Citation Nr: 20036493 Decision Date: 05/28/20 Archive Date: 05/28/20 DOCKET NO. 15-42 948 DATE: May 28, 2020 ORDER Service connection for hypothyroidism is denied. FINDING OF FACT The Veteran’s currently diagnosed hypothyroidism did not have its onset and is not otherwise related to active service, including claimed symptoms experienced therein. CONCLUSION OF LAW The criteria for service connection for hypothyroidism are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1973 to October 1993. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from a June 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). By way of procedural background, this matter was previously before the Board in September 2018. The Board remanded the service connection claim for hypothyroidism for a VA examination and medical etiology opinion. The September 2018 remand directives have been substantially completed, and the claim has now been returned to the Board for further appellate consideration. Of note, after the Board remanded the claim but before the RO had issued a supplemental statement of the case (SSOC), the Veteran attempted to withdraw her claim from the Legacy appeal system and elect to proceed under the modernized review system, also known as AMA. However, the Veteran’s election was premature, and she did not submit a timely election after the issuance of the most recent SSOC. Thus, the Board has considered and reviewed her claim under the legacy appellate system. All the evidence in her claims file up to the present date has been considered in this decision. The Veteran waived a hearing before the Board in her November 2015 substantive appeal, via a VA Form 9. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service connection for hypothyroidism 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, 1131; 38 C.F.R. § 3.303(a). 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). Chronic diseases listed under 38 C.F.R. § 3.309(a) are entitled to the presumptive service connection provisions of 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331 Fed. Cir. 2013). Hypothyroidism is not included in the list of chronic diseases listed in 38 C.F.R. § 3.309(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the 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. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran contends that, despite not being diagnosed with hypothyroidism until after discharge from service, her in-service symptoms of depression, stress, weight gain, hair loss, electrolyte imbalance, high blood sugar levels, and constant diarrhea were symptoms of hypothyroidism. See September 2006 statement, October 2006 VA treatment records, June 2012 notice of disagreement, August 2012 letter, January 2014 statement, and November 2015 VA Form 9. As an initial matter, the Veteran has been currently diagnosed with hypothyroidism. See October 2019 VA examination. Service treatment records are negative for any diagnosis of thyroid conditions during service. The Veteran was treated twice in-service for hair loss. See December 1984 and September 1992 service treatment records. Thyroid function testing was conducted, and the results were within normal limits. See December 1984 and September 1992 laboratory testing results. The Veteran has reported that she was first diagnosed with hypothyroidism in 1995. See October 2019 VA examination. The earliest notation in the record of a hypothyroidism diagnosis was in June 1998 private treatment records. Further, VA and private treatment records after June 1998 show consistent treatment for hypothyroidism. However, neither VA nor private treatment records report that any physician has attributed the Veteran’s hypothyroidism to service. In March and May 2019 statements, Dr. D.L.H., the Veteran’s husband, submitted statements in support of her claim. Dr. D.L.H. noted the Veteran was diagnosed with hypothyroidism one to two years after she retired from service, and in his opinion, her hypothyroidism began during service. Of note, the Veteran’s husband holds a Doctor of Divinity and is not a medical clinician. In addition, the Veteran submitted multiple medical journal articles, internet articles, and 44 pages from a book entitled, “The Thyroid Solution” in March and June 2019. Generally, the articles and the book excerpts detail psychiatric symptoms that are associated with hypothyroidism, such as depression and anxiety. However, at least one article also noted “the mechanism underlying the interaction between thyroid function and depression remains to be further clarified” and “a causal relationship between [thyroid dysfunction and depression] cannot be established yet.” The Link Between Thyroid Function and Depression, Journal of Thyroid Research, December 2011. A fellow service-member, P.J., submitted a May 2019 statement attesting that the Veteran experienced hair loss and weight gain between 1984 to 1992, and they joined a weight loss program together during service. The Veteran’s twin brother also submitted a June 2019 statement indicating the Veteran had symptoms of migraines, depression, and weight gain beginning in service after a tour of duty in Germany. The Veteran submitted a copy of a May 2019 e-mail correspondence with Dr. K.D., a private physician. Dr. K.D. indicated that she no longer had the credentials to provide an etiology opinion as requested by the Veteran, but Dr. K.D. enclosed several medical articles and website links regarding thyroid disorders. She also noted that there was an article entitled, “Thyroid disorders are common for Veterans of the Military.” However, this article is not of record. Regardless, the Court has held that "generally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive." Mattern v. West, 12 Vet. App. 222, 228 (1999) (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)). Medical treatise evidence may indicate enough of a basis of a generic relationship to establish "a plausible causality based on objective facts." Mattern, 12 Vet. App. at 228 (citing Wallin v. West, 11 Vet. App. 509, 514 (1998)). Dr. K.D. did not provide an etiology opinion. The Veteran submitted a June 2019 letter from Dr. S.H., her private primary care physician. The letter stated that he treats her for hypothyroidism. However, Dr. S.H. did not provide an etiology opinion. The Veteran was afforded a VA examination in October 2019. The Veteran asserted that she was diagnosed with hypothyroidism shortly after discharge from service by laboratory findings with symptoms during service of weight changes, depression, and hair loss. The examiner reviewed the Veteran’s medical records and the multiple medical journal articles, internet articles, book excerpts, and lay statements submitted by the Veteran. Service treatment records confirmed that she was treated for hair loss in service in 1984 and again in 1992. Both evaluations in service included laboratory testing for thyroid function, which was within normal limits. In September 1992, TFTs were normal with a recommendation to confirm by laboratory testing after a few months. No additional reports of hair loss were indicated, and no follow up laboratory testing was conducted. Service treatment records did not contain a diagnosis of hypothyroidism during service. The examiner noted that post-service treatment records, and the Veteran, report that she was diagnosed with hypothyroidism after discharge from service in 1995. The examiner noted that the December 1984 T4 was 8.09 (normal range is between 4.5-12) and T3 was 1.10 (normal range is between 0.72 to 1.24). September 1992 laboratory testing showed TSH of 3.00 (normal range is 0.15 to 3.25) and T4 of 6.7 (normal range of 4.5 to 12). The examiner referenced “Up to Date,” an electronic medical resource, which indicated a diagnosis of hypothyroidism is based on laboratory testing because of the general type of typical clinical manifestations of hypothyroidism. For instance, the examiner indicated that absent abnormal thyroid testing results, her non-specific symptoms experienced in service, such as hair loss, weight changes, and psychiatric symptoms could be attributed to the service-connected depressive disorder. The examiner indicated that primary hypothyroidism is characterized by a high serum thyroid-stimulating hormone (TSH) concentration and a low serum free thyroxine (T4) concentration. Subclinical hypothyroidism is defined as normal free T4 concentration and elevated TSH concentration. Because the Veteran’s laboratory testing for thyroid function was normal in service and due to the lack of specificity of the clinical manifestations of thyroid symptoms, the examiner determined it was less likely than not that the Veteran’s currently diagnosed hypothyroidism had its onset during or was otherwise related to service. After a review of the evidence, both lay and medical, there is no competent evidence of record that links the Veteran’s hypothyroidism to service. The Board has considered the Veteran’s statements, as well as the statements of her family members and fellow service-member, relating the currently diagnosed hypothyroidism to service. Nevertheless, as a lay person, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorder, such as hypothyroidism. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The etiology of hypothyroidism is a complex medical question involving internal system processes which are unobservable by the Veteran through her senses. The Board also notes that the Veteran’s spouse, friends, and family members have also provided positive nexus statements relating the hypothyroidism to service. However, there is no indication that her family or friends are medical clinicians or have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion. In addition, as noted above, her husband holds a Doctor of Divinity and is not shown to be a medical clinician. The Board has reviewed the multiple internet articles, medical journal articles, and book excerpts discussing hypothyroidism and its associated psychiatric symptoms. However, these articles fail to provide an etiological opinion as to this Veteran’s hypothyroidism, after considering the specific facts, medical evidence, and lay evidence in this specific case. See 38 C.F.R. § 3.102; Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); see also Obert v. Brown, 5 Vet. App. 30, 33 (1993). In addition, these articles do not provide a causal link between thyroid dysfunction and psychiatric symptoms. Finally, the Board also notes that there is no positive etiology opinion of record. For these reasons, the Board finds that the weight of the evidence demonstrates that the Veteran’s currently diagnosed hypothyroidism is not related to service. Further, no medical professional, VA or private, has attributed the currently diagnosed hypothyroidism to an in-service injury, event, or disease. As discussed above, the Board has given consideration to the Veteran’s contention that the disabilities are related to service; however, the Veteran is a lay person and, while competent to discuss observable symptoms, does not have the requisite medical training or credentials to be able to render a competent opinion as to a thyroid disorder etiology. (Continued on the next page)   For the above stated reasons, the preponderance of the evidence is against service connection for hypothyroidism, and the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Finally, the Board notes that neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Harper, Associate Counsel 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.