Citation Nr: 1623182 Decision Date: 06/09/16 Archive Date: 06/21/16 DOCKET NO. 07-14 916 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for recurrent ovarian cysts, status post left oophorectomy. 2. Entitlement to service connection for migraine headaches. 3. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) with anxiety, depression, and adjustment disorder. 4. Entitlement to initial evaluations in excess of 10 percent prior to November 6, 2009, and thereafter, an evaluation in excess of 20 percent for fibromyalgia. 5. Entitlement to an effective date prior to April 22, 2009 for award of service-connection for fibromyalgia. 6. Entitlement to a total disability rating due to individual unemployability (TDIU). REPRESENTATION Appellant represented by: Mr. Robert v. Chisholm, Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Murray, Counsel INTRODUCTION The Veteran served on active duty from November 1987 to September 1993. This matter comes before the Board of Veteran's Appeals (Board) on appeal from various decisions by the above Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for the listed issues as well as various other issues. In December 2008, a hearing was held before the undersigned Veterans Law Judge (VLJ) during a Travel Board hearing held at the RO. A transcript of the hearing has been associated with the claims file. The Travel Board hearing was sufficient to fulfill his right to a hearing under 38 C.F.R. § 20.700(a) (2015). The Veteran's service connection claims were remanded in May 2009 to the RO (via the Appeals Management Center (AMC)) for additional development of the record, to include obtaining service records, VA treatment records, and VA examinations. In a September 2011 decision, the Board denied the Veteran's claim for entitlement to service connection for a psychiatric disorder. The Veteran appealed to denial of her claim to the United States Court of Appeals for Veterans Claims (CAVC or Court), which vacated the Board's September 2011 decision and remanded for compliance with instructions contained therein. Also, in September 2011, the Board remanded the remaining service connection claims to the AMC for additional development, to include compliance with the previous 2009 remand instructions for VA examinations with medical opinions that addressed question of undiagnosed illness. The Veteran underwent such additional examinations in September 2011. In December 2013, the Board again remanded the issues of entitlement to service connection for psychiatric disorder, recurrent ovarian cysts, and headaches for additional notice and development prior to adjudication of the claims. In particular, the Board instructed that the Veteran should be provide with notice on secondary service connection and she should be afforded additional VA examinations with medical opinions were needed to address whether her diagnosed psychiatric disorder and headaches were secondary to her service-connected fibromyalgia, as well as a medical opinion regarding the etiology of her recurrent ovarian. The record reflects that the Veteran was issued complaint notice in October 2014, and the reports of VA examinations and medical opinions have been associated with the claims folder. The Veteran's claims were re-adjudicated in an October 2015 supplemental statement of the case (SSOC). As there has been compliance with the Board's 2009, 2011, and 2013 remand directives, no further action is required and the Board may proceed with adjudication of the claim. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). While the claims were pending on appeal, the RO, in a September 2012 rating decision awarded service connection for fibromyalgia, which included the Veteran's symptoms of bilateral shoulder pain, bilateral hip pain, headaches, and sleep disorder, and assigned staged ratings of 10 percent, effective from April 22, 2009 to November 5, 2009, 20 percent, effective from November 6, 2009 to November 21, 2011, and 40 percent, effective from November 22, 2011. Although the Board previously noted in December 2013 that the Veteran had not initiated an appeal as to that rating decision, since the Veteran's claims folder has been converted to the paperless claims systems, the Veteran's timely August 2013 notice of disagreement as to the initial assigned effective date and initial assigned rating, to include consideration of a TDIU, has been associated with the claims folder. The Veteran has not yet been issued a statement of the case (SOC) on those matters, and they are further discussed in the REMAND portion below. FINDINGS OF FACT 1. The competent evidence shows that the Veteran's recurrent ovarian cysts manifested after her separation from service, and the preponderance of the evidence is against that her diagnosed disorder is related to her period of service. 2. The preponderance of the evidence is against a finding that the Veteran's current migraine headaches are related to her period of service, or proximately caused or aggravated by her service-connected disability. 3. The competent evidence of record demonstrates that the Veteran's current diagnosed psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression, are likely related to her period of service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for recurrent ovarian cysts have not been met. 38 U.S.C.A. §§ 1110, 1113(b), 1117, 5107(b) (West 2014); 38 C.F.R. §§ 3.303, 3.306, 3.317 (2015). 2. The criteria for entitlement to service connection for migraine headaches have not been met. 38 U.S.C.A. §§ 1110, 1113(b), 1117, 5107(b) (West 2014); 38 C.F.R. §§ 3.303, 3.317 (2015). 3. The criteria for entitlement to service connection for a psychiatric disorder, to include PTSD and depression, have been met. 38 U.S.C.A. §§ 1110, 1113(b), 1117, 5107(b) (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. VA's Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Here, VA sent a letter to the Veteran in December 2005, June 2009, and October 2014 that addressed of the elements concerning her claims for service connection that provided her with proper notice, including of what was necessary to establish the underlying claims of service connection on direct and secondary basis and VA's responsibilities in claims development. Concerning the VA's duty to assist, the Board notes that the Veteran's service treatment records, her lay statements of argument, and identified VA and private treatment records have been obtained. Pertinently, the Veteran has not indicated that any other VA treatment reports relevant to his asthma disorder currently exist, nor has she requested that the VA attempt to obtain any other private treatment records. VA has provided the Veteran with a VA Persian Gulf War examination in September 2005 as well as VA examinations in November 2009, September 2011, and July 2015 to determine the nature and etiology of her claimed recurrent ovarian cysts and headaches. She was also provided with VA psychiatric examinations dated in November 2009, January 2013 and July 2015. Specifically, in the September 2011 VA examination reports, the examiner addressed the question of whether the Veteran's various complaints were attributable to an undiagnosed illness, and in the July 2015 VA examination reports the VA examiners discussed whether the Veteran's migraine headaches and psychiatric disorder were secondary to her service-connected disability. Collectively, these VA examination and medical opinion reports reflect that the examiners reviewed the claims folder, recorded the Veteran's reported history as well as the findings from clinical examination, and rendered appropriate opinions supported by rational statements. Therefore, the Board finds that the evidence of record is adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 [affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim]. There has been compliance with the Board's 2009, 2011, and 2015 remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations or opinions with respect to the issues on appeal have been met. 38 C.F.R. § 3.159(c)(4). In short, the Board has carefully considered the provisions of the VCAA, in light of the record on appeal and, for the reasons expressed above, finds that the development of these issues has been consistent with said provisions. The Board is satisfied that any procedural errors in the originating agency's development and consideration of the claims were insignificant and nonprejudicial to the Veteran. The Veteran has been accorded ample opportunity to present evidence and argument in support of her claim. See 38 C.F.R. § 3.103. She has retained the services of a representative, and she testified before the undersigned Board member. 2. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. Id. In general, to prevail on the issue of service connection, a claimant must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b). In addition, a disability that is proximately due to or the result of a service-connected injury or disease shall be service connected. 38 C.F.R. § 3.310. When service connection is thus established for a secondary condition, the secondary condition shall be considered part of the original condition. Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists, and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. A disability which is aggravated by a service-connected disorder may be service connected, but compensation is only available for the degree to which that condition was made worse by the service-connected condition - only to the degree that the aggravation is shown. 38 C.F.R. § 3.310. In such a situation, VA laws require that the medical evidence must show a baseline level of severity of the nonservice-connected disease or injury, which is established by medical evidence created before the onset of aggravation. Id. The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. Undiagnosed Illness Claims Inasmuch as the record indicates that the Veteran served in served in Southwest Asia from October 1990 to April 1991; she is a Persian Gulf War Veteran within the meaning of the applicable statute and regulation. 38 C.F.R. § 3.317(b). Service connection may be established for a chronic disability resulting from an undiagnosed illness which became manifests during active service in the Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1)(i). For purposes of this section, a qualifying chronic disability means a chronic disability resulting from an undiagnosed illness, to include chronic medically unexplained multi-symptom illnesses that the Secretary determines under 38 U.S.C.A. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2)(i). Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from the VA's Schedule for Rating Disabilities for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317(a)(5). A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(6). Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b). Here, the competent evidence of record does not demonstrate that presumptive service connection is warranted for a qualifying chronic disability under 38 C.F.R. § 3.317. The Veteran's claimed ovarian and headache symptomatology is not eligible to be considered as a qualifying chronic disability under 38 C.F.R. § 3.317, because her symptomatology has been attributed to known condition. The medical records do not establish that the Veteran's headaches and ovarian condition have been attributed to a medically unexplained multi-symptom illness, or as residuals of one of the infectious diseases listed in 38 C.F.R. § 3.317. In this regard, VA and private medical treatment records show that the Veteran has been diagnosed with migraine headaches and recurrent ovarian cysts. Moreover, the September 2011 VA examiners specifically opined against the findings that the Veteran's headaches and ovarian cysts were symptoms of an undiagnosed illness or unexplained multi-symptom illness. Since there are either clinical diagnoses of record for the claimed disorders or known conditions for which the symptoms are attributable to, the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 cannot be used to establish service connection for these conditions. The availability of presumptive service connection for a disability based on a qualifying chronic disability under 38 C.F.R. § 3.317, however, does not preclude an appellant from establishing service connection with proof of direct causation. Recurrent Ovarian Cysts The Veteran seeks entitlement to service connection for recurrent ovarian cysts. The Veteran contends that her ovarian cysts were first detected after she had her baby and she still has them at present. The Veteran reports that she was first diagnosed with gynecological problems during service. She had also previously indicated that current conditions are linked to her breast cancer. See December 2008 Board hearing transcript, pages 15 and 16. Service treatment records show that on report of medical history completed at entrance in August 1987, the Veteran reported history of a cyst on the right ovary that had resolved with medication. The August 1987 examination report at enlistment shows that the Veteran had no problems at that time and pelvic examination was normal. Gynecologic consultation in October 1990 included an impression of right adnexal tenderness, probably ovulatory in nature. Review of service treatment records shows abnormal cytological examinations and treatment for pelvic inflammatory disease (PID). Her April 1993 medical history report prior to separation noted that she had been treated for abnormal gynecology examinations for the past three years. None of the service treatment records indicated that the Veteran had been diagnosed or treated for ovarian cysts during her period of service. VA treatment record dated in July 1997 shows that an ultrasound revealed findings of left ovarian cyst. The Veteran was assessed with breast cancer in January 2003 and she underwent a double mastectomy, and then received chemotherapy treatment. In November 2003, the Veteran presented with complaint of pelvic pain, and diagnostic testing and clinical examination revealed negative findings except for tender uterus. It was felt that the Veteran had irregular menses secondary to her chemotherapy treatment for breast cancer. VA treatment records dated in January 2004 show that the Veteran presented with right lower quadrant and pelvic pain. Clinical evaluation and diagnostic testing suggested a finding of right ovarian cyst, which was felt to have resolved based on diagnostic test results a month later. Another right ovarian cyst was observed in December 2004, and the Veteran underwent a cystotomy in January 2005. Right ovarian cysts were detected again in 2006, 2008, 2009, and 2011. In 2006, VA treatment records show that the Veteran had a left ovarian cyst, and she underwent a left ovarian cystoscopy in April 2007, and then she underwent a left oophorectomy in June 2007. On VA examination in November 2009 the assessment was asymptomatic right ovarian cyst, and it was noted that the Veteran had a history of left oophorectomy in 2007. No medical opinion on the etiology of the Veteran's recurrent ovarian cysts was render. The VA examiner in a September 2011 VA examination report noted that the Veteran had recurrent right ovarian cysts, and she was status-post left oophorectomy. The September 2011 VA examiner opined that the Veteran's recurrent ovarian cysts were attributable to a diagnosed disorder, and it was less likely than not that her current diagnosed disorder was related to her period of service. In an addendum medical statement, the VA examiner confirmed the medical conclusion that it was likely than not that the Veteran's recurrent ovarian cysts were due to her period of service, as they were not diagnosed until 2005, which comes more than a decade after her service. A supplemental VA medical opinion report was obtained in September 2015. The VA examiner noted a review of the claims folder, to include the Veteran's service treatment records as well as the findings contained in the 2009 and 2011 VA examination reports. The VA examiner concluded that the Veteran's recurrent ovarian cysts, status post left oophorectomy, less likely than not had an onset during her period of service. The VA examiner noted that upon entrance into service, the Veteran reported a medical history of right ovarian cyst, which resolved with medication, and there was no treatment for ovarian cyst shown during military service. While the Veteran's service treatment records show treatment for vaginitis, pelvic pain, menstrual cramps, and a yeast infection, there was no treatment for ovarian cysts. The post-service treatment for ovarian cysts in 1997, but her current recurrent ovarian cysts were not diagnosed until 2005, which comes well after her period of service. The VA examiner concluded that the Veteran's recurrent ovarian cysts were less likely than not related to her period of service. Based on a review of the foregoing evidence, the Board finds there is no competent and credible evidence that the Veteran's recurrent had an onset during her period of service, and the weight of the evidence is against a finding that her recurrent ovarian cysts, status post left oophorectomy, is otherwise related to her period of service. Initially, the Board observes that there is no medical evidence showing that the Veteran's recurrent ovarian cysts were first incurred during her period of service. Despite her history for right ovarian cyst, which resolved with treatment, there was no evidence of chronic ovarian disorder at enlistment. The August 1987 examination prior to enlistment shows that she received a normal gynecological evaluation and there was no disqualifying defects observed. The Veteran is presumed to have entered service in sound condition. 38 U.S.C.A. § 1111. While the service treatment record does show that she was treated for various gynecological problems during her period of service, there is no medical evidence of an ovarian cyst until 1997, and no evidence of recurrent ovarian cysts until 2005. There is no medical evidence that shows the Veteran's recurrent ovarian cysts first manifested during her period of service. 38 C.F.R. § 3.303. With respect to the Veteran's lay assertions of continuity of symptomatology since service, the Federal Circuit recently held that continuity of symptomatology under 38 C.F.R. § 3.303(b) only applies to those conditions recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran's diagnosed recurrent ovarian cysts are not listed as chronic conditions. Therefore, service connection based on continuity of symptomatology is not warranted. In addition, the record lacks medical evidence establishing a possible relationship between the Veteran's recurrent ovarian cysts and her period of service. The 2015 VA examiner concluded that the Veteran's recurrent ovarian cysts were less likely than not related to her period of service. The examiner supported this medical conclusion by noting the lack medical evidence of recurrent ovarian cysts prior to 2005 as well as the absence of treatment for ovarian cysts in service. There is no medical opinion contained in the record that links the Veteran's recurrent ovarian cysts to her service in order to support an award for service connection. See 38 C.F.R. § 3.303. The Veteran's assertions are the only evidence relating her recurrent ovarian cysts to service. However, the Veteran is not a medical professional, and therefore, her beliefs and statements about medical matters do not constitute competent evidence regarding matters that go beyond lay observation, such as etiology of gynecology diseases. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (under certain circumstances, lay person is competent to identify a simple medical condition). Notably, the question of etiology of recurrent ovarian cysts is based on diagnostic testing and extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not competent to address etiology in the present case. The Veteran lacks the medical expertise to diagnose the condition and to relate its etiological origin in service. See Bostain v. West, 11 Vet. App. 124, 127 (1998). In sum, the Veteran's recurrent ovarian cysts did not manifest until after her separation from service, and the weight of the evidence is against a finding that her endometriosis is related to her service. As such, the preponderance of the medical evidence is against an award of service. Consequently, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The claim must be denied. Migraine Headaches The Veteran seeks entitlement to service connection for migraine headaches. She has asserted that her headaches had an onset during her period of service, and she has continued to experience headaches and that they have become progressively worse since her period of service. During the December 2008 Board hearing, the Veteran testified that her migraine headache symptoms began after she started hormonal therapy treatment for breast cancer. See December 2008 Board hearing transcript page26. In the alternative, she contends that his migraine headaches are secondary to her service-connected fibromyalgia. The Veteran's service treatment records do show complaints of headaches. In May 1989, the Veteran presented with complaints of headache with associated photophobia. She was assessed with tension headache. Although none of the subsequent service treatment records show complaints indicative of migraine or severe headaches, on her April 1993 report of medical history, the Veteran indicated that she had experienced frequent and severe headaches. The examining physician noted that the Veteran associated these headaches with sinus problems. The April 1993 examination report prior to separation shows the Veteran received a normal neurologic evaluation. Post-service treatment records show that the Veteran reported having intermittent headaches when she presented for follow-up treatment for her mental health symptoms. She specifically sought treatment for headaches in July 1997, and she was evaluated with tension headaches. VA treatment records dated in November 2001 shows that her headache complaints were considered "sinus vs migraine" in nature. VA treatment records dated in 2002 note that the Veteran reported the onset headaches associated with her new psychotherapy medication (BuSpar), and it was later noted that her headaches had subsided. VA treatment records starting in 2005 show that the Veteran complained of intermittent headaches, which increased in severity following her treatment for breast cancer. See September 2005 VA treatment record. She was first assessed with migraine headaches in 2006 after she sought emergency medical treatment for a severe headache, level 10 out 10 in pain. On VA examination in November 2009 the assessment was migraine headaches. The Veteran informed the VA examination that her current headache symptoms began after her breast cancer treatment in 2003. She complained of severe headache attacks with light and sound sensitivity that occurred 2 to 3 times a month. The VA examiner concluded that it was less likely than not that the Veteran's current migraine headaches were related to period of service since her current symptoms did not begin until 2003 after her treatment for breast cancer. Similarly, the report of a September 2011 VA examination reflects a current diagnosis of migraine headaches; however, she informed the 2011 VA examiner that she first experienced symptoms of migraine headaches during her period of service, but she was not assessed with migraine headaches at that time. Based on a review of the claims folder, including the Veteran's service treatment records, the VA examiner opined that the Veteran's headaches were attributable to a diagnosed disorder, migraines, and it was less likely than not that her current diagnosed disorder was related to her period of service. The VA examiner considered that the Veteran had only one instance of headaches with photophobia during her period of service; however, there was no evidence of recurrence of similar symptoms. Rather, the evidence demonstrated that the Veteran's migraine headaches had an onset in the 2000s, which comes after her period of service. A July 2015 VA examination report also shows a diagnosis of migraine headaches. In a supplement September 2015 VA medical opinion report, the VA examiner concluded that the Veteran's migraine headaches are less likely than not proximately caused by or aggravated by her service-connected fibromyalgia. The VA examiner supported this medical conclusion by noting that the Veteran reported that her migraine symptoms had onset following her breast cancer treatment in 2003 and usually resolved with pain medication. In addition, the VA examiner cited to medical literature regarding the nature and etiology of migraine headaches, and observed that a review of medical literature failed to demonstrate that migraine headaches were caused or aggravated by fibromyalgia. The Board will first address the Veteran's claim for service connection on a direct basis. Here, the medical evidence of record demonstrates that the Veteran has a current diagnosis of migraine headaches during the pendency of the appeal. The most probative evidence of record does not show that the Veteran has been treated for or diagnosed with migraine headaches or chronic headache problems in service, at separation, or until several years after her discharge from service. 38 C.F.R. §§ 3.303, 3.307, 3.309. In addition, the most probative evidence of record does not establish element (3), nexus or relationship between the current disability and the Veteran's period of service. Both the September 2009 and September 2011 VA examiners concluded that it was less likely than not that the Veteran's current migraine headaches were caused by her period of service because the Veteran's current symptoms began in 2003 after her treatment for breast cancer and after her separation from service. The September 2011 VA examiner specifically considered that the Veteran presented with complaints of headaches and associated photophobia in 1989; however, the VA examiner found that this was a single occurrence and it did not demonstrate a chronic disorder. The VA examiner concluded that the Veteran's current migraine headaches were less likely than not related to her period of service. The Board observes that the 2011 VA examiner's opinion is based, in part, on the finding that there was no documentation of migraine headaches during the Veteran's period of service, or until 2000s. In essence, the examiner did not find the Veteran's reports that she began to experience migraine headaches during service and has had them since to be persuasive evidence. The Board cannot determine that competent lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In this case, the Board places less probative weight on the Veteran's report of continuity of symptoms after service because it is inconsistent with his service treatment records. While the Veteran's service treatment record does show complaints of headaches during her period of service, her description of symptoms were not attributed to migraine-type headaches at that time. Rather, she was assessed with tension headaches in May 1989, and her subsequent headache complaints were associated with a sinus disorder. Moreover, her post-service treatment record show that she reported the onset of her migraine headaches came after her treatment for non-service connected breast cancer. The evidence of record shows that Veteran did not report her migraine headaches had an onset during her period of service until the 2011 VA examination. For the reasons set forth above, the Board finds any statement with regard to continuity of symptomatology since service is not persuasive and is of limited probative value. See, e.g. Madden v. Gober, 125 F.3d 1477, 1481 (1997) (finding that the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); see Curry v. Brown, 7 Vet. App. 59 (1994) (contemporaneous evidence can have greater probative value than inconsistent testimony provided by the claimant at a later date). As the Board has afforded the Veteran's statements that she has experienced migraine headaches during service and since service to lack probative value, the Board finds the 2011 VA examiner's opinion to be highly probative because it is based on an accurate factual premise. In addition, the VA examiner's medical conclusion was based on a review of the claims folder and the findings from clinical evaluation. The Board finds it highly pertinent that there is no contradictory medical opinion of record. The Veteran has been accorded ample opportunity to furnish medical and other evidence in support of her service-connection claim, and against the reasoned conclusions of the VA examiner; she has not done so. The Board considered whether the Veteran's lay evidence constitutes competent and credible evidence of etiology in this particular case. In this case, the Board concludes that the etiologies of headaches go beyond the capabilities of lay observations. Although the Veteran is competent to report her symptoms of headaches, diagnosis of this disease and determination of the cause requires medical examination and detailed assessment of medical history. The Board concludes that the Veteran does not possess the necessary medical training and is not competent to provide an etiology of her diagnosed migraine headaches. The preponderance competent evidence of record is against a finding that the Veteran's migraine headaches had an onset during her period of service, or within first year thereafter, and the preponderance of the competent evidence is against a finding that her migraine headaches are related to her period of service. Service connection on a direct basis is not warranted. Turning to the Veteran's alternative assertion, entitlement to service connection on a secondary basis, the remaining question is whether the current migraine headache disorder is proximately caused or aggravated by his service-connected fibromyalgia. See 38 C.F.R. § 3.310. In the September 2015 VA medical opinion report, based on a review of the medical evidence and the findings from examination, the VA examiner concluded that it is less likely as not that the Veteran's migraine headache disorder is proximately due to, or alternatively, aggravated by (permanently worsened beyond its natural course) service-connected fibromyalgia disability. The VA examiner noted that the Veteran's migraine headaches began in 2005 after her treatment for breast cancer, and each episode resolved with pain medication and rest. The VA examiner stated that there was no basis in the identified medical literature to support the claim that her migraine headache disorder was caused or aggravated by fibromyalgia. The most persuasive evidence does not support a causal relationship, to include aggravation, between the Veteran's current migraine headaches and her service-connected disability. The VA examiner's medical opinions weigh heavily against a secondary basis for service connection. In sum, the most probative evidence does not show any findings of headache problems during her period of service, and there is no competent evidence linking the Veteran's current complaints directly to her period of service. See 38 C.F.R. § 3.303. Furthermore, the weight of the most probative evidence is against a finding that the Veteran's current migraine headache disorder is proximately caused or aggravated by her service-connected disability. See 38 C.F.R. § 3.310. Service connection for migraine headache disorder is therefore not warranted, and the claim must be denied. Psychiatric Disorder The Veteran seeks entitlement to service connection for an acquired psychiatric disorder, to include PTSD, depression, and adjustment disorder. Initially, the Board notes that service connection for PTSD requires (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). VA employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders for purposes of evaluating psychiatric disorders. See 38 C.F.R. § 4.130. For cases certified to the Board on or after August 4, 2014, a diagnosis of PTSD must be in accordance with the American Psychiatric Association, Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-V). 38 C.F.R. § 4.125(a); Schedule for Rating Disabilities-Mental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14,303 (March 19, 2015) (updating 38 C.F.R. § 4.125 to reference DSM-V). In the present case, the claim was originally certified to the Board prior to August 4, 2014. Therefore, in this case 38 C.F.R. §§ 4.125 and 4.130 require there to be a current diagnosis for PTSD conforming to the criteria set forth in DSM-IV only. In this case, the competent medical evidence of record demonstrates that the Veteran has current diagnoses of PTSD, depression, and adjustment disorder. See March 2016 private psychiatric evaluation, as well as VA medical records, including the report of a July 2015 VA examination. Accordingly, a current diagnosed disorder has been shown in conjunction with the Veteran's claim. The Veteran contends that she suffers from psychiatric problems after several traumatic experiences in service. In addition to her exposure to combat-related stressors while serving in Saudi Arabia, the Veteran contends that she was repeatedly sexually harassed by her supervisor as well. According to the Veteran, she tried to report these incidents to her other supervisors, but she did not feel that she would be taken seriously and she worried about retribution. Although her service treatment records do not document any evidence of a sexual assault, the record does reflect that the supervisor, who Veteran's contends sexually harassed her, was dishonorably discharged to numerous sexual assaults and harassments of other service members. In addition to her reported military sexual trauma, both the RO and the Board have conceded the Veteran's exposure to combat stressors in service while she was deployed to Southwest Asia. Lastly, after review of the lay and medical evidence of record, the Board finds that the evidence is in equipoise on the question of whether the current acquired psychiatric disability, diagnosed as PTSD and depression, is related to her period of service, to include as secondary to her service-connected disability. In this regard, the record contains the report of a March 2016 private psychiatric evaluation, in which the private psychologist concluded that the Veteran's current acquired psychiatric disorders were related to the sexual trauma that she experienced during her period of service. The private psychologist noted that the diagnosis and medical conclusion were based on the findings from a two-hour clinical interview as well as an extension review of the claims folder. Furthermore, in the report of a July 2015 VA psychiatric examination, the VA examiner observed that the Veteran's physical medical conditions, including her fibromyalgia, aggravated her depression disorder, despite the finding that it was unclear whether the aggravation was solely attributable to her fibromyalgia disability. In consideration of the foregoing, and resolving reasonable doubt in favor of the Veteran, the Board finds that the criteria for service connection for acquired psychiatric disorder, currently diagnosed as PTSD and depression disorder have been met. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 3.303. ORDER Entitlement to service connection for recurrent ovarian cysts is denied. Entitlement to service connection for headaches is denied. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depression, is granted. REMAND A review of the documents contained in the Veteran's electronic claims on the Veterans Benefits Management System (VBMS) shows that the Veteran has expressed a timely disagreement with the RO's September 2012 rating decision that assigned an initial effective date and evaluations for his service-connected fibromyalgia, to include consideration of TDIU. See August 2013 notice of disagreement. As a timely notice of disagreement has been filed, the Board's jurisdiction has been triggered and these issues must be REMANDED so that a statement of the case on the underlying claim that adequately notifies the appellant of the action necessary to perfect an appeal may be provided. See Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: The RO should provide the Veteran a Statement of the Case as to the issue of entitlement to initial earlier effective date for award of service connection for fibromyalgia and entitlement to initial increased evaluations for fibromyalgia, to include consideration of TDIU. The Statement of the Case should be sent to the latest address of record for the Veteran. The RO should inform the Veteran that he must file a timely and adequate substantive appeal in order to perfect an appeal of the issue to the Board. See 38 C.F.R. §§ 20.200, 20.202, and 20.302(b) (2015). The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs