Citation Nr: 20005629 Decision Date: 01/23/20 Archive Date: 01/23/20 DOCKET NO. 18-37 479 DATE: January 23, 2020 ORDER Entitlement to service connection for anemia with syncope and fatigue syndrome is denied. Entitlement to service connection for uterine fibroids (claimed as menstrual disorder syndrome) is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s anemia with syncope and fatigue syndrome began during her active military service or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that the Veteran’s uterine fibroids began during her active military service or are otherwise related to an in-service injury or disease.   CONCLUSIONS OF LAW 1. The criteria are not met for entitlement to service connection for anemia with syncope and fatigue syndrome. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 2. The criteria are not met for entitlement to service connection for uterine fibroids, claimed as menstrual disorder syndrome. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the Army from November 1989 to January 1992, including in Southwest Asia. This appeal originates from a May 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded these claims in July 2019 for further development. Also, in July 2019, the Board remanded an additional claim of entitlement to service connection for dermatitis, but this claim since has been granted. If the Veteran disagrees with the initial rating and/or effective date assigned for this disability, she must separately appeal these “downstream” issues. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Service Connection Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or an injury; and (3) a causal relationship between the current disability and the disease or injury in service. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 1. Entitlement to service connection for anemia with syncope and fatigue syndrome is denied. The Veteran contends that her anemia, which she has been intermittently diagnosed with during the pendency of this appeal, is the result of environmental exposures she experienced during her service in Southwest Asia. However, the Board concludes that, while she has a current anemia diagnosis, the preponderance of the evidence is against finding that it is the result of an injury, event, or disease during her military service – including in Southwest Asia. Certain chronic diseases will be presumed related to service if they were shown as chronic (reliably diagnosed) in service or if they manifested to a compensable degree within a presumptive period following separation from service or if they were noted in service with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015). Here, the Veteran was noted as having menorrhagia on her entrance examination, but no anemia. She began serving on active duty in November 1989. According to her service treatment records (STRs), she was later diagnosed with anemia during her service in June 1991. She was again found to have anemia in October 1991. Her separation examination in January 1992 noted an abnormal complete blood count (“abnormal CBC”); however, a follow-up blood test (CBC) ultimately determined she was not anemic at that time. Her military service ended in January 1992. In 2019 a VA examiner indicated that menorrhagia is a common cause of anemia and that, given the Veteran’s medical history, is the likely cause of her periodic anemia.   As particularly relevant to this case at hand, every Veteran is presumed to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Only such conditions as are recorded in examination reports are to be considered as "noted" for the purpose of this analysis. 38 C.F.R. § 3.304(b). See Quirin v. Shinseki, 22 Vet. App. 390, 394, 396 (2009). Consequently, while anemia is on the list of diseases that may be presumed to be related to service, if the condition was noted in service and shown as chronic, because the Veteran’s anemia is associated with a condition (menorrhagia) that clearly and unmistakably pre-existed her service (in that it was clearly “noted” during her military entrance examination), the chronic disease presumption and presumption of soundness are inapplicable in this case. The 2019 VA examiner explained that commonly accepted medical literature indicates iron deficiency anemia has a clear and specific etiology (in this case the Veteran’s menorrhagia). And in this circumstance, 38 U.S.C. § 1153 applies and the burden falls on her, not VA, to establish aggravation of this pre-existing disability by her service. Smith v. Shinseki, 24 Vet. App. 40, 47-48 (2010), citing Wagner, v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004; Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). A preexisting injury or disease will be considered to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. Independent medical evidence generally is needed to support a finding that a pre-existing disorder increased in severity during service beyond its natural progression. See Paulson v. Brown, 7 Vet. App. 466, 470-471 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1994). But the presumption of aggravation applies where there was a worsening of the disability in service, regardless of whether the degree of worsening was enough to warrant compensation. Browder v. Derwinski, 1 Vet. App. 204, 206-207 (1991).   Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b); Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Temporary or intermittent flare-ups during service of a preexisting injury or disease are insufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The 2019 VA examiner concluded that the Veteran’s pre-existing condition was not aggravated by her service, particularly given that she was not found to have anemia during her military discharge (exit) examination. With regards to the Veteran’s contentions that her disability is related to her environmental exposures, for Veterans who served in the Southwest Asia theater of operations during the Persian Gulf War, service connection may be established for chronic disability that cannot be attributed to a known clinical diagnosis (undiagnosed illness) or medically unexplained chronic multi-symptom illness (MUCMI) (e.g., chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome (IBS)). See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Among the requirements for service connection for a disability due to undiagnosed illness of a Veteran who served in the Southwest Asia theater of operations during the Persian Gulf War are that there are objective indications of a qualifying chronic disability, which means a chronic disability resulting from an undiagnosed illness, MUCMI defined by a cluster of signs or symptoms (i.e., chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, or any other illness specified by the Secretary), or any diagnosed illness specified by the Secretary. 38 U.S.C. § 1117; 38 C.F.R. § 3.317.   Signs or symptoms which may be manifestations of undiagnosed illness or MUCMI include, but are not limited to fatigue, signs and symptoms involving the skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs and symptoms involving the respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. The illness must become 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, under the appropriate diagnostic code of 38 C.F.R. Part 4, not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Further, by history, physical examination, and laboratory tests, the disability cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. There must be objective signs that are perceptible to an examining physician and other non-medical indicators that are capable of independent verification and a minimum of a six-month period of chronicity. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. There must be no affirmative evidence that relates the undiagnosed illness to a cause other than being in the Southwest Asia theater of operations during the Persian Gulf War. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. If signs or symptoms have been medically attributed to a diagnosed rather than undiagnosed illness, the Persian Gulf War presumption of service connection does not apply. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Here, while the Board acknowledges the Veteran’s contentions, the record indicates her symptoms of fatigue and syncope are associated with her clinically diagnosed anemia, which in turn has been attributed to her menorrhagia that as explained clearly and unmistakably predated her service and was not aggravated by her service. While the Veteran believes her anemia is related to her service, or was aggravated by it, the preponderance of the evidence weighs against finding a link between her service and her history of anemia, primarily because it is associated with a condition (menorrhagia) that preexisted her military service since noted on her entrance examination and because it was not aggravated by her service. Consequently, the preponderance of the evidence is against the Veteran’s claim for service connection for her anemia and for her symptoms of fatigue and syncope. In denying the claim, the Board finds the benefit-of-the-doubt doctrine inapplicable since there is not the required relative balance of evidence for versus against the claim. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to service connection for uterine fibroids (claimed as menstrual disorder syndrome) is denied. The Veteran also contends that her uterine fibroids are related to her service, to include the environmental exposures she experienced during her service in Southwest Asia (SWA). But, again, the Board concludes that, although she has the required diagnosis of uterine fibroids, the preponderance of the evidence is against finding that they incepted or onset during her time in service or are otherwise related to an in-service injury, event, or disease – including the environmental exposures in SWA. According to her treatment records, the Veteran was not diagnosed with uterine fibroids until June 2006—14 years after her separation from active duty. Moreover, during an October 2019 VA examination, an examiner clarified that the pathophysiology (physiological processes that cause a specific disease or injury) of uterine fibroids include a genetic predisposition, steroid hormone concentrations and lifestyle choices associated with smoking, alcohol use, and red meat consumption. Also, to specifically address the Veteran’s contentions regarding her SWA environmental exposures, this examiner additionally explained that current medical research has not established any relationship between uterine fibroids and SWA environmental exposures. This VA examiner further indicated that the Veteran’s SWA environmental exposures also did not aggravate her uterine fibroids, again, primarily because current medical literature and research “has not established causality/aggravation” for fibroids due to potential SWA environmental exposures. In addition, as discussed in the previous section, because uterine fibroids have a known clinical diagnosis, they are not considered a chronic disability that cannot be attributed to a known clinical diagnosis (undiagnosed illness) or a MUCMI of the type contemplated by 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. While the Veteran believes her uterine fibroids are the result of her service—specifically, her environmental exposures in SWA, the Board reiterates that the preponderance of the evidence weighs against finding that there is a link between her current disability and her service. In this circumstance there is no reasonable doubt concerning this to be resolved in her favor, in turn meaning her claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C.B. Kucera The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.