Citation Nr: 20049930 Decision Date: 07/27/20 Archive Date: 07/27/20 DOCKET NO. 14-35 234A DATE: July 27, 2020 ORDER Entitlement to service connection for a hysterectomy due to sexual assault is denied. FINDING OF FACT The weight of competent and credible evidence is against finding that the Veteran's hysterectomy is caused by an in-service injury, event or disease, or caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for hysterectomy due to sexual assault, as secondary to service-connected posttraumatic stress disorder (PTSD) have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service in the United States Air Force from January 1974 to August 1977 and from July 1979 to April 1983. This matter is before the Board of Veteran’s Appeals (Board) from a May 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia, denying service connection for hysterectomy due to sexual assault and as secondary to the service-connected disability of posttraumatic stress disorder (PTSD). This case was previously before the Board in April 2018 and April 2019; it was remanded to obtain an examination opinion that discussed whether the Veteran’s sexual assault caused her 1987 hysterectomy; or if the Veteran’s hysterectomy was caused or aggravated by her service-connected PTSD. An examination opinion discussing the issues was obtained. For this reason, there has been substantial compliance with Board's prior remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. §§ 1110, 1131. To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice connected disease or injury will be service connected. 38 C.F.R. § 3.310(b). Hysterectomy due to sexual assault The Veteran contends that her hysterectomy incurred in, was caused by, or aggravated by active duty service. Alternatively, the Veteran contends that her hysterectomy was proximately caused by her service-connected PTSD. In a July 1974 service treatment record (STR), the Veteran complained of lower abdomen cramps and indicated her period had started 1 day prior. See May 1987 STR-Medical, p.80. In a November 1975 STR, a clinician indicated that the Veteran had a yellowish vaginal discharge and diagnosed vaginitis. See May 1987 STR-Medical, p.28. In April 1976, the Veteran was given a cytology examination vaginal and cervical. The clinician indicated that the cervix, uterus and adnexa were normal, and results were negative. See May 1987 STR-Medical, p.62. In February 1977, a clinician diagnosed dysmenorrhea. See May 1987 STR-Medical, p.47. In a March 1977 report of medical separation examination, the Veteran indicated that she had severe cramps. The Veteran noted that she had or had in the past stomach trouble, cramps during her period, a tumor, growth, cyst or cancer and had a change in menstrual pattern. The examiner noted that the Veteran’s vaginal pelvic examination was normal. In addition, her October 1976 pap smear was negative. Furthermore, the Veteran stated that she had stomach cramps during her period and had been treated for an anal cyst in 1976. See May 1987 STR-Medical, p.3; 6-7. After a break in active duty service, during an April 1979 enlistment report of medical history examination, the Veteran stated she was in good health and denied ever having stomach trouble; tumor, growth, cyst or cancer. However, the Veteran indicated that she had a sexually transmitted disease such as syphilis or gonorrhea. See May 1987 STR-Medical, p.9. In August 1979, the Veteran was seen for vaginal discharge that was yellowish and had been itching for two weeks. The clinician indicated that the Veteran did not have a yeast infection and diagnosed non-specific vaginitis. See May 1987 STR-Medical, p.150. In September 1979, the Veteran was seen for severe menstrual cramps with a diagnosis of dysmenorrhea. The Veteran indicated that her periods were always irregular and that she was taking medication. See May 1987 STR-Medical, p.148. In February 1980, a clinician noted that the Veteran had menstrual cramps and dysfunctional uterine bleeding. See May 1987 STR-Medical, p.61. In a September 1981 STR, the Veteran was seen for painful swelling of the labia majora, she also had an abscess on the labia. See May 1987 STR-Medical, p.3. In August 1980, the Veteran had menstrual cramps and dysmenorrhea. See May 1987 STR-Medical, p.63. In July 1981, a clinician noted that the Veteran had an abcess on her labia, that was healing. See May 1987 STR-Medical, p.149. In February 1982, the Veteran was seen for menstrual cramps and was given motrin. See May 1987 STR-Medical, p.16. In another February 1982 STR, the Veteran stated that her menstrual cycle occurred for 3 days. The Veteran did not have spotting or bleeding between periods and denied having abnormal vaginal discharge. See May 1987 STR-Medical, p.18. In a March 1983 report of medical separation examination, the Veteran stated that she had or had in the past a tumor, growth, cyst or cancer and VD-syphilis, gonorrhea etc. The Veteran denied ever having stomach trouble, being treated for a female disorder or a change in menstrual pattern. The Veteran stated that in August 1981 had a non-malignant cyst that was removed from the labia. Also, a pap smear was not performed because the Veteran was on her period. See May 1987 STR-Medical, p.34-36. On July 27, 1987; the Veteran was admitted to a hospital with a diagnosis of pelvic mass and dysmenorrhea. The examiner also noted that the Veteran was first seen 7/7/87 with a complaint of dysmenorrhea and occasional abnormal uterine bleeding. The pathology report on the uterus showed leiomyoma, the endometrium was secretory, and the cervic showed squamous metaplasia, and fallopian tubes right and left showed hydrosalpinx with chronic inflammation. An examination revealed that the Veteran had a 2-centimeter labial cyst; a 15-centimeter mass but the vagina and cervix were normal. See May 2016 Medical Treatment Record-Government Facility, p.4. On July 28, 1987, the Veteran had a total abdominal hysterectomy surgery. At the time the Veteran had a diagnosis of a pelvic mass, uterine fibroids. The Veteran’s right ovary and left and right tubes were removed. Also, her uterus and cervix. The surgeon found that sections of both fallopian tubes showed cystic dilation with blunting and loss of normal plicae. There were also aggregates of chronic inflammatory cells and the right ovary was unremarkable. See May 2016 Medical Treatment Record-Government Facility, p.1;6. In a July 1995, VA treatment record, the Veteran reported a recent history of sexual abuse. The Veteran stated that she needed to engage in safe sex activities, and she had been educated in the area but had not complied. See May 2010 Medical Treatment Record-Government Facility, p.136. In December 1995, the Veteran was seen for itching for 3-4 days. The Veteran complained of thick malodorous discharge and burning upon urination inside and outside of her vagina. The Veteran had antibiotic treatment three weeks prior to the visit. There were no masses palpable. See May 2010 Medical Treatment Record-Government Facility, p.113. In a September 2001 gynecology clinic note, the Veteran was seen for vaginal itching and discharge. The clinician noted that there was a small ulcer on the right labia and there was moderate amount of thin bubbly yellow discharge. The assessment was that the Veteran had trichomonas vaginitis and a lesion on the labia. See May 2010 Medical Treatment Record-Government Facility, p.91. In correspondence in March 2010, the Veteran reported that she had been raped in 1974 at some time after reporting to her first duty station after initial training. After additional development including records of mental health treatment, the RO granted service connection for PTSD arising from the sexual assault in April 2011. In a September 2011 private treatment record, the Veteran was seen for a routine checkup. The Veteran stated that she was raped at 18 years old and had bad menstrual cramps since that time. The Veteran indicated that she had a hysterectomy at 32 and had been wondering if the rape could have had anything to do with her having the hysterectomy. See January 2020 Medical Treatment Record-Furnished by SSA, p.184. In a May 2014 private treatment record, the Veteran was diagnosed with vulvovaginitis and the clinician noted that she did not have a hysterectomy and made a referral for a cervical cancer pap smear. See April 2019 Medical Treatment Records-Furnished by SSA, p.13. In July 2014, the Veteran complained of vaginal itching, burning and thin white discharge. The Veteran denied having sexual activity for 9 years. The Veteran had a hysterectomy in 1987. At the time her last pap smear was in 2009. The Veteran reported having a biopsy that was negative. See April 2019 Medical Treatment Records-Furnished by SSA, p.38. In September 2018, the Veteran was afforded gynecological conditions. The examiner reviewed the claims file; considered the subjective accounts and conducted an evaluation. The examiner noted a diagnosis of hysterectomy. The Veteran stated that she had a hysterectomy in 1987 after military service due to fibroid with associated heavy menses and dysmenorrhea. The Veteran indicated after the surgery she did not have any more period cramps and did not suffer any other problems. The Veteran stated that she believed her fibroids and its symptoms were the result of a sexual assault that occurred in 1974, when her symptoms became worse and progressed after the incident. The examiner also indicated that the Veteran’s service treatment records did not show treatment or trauma related to sexual assault. There were also no records related to her hysterectomy in 1987. The examiner stated that the Veteran did not have any symptoms related to a gynecological condition. Although the Veteran stated the Veteran had a hysterectomy in 1987, the examiner noted that she did not have a hysterectomy. The Veteran did not have any conditions of the vulva, clitoris, vagina or cervix. The Veteran also did not have incontinence, fistulae, endometriosis, no pelvic organ prolapse, and no tumors or neoplasms. The examiner also stated that the condition did not impact the Veteran’s ability to work. The Veteran did not have uterine fibroids or uterine prolapse. In December 2018, the September 2018 VA examiner provided an addendum. The examiner indicated that she previously incorrectly stated that the Veteran had not had a hysterectomy but in fact did have the surgery. The examiner concluded that it was less likely than not that the condition was incurred in or caused by the claimed in-service injury, event or illness. The rationale was that the Veteran had a hysterectomy in 1987 due to uterine fibroids and abnormal uterine bleeding and dysmenorrhea. The examiner stated that the Veteran’s STR’s did not indicate any signs of excessive uterine bleeding or of enlarged uterus; which would have shown that problems in-service lead to the hysterectomy. The examiner noted that the Veteran was treated for a variety of vaginal infections, pelvic inflammatory disease and cysts. However, the examiner indicated that those infections do not affect the uterus or lead to fibroids or other issues that lead to a hysterectomy. In December 2019, the Veteran was afforded another VA examination. The examiner indicated that it was less likely than not that the Veteran’s hysterectomy was caused by or aggravated by her PTSD due to sexual assault. The rationale was that the Veteran had intermittent dysmenorrhea (menstrual cramps) during service with records indicating that motrin helped. The Veteran had numerous sexual transmitted diseases including pelvic inflammatory disease which can cause pelvic cramping but was unrelated to subsequent hysterectomy in 1987. The hysterectomy occurred 4 years after service. Also, the examiner indicated that in-service vaginal exams were normal, and no fibroids or abnormal uterine masses were noted during service. The examiner stated that there were no unusual symptoms in-service and no fibroids were suspected in-service. The examiner further indicated that there was no recurrent pattern, or abnormal or excessive menstrual bleeding noted during service. Also, the examiner stated that PTSD does not affect uterine anatomy and therefore would not cause or aggravate any need for a hysterectomy. Also, the examiner indicated that no exams indicated that there was any ongoing physical trauma related to the Veteran’s 1974 sexual assault and it did not cause or was an aggravating factor leading to the hysterectomy in 1987. In light of the evidence noted above, the Board concedes that the Veteran has a had a hysterectomy. However, the Board notes that none of the Veteran's treatment providers have provided an opinion that the hysterectomy is directly related to her military service. There is simply no competent medical evidence of record to suggest that the Veteran's hysterectomy is in any way related to her time on active duty. Thus, in this case, when weighing the evidence of record, the Board finds that the compelling the lack of evidence linking the Veteran's hysterectomy her military service on a direct basis. To be clear, the Board notes that the Veteran had gynecological complaints during service. However, when considered in context, each of these complaints were given in association with symptoms, and diagnoses, that did not require a hysterectomy. Also, the Veteran was separated from service with no mention of the need for follow up on any gynecological condition, or the need for a hysterectomy. In this case, the only evidence in favor of the Veteran's claim is her own statements concerning the belief that the hysterectomy, which occurred approximately 4 years after service, was due to service. With regard to the Veteran's contentions, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, it falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although the Veteran is competent to report symptoms that may require a hysterectomy, the claimed disability is not the type of condition that is amenable to lay determination regarding its etiology, as specific findings are needed to properly determine etiology. Id. As such, the Board finds that, other than the Veteran's unsupported contentions, there is simply no evidence in the record of any etiological relationship between the Veteran's hysterectomy and her time in service. Thus, the criteria for service connection for a hysterectomy on a direct basis have not been met. The evidence weighs against the Veteran's claim. Therefore, service connection for a hysterectomy on a direct basis must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Secondary Service Connection Regarding the Veteran's claim that her hysterectomy was caused or aggravated by her service-connected PTSD, VA obtained a medical opinion in December 2019 to address this question. As noted above, after review of the Veteran's file, the December 2019 examiner opined that the Veteran's hysterectomy was less likely than not caused or aggravated by her PTSD, finding that the Veteran had intermittent dysmenorrhea (menstrual cramps) during service and the Veteran had numerous sexual transmitted diseases including pelvic inflammatory disease which can cause pelvic cramping but was unrelated to subsequent hysterectomy in 1987. The examiner further indicated that in-service vaginal exams were normal, and no fibroids or abnormal uterine masses were noted during service. The examiner stated that there were no unusual symptoms in-service or fibroids suspected in-service. The examiner said that there was no recurrent pattern, or abnormal or excessive menstrual bleeding noted during service. Also, the examiner stated that PTSD does not affect uterine anatomy and therefore would not cause or aggravate any need for a hysterectomy. In addition, the examiner indicated that no exams revealing that there was any ongoing physical trauma related to the Veteran’s 1974 sexual assault and it did not cause or was an aggravating factor leading to the hysterectomy in 1987. A review of the medical records reflects the Veteran had a hysterectomy in 1987. However, none of these records provide a nexus or link between the Veteran's hysterectomy and her service-connected PTSD. In this case, the only evidence in favor of the Veteran's claim is her own statements concerning her belief that her hysterectomy, which occurred 4 years after service, is due to her service-connected disability. With regard to the Veteran's contentions, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, it falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although the Veteran is competent to report symptoms that may require a hysterectomy, the claimed disability is not the type of condition that is amenable to lay determination regarding its etiology, as specific findings are needed to properly determine etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Further, the Veteran's statements are outweighed by the findings of the December 2019 VA examiner, who reviewed the claims file, examined the Veteran, and found it less likely than not that her hysterectomy was caused or aggravated by service-connected PTSD. As such, for the reasons noted above, the Board finds that the weight of the competent, probative evidence of record does not support a finding that there is any etiological relationship between the Veteran's hysterectomy due to military sexual trauma and her service-connected PTSD. Thus, service connection for a hysterectomy on a direct or secondary must be denied. 38 U.S.C. § 5107(b); Gilbert, supra. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Long-Ellis, 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.