Citation Nr: 18152877 Decision Date: 11/26/18 Archive Date: 11/26/18 DOCKET NO. 10-42 919 DATE: November 26, 2018 ORDER Entitlement to service connection for a gynecological disorder, to include endometriosis, hydrosalpinx, hysterectomy, and any surgical residuals, is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran has a gynecological disorder, to include endometriosis, hydrosalpinx, hysterectomy, and any surgical residuals, that had its onset during, or is otherwise related to, her military service. CONCLUSION OF LAW The criteria for service connection for a gynecological disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1981 to March 1984. She also had periods of active duty for training and inactive duty for training in the Army National Guard. The Veteran claims that her currently-diagnosed gynecological disorders, to include endometriosis, hydrosalpinx, hysterectomy, and any surgical residuals, had onset during, or are otherwise related to, her active duty service. The question for the Board is whether the Veteran has a current gynecological disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has been diagnosed with fallopian tubes with hydrosalpinx and vascular congestion, endometritis, myometrium with leiomyoma, endometriosis, and she underwent a laparoscopic assisted vaginal hysterectomy and salpingectomy in August 2013, the preponderance of the evidence weighs against a finding that those diagnoses and surgical residuals began during service or are otherwise related to her military service, to include her in-service treatment for premenstrual pelvic congestion. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). In a March 1982 gynecological questionnaire, the Veteran denied having problems with vaginal discharge, or bleeding or spotting between periods. She did report occasional severe pain with menstrual periods. Following an examination, her assessment was “normal adult female.” A September 1982 service treatment record noted the Veteran’s complaint of abdominal cramping for the last three days. She denied any venereal disease or vaginitis. Upon examination, the treatment provider noted a small amount of white discharge; however, the remainder of the examination was within normal limits and test results were negative for any organisms. Subsequently, the Veteran was diagnosed with premenstrual pelvic congestion. In a January 1984 Report of Medical History, she reported that she had been hospitalized in September 1982 for “stomach cramps;” however, she specifically denied receiving treatment for a female-related disorder. In an October 1985 Report of Medical History, the Veteran also denied a change in menstrual pattern. The examiner noted in the summary section that she experienced menarche at the age of 15, that her periods were regular every month, that they lasted for five days, and that she experienced no pain. In August 2014, the Veteran testified before a Veterans Law Judge. With regard to her in-service symptoms, she stated that she experienced very severe, heavy bleeding, endometriosis, and lower abdominal pain. See August 2014 Hearing Transcript, p. 3. She indicated that she symptoms occurred very often, and that required continuous treatment. Id. at 4. She stated that those symptoms continued to the present. Id. at 6. Although VA medical opinions were obtained in July 2010, December 2014, March 2015, in the Board’s prior remands, it determined these opinions were insufficient to adjudicate the Veteran’s claim. In August 2017, the Veteran submitted a statement from a fellow servicemember who stated that she and the Veteran served together, and that she felt that the meals they were provided adversely affected their menstrual cycles. In accordance with the Board’s August 2017 remand, the Veteran was afforded a new VA examination in October 2017. Initially, the examiner noted her report of heavy and painful periods, beginning at the age of 15, as well as her reports of in-service symptoms, including heavy bleeding, a lot of discomfort, and pain. With regard to her post-service symptoms and treatment, she stated that she continued to experience symptoms, including pain in her low back, hips, and leg, and that she saw a private gynecologist and underwent a laparoscopy. She stated that her post-service treatment provider told her she had endometriosis and scar tissue at some point from 1986 to 1988. The Veteran also reported three normal pregnancies and deliveries. She recalled being treated for pelvic inflammatory disease when she was incarcerated. The examiner then discussed the Veteran’s surgical history, including a 2008 laparoscopy which found blockages in her fallopian tubes, and an August 2013 hysterectomy and salpingectomy for management of her menorrhagia and pelvic pain. Although the Veteran reported that her gynecological problems began during her active duty service, the examiner noted that her post-service treatment records contradicted her statements. The examiner specifically pointed to the October 1985 report of medical history wherein the Veteran denied a change in menstrual pattern, and the note in the summary section that her periods were regular every month, that they lasted for five days, and that she experienced no pain. With regard to the Veteran’s current diagnoses, the examiner noted the following: acquired absence of uterus, cervix, and tubes, status-post laparoscopic assisted vaginal hysterectomy and bilateral salpingectomy; history of fallopian tubes with hydrosalpinx and vascular congestion; history of endometritis; history of myometrium with leiomyoma; history of incidental pathological identification of uterine cervix with nabothian cysts and benign squamous epithelium; endocervix with benign squamous metaplasia; and a history of endometriosis, per the Veteran’s report. Ultimately, the examiner opined that it was less likely than note that any of the Veteran’s currently-diagnosed gynecological disorders were related to her military service, to include her in-service diagnosis of premenstrual pelvic congestion. With regard to her in-service diagnosis of premenstrual pelvic congestion, the examiner noted that such was a diagnosis of exclusion, and it referred to discomfort attributed to congestion of blood within the veins of the pelvic region. Furthermore, the examiner noted that the emergency room findings noted in the September 1982 service treatment record weighed against a finding of gynecologic etiology. The examiner also noted that premenstrual pelvic congestion was not the same as, or a precursor to, the histopathologically visualized vascular congestion found in conjunction with the Veteran’s August 2013 hysterectomy. Concerning the September 2008 VA findings of bilateral proximal tubal occlusion, hydrosalpinx, and normal ovaries, and the September 2008 peritoneal biopsy findings of a peritoneal lining with fibrosis, but no evidence of endometriosis, the examiner stated that such were non-specific laparoscopic findings that were likely related to a prior infection—pelvic inflammatory disease. With regard to the August 2010 finding of bilateral tubal disease, the examiner opined that such was most likely due to post-service infections given that the Veteran had three successful pregnancies and deliveries, which indicate that there was no tubal disease at the time of the pregnancies. The Board finds that the October 2017 VA examination and opinion is the most probative evidence of record addressing whether any of the Veteran’s currently diagnosed gynecological disorders are related to her military service. Significantly, the opinion is probative because the examination report and opinion clearly reflect consideration of the Veteran’s pertinent medical history, including her service and post-service treatment records, pertinent medical literature, and her lay statements concerning the alleged onset and continuity of her gynecological symptoms. Furthermore, the opinion provides a complete rationale that takes into consideration all pertinent evidence of record, including her lay statements. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinion.”). The Board recognizes that the Veteran is competent to report that a prior treatment provider told her that her disabilities could have had onset during service. The Board nevertheless finds the October 2017 VA examiner’s opinion to the contrary to be more probative than the Veteran’s report of what her physician told her. Indeed, the VA examiner has specifically considered and addressed the Veteran’s contentions, and came to a reasoned conclusion with explanatory and supportive clinical discussion of the intricacies of her medical history. The bare assertion of the Veteran’s physician that such disabilities had in-service onset, without more, does not outweigh the comprehensive opinion of the October 2017 VA examiner, described above. While the Veteran herself believes that her current gynecological disorders are related to her military service, neither she nor her fellow servicemember is competent to provide a nexus opinion in this case. Here, the specific matter of whether the Veteran’s gynecological disorders are related to her military service is a complex medical matter that falls outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Specifically, the question of causation of gynecological disorders involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. The Veteran is not shown to have the necessary training and expertise to provide a competent opinion as to the causes of any gynecological disorders. Consequently, the Board finds that the only probative evidence of record is the October 2017 VA examination report and opinion. Moreover, as for the Veteran’s lay statements concerning the onset and continuity of her symptoms, the Board finds that those statements lack credibility in light of prior inconsistent statements made to medical professionals. Specifically, although the Veteran indicated that she began to experience have problems with heavy bleeding and pain during service, up to three weeks out of a month, and that they continued after discharge, in September 1985, less than two years after discharge, she denied any change in her menstrual pattern, and the examiner noted that her periods were regular every month, that they lasted for five days, and that she experienced no pain. The October 2017 VA examiner also considered the Veteran’s statements regarding her reported in-service symptoms, and found them to be contradictory to contemporaneous reports of history during and shortly after service. The Board places greater weight of probative value on the history the Veteran presented to medical professionals for treatment purposes (i.e., during active service and shortly thereafter) than it does on her recent statements to VA in connection with her claim for monetary benefits. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the veteran). In addition, the Veteran’s history of prior inconsistent statements weigh against her credibility. See Caluza v. Brown, 7 Vet. App. 498 (1995). Absent competent and credible evidence demonstrating that the Veteran’s gynecological disorders had their onset in, or are otherwise related to her military service, the preponderance of the evidence is against her claim. As such, reasonable doubt does not arise and her claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD James R. Springer, Associate Counsel