Citation Nr: 18153683 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 16-35 098 DATE: November 28, 2018 ORDER Entitlement to service connection for recurrent urinary tract infections is granted. Entitlement to service connection for migraine headaches is granted. REMANDED Entitlement to service connection for arthritis is remanded. Entitlement to service connection for allergic rhinitis is remanded. Entitlement to service connection for irregular menses with menorrhagia is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, her recurrent urinary tract infections began in service and have continued throughout the appeal. 2. The Veteran developed migraine headaches during service. CONCLUSIONS OF LAW 1. The criteria for service connection for recurrent urinary tract infections are met. 38 U.S.C. §§ 1110, 1111, 5107(b) (2014); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 2. The criteria for service connection for migraine headaches are met. 38 U.S.C. §§ 1110, 1111, 5107(b) (2014); 38 C.F.R. §§ 3.102, 3.303(a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Army from February 1992 to August 1999. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. The May 2013 rating decision denied 17 service connection claims. The Veteran filed a timely notice of disagreement with 16 issues, and a May 2016 Statement of the Case (SOC) addressed all 16 issues. On her July 2016 substantive appeal VA Form 9, the Veteran indicated that she only wished to appeal the issues of entitlement to service connection for headaches, “arthritis,” recurrent urinary tract infections, allergic rhinitis, and menorrhagia to the Board. As such, this decision and remand only addresses these five issues. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). The Board must determine the value of all evidence submitted, including lay and medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). 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. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for recurrent urinary tract infections The Veteran contends that she developed recurrent urinary tract infections (UTIs) in service, and that she continues to suffer from UTIs on a yearly basis since discharge from service. The Board that this is a credible and accurate contention and grants entitlement to service connection for recurrent UTIs. The Veteran’s service entrance medical examination does not include any findings related to UTIs, and she did not report a history of UTIs on her entrance medical history. The Veteran’s service treatment records include that in February 1997 she was diagnosed with a UTI, and went through three courses of antibiotics to treat that “original UTI.” In March 1997, she continued to have hematuria during urinalysis. She underwent urology and nephrology consultations due to ongoing hematuria and amenorrhea (absence of menses). Testing at Walter Reed in February 1998 ruled out renal familial disease and systemic disease related to her persistent microscopic hematuria. She was noted to again have “recurrent UTI” in February 1998. A March 1998 renal ultrasound revealed “slight increased echotexture noted in the renal cortices which may represent medical renal disease.” In April 1998, she complained of right upper quadrant pain, and dark urine with odor. She was found to again have a UTI. It is unclear when a diagnosis was made, but an April 1998 record noted that the Veteran had been diagnosed with papillary necrosis, suspected as a result of NSAID use. She was referred back to nephrology. She continued to have menstrual irregularity with amenorrhea prominent. She had a normal pelvic ultrasound in March 1999. She separated from service in April 1999 with “ongoing microhematuria consistent with papillary necrosis, and recurrent UTIs with persistent microhematuria with a history of the same” noted on her separation medical examination. She was again referred to nephrology for follow-up care. A post-service record from April 1999 included that she had been diagnosed with papillary necrosis in March 1998, and that she continued to have flank pain with a large amount of blood in her urine. A sonogram of the liver did not show evident abnormality, and a CT scan of the kidneys and bladder were normal. The claims file does not contain post-service treatment records from April 1999 through September 2006. The September 2006 VA treatment record was an annual gynecological evaluation. The next earliest record of treatment for a UTI is from February 2009. She was diagnosed with UTIs in February 2009, February 2010, September 2011, February 2013, and December 2013. She was also noted to continue to have hematuria, with a negative ultrasound of the kidneys in August 2012. The Veteran was afforded a VA examination in April 2013. She reported frequent UTI and bladder infections, and she estimated that she had approximately two per year which required medical treatment. She stated she was last treated in February 2013, and that she was aware of preventative measures. The examiner noted that she had a history of recurrent symptomatic bladder or urethral infections, and that the etiology of the infections was “unknown.” The examiner commented that there was “not sufficient clinical evidence to diagnose a current acute or chronic condition of the urinary tract or kidneys at this time.” The examiner provided a negative nexus opinion, noting that UTIs are a “common occurrence in females because of proximity of rectum and vagina to urethra. On testing completed in service, no causative factor was found.” Despite the negative nexus opinion provided by the April 2013 VA examiner, the Board finds that the Veteran developed recurrent UTIs in service, and that the evidence shows that she has continued to have recurrent UTIs post-service. The VA examiner noted that the etiology, or cause, of her recurrent UTIs was unknown as in-service testing had not provided cause of her development of recurrent UTIs. Nonetheless, the recurrent UTIs developed in service, and the credible and competent evidence of record shows that they have continued from service to the present. As such, entitlement to service connection for recurrent UTIs is warranted. 2. Entitlement to service connection for migraine headaches The Veteran contends that her current migraine headaches began in service. A review of her service treatment records show that she did not report headaches on her entrance medical history, and was not noted to have a headache disorder on her entrance medical examination. As such, she is considered to have entered service in sound condition as related to a headache condition. An April 1998 treatment record included the Veteran’s complaint of frequent headaches, which the medical provider noted sounded “like common migraines, including photophobia. Motrin did not help.” She was also recently diagnosed with papillary necrosis due to NSAID use, and the diagnosis provided was “probably migraine headaches.” She was given prescription migraine medication. On her April 1999 separation medical history, she noted that the prescription provided for her migraines provided some relief, and her headaches were only “occasional” now. She was noted to have been diagnosed with renal necrosis secondary to analgesic abuse due to using Motrin to treat her migraines. Post-service treatment records show that the Veteran has an ongoing prescription for migraine medicine. The Veteran was afforded a VA examination in April 2013, and the examiner diagnosed migraine headaches. He provided a negative nexus opinion, which appears to be based on the fact that he missed several in-service treatment records related to her migraine headaches. He found a referral to neurology, but did not find the records where her migraines were diagnosed and that she was placed on prescription medication, including her separation evaluation and history. The Board does not that many of her service treatment records are difficult to read due to the handwriting of the medical professionals. As the Veteran’s migraine headaches began during, and were first diagnosed in, service, entitlement to service connection is warranted. REASONS FOR REMAND 1. Entitlement to service connection for arthritis is remanded. The Veteran’s claim of entitlement to service connection for “arthritis” requires clarification. The August 2016 and August 2018 briefs provided by her representative did not indicated which joint or joints she argued had developed arthritis due to her service. Her substantive appeal noted that “as a radiologic technologist [she] spent countless hours on [her] feet” in service. She described frequently using her arms, and that her MOS resulted in “wear and tear on [her] bones and joints.” She then stated that she had an ibuprofen prescription and store-bought braces for her hands and knees. Notably, the Veteran had claimed entitlement to service connection for her hands and wrists, but did not substantively appeal those decisions. However, she did not have a prior claim of entitlement to service connection for a knee disorder. On remand, the RO should request that the Veteran clarify her claim for “arthritis” by indicating which joint or spine she argued had developed arthritis due to her service. 2. Entitlement to service connection for allergic rhinitis is remanded. The Veteran alleges that she developed allergic rhinitis in service. Her September 1991 enlistment medical history included her selection of “sinusitis” from a list of prior medical conditions. She explained that she had a pollen/golden rod allergy which caused mild symptoms that were relieved with over-the-counter (OTC) medication. On another September 1991 form she reported a mild allergy to fresh cut grass with use of OTC medication. Ongoing service treatment records included September 1992 complaints of allergies with itchy, runny nose, and constant sneezing for three weeks. She was assessed with allergic rhinitis and given medication. She complained of similar symptoms in September 1995, and was again assessed with allergic rhinitis and treated with Sudafed and a “nasal inhaler.” She was noted to have “hay fever” in June 1996, and she had similar symptoms with an unknown diagnosis (handwriting) in June 1997. Her April 1999 separation medical history included a notation of seasonal allergic rhinitis. The Veteran was afforded a VA examination in April 2013. The examiner diagnosed allergic rhinitis, and provided a negative nexus opinion finding that she entered service with pre-existing allergies which were not aggravated beyond the natural progression in service. On her substantive appeal, the Veteran reported that she first experienced allergic rhinitis while at “Fort Sam Houston in 1992.” She stated she was seen by her primary care manager for seasonal allergies that were not improving and referred to the allergy clinic while stationed at Fort Belvoir in Virginia. She stated she underwent allergy testing in service, and was put on maintenance injections (six shots a week) to build her immunity, and then was placed on allergic medicine to be taken daily. She stated she was still using Singulair and Claritin to treat her seasonal allergies. Given that the Veteran has reported an increase in her treatment and symptoms of allergies in service (from OTC medications to shots, medicine, and nasal sprays), the Board finds that a second VA examination should be provided where the examiner solicits information on the severity of her allergies pre-service, during service, and post-service as this information was not recorded in the April 2013 examination. 3. Entitlement to service connection for irregular menses with menorrhagia is remanded. The Veteran’s service treatment records show that she initially reported an unusual menstrual cycle in October 1994, where she stated she had an occasionally late cycle, usually right after a large amount of exercise and stress. She was then currently having a “delayed onset menses probably due to stress and exercise.” A March 1997 treatment record noted she had not had a period in 8 months. An October 1997 record assessed amenorrhea, with no menses since December 1994, with one episode of spotting in June 1996. She had a C-section delivery of a healthy baby in October 1995, and she reported “normal” periods prior to pregnancy; although, this contrasts with her report of delayed periods with exercise and stress. A December 1997 record noted that she continued to have amenorrhea despite starting medications nearly two months ago. A March 1999 treatment record for menstrual irregularity noted she underwent a trial of Premarin and Provera, possibly in March 1998. The handwriting for the March 1999 record is difficult, but appears to note “positive withdrawal bleeding” and that she had a history of “oligomenorrhea” (handwriting is such, that this may be incorrect). The last service treatment records indicated she still had an absence of menses. The first post-service treatment record is from September 2006 and noted a normal pelvic evaluation, with no complaints related to periods. Starting in January 2008, the Veteran began complaining of menstrual cramps and heavy bleeding, and was initially assessed with premenstrual syndrome, and eventually with menorrhagia. In August 2011, she was found to have a 1 cm fibroid and 7 mm endometrial strip. She reported no prior history of heavy bleeding, and that she developed hot flashes in August 2010. She also noted that her mother and sister started hot flashes at around age 38, with menstrual cycles until their 50s. In September 2011, she was assessed with menorrhagia perimenopausal, and it was found that “most likely her bleeding and pain was perimenopausal changes.” In October 2011, she was seen for absent menses for five weeks and a history of irregular menses. In April 2012, she was found to be perimenopausal. The Veteran was afforded a VA examination in April 2013. The examiner diagnosed irregular menses with menorrhalgia. The examiner provided a negative medical nexus opinion, noting that she suffered from amenorrhea in service, which “resolved” and noted that she experienced no periods for long periods of time, and that this was a “common occurrence in women athletes and service members who do intense physical training.” He noted that 9 years after service, in 2008, she first suffered from cramps and heavy bleeding. He noted that menorrhalgia (dysmenorrhea), fibroid, menorrhagia, and premenopausal syndrome all did “not occur according to the records until several years after discharge.” He found that although all complaints involved the female reproductive system, they were different, with differing etiologies. The Board is remanding for an addendum opinion where the examiner addresses that the Veteran was treated with Premarin and Provera in service, and that her menorrhalgia was associated with being premenopausal post-service. The Board notes that Premarin and Provera are sometimes used to treat menopause, and is seeking a statement from a medical professional to address whether the Veteran’s in-service menstrual symptoms were a pre-cursor to, or otherwise related to, her post-service perimenopausal symptoms. The matters are REMANDED for the following action: 1. Contact the Veteran and her representative and request that they clarify her claim of entitlement to service connection for “arthritis” by indicating which joint, bone, or spine the Veteran is alleging developed arthritis as a result of her service. 2. Schedule the Veteran for a VA allergic rhinitis examination. The examiner should specifically solicit subjective information from the Veteran regarding the severity of her allergies pre-service, during service, and post-service. Following a review of the record and interview of the Veteran, the examiner should provide the following: (a.) Is it at least as likely as not (50/50 probability or greater) that the grass, pollen, and golden rod allergies reported on her September 1991 medical history are the same seasonal allergies/allergic rhinitis she sought treatment for throughout her service? (b.) If so, is it at least as likely as not that her service aggravated (beyond the natural progression of the disease) her pre-existing allergies/allergic rhinitis? Provide a full explanation for each opinion expressed. 3. Return the claims file to the April 2013 VA examiner, or another qualified medical provider for an addendum gynecological opinion. Is it at least as likely as not (50/50 probability or greater) that the Veteran’s in-service irregular menstrual cycle/amenorrhea is related to, or was the beginning of, her current perimenopausal menorrhagia? In addressing this question, address the Veteran’s in-service treatment with Premarin and Provera and whether her in-service symptoms were also symptoms of perimenopause. Provide a full explanation for each opinion expressed. 4. After completing the development requested above, readjudicate the Veteran’s claims. If any of the benefits sought are not granted in full, the Veteran and his representative should be furnished a Supplemental Statement of the Case and given the opportunity to respond thereto. The case should then be returned to the Board, if otherwise in order. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M.H. Stubbs, Counsel