. Her hirsutism did not resolve despite these treatments. Her service treatment records show that the cause of her hirsutism was not definitively established by her treating physicians; a February 1983 treatment record noted that her hirsutism was of unknown etiology. A January 1984 treatment note shows the following assessment: "(P)atient probably had mild block/deficiency in 21-OH enzyme, accounting for her hirsutism." Hirsutism manifested by increased facial hair was also noted on the Veteran's discharge examination. Private and VA treatment records dated from 1993 to 2013 show that the Veteran's hirsutism continued post-service. The steroid therapy that began in service to treat hirsutism continued for several years post-service. However, during her February 2009 Board hearing, the Veteran testified that she discontinued the steroid therapy because it made her "grouchy" and she received no perceptible improvement in her hirsutism when she took steroids, and experienced no perceptible worsening of it when she ceased taking steroids. Private medical records dated in November 2001 relating to treatment for the Veteran's hirsutism show the following physician's notation: "(The Veteran has a) (r)eported history of congenital adrenal hyperplasia expected to be partial 21 hydroxylase deficiency. . . . We do not have prior records that give a definitive diagnosis for congenital adrenal hyperplasia. Today, we will check a 17 hydroxyprogesterone and DHEAs levels to attempt to look for a sign of this." The report of the Veteran's DHEAs levels, as tested in November 2001, characterized the levels as being elevated and abnormal, but no commentary is shown regarding the significance of this finding as it may relate to her hirsutism. An April 1993 VA treatment note reflects that the etiology of her hirsutism was unknown. Reports of her treatment for hirsutism in August 2003 - October 2003, while on referral to a VA endocrinologist at the Washington, D.C. VA Medical Center, provide no clarification as to the cause of her hirsutism. With regard to hirsutism, an October 2003 VA laboratory study showed that the Veteran's testosterone and cortisol levels were normal. VA medical records dated in April 2005 and September 2005 noted a past medical history of hirsutism and that she was then on Aldactone. At the Veteran's February 2009 Board hearing, she reported that despite actively seeking treatment for her hirsutism, she was unable to recall being given any definitive explanation as to the cause of the condition by her care providers. The claims file also includes submissions from the Veteran of copies of various medical articles downloaded from Wikipedia, the open-source internet reference data base, which discuss hirsutism and adrenal gland abnormalities and diseases. In an earlier decision, the Board took note of these articles, but found for various reasons that the credibility of any facts presented on Wikipedia is deemed to be highly questionable. The Veteran was scheduled for a VA examination in February 2011. The VA examiner determined that a laboratory study of the Veteran's blood and endocrine system was normal. Although an adrenal adenoma was detected on CT scan in March 2009, a subsequent MRI conducted in August 2009 revealed no adrenal adenoma being present. Following examination, the Veteran was diagnosed with mild hirsutism with no evidence of endocrine or metabolic abnormality as being the cause. A full endocrine and metabolic evaluation revealed laboratory values that all fell within the normal range. The examiner opined that the Veteran did not have an abnormality of her blood chemistry, that there was no evidence of a chronic disabling disease process, that mild observed hirsutism was not a manifestation of a chronic disease process nor a disability in its own right, that the Veteran's hirsutism was a variation of normal and not the result of any disease process, and that her hirsutism was not aggravated by active military service. The examiner, a VA nurse, cited as her rationale standard medical textbooks and a published medical article regarding the medical condition of idiopathic hirsutism. Subsequently, the parties in the JMR explained that the February 2011 VA examination and medical opinion was inadequate for several reasons. Therefore, on remand the Board requested a new VA examination and medical opinion. The Veteran was scheduled for a VA examination in April 2013 with a VA physician's assistant. She told the examiner that she was 20 years old when she went into the Army. It was only then she said that she started having trouble with hirsutism. She said that she took a spironolactone diuretic medication intermittently for years, but was no longer doing so since about 2003 or 2004. She also told the examiner that VA specialists over the years had never provided a specific cause for her hirsutism. On examination, there was evidence of fine upper anterior chest hair stubble. While no facial hair was noted at the examination, the Veteran reported that she had shaved that day on the upper lip and chin areas. The examiner noted recent normal laboratory results. He also reported that the adrenal adenoma seen on a CAT scan in March 2009 was not seen on the subsequent follow-up MRI scan in August 2009. Diagnosis was a mild hirsutism affecting the face and upper chest areas. He said there was no evidence currently of endocrine or metabolic abnormality being the cause. In reply to several questions posed by the Board's remand, the April 2013 examiner replied that there was no definite congenital condition documented in the Veteran's case; hirsutism was not disabling by itself; no Cushing's syndrome was found; and there was no evidence pointing to any cause or aggravation since service. The April 2013 VA examiner also said that it was not quite clear whether the Veteran's condition truly preceded service or not, but that the Veteran claimed it was only found during service. The April 2013 VA examiner also suggested that the Veteran be examined by an endocrinologist if further examination or opinion was necessary. The Veteran was then scheduled for another VA examination in May 2013 when it was discovered that the Board had requested the examination be done by an endocrinologist. This examiner reviewed the claims file and examined the Veteran. The only endocrine diagnosis noted was for hirsutism. The Veteran told the examiner that she started developing hirsutism shortly after joining the service at 19 and that hirsutism had progressed since then to the point where she shaved her face every day. It was noted that she had hair growth on her chest, but not in any other androgen dependent area. Features suggestive of Cushing's syndrome were noted including: weight gain, easy bruisability, moon face, hypertension, and menses of varying severity and some irregularity. In response to the Board's March 2013 remand questions, the May 2013 VA examiner noted the following: the Veteran had been menopausal for about three years; she had normal lab and test results and did not have congenital hyperplasia; and that while she was told she had late onset congenital adrenal hyperplasia while in service, and her history was very suggestive for this also, normal test results ruled it out. The May 2013 VA examiner also found various causes for hirsutism in this case wanting. For example, the likelihood of an androgen secreting tumor of the adrenal or ovary was small given that these tumors were often malignant and would not have existed for 30 years. Also, that hirsutism is quite unusual as the initial presentation of Cushing's disease and in any event the examiner's suspicion of Cushing's was low. The examiner thought polycystic ovarian syndrome was also unlikely given the length of time she had hirsutism despite normal glucose tolerance. The examiner also explained that hirsutism is a disability in its own right and need not be associated with Cushing's syndrome. He noted that hirsutism started during service, according to the Veteran's history. The examiner also said there was nothing clear or unmistakable about the onset of hirsutism. The May 2013 VA examiner reported that he felt the underlying cause of hirsutism in this case had not been established. He said there was no scenario he could envision that would fit with hirsutism being "triggered" by service. The May 2013 VA examiner scheduled laboratory testing to rule out Cushing's disease. The June 2013 laboratory results are noted in the June 2013 supplemental statement of the case (SSOC), although for unexplained reasons they do not appear in the claims file or on the Veteran's eFolder on her Virtual VA file. In any event, the detailed laboratory workup in June 2013 at the Butler, Pennsylvania, VA Medical Center were within normal limits, thereby not showing any Cushing's disease, according to the June 2013 SSOC. Based on review of the evidence of record, the Board finds that service connection for hirsutism is warranted. Initially, the Board notes that there is some question as to whether the Veteran's hirsutism preexisted her entry into service in 1980. Most importantly, her January 1980 entrance physical noted a normal endocrine system. Clear and unmistakable evidence that a disability existed prior to service and was not aggravated by service will rebut the presumption of soundness. 38 U.S.C.A. § 1111; VAOPGCPREC 3-2003. A preexisting disease will be considered to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. Because the presumption of soundness has attached in this case, VA has the burden of proving by clear and unmistakable evidence that both (1) the Veteran's hirsutism preexisted service and (2) that such disease or injury was not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). A lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. Id. at 1096; 38 U.S.C.A. § 1153. In the present case, there is no competent medical evidence reflecting a diagnosis of hirsutism before entry into service. The only medical records which refer to the possible existence of hirsutism prior to service are post-service VA examinations wherein examiners found no definite congenital condition documented prior to service. Moreover, some of the VA examiners appear unsure whether the Veteran's hirsutism is congenital or whether it preexisted her period of service. In sum, the Board believes that the May 2013 VA examiner is correct in noting that there is no clear and unmistakable evidence of hirsutism before service. As such, the Board finds that indefinite medical findings as to whether hirsutism was congenital in the Veteran's case are insufficient to rebut the presumption of soundness in this case. The Board's review of the record leads it to a firm belief that there is no clear and unmistakable evidence that hirsutism preexisted service. As an endocrine abnormality was not noted at service entrance in 1980, the Veteran is presumed to be in sound condition on service entry. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b). Because the presumption of soundness has not been rebutted for this claim, it becomes one for direct service connection, without consideration of aggravation of a preexisting condition. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). As to the direct service connection claim for hirsutism, the Board notes that the Veteran has been treated for hirsutism since service. It is clear from the May 2013 VA examination that the Veteran has a current hirsutism disability and, therefore, the first requirement for direct service connection has been met. The Veteran's service treatment records and her written submissions and Board testimony constitute competent medical and lay evidence to show possible in-service occurrence of a disease or injury in this case. The experience of hair on the female face and chest is something capable of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Barr v. Nicholson, 21 Vet. App. 303 (2007). Although the Veteran is not competent to assess and diagnose hirsutism, she is clearly competent to relate her experience of the appearance of unusual body hair during her period of active duty. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As lay and medical evidence shows in-service complaints of excessive body hair during the Veteran's period of active duty, the second requirement for establishing service connection has been met. The question remains, therefore, whether her current hirsutism is related to her active duty service. While the VA medical opinions noted above do not formally support such a nexus, the plain fact that the Veteran was first treated for hirsutism during service does. As there is no mention of hirsutism in the record before the Veteran's treatment in service, and the Veteran is currently diagnosed with hirsutism, the Board believes such is sufficient to place the evidence for and against this claim into relative equipoise, so as to warrant resolving any reasonable doubt in the Veteran's favor regarding whether her current hirsutism is related to her service. 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b) (West 2002). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, that reasonable doubt will be resolved in favor of the claimant. By reasonable doubt is meant one that exists because of an approximate balance of positive and negative evidence which satisfactorily proves or disproves the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board finds that the evidence found within the claims file is, at the very least, in equipoise as to the question of whether the Veteran's hirsutism is related to service. There can be no doubt that further medical inquiry could be undertaken with a view towards clarifying the medical opinions of the medical reviewers noted above and requesting more detailed studies of whether the Veteran's hirsutism is a symptom of Cushing's syndrome. However, the Board finds that would only prolong adjudication of this claim from a veteran whose claim has been pending for more than eight years, especially in view of the fact VA has been unable to secure a definitive medical opinion from three different examiners during the past two years. Therefore, resolving reasonable doubt in favor of the Veteran, the Board finds that the conclusions of the May 2013 VA examiner to the effect that hirsutism is a disability and that the Veteran said she manifested this disorder during service are sufficient to provide proof of a relationship between the Veteran's hirsutism and her period of active service. Resolving reasonable doubt in favor of the Veteran, the Board finds that hirsutism was incurred during service and the claim for service connection for hirsutism is granted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board also notes that service connection is not warranted at this time for any other chronic disability manifested by abnormal blood chemistry and/or endocrine dysfunction. The May 2013 VA examiner thoroughly reviewed the record and provided specific reasons why service connection was not warranted for other suspected diseases inasmuch as the Veteran did not have Cushing's syndrome, polycystic ovarian syndrome, or late-onset congenital adrenal hyperlasia. ORDER Service connection for hirsutism is granted. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs