Citation Nr: 18107521 Decision Date: 06/04/18 Archive Date: 06/02/18 DOCKET NO. 14-18 181 DATE: June 4, 2018 ORDER Entitlement to service connection for a partial hysterectomy, to include as due to a service-connected post-operative corpus luteum cyst, is denied. FINDING OF FACT The probative evidence is against a finding that the Veteran’s partial hysterectomy was caused or aggravated by her military service or a service-connected disability. CONCLUSION OF LAW The criteria for entitlement to service connection for a partial hysterectomy have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1974 to July 1978, and from October 1980 to August 1996. This matter comes before the Board of Veterans’ Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in December 2016. A transcript of the hearing is of record. Neither the Veteran nor her representative has raised any issues with the duty to notify or duty to assist other than suggesting that a February 2018 medical opinion is inadequate, which is addressed below. 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 a duty to assist argument). Service connection will be granted on a direct basis if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1110; 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 on a secondary basis will be awarded for a disability that is proximately due to, the result of, or permanently aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Additionally, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Further, it is the Board’s responsibility to evaluate the entire record on appeal. 38 U.S.C. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran seeks service connection for a post-service hysterectomy, to include as secondary to service-connected post-operative corpus luteum cyst. Specifically, she claims that a 2006 hysterectomy was the result of her in-service gynecological conditions and treatment, including menorrhagia and long-term treatment with birth-control medication, pregnancies with breakthrough bleeding, an April 1981 burst corpus luteum cyst with a resulting terminated pregnancy, a 1982 tubal ligation, and a purported history of in-service fibroids. By way of history, the Veteran reports menorrhagia beginning with the birth of her second child in April 1976 (where she experienced breakthrough bleeding) and that she was prescribed oral contraceptive pills as treatment. In April 1981, the Veteran underwent an exploratory laparotomy for a suspected ectopic pregnancy which resulted in a diagnosed corpus luteum cyst which ruptured during the procedure, and a subsequent miscarriage. The Veteran gave birth to another child in February 1982 where she experienced breakthrough bleeding again and underwent an elected bilateral tubal ligation. She continued having breakthrough bleeding and menorrhagia with pain and cramping, and was again treated with oral contraceptives to control her symptoms. The Veteran reports that this treatment continued until a 2006 hysterectomy secondary to a stage II uterine prolapse with traction cystocele. The Board notes that service treatment records do confirm a history of prescribed oral contraception – even after her tubal ligation – as well as of pain medication such as Motrin and Sudafed. A physical examination in October 1978, after her first period of active duty, noted a history of urinary tract infections and a tilted uterus during pregnancy. Upon separation from service in August 1996, a physical examination indicated normal pelvic examination and Pap smear. Prior to the Veteran’s 2006 hysterectomy, she was also treated for urinary stress incontinence, and underwent a suction lipectomy of the abdomen and hips. As to her asserted in-service fibroids, the only evidence of fibroids in service was a statement from the Veteran during an in-service examination in June 1993 during treatment for additional light bleeding (spotting). An actual diagnosis of fibroids was not provided until the time of her 2006 hysterectomy. The Veteran was afforded a VA examination in June 2009. However, the examiner was unable to provide an opinion as to whether the Veteran’s hysterectomy was due to her gynecological treatment during active duty without resorting to mere speculation. Additionally, in a May 2014 letter, a United States Air Force physician stated that the Veteran’s history of heavy menstrual bleeding treated with oral contraception, along with other associated conditions, led to her hysterectomy but provided no rationale for this conclusion. As such, the Board sought a medical opinion from a VA gynecological specialist to clarify whether the Veteran’s 2006 hysterectomy was related to service or, in the alternative, was caused or aggravated by her now service-connected post-operative corpus luteum cyst. The specialist’s opinion was provided in February 2018 by Dr. H.M., a VA gynecological specialist. After review of the Veteran’s medical records, the Dr. H.M. opined that her hysterectomy for uterine prolapse with traction cystocele was not the result of her in-service gynecological conditions and treatment. In support of her opinion, Dr. H.M. reviewed the Veteran’s medical history and noted several observations. First, the examiner noted that the Veteran had no complaints of bulge symptoms (indicating uterine prolapse) throughout her active duty service. As to her asserted in-service treatment for dysmenorrhea (cramps), Dr. H.M. noted that while she received a prescription for Motrin through most of her active duty period, the reasons for that prescription varied, with only one service treatment record noting the Veteran needing a “refill of Motrin for cramping” in February 1989. In addition, the preadmission history and physical examination obtained just prior to her hysterectomy notes that the Veteran denied dysmenorrhea, dyspareunia, and menorrhagia at that time. Regardless, Dr. H.M. stated that her treatment for dysmenorrhea during her active service would not increase her risk of a hysterectomy. Regarding the relationship between the Veteran’s in-service use of oral contraceptives and her uterine prolapse and subsequent partial hysterectomy, Dr. H.M. noted that the treatment of a patient with oral contraceptives for either contraception or, as in the Veteran’s case, menstrual irregularity has not been associated with any causative correlation with a later hysterectomy. Of note, Dr. H.M. also stated that, in fact, the risk of endometrial disease is decreased by up to 80 percent, lifelong, in patients who are administered combined hormonal contraceptives for five or more years in their lifetime. Dr. H.M.’s observations also weigh against a finding that the Veteran’s purported in-service fibroids may have led to her post-service hysterectomy, as her medical records prior to her 2006 hysterectomy note only one specific mention of fibroids in June 1993 which, the Board notes, does not contain an actual diagnosis of fibroids but rather the Veteran’s statement that “somebody told her that she had fibroids of the uterus” a number of years prior. Dr. H.M. noted that fibroids can certainly cause irregular and heavy vaginal bleeding, spotting in pregnancy, and dysmenorrhea, all of which the Veteran has complained of at one time or another during her active duty. As such, she opined it was more likely than not that the Veteran’s heavy bleeding prior to her 2006 hysterectomy was due to fibroids. Dr. H.M. continued, however, that the reasons stated for her hysterectomy were stage II uterine prolapse and traction cystocele, not fibroids. Although the Veteran has asserted an in-service history of fibroids, Dr. H.M. noted that there was unfortunately no diagnosis of uterine fibroids in the Veteran’s active duty medical records, as every in-service uterine examination was noted as normal. Finally, as to the Veteran’s secondary-service connection theory of entitlement, i.e., whether her service-connected post-operative corpus luteum cyst caused or permanently aggravated a condition leading to her hysterectomy, Dr. H.M. also provided a negative opinion, explaining that a corpus luteum cyst is the natural result of ovulation. She noted that an ovarian corpus luteum cyst is created every month, persisting for roughly a week, in a patient who is menstruating regularly and is not pregnant. In a patient who is pregnant, the corpus luteum takes on the specific role of producing progesterone throughout the majority of the first trimester, and is therefore present for several weeks. It would therefore have been abnormal for a corpus luteum to have been absent at the time of the Veteran’s 1981 first trimester laparoscopy, and after miscarriage the corpus luteum resolves spontaneously. Dr. H.M. therefore opined that the postoperative corpus luteum cyst was not related to her hysterectomy that occurred 25 years later. Based on the foregoing, the Board finds the most probative evidence is against the Veteran’s service connection claim on either a direct or secondary basis. The Board acknowledges the Veteran worked as a pharmacy craftsman in service and that she believes her partial hysterectomy was caused or aggravated by her military service or a service-connected disability. However, the Board finds that her statements are outweighed by the other medical evidence against the claim – particularly the February 2018 opinion rendered by the VA gynecological specialist. To the extent there are medical opinions in the record in support of the Veteran’s claim, the Board finds the February 2018 VA specialist’s opinion to be of higher probative value. Greater weight may be placed on one physician’s opinion than another’s depending on factors such as reasoning employed by the physicians and whether or not (and the extent to which) they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). The United States Court of Appeals for Veteran’s Claims (Court) has held that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez, 22 Vet. App. at 295; 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 opinions.”). Here, where the Veteran’s USAF physician provided no rationale for his opinion, the February 2018 opinion of Dr. H.M. considered the Veteran’s relevant medical history and provided a thorough analysis to support his opinions concerning the etiology of the Veteran’s partial hysterectomy. The Board therefore finds the VA gynecological specialist’s opinion to be the most probative medical evidence of record. The Board also acknowledges the Veteran’s argument that Dr. H.M. erroneously rejected her lay assertions that she had uterine fibroids in service, and instead blindly endorsed the findings of the in-service medical examiners that noted the Veteran’s uterus to be normal. In Dalton v. Nicholson, 21, Vet. App. 23 (2007), the Court held that an examination was inadequate where the examiner did not comment on the Veteran’s report of in-service injury, but relied instead on the service treatment records to provide a negative opinion. However, the Board notes that the probative value of a medical opinion depends on the medical expert’s personal examination of the patient, his/her knowledge and skill in analyzing the data, and his/her medical conclusion. Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the Board’s adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims folder and the thoroughness and detail of the opinion. See Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, Dr. H.M.’s opinion was based on a review of the Veteran’s record and is accompanied by a lengthy analysis and sufficient explanation based on sound medical principles. Moreover, nothing in the record other than the Veteran’s own assertions suggests that the Veteran’s in-service examinations were inadequate, nor is a VA examiner required to make such a determination in considering such evidence. For these reasons, the Board finds Dr. H.M.’s opinion dispositive of the direct service connection nexus question presented in this case. In summary, as the preponderance of the evidence is against a finding that the Veteran’s partial hysterectomy was caused or aggravated by her military service or a service-connected disability, the claim for service connection must denied. In reaching this determination, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Scarduzio, Associate Counsel