Citation Nr: 1339227 Decision Date: 11/27/13 Archive Date: 12/13/13 DOCKET NO. 05-01 521 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a thyroid disability. 2. Entitlement to service connection for uterine fibroids and menorrhagia, status-post hysterectomy. 3. Entitlement to service connection for ovarian cysts and adhesions, status-post oophorectomy. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD N. Snyder, Counsel INTRODUCTION The Veteran served on active duty from January to June 1991 and from January to May 1992 with subsequent service, including active duty for training, in the Army Reserve and the Army National Guard. This appeal comes before the Board of Veterans' Appeals (Board) from a February 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. When the case was most recently before the Board in November 2012, it was remanded for additional development. The record before the Board consists of the Veteran's paper claims files and an electronic file known as Virtual VA. The issue of entitlement to service connection for ovarian cysts and adhesions, status-post oophorectomy, is addressed in REMAND that follows the ORDER section of this decision. FINDINGS OF FACT 1. No thyroid disability has been present during the period of this claim. 2. The uterine fibroids and menorrhagia developed after the Veteran's last period of active duty; they did not originate or increase in severity beyond natural progress during a period of active duty for training; and they are not otherwise etiologically related to the Veteran's periods of active duty or active duty for training. CONCLUSIONS OF LAW 1. The criteria for service connection for a thyroid disability have not been met. 38 U.S.C.A. §§ 101, 106, 1101, 1110 (West 2002); 38 C.F.R. §§ 3.6, 3.303 (2013). 2. The criteria for service connection for uterine fibroids and menorrhagia, status-post hysterectomy, have not been met. 38 U.S.C.A. §§ 101, 106, 1101, 1110 (West 2002); 38 C.F.R. §§ 3.6, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2013), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided 'at the time' that or 'immediately after' VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the Veteran was provided all required notice in letters mailed in December 2002, May 2004, and March 2006. Although complete notice was not provided until after the initial adjudication of the claims, the Board finds that there is no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the receipt of all pertinent evidence, the originating agency readjudicated the claims. There is no indication or reason to believe that the ultimate decision of the originating agency on the merits of the claims would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). The record reflects that all available service treatment records (STRs) and service personnel records and all available post-service medical evidence identified by the Veteran have been obtained. Neither the Veteran nor the representative has identified any outstanding, existing evidence that could be obtained to substantiate the claims; the Board is also unaware of any such evidence. The Veteran was afforded appropriate VA examinations, and probative opinions (i.e. opinions supported by a detailed rationale) have been obtained. The Board acknowledges that the opinions provided in February 2012 and May/June 2013 for the gynecological claim are not probative. As discussed below, the Board finds the May 2013 VA gynecological opinion and June 2013 addendum are not probative because they are incompatible and the May 2013 opinion is not supported by adequate rationale. The Board also finds the February 2012 gynecological opinion is not probative because it is based on an inaccurate factual premise, namely that the Veteran only had active service between 1990 and 1992. The record includes other opinions, notably those dated in January 2013 and July 2013, which are probative, however, and the Board finds the record contains sufficient competent evidence to decide the claim for service connection for fibroids and menorrhagia. Furthermore, there has been substantial compliance with the Board's remand directives with respect to the issues decided herein. Accordingly, the Board will address the merits of the Veteran's claims. Legal Criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty or active duty for training or for disability resulting from injury incurred in or aggravated by inactive duty for training. 38 U.S.C.A. §§ 101, 106, 1110 (West 2002); 38 C.F.R. §§ 3.6, 3.303. Service connection may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Presumptions of soundness, aggravation, and regarding certain conditions that are considered to be chronic, per se, apply to periods of active duty. They also apply to periods of active duty for training for which an entrance examination was provided. See Smith v. Shinseki, 24 Vet.App. 40 (2010) (presumption of soundness does not apply without entrance examination), Paulson v. Brown, 7 Vet. App. 466 (1995); Biggins v. Derwinski, 1 Vet. App. 47478 (1991). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2013); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Factual Background and Analysis Thyroid Disability A November 2002 VA treatment records reflects the Veteran's history of thyroid disease, for which she was prescribed medication. She reported that she did not know the specific diagnosis and indicated that she had quit taking the prescribed medication four months earlier. The record reveals a diagnosis of "thyroid disorder, no details available." A subsequent November 2002 non-VA treatment record reflects the Veteran's history of hypothyroidism. The record notes that the Veteran had been on thyroid hormone but her thyroid function tests were normal off the medication for three months. A December 2002 VA examination record reflects the Veteran's history of being diagnosed with a thyroid disability in 2001. She reported that she was positive for fatigability and had started experiencing mild depression and forgetfulness. She also had mild facial puffiness, cold intolerance, voice hoarseness, modest to severe weight gain, and chronic sore throat sensation. She denied current treatment for her thyroid but reported short-term treatment with Synthroid. Laboratory test results were within normal limits. Examination revealed tenderness to palpation and irregular size of the right lobe. The Veteran was diagnosed with thyroid goiter with lower limits of normal size lobes of thyroid and residuals of mood swings, dysphagia, and cold intolerance. A January 2003 private treatment record reflects the Veteran's history of weight gain, cold intolerance, and fuzzy headedness. She reported a history of a thyroid problem. After examination she was assessed with fatigue and weight gain; laboratory testing was ordered. A May 2003 private treatment record reflects that the laboratory tests were ordered. The Veteran was still diagnosed with fatigue and weight gain. A September 2003 VA mental health examination record reflects an Axis III diagnosis of hypothyroidism. An August 19, 2004, service examination record reflects the Veteran's history of hypothyroidism. The examiner noted that the Veteran was on Synthoid for hypothyroid and reported hypothyroid on the "summary of defects and diagnoses." An October 2004 Tricare treatment record reflects the Veteran's history hypothyroidism for about two years, for which she was on Synthoid. The record reflects a diagnosis of "hypothyroidism, on Synthroid for two years." A February 2013 VA examination record reflects the examiner's history of an inability to provide an opinion due to the lack of pertinent medical records. The examiner found it unclear when treatment began for hypothyroidism. In an addendum, after review of the record, the examiner found it less likely than not that the claimed condition was related to active service. The examiner noted that although the Veteran reported hypothyroidism, the history was not supported by the record. The examiner acknowledged that the Veteran had been treated intermittently with thyroid hormone replacement and that a 2002 examiner diagnosed a thyroid goiter. The examiner noted that the 2002 examination did not reveal a diagnosis of hypothyroidism, however, and that the Veteran's thyroid function tests were normal, showing no hypo- or hyperthyroid diagnosis. The examiner found no hypothyroid or hyperthyroid condition and thus, no aggravation during active service. The record does not reflect probative evidence of the existence of a thyroid disability when the Veteran filed this claim or thereafter. With regard to the claimed hypothyroidism, although treatment records document the Veteran's histories of hypothyroidism and use of medication, no contemporaneous diagnosis has been rendered based on the proper testing, and the 2012 VA examiner determined that the Veteran does not and has not had hyper or hypothyroidism since at least December 2002, when testing revealed normal thyroid function even though the Veteran was not taking medication. Furthermore, the Board notes that although the Veteran reported a two-year history of use of medication for a thyroid condition in October and December 2004, this history is not corroborated by the treatment records, which do not reflect prescription of Synthoid or other thyroid medication, and is contradicted by earlier histories provided by the Veteran that she had ceased taking the medication before November 2002. The December 2002 VA examination record does reveal a finding of a thyroid goiter. A goiter is an enlargement of the thyroid gland, causing a swelling the front part of the neck. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (31st Ed. 2007). Although a goiter can be a result of a thyroid disability, there is no competent and probative evidence establishing that the Veteran's goiter was attributable to or productive of hyperthyroidism or any other thyroid disability. In this regard, the Board notes that the examiner who diagnosed the goiter did not diagnose a thyroid disability. Except in circumstances not applicable here, service connection will not be granted for symptoms such as a goiter; there must be a diagnosed or identifiable underlying malady or condition. Sanchez-Benitez v. West, 13 Vet. App. 283, 285 (1999). Although the record includes diagnosis of thyroid disease in November 2002 and hypothyroidism in September 2003, August 2004, and October 2004, the context of the records associated with the diagnoses indicate that the diagnoses was based solely on the Veteran's history of past diagnosis. The November 2002, September 2003, and October 2004 records clearly indicate that no examination was performed and no tests were concluded. The Board acknowledges that the October 2004 Tricare record notes under "Physical Finding," that physical examination Medical DD Form 2808 was completed and under "Objective," that Physical Profile DD Form 3349 was completed. However, the record clarifies that the DD Forms 2808 was done August 19, 2004, and DD Form 3349 was prepared on August 19, 2004. In the absence of evidence that the diagnoses were based on independent examination or testing, the Board finds they are based solely on the Veteran's history of diagnosis and treatment. Examination was performed in conjunction with the August 19, 2004, diagnosis. However, the record documents that clinical evaluation of the "head, face, neck, and scalp," "mouth and throat," and "skin, lymphatics," were normal, that blood work did not reveal any apparent thyroid abnormality, and that thyroid function tests were not performed. The record reveals no basis for the diagnosis other than the Veteran's history of hypothyroidism treated with Synthoid. In the absence of evidence of a medical basis for the diagnosis, the Board finds the diagnosis is based solely on the Veteran's history of a diagnosis. In sum, the Board finds the diagnoses were based solely on the Veteran's history of a diagnosis and not independent medical opinion. As such, the Board finds the diagnoses without independent probative value. The Board is mindful that competent medical evidence is not necessarily required where the determinative issue in a case involves the existence of a disability. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); see also; Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). However, the Veteran is not providing statements related to the diagnosis of a simple disorder but is instead rendering an opinion as to the existence of a current thyroid disability. This is a matter that requires medical expertise, which the Veteran lacks. The Board is further mindful that a lay person may be competent to report a contemporaneous diagnosis. The Veteran is not reporting the existence of a contemporaneous diagnosis, however, but is referring to a diagnosis that preexists the applicable period and which is not corroborated by medical examination during the applicable period. Accordingly, service connection is not warranted for a thyroid disability. In reaching this decision, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. Uterine Fibroids and Menorrhagia, Status-Post Hysterectomy The Veteran contends that her gynecological disability, namely uterine fibroids and menorrhagia, began during active service. In support of this contention, she has submitted statements from her husband and former colleague from service who reported their memories of the Veteran complaining of her heavy menses and pain prior to her hysterectomy and receiving treatment during active duty. An April 2001 gynecological treatment record indicates that the Veteran "desire[d] operation for tumors." She reported having an elective abortion in March 2001. The record notes that a March 2001 ultrasound apparently did not show fibroids, but the Veteran was told she had fibroids and irregular menses. An ultrasound revealed a fibroid. A June 2001 gynecological treatment record indicates that the Veteran's menses had begun to lighten up. She denied any current problem. An October 2002 treatment record reflects the Veteran's history of abnormal bleeding for three months. She explained that she had her period for two weeks, the flow was heavier, and the cramps were worse. She also reported feeling very sick with dizziness, nausea, and headaches. She reported a history of uterine fibroids, which were diagnosed in March 2001, and hypermenorrhea. She explained that she was unable to carry her second pregnancy due to the fibroids. Ultrasound revealed fibroid uterus and cysts on the ovaries. After examination, she was diagnosed with rule out uterine fibroids and bacterial vaginosis. A December 2002 VA examination record reflects the Veteran's history of diagnosis of fibroids in September 2002. The Veteran reported irregular and heavy periods since 1994. She indicated that her menstrual pain had increased significantly in the previous 12 months and that she was scheduled for a total hysterectomy in 2003. After examination, she was diagnosed with left ovarian cyst and uterine fibroids with dysmenorrhea, dysfunctional uterine bleeding, intermittent anemia, and pelvic pain. Subsequent records reflect treatment for fibroids, menorrhagia and pelvic pain. May 2003 gynecological treatment records reflect the Veteran's history of heavy and long-lasting menses for two to three years. She added that she had clots and pain, that she had been diagnosed with anemia, and that she had been found to have fibroids in October 2002. December 2003 and February 2004 service records indicate that the Veteran was on physical profile (no pushups, sit-ups, or running) due to uterine fibroids, pelvic pain, anemia, and menorrhagia. The Veteran underwent a total vaginal hysterectomy for fibroids, menorrhagia, and pelvic pain in March 2004. In December 2008, she underwent a diagnostic laparoscopy with lysis of adhesions and exploratory laparotomy extensive lysis of adhesions and bilateral salpingo-oophorectomy. The record notes that there were dense adhesions related to a previous umbilical hernia repair. There were also adhesions to the ovaries, which had been causing the Veteran's pelvic pain. A February 2012 VA examination record reflects a diagnosis of menorrhagia, surgically treated with hysterectomy, reportedly beginning in 1992. The Veteran reported that during military service she began having menstrual bleeding two to three times a month, lasting up to two weeks. She added that she received private treatment during active duty and that she was diagnosed with associated anemia, which had improved since the hysterectomy, and fibroids. She also reported continued pelvic pain and indicated that she underwent a bilateral oophorectomy in 2002 for ovarian cysts and later underwent a hysterectomy. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that active service was listed as dating from January 13, 1992, to May 20, 1992, with additional active duty in 1990-1991. The examiner noted that the service medical record was silent for gynecological treatment, that fibroids were first shown in April 2001, and that the Veteran reported in March 2004 that the symptoms first appeared in October 2002. The examiner found the record indicated that the condition began after service. A January 2013 VA opinion reveals the determination that the claimed gynecological condition was less likely than not incurred in or caused by service. The examiner noted that the Veteran had active duty from January to June 1991, January to May 1992, October 1 - 14, 2002, and December 8 - 13, 2003. The examiner explained that the documentation supports that the Veteran began to have problems with fibroids in the early 2000s and that the October 10, 2002, ultrasound documented a history of hypermenorrhea, fibroids, and problems conceiving. The examiner determined that the onset was likely before the October 2002 period of active duty and was not likely aggravated during the periods of active duty. The examiner added that the claimed condition, which clearly and unmistakably preexisted service, was clearly and unmistakably not aggravated beyond its natural progression. The examiner indicated that the gynecological condition more likely occurred following discharge in 1992 and prior to 2002 active duty, as shown on the ultrasound report and the fact that the Veteran was already having significant problems as of October 2002. The examiner added that the condition followed its natural course during the subsequent active duty dates in 2002 and 2003. The examiner provided an addendum, reiterating that the claimed condition was less likely than not incurred in or caused by service. The examiner explained that the documentation indicated that the fibroids began in the early 2000s and that the Veteran already had a history of hypermenorrhea, fibroids, and problems conceiving in October 2002. The examiner indicated that the onset was not likely within the previous nine days of active duty in October 2002 and that there was no permanent aggravation beyond the normal course during active duty. The examiner added that an April 2001 ultrasound showed fibroid and that it was more likely that the condition occurred between 1992 and 2002 and that the condition followed its natural course during subsequent active duty. A May 2013 VA examination record reflects the Veteran's history of heavy bleeding while on active duty due to having to perform heavy lifting. She reported that she underwent a hysterectomy in 2003 for heavy bleeding. The examiner opined that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated during service. The examiner explained that the Veteran had some nonspecific abdominal pain of unknown etiology. The examiner stated that records did indicate that an October 2002 ultrasound showed fibroids. The examiner found that if the Veteran was on active duty at that time, then the condition was probably aggravated by military duty. However, the examiner found that because the Veteran had a hysterectomy, no aggravation existed as the condition was resolved by the surgery. The examiner asked for the dates of active duty. The examiner provided an addendum in June 2013. At that time, the examiner stated that it was less likely that the condition, including fibroids/heavy menstrual periods/hysterectomy, was related to service. The examiner stated that the record was reviewed and the condition was not diagnosed while on active duty. Another opinion was obtained in July 2013. The physician determined it was less likely than not that the claimed gynecological condition, to include fibroids and heavy menstrual bleeding, was incurred, caused by, or aggravated beyond its natural aging process by the Veteran's periods of military service. The physician noted that there is no medical based, scientific evidence to support a connection between heavy lifting and heavy menses. The examiner stated that it was less likely than not that the current medical literature supported the Veteran's allegations. Furthermore, the physician noted that the fibroids were diagnosed in 2001, nine years after active duty. The physician determined it was more likely that the condition occurred during the 10-year window between her active duty tours in 1992 and 2002 and that it followed its natural course during subsequent active duty. Service connection is not warranted because the preponderance of the evidence shows that the fibroids and menorrhagia did not begin during active duty or active duty for training , was not aggravated by periods of active duty for training, and was not otherwise related to active duty or active duty for training. The Board notes that in the case of inactive duty for training, only an "injury," not a "disease," incurred or aggravated in line of duty can be the basis of eligibility for disability compensation. VAOPGCPREC 8-2001. As the Veteran is not seeking service connection for an injury, any periods of inactive duty for training are irrelevant to this claim. The medical records indicate that the Veteran was first shown to have fibroids, and first reported irregular menses, in April 2001 and that she initially reported a three-month history of menorrhagia in October 2002, amending the history in December 2002 to date the menorrhagia to 1994, with a worsening the previous year. Service records document that the Veteran earned no active duty points from August 20, 1992, to August 19, 1998, and that she was on non-military civilian break from August 20, 1998, to August 8, 2001. The service records do show that the Veteran performed periods of active duty for training in July 2002. Although the Veteran reported a three month history of menorrhagia in October 2002, which would place its onset in approximately July 2002, the evidence does not include any probative evidence, to include history, that the menorrhagia onset during active duty for training in July 2002. Although the Veteran, her spouse and former colleague have reported that she had symptoms during active duty for training, their statements, notably the reference to treatment, indicate that they were referencing the October 2002 period of active duty for training. Moreover, the Veteran later amended her history, to date the onset of the menorrhagia to either the 1990s (either 1992 or 1994) or October 2002. She has never again reported an onset of the menorrhagia in approximately July 2002. In light of the inconsistent histories as to the date of onset of the menorrhagia, including prior to and soon after the three month history, the Board finds the October 2002 history of menorrhagia for three months, standing alone, is not probative evidence that the menorrhagia began during active duty for training in July 2002. The Veteran currently contends that the fibroids and menorrhagia began in October 2002, while she was on active duty for training. Although the Veteran, and her spouse and former colleague, are competent to report this history, the Board finds the current history is not credible as it is contradicted by the histories and findings reported in April 2001 and October and December 2002, at which times she reported menorrhagia, and fibroids prior to October 2002. In sum, the Board finds the Veteran was not performing active duty or active duty for training at that time of the onset of the fibroids or menorrhagia. Furthermore, the Board finds the fibroids and menorrhagia were not aggravated by any active duty for training performed prior to the hysterectomy in March 2004. The record does not include any probative medical evidence indicative of aggravation. In this regard, the Board notes that the record includes probative opinions dated in January and July 2013 that the condition was not aggravated by any period of active service, to include the October 2002 active duty for training. The Board acknowledges that the record also includes a May 2013 opinion that the condition was "probably" aggravated by service if the Veteran was on active duty in October 2002 based on the evidence of fibroids in October 2002. The same examiner determined that the condition clearly and unmistakably preexisted and was not aggravated by service, however, and provided an addendum opinion that the condition was not related to service because it was not diagnosed during active duty. Furthermore, the examiner did not provide a rationale for how it was determined that the continued presence of fibroids and symptoms in October 2002 indicated an aggravation. In light of the inconsistencies presented in the May 2013 opinion and July 2013 addendum and the lack of a rationale, the Board finds the opinion is not probative evidence of aggravation. The Board acknowledges that the Veteran reported symptoms during active duty for training in October 2002. The Veteran did not report an increase in the symptoms during the period of active duty training, however; rather, she indicated that the symptoms had existed for at least several months. This history is consistent with the history provided in December 2002, which indicated consistent symptoms over the previous year. The Board finds the lack of such a history of an increase in symptoms is probative evidence against aggravation during the October 2002 active duty for training. The evidence also does not suggest aggravation during a subsequent period of active duty for training: the record indicates that the Veteran was placed on limited duties during the December 2003 and February 2004 periods of active duty for training, and the records dated contemporaneous with these periods of active duty training do not reflect any complaints or findings indicative of aggravation during either period. The Board further acknowledges the Veteran's contention that her condition was aggravated during active duty for training, to include as a result of heavy lifting during active duty for training. The Veteran is not competent to conclude that the existence of symptoms in service was due to aggravation rather than normal progression of the preexisting condition or that heavy lifting resulted in an aggravation of the preexisting condition, however. Such a determination is a matter of medical complexity and requires specialized knowledge. As such, her contentions are not probative evidence of aggravation. In sum, the Board finds the fibroids and menorrhagia were not aggravated during active duty for training. Finally, the Board finds the fibroids and menorrhagia are not otherwise related to service. The record includes opinions from VA medical professionals that the condition is not related to service. The record does not include a contrary medical opinion. The Veteran contends that her condition is related to service, to include heavy lifting during service. A VA medical professional has indicated that medical literature does not include any evidence of such a link, however, and the record does not suggest that the Veteran is competent to make that determination. As such, her contentions are not probative evidence of a relationship between the fibroids and menorrhagia and active service. Accordingly, service connection is not warranted for uterine fibroids and menorrhagia, status-post hysterectomy. In reaching this decision, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. ORDER Service connection for a thyroid disability is denied. Service connection for uterine fibroids and menorrhagia, status-post hysterectomy, is denied. REMAND Based on the finding of ovarian cysts on ultrasound in October 2002, during active duty for training, and the Veteran's history of pelvic pain, which was attributed to ovarian adhesions in 2008, during active duty for training, a VA opinion is needed to determine whether an ovarian disability began during the October 2002 active duty for training or is otherwise related to active duty or active duty for training. Accordingly, this case is REMANDED to the RO or the Appeals Management Center (AMC), in Washington, D.C., for the following actions: 1. Obtain an opinion from a physician with sufficient expertise to determine whether the ovarian cysts or adhesions were related to any period of active duty or active duty for training. The claims folders and any pertinent evidence in Virtual VA that is not contained in the claims folders must be made available to and reviewed by the physician. The physician should state an opinion as to whether there is a 50 percent or better probability that an ovarian disability, manifested as cysts or adhesions, is related to any period of active duty or active duty for training, including whether the disability pre-existed the October 2002 active duty for training and was aggravated by the period of active duty training. The rationale for all opinions expressed must also be provided with discussion of the October 2002 ultrasound, taken during active duty for training, showing ovarian cysts. If the physician is unable to provide any required opinion, he or she should explain why. 2. Undertake any other indicated development. 3. Thereafter, readjudicate the claim of entitlement to service connection for ovarian cysts and adhesions, status-post oophorectomy. If any benefit sought on appeal is not granted to the appellant's satisfaction, issue a supplemental statement of the case to the appellant and her representative and afford them the requisite opportunity to respond before returning the case to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran need take no action until she is otherwise notified, but she may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) This REMAND must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ____________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs