Citation Nr: 18150629 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 15-21 946 DATE: November 15, 2018 ORDER Service connection for pelvic inflammatory disease (PID), to include as due to Gulf War environmental hazards, is denied. Service connection for residuals of a hysterectomy, to include as due to Gulf War environmental hazards, is denied. REFERRED On her May 2015 VA Form 9, the Veteran indicated that she wished to appeal the issues of entitlement to service connection for menstrual problems, including heavy bleeding, and hot flashes/vaginal dryness. These claims were initially denied in a May 2012 rating decision and vaginal dryness denied again in June 2017. At this juncture, the Board does not have jurisdiction over these claims, and they are referred to the agency of original jurisdiction (AOJ) for appropriate action.   OTHER ISSUES ON APPEAL In October 2017, the Veteran filed a timely notice of disagreement (NOD) with a June 2017 rating decision that denied, among other things, claims for irritable bowel syndrome (IBS), abnormal pap smear, and a disability secondary to exposure to oil, smoke, and/or petrochemicals. These appeals have been entered in the VACOLS appeals tracking system as an active appeal at the RO. The RO has fully acknowledged the NOD and is currently in the process of adjudicating the claims. As action by the Board could delay the RO’s action on those appeals, the Board will not take jurisdiction of those issues at this time. FINDINGS OF FACT 1. The Veteran served on active duty from September 1990 to February 1992, to include service in Saudi Arabia (within the Southwest Asia Theater of Operations) from November 1990 to May 1991, during the Persian Gulf War era. 2. The Veteran does not have objective indications of a qualifying chronic disability associated with Persian Gulf War service. 3. A current diagnosis of PID is not shown. 4. The residuals of a hysterectomy were not shown during service or within one-year of service discharge and are not otherwise etiologically related to active service or to service-connected disability. CONCLUSIONS OF LAW 1. PID was not incurred in service. 38 U.S.C. §§ 1110, 1117, 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2018). 2. Residuals of a hysterectomy were not incurred in service nor are they a result of a service-connected disability. 38 U.S.C §§ 1110, 1117, 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310, 3.317 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As a procedural matter, the March 2015 statement of the case (SOC) denied issues of entitlement to service connection PID, hysterectomy, and genital warts, as well as an increased rating claim for posttraumatic stress disorder (PTSD). On her May 2015 VA Form 9, the appellant limited her appeal to the claims for service connection for PID and hysterectomy. Therefore, the Board does not have jurisdiction over the genital warts and PTSD claims at this time. Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Additionally, service connection may also be established on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest 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, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1). A “qualifying chronic disability” for VA purposes is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. 38 U.S.C. § 1117 (a)(2); 38 C.F.R. § 3.317 (a)(2)(i)(B). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317 (a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbance; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; and (12) abnormal weight loss. 38 C.F.R. § 3.317 (b). Service personnel records confirm the Veteran’s service during the Persian Gulf War in Iraq, within the Southwest Asia Theater of operations, from November 1990 to May 1991. Therefore, she is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). However, although she has claimed disabilities as a result of environmental toxins to which she was exposed to in the Persian Gulf, she has not claimed an undiagnosed illness. In addition, a May 2012 VA gynecological examiner indicated that fibroids were not undiagnosed condition and have definitive etiology. A January 2017 VA Gulf War examiner noted her subjective complaints of a history of hysterectomy, abnormal pap smear, vaginal dryness, and PID, as well as constipation and irritable bowel syndrome. The examiner found no undiagnosed illness or medically unexplained chronic multi-symptom illness of unknown etiology attributable to environmental exposures and no conditions presumptive of Gulf War environmental hazards. In support of this opinion, the examiner cited to the Institute of Medicine’s “Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War, 2016” which found that sufficient time had passed to determine that Gulf War veterans do not have an increased incidence of disorders of the gastrointestinal, genitourinary, or reproductive systems, among others. As for service connection on a direct basis, service treatment records reveal that the Veteran was treated for PID in 1991. However, the disorder was noted to have resolved with a normal pelvic examination in September 1991 and PID was not noted at the Veteran’s Medical Evaluation Board or January 1992 retirement physical. Moreover, post-service treatment notes do not reveal complaint, treatment, or diagnosis of PID since service discharge. Moreover, the Veteran does not contend that she has had PID since service. Rather, she contends that she developed uterine fibroids and ultimately needed a hysterectomy as a result of her in-service PID. Absent a current diagnosis of PID that could be associated with service, there can be no entitlement to compensation. Therefore, the appeal for PID is denied. With regard to the Veteran’s hysterectomy, post-service treatment notes reveal that she underwent a total abdominal hysterectomy with bilateral salpingo-oopherectomy in 2001 as treatment for uterine fibroids. However, the evidence does not support a finding of service connection. Initially, as service connection for PID has been denied, service connection for hysterectomy claims as secondary to PID based on a secondary theory of entitlement is also denied. Further, the evidence does not demonstrate that the hysterectomy was a result of service. As noted, the Veteran was treated for PID in service. She was also treated for vaginitis and urinary retention due to urethral stricture. In March 2012, a VA examiner found that the fibroid uterus resulting in hysterectomy was not caused by urethral stricture, vaginitis, or PID diagnosed during active duty. The examiner reasoned that the urethral stricture and urinary retention resolved in 1991 that the PID was treated with antibiotics and so did not share an etiology with the fibroid uterus diagnosed in 2001. The examiner stated that fibroid uterus is a benign tumor of the smooth muscles of the uterus and that PID is a transient disorder which is alleviated with antibiotic treatment. The examiner noted that urinary retention was resolved with temporary catheterization in 1991 and although the etiology of retention was not mentioned in the record, it is a disorder of the urethra, not the uterus. Subsequently, a May 2012 VA examiner stated that the Veteran’s fibroids were not associated, caused by, or aggravated by Southwest Asia environmental hazards or exposure to environmental hazards experienced during service in Southwest Asia. The examiner reported that uterine fibroid, which was diagnosed in 2001, was not related to the environmental hazards or aggravated by it. The examiner noted that fibroids were a very common condition, especially among the African-American population, and stated that according to medical literature the incidence rates of fibroids were typically found to be two- to three-fold greater in black women than in white women. The examiner indicated that uterine leiomyomas or fibroids were the most common pelvic tumor in women. The Veteran has not offered and the record does not show any contradictory medical opinion. Thus, the medical evidence weighs against the claims. The Board has considered the lay statements that PID and hysterectomy were a result of service. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to her through her senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, she is not competent to offer an opinion as to the existence and etiology of PID, fibroids, and hysterectomy due to the medical complexity of the matters involved. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462. Such competent evidence has been provided by the medical personnel who have examined the Veteran during the current appeal and by service records obtained and associated with the claims file. Here, the Board attaches greater probative weight to the examination reports and clinical findings than to her statements. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. M. Schaefer, Counsel