Citation Nr: 18158282 Decision Date: 12/18/18 Archive Date: 12/14/18 DOCKET NO. 17-01 427 DATE: December 18, 2018 ORDER Service connection for the early onset of menopause, to include as due to an undiagnosed illness, is denied. REMANDED The issue of entitlement to service connection for obstructive sleep apnea, to include as due to an undiagnosed illness, is remanded. VETERAN’S CONTENTIONS The Veteran contends that she experienced an early onset of menopause as a result of exposure to a SCUD missile attack, nerve gas, and burning oil fumes while deployed in Southwest Asia. Alternatively, the Veteran contends that she experienced the early onset of menopause due to an undiagnosed illness related to service. FINDING OF FACT The probative medical evidence of record does not show that the Veteran became menopausal at an age at which menopause would be considered to have occurred earlier than is normal. CONCLUSION OF LAW The criteria for service connection for early onset of menopause, to include as due to an undiagnosed illness, have not been met. 38 U.S.C. §§ 1101, 1110, 1111, 1112, 1113, 1131, and 1137. 38 C.F.R §§ 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1985 to October 1988 and from December 1990 to May 1991. These matters come to the Board of Veterans' Appeals (Board) on appeal from a June 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. 1. Entitlement to service connection for early onset of menopause, to include as due to an undiagnosed illness The Veteran seeks service connection for the early onset of menopause. Specifically, the Veteran contends that she experienced the early onset of menopause as a result of exposure to a SCUD missile attack, nerve gas, and burning oil fumes while deployed in Southwest Asia. Alternatively, the Veteran contends that she experienced the early onset of menopause due to an undiagnosed illness related to service. Generally, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a) (2017). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Service connection may also be established for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability which became manifest either 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 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" includes an undiagnosed illness or a medically unexplained chronic multi symptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders. 38 C.F.R. § 3.317 (a)(2)(i). The term "medically unexplained chronic multi symptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi symptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). "Objective indications of 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). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi symptom 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 disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317 (b). For purposes of section 3.317, 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)(3)(4). The Board notes that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. §§ 1110, 1131. In the absence of proof of present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Degmetich v. Brown, 104 F.3d 1328 (1997); Wamhoff v. Brown, 8 Vet. App. 517, 521 (1996). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical evidence. VA must also consider all favorable lay evidence of record. See 38 U.S.C. § 5107 (b); see also Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (a Veteran is competent to report on that of which he or she has actually observed and is within the realm of his or her personal knowledge). The Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War and is a Persian Gulf Veteran. 38 C.F.R. § 3.317 (e). The Veteran's service treatment records (STRs) are negative for evidence of a diagnosis of early onset of menopause. Post-service treatment records are also negative for evidence of a diagnosis of early onset menopause. The Veteran was afforded a VA examination in May 2016. The May 2016 VA examiner diagnosed the Veteran with menopause and noted that the Veteran was originally determined to be menopausal in 2014, at the age of 44 years. However, the examiner did not indicate that the Veteran experienced menopause earlier than is normal; the examiner indicated that the Veteran had undergone “natural menopause”. The examiner further opined that there was no evidence of an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, or a diagnosable chronic multi-symptom illness with a partially explained etiology. The examiner reasoned that all of the Veteran’s conditions were consistent with a clear and specific etiology and diagnosis. As the competent evidence of record fails to show that the Veteran has been diagnosed with early onset of menopause, an undiagnosed illness, or a medically unexplained chronic multi symptom illness, her claim for service connection for early onset of menopause must be denied. See Brammer, 3 Vet. App. at 225. Although the Veteran has asserted that she experienced the early onset of menopause due to service, and/or an undiagnosed illness, the Board notes that she is not competent to provide evidence pertaining to the diagnosis and etiology of a complex medical condition. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson, 581 F.3d at 1316. Whether the Veteran has a genitourinary disability and whether this condition is related to her period of active service are complex questions that are not answerable by personal observation alone or by the application of knowledge within the realm of a lay person. See Layno, 6 Vet. App. at 469-70; see also Jandreau, 492 F.3d at n.4. REASONS FOR REMAND Entitlement to service connection for obstructive sleep apnea, to include as due to an undiagnosed illness is remanded. The Veteran seeks service connection for obstructive sleep apnea. Specifically, the Veteran contends that she has obstructive sleep apnea as a result of exposure to a SCUD missile attack, nerve gas, and burning oil fumes while deployed in Southwest Asia. Alternately, the Veteran contends that she has obstructive sleep apnea due to an undiagnosed illness related to service. In this regard, the evidence of record includes a May 2016 VA examination report in which the examiner opined that there was no evidence of an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, or a diagnosable chronic multi-symptom illness with a partially explained etiology. The examiner reasoned that all of the Veteran’s conditions were consistent with a disease with a clear and specific etiology and diagnosis. The examiner further opined that the Veteran’s obstructive sleep apnea was not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. However, the examiner did not provide a rationale for this opinion. “A medical opinion…must support its conclusion with analysis that the Board can consider and weight against contrary opinions.” Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Therefore, the Board finds the May 2016 VA examiner opinion inadequate upon which to decide the Veteran’s claim for service connection and an addendum opinion with an adequate rationale should be obtained on remand. The matters are REMANDED for the following action: 1. Request that the Veteran provide or authorize VA to obtain records of her relevant treatment that have not yet been associated with the claims file, and associate with the claims file any outstanding VA treatment records. 2. Return the file to the May 2016 VA examiner for an addendum opinion. If that examiner is unavailable, the opinion should be provided by another examiner. If a clinical evaluation is deemed necessary to answer the questions presented, one should be scheduled. The claims file, and a copy of the remand, must be reviewed by the examiner. A notation indicating that the claims file and remand was reviewed should be included in the examination report. Following review of the file, and the remand, the examiner is to address the following: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s obstructive sleep apnea had its onset during active service, or within one year of the Veteran's separation from active service, or is otherwise related to service? The examiner is asked to specifically discuss the Veteran’s contention that she has obstructive sleep apnea as a result of exposure to a SCUD missile attack, nerve gas, and burning oil fumes while deployed in Southwest Asia. All findings and conclusions should be supported with a complete rationale which reflects the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Smith-Jennings, Associate Counsel