Citation Nr: 1808634 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 14-10 646 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUE Entitlement to service connection for a gynecological disorder to include dysmenorrhea (claimed as endometriosis), uterine fibroids, adenomyosis, and ovarian cyst (hereinafter gynecological disorder). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran, and E.P., observer ATTORNEY FOR THE BOARD M. R. Woodarek, Associate Counsel INTRODUCTION The Veteran had active service with the Army from August 1987 to July 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 21012 rating decision from the Department of Veterans Affairs (VA) Regional Office in Des Moines, Iowa (RO), which denied entitlement to service connection for a gynecological disorder. The appeal was previously before the Board in October 2015 and was remanded for a videoconference hearing. The Veteran testified before the undersigned Veterans Law Judge in a December 2015 videoconference hearing. A copy of the hearing transcript has been associated with the record. Upon return to the Board, the claim was remanded in February 2016 for VA examination and opinion, which were obtained in April 2016 and October 2016. The appeal was again before the Board in September 2017 and was remanded for further record development, specifically to obtain medical treatment records. A negative search result for these records was associated with the record in October 2017. The Board finds that the RO substantially complied with prior remand directives and the claim is now properly before the Board for further appellate proceedings. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. The Veteran sought treatment for an ovarian cyst and pelvic pain while in service. 2. Currently diagnosed gynecological disorders, to include dyspareunia, status post hysterectomy for dysmenorrhea, are not etiologically related to service. CONCLUSION OF LAW The criteria for service connection for a gynecological disorder to include dysmenorrhea (claimed as endometriosis), uterine fibroids, adenomyosis, and ovarian cyst, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide veterans with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2017); see also Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO issued a December 2011 preadjudicatory notice letter to the Veteran which met the VCAA notice requirements in reference to the claim of service connection for a gynecological disorder. The Board is also satisfied that VA has made reasonable efforts to obtain relevant records and evidence in reference to the Veteran's claim on appeal. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017). The information and evidence that has been associated with the claims file includes service treatment records, military personnel records, VA treatment records, private medical opinions and treatment records, lay statements, online medical literature, VA examinations and a videoconference hearing transcript. The Veteran was afforded VA examinations and addendum opinions in January 2013, May 2012, October 2012, April 2016, and October 2016. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations to address the Veteran's claimed disability has been met. 38 C.F.R. § 3.159(c)(4) (2017). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2017). Service Connection Law and Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303(a) (2017). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The gynecological conditions of dysmenorrhea, uterine fibroids, adenomyosis, ovarian cyst, dyspareunia, and uterine fibroids are not "chronic diseases" listed under 38 C.F.R. § 3.309(a). Therefore, the provisions of 38 C.F.R. § 3.303(b) do not apply in the instant case. In rendering a decision on appeal, the Board must analyze the credibility and probative value of all medical and lay evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. 38 U.S.C. § 1154(a) (2012); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C. § 5107. A veteran is entitled to the benefit of the doubt when there is an approximate balance of evidence for and against the claim. See 38 C.F.R. § 3.102 (2016). When a veteran seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert, 1 Vet. App. 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran contends that her in-service treatment for an ovarian cyst and pelvic pain, with subsequent abdominal pain, led up to the need for a post-service total hysterectomy and additional gynecological disorders. Upon review of all the evidence of record, lay and medical, the Board finds that the Veteran's current gynecological disorders were not incurred in or caused by service. Service treatment records from September 1988 show the Veteran complained of pelvic pain. The clinician ruled out ectopic pregnancy but could not rule out pelvic inflammatory disease or ruptured ovarian cyst. In October 1988, the Veteran was diagnosed with unspecified ovarian cyst, and probable ruptured ovarian cyst. The Veteran also sought treatment in September 1989 for abdominal pain and tenderness, in which the physician noted the Veteran had a history of a ruptured ovarian cyst. Upon a gynecological examination the following day, the licensed practical nurse indicated possible appendicitis and doubted pelvic inflammatory disease. In an April 1990 separation examination report of medical history, the Veteran indicated she had a history of cysts, and reported that she was hospitalized in 1988 for an ovarian cyst, no sequelae. A May 1990 Medical Evaluation Board examination showed an unremarkable abdominal examination and a remarkable pelvic exam for a 10 week size uterus, which was otherwise unremarkable. Private treatment records from Great River Women's Health show the Veteran received gynecological treatment with Dr. G.W.C. from December 1997 to May 2009. During a February 1999 annual examination, Dr. G.W.C. noted that she had a previous abnormal pap smear. March 2000 and February 2001 annual exams show that the Veteran did not have a tender uterus. In an October 2001 note, the Veteran had complained of secondary dysmenorrhea, which was not responsive to over the counter ibuprofen, Motrin, or birth control pills. The Veteran was then scheduled for a laser ablation procedure for a separate condition. Dr. G.W.C. discussed treatment options with her, and she declined a hysterectomy at this point. In a March 2002 annual exam note, the Veteran indicated that she was having a problem with severe dysmenorrhea since having her laser ablation the previous fall. Upon examination, the private physician also noted a tender cervix and uterus. In May 2002, the Veteran presented for a follow up regarding her secondary dysmenorrhea, and indicated that she was missing two to three days of work each month due to the cramping. The Veteran was prescribed Percocet and decided to have a CIN III operative laparoscopy, which occurred in August 2002. In December 2002, the Veteran continued to have severe pain with her menses, with cramping all month long which worsened around menstruation, despite taking Percocet. A July 2004 annual exam shows that the Veteran was complaining of severe secondary dysmenorrhea which was not responding to medical management. The Veteran wished to proceed with a hysterectomy at this point. In August 2004, the Veteran had undergone a complete hysterectomy for severe secondary dysmenorrhea. In September 2004, the Veteran reported still experiencing some discomfort, which overall appeared to be somewhat improved. A recent CT scan also revealed cysts on both ovaries but were clearing based on ultrasound taken that day. April 2006 records show the Veteran had left lower quadrant pain with a history of abnormal pap smears prior to her hysterectomy. In October 2009, the Veteran continued to complain of left lower quadrant pain. The physician opined that the Veteran had an unremarkable pelvic ultrasound and no evidence of a gynecologic source for her discomfort, and opined that it may represent a gastrointestinal source, such as diverticulitis. In a January 2012 VA examination, the Veteran was diagnosed with ovarian cyst, abnormal PAP, cervical carcinoma in situ, dysmenorrhea, uterine fibroids and adenomyosis. In March 2012, upon review of the private medical records from Great River Women's Health and the Veteran's claims file, to include the January 2012 VA examination, the VA examiner, in an addendum opinion, opined that the diagnosed conditions were less likely than not incurred in or caused by service. The examiner indicated that the Veteran's private treatment records showed a gynecological condition, which led to a total hysterectomy in August 2004 were from dysmenorrhea, a uterine condition, and CIN III, a cervical condition. The August 2004 operative report indicated that the adnexa were normal, implying no endometriosis or adhesions. A surgical pathology summary showed the uterus with adenomyosis, koilcytic atypia, leiomyomata, and a benign paratubal cyst. Pelvic imaging and private treatment notes indicated physiological ovarian cysts, which occur normally with hormonal cycles, had resolved without treatment, with no indication that these contributed to the need for surgery. The VA examiner additionally stated that from August 1987 to July 1990, service treatment records showed that the Veteran was evaluated for right lower quadrant pain thought to be secondary to ovarian cysts. She indicated that there was no record within service treatment records of any cervical or uterine conditions being identified or suspected, as several pelvic examinations were marked as normal. In an August 2012 letter, Dr. G.W.C. reported he had performed a total abdominal hysterectomy on the Veteran in August 2004, and a summary pathology from that procedure demonstrated adenomyosis and fibroids, which are most likely the causes of the Veteran's pain. He stated that these are conditions which are not detectable by a pap smear and can only be diagnosed on a pathologic specimen from a hysterectomy. In a June 2012 letter, the Veteran's former spouse indicated that the Veteran had experiencing pelvic pain when they were dating in 1988, and she had been hospitalized three times while in service because of her pain. After service, she sought continuous medical treatment for pelvic pain, and eventually had a hysterectomy due to the incapacitating pain. In an October 2012 VA addendum opinion, the VA examiner opined that the Veteran's current gynecological diagnoses were less likely than not incurred in or caused by service. The VA examiner indicated that the Veteran's onset of dysmenorrhea was in 2001 per private treatment records, and that there was no evidence of any abnormal pap smears in service. The examiner further stated that the Veteran had a normal pelvic examination in 1988 after she recovered from the ovarian cyst, and a 1990 pelvic examination was also normal aside from a pregnant uterus. VA treatment records from May 2013 show the Veteran complained of dyspareunia that began a few months ago in the low left quadrant during intercourse. In December 2014 correspondence, the Veteran's previous representative argued that the Veteran's gynecological disorders should be service connection, as her entry examination did not show any gynecological problems, and her service treatment records showed evidence of an ovarian cyst in September 1989 with a hospitalization in September 1988 for abdominal pain. The representative argued that the etiology of the Veteran's abdominal pain was never determined during service. An August 2004 total hysterectomy showed endometrium, andenomyosis, slight cervical kolloytic atypia, and mild cervicitis. The representative contested the rationale supporting the March 2012 and October 2012 VA medical opinions regarding the medical evidence within the Veteran's service treatment records. She argued that there was evidence within the Veteran's service treatment records showing irregular pelvic examinations in service, as the Veteran's uterus and adnexa showed significant tenderness, and that the in-service medical provider did not rule out pelvic inflammatory disease, which is an infection of the reproductive organs, including the uterus. Further, the representative contended that, per the August 2012 private physician letter, the Veteran's current diagnoses were not detectable by pap smear but only by hysterectomy, as conducted in August 2004, and therefore, these conditions would not have been detected by any of the testing done in service. In December 2015, the Veteran submitted an internet article from the Mayo Clinic providing definitions and symptoms of adenomyosis and uterine fibroids. The article indicates that adenomyosis may cause dysmenorrhea, with symptoms often starting late in the childbearing years after having children. The cause of adenomyosis remains unknown, and women who experience severe discomfort from adenomyosis may opt for hysterectomy as the only cure. The materials also discuss uterine fibroids, which also present as pelvic pressure or pain. In December 2015, the Veteran testified in a videoconference hearing that she experienced a lot of heavy bleeding and severe, painful cramping while in service where she was diagnosed with probable ovarian cyst. She testified that she had a lot of heavy clotting during her cycle, which went on for very long periods of time. She characterized her pain as debilitating which would cause her to miss work and she would seek treatment. The physician examining her in service indicated that her uterus was abnormal but she did not have abnormal pap smears. She argued, however, that her private gynecologist, Dr. G.W.C., indicated that her current gynecological issues were not detectable by pap smear, so she continued to experience these symptoms after getting out of the military. Eventually, she had a total hysterectomy because her symptoms were not reacting to medication. The results of her hysterectomy showed that she had adenomyosis, which she indicated could only be diagnosed after undergoing this procedure. In April 2016, the Veteran was afforded a VA examination, where she was diagnosed with dyspareunia, status post hysterectomy for dysmenorrhea, abdominal and pelvic pain symptoms with reported bladder infections, with a history of abnormal pap smears and cervical carcinoma in situ (cis), fibroids and adenomyoisis. The VA physician listed pertinent medical history from the Veteran's claims file and discussed the Veteran's current conditions and their impact on her work. The examiner indicated that dyspareunia was onset in 2013 per private treatment notes, and that she was currently experiencing hard cramping located low in the pelvic area, which would start during every time she had intercourse and last for about 20 minutes after intercourse. The Veteran reported that when she had a hysterectomy, the doctor found adenomyosis, uterine fibroids, and endometriosis. The pain prior to having the hysterectomy was debilitating, but afterwards, she went for a while that she was feeling pretty good, but eventually had some pelvic pain that developed, which was mild and intermittent. The Veteran also started having bladder infections after the hysterectomy. She currently experienced moderate bilateral lower pelvic pain daily for which she takes ibuprofen, which is aggravated with bladder infections and intercourse to severe pain. During the April 2016 VA examination, the Veteran reported that she was working as an office manager for Aspen Dental. She indicated that if she is in a lot of pain, she can't think or focus, which could create a liability for her employer. She stated that she has to be sharp for her job, and get up and move around the office, and her pain impairs her in doing this. Upon review of the Veteran's claims file and examination of the Veteran, the VA examiner opined that it is less likely than not that the current pelvic pain is related to the presumed ovarian cyst and abdominal pain reported in service. She noted that these conditions were not noted to be chronic and ongoing in service, and that the abdominal and pelvic pain symptoms in service appeared to have resolved per the April 1990 separation examination, which stated the 1988 ovarian cyst with no sequelae. The VA examiner indicated that the gynecological conditions, that were not caused by ovarian cysts, which occurred after military service account for her intermittent gynecological issues. The dyspareunia and intermittent abdominal and pelvic pain reported with bladder infections account for the Veteran's pelvic pain. She opined that neither of these conditions were a result of a prior ovarian cyst, which may cause pain and require treatment at the time but without long term symptoms. Dyspareunia has numerous causes but a ruptured ovarian cyst from the 1980s is less likely than not the cause of the dyspareunia that developed in 2008 per the 2013 private treatment note. The VA examiner acknowledged the August 2012 letter from Dr. G.W.C. but indicated that a ruptured ovarian cyst in general is a short lasting condition which does not cause adenomyosis, uterine fibroids, cervical cancer or abnormal pre-cancerous pap smears. Therefore, the examiner opined that it is less likely than not that the uterine fibroids or adenomyoisis were incurred in service. There was no evidence of dysfunctional uterine bleeding, dysmenorrhea, or chronic pelvic pain in service. Additionally, the examiner noted that Dr. G.W.C., in private treatment notes, attributed the Veteran's dysmenorrhea to a 2001 laser ablation and two ovarian cysts present after the 2004 hysterectomy. Lastly, the VA examiner opined that it was less likely than not that the cervical cis was incurred in or result of military service because it was not detected while in service nor was it detected within a year after service separation. In November 2016, the Veteran's former representative submitted additional arguments on the Veteran's behalf. The representative argued that the April 2016 VA examiner relied heavily on the fact that the Veteran did not have heavy bleeding in service, but within the December 2015 videoconference hearing, the Veteran testified that she did have heavy bleeding and severe cramping during menstrual periods in-service. The representative also took issue with the April 2016 VA examiner's reliance on the Veteran's lack of "chronic" pelvic pain in service, arguing that "chronic" pelvic pain was not a symptom of adenomyosis or fibroids, but rather that severe cramping or sharp pelvic pain during menstruation was a symptom. The representative argued that in-service records never definitively diagnosed the Veteran with a ruptured cyst, and that the VA examiner erred in opining that the hysterectomy was not caused by an in-service ovarian cyst. She contended that the examiner ignored the issue of whether the Veteran's in-service pelvic pain was caused by adenomyosis and fibroids. The representative concluded that the Veteran's subsequent history of ongoing episodic pain very similar to that which she had in service was at least as likely as not the cause for the Veteran's hysterectomy. In an October 2016 VA addendum opinion, the VA physician opined that the claimed gynecological disorder was less likely than not incurred in or caused by service. The examiner reasoned that service treatment records show the veteran was evaluated for a probably ruptured ovarian cyst in 1988, to which a follow up examination was normal with a normal pelvic examination. The diagnosis of dysmenorrhea, uterine fibroids and adenomyosis was made more than one year after service separation, and a ruptured ovarian cyst is an acute temporary condition which does not cause the above gynecological conditions. Upon review of the record, the Board finds that a currently diagnosed gynecological disorder was not incurred in service, and is not related to an ovarian cyst or pelvic pain shown in service. VA examinations and opinions of record from May 2012, October 2012, April 2016 and October 2016 indicate that the Veteran's current gynecological diagnoses are not related to service or in-service treatment for an ovarian cyst or pelvic pain. A March 2012 VA examination shows, upon review of private treatment records and the Veteran's claims file, that the currently diagnosed gynecological conditions were not incurred in or caused by service. The March 2012 VA examiner indicated that private treatment records showed the gynecological condition, which led to a total hysterectomy in August 2004, were from dysmenorrhea, a uterine condition, and CIN III, a cervical condition, which were not conditions reported within service treatment records. The examiner further opined that the in-service ovarian cyst had resolved without treatment, and that her reported lower quadrant pain in service was secondary to the ovarian cyst. An October 2012 VA examiner, who opined that the Veteran's gynecological conditions were less likely than not incurred in or caused by service, cited that the Veteran had a normal pelvic examination in 1988, after she recovered from the ovarian cyst, and a 1990 pelvic examination was also normal aside from a pregnant uterus. While the record includes an August 2012 letter from Dr. G.W.C., the Veteran's private gynecologist, which states that a summary pathology from the August 2004 total abdominal hysterectomy showed adenomyosis and fibroids, which were most likely the causes of the Veteran's pain and not diagnosable by pap smear, the Board finds probative the April 2016 VA examination, in which the VA examiner acknowledged the August 2012 letter, but indicated that a ruptured ovarian cyst was a short lasting condition that does not cause adenomyosis, uterine fibroids, dyspareunia, cervical cancer or abnormal pre-cancerous pap smears, all of which were gynecological conditions that occurred after military service and accounted for her intermittent gynecological issues. The April 2016 examiner indicated that the abdominal and pelvic pain symptoms in service appeared to have resolved per an April 1990 separation examination, which noted "1988 ovarian cyst no sequelae." Additionally, service treatment records did not show treatment for dysfunctional uterine bleeding, dysmenorrhea or chronic pelvic pain in service. Additionally, the April 2016 VA examiner, along with the March 2012 VA examiner, both indicated that the Veteran's private gynecologist had associated her post-service dysmenorrhea to a laser ablation procedure in 2001 and to adenomyosis, koilcytic atypia, leiomyomata and a benign paratubal cyst of the uterus upon a total hysterectomy in 2004. While the Veteran submitted online medical literature discussing the symptoms and definitions of adenomyosis and uterine fibroids, the Board finds that generic texts, such as the one offered, which does not address the facts of this particular Veteran's case with a sufficient degree of medical certainty, does not amount to competent medical evidence of causality. See Sacks v. West, 11 Vet. App. 314 (1998); Beausoleil v. Brown, 8 Vet. App. 459 (1996). Therefore, the Board finds that the online medical literature offered by the Veteran does not amount to probative evidence of a nexus between the Veteran's current gynecological disorders and service. The only other evidence of record that tends to relate the Veteran's current gynecological disorders to service are the testimony and arguments advanced by the Veteran, her former spouse, and her former representative. These lay statements do not establish the required nexus between any acquired pathology and her military service. Although lay evidence is acceptable to prove the occurrence of an injury during active duty or symptomatology over a period of time when such symptomatology is within the purview of or may be readily recognized by lay persons, lay testimony is not competent to prove a matter requiring medical expertise, such as a medical nexus opinion. Layno v. Brown, 6 Vet. App. 465, 469 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Veteran's former representative contested the opinions and rationale provided within the March 2012, May 2012 and April 2016 VA examinations and opinions of record by disagreeing with the VA examiners' characterization of the medical evidence of record. The Board, however, finds that the medical opinions provided were adequate and were based on a thorough and complete examination of record and an accurate factual premise consistent with the Board's own findings. In that regard, the March 2012, May 2012 and April 2016 VA examiners accurately cited and thoroughly reported findings from service treatment records and post-service treatment records in providing their opinions. Insomuch that the Veteran's former representative argued that the April 2016 VA examiner did not consider the Veteran's December 2015 videoconference hearing testimony, the Board has found that the Veteran's testimony alone is not enough to establish a medical nexus opinion. Layno, 6 Vet. App. at 469; Jandreau, 492 F.3d at 1377. Further, it is noted that the Veteran was requested to provide her medical history by the examiner at each examination. The Board finds that the March 2012 VA opinion provides further support for the April 2016 VA examination findings, and these opinions show that the Veteran's diagnosed gynecological disorders are less likely than not related to service. The Board finds that the evidence of record does not otherwise tend to establish a nexus between the Veteran's currently diagnosed gynecological disorders and service. Therefore, the Board finds that the weight of the evidence is against a finding of service connection for a gynecological disorder. Because a preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017). ORDER Service connection for a gynecological disorder to include dysmenorrhea (claimed as endometriosis), uterine fibroids, adenomyosis, and ovarian cyst is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs