Citation Nr: 20060366 Decision Date: 09/14/20 Archive Date: 09/14/20 DOCKET NO. 13-15 602 DATE: September 14, 2020 ORDER The claim of entitlement to service connection for multiple menstrual disorders, to include pelvic organ prolapses, hysterectomy, and resulting bowel and bladder issues, is denied. The claim of entitlement to service connection for migraine headaches is granted. The claim of entitlement to an initial evaluation of 10 percent, but no higher, prior to June 23, 2017, for irritable bowel syndrome (IBS) is granted. The claim of entitlement to an initial evaluation of 30 percent, but no higher, from June 23, 2017, for IBS is granted. REMANDED The claim of entitlement to service connection for chronic laryngitis, also claimed as pharyngitis, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s multiple menstrual disorders, to include pelvic organ prolapses, hysterectomy, and resulting bowel and bladder issues began during active service, or are otherwise related to an in-service injury or disease, to include her service connected tubal ligation as a residual of hyperemesis gravidarum. 2. The Veteran’s headache disability began during active service. 3. Prior to June 23, 2017, the Veteran’s service-connected IBS was moderate, and manifested by frequent episodes of bowel disturbance with abdominal distress. 4. From June 23, 2017, the Veteran experienced severe IBS, with more or less constant abdominal distress, but her combination of symptoms did not more nearly approximate symptoms productive of a severe impairment of health. CONCLUSIONS OF LAW 1. The criteria for service connection for menstrual disorders, to include pelvic organ prolapses, hysterectomy, and resulting bowel and bladder issues, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 2. The criteria for service connection for a headache disability, to include migraines, have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 3. The criteria for an initial disability rating of 10 percent, but no higher, for IBS prior to June 23, 2017, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.7, 4.21, 4.114, Diagnostic Codes 7319, (2019). 4. The criteria for an initial disability rating of 30 percent, but no higher, for IBS from June 23, 2017, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.7, 4.21, 4.114, Diagnostic Codes 7319, 7346 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from February 1982 to February 1992 in the United States Air Force. She had additional reserve service. She received the Southwest Asia Service Medal with three Bronze Stars, among other notable commendations. These matters come before the Board of Veterans’ Appeals (Board) from a September 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board video conference hearing before the undersigned in June 2017. A written transcript of that hearing has been prepared and is associated with the evidence of record. In August 2018, the Board remanded these matters back to the RO for additional development, including to obtain outstanding VA treatment records, and to provide medical examinations regarding the claimed disabilities. The Board concludes that there has been substantial compliance with its prior remand directives as to the claims regarding menstrual disorders, migraine headaches, and IBS. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Generally, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 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 injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including certain organic diseases of the nervous system, may be presumed to have been incurred in or aggravated by service if manifested to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 101, 1112; 38 C.F.R. §§ 3.307, 3.309. To show chronicity there is a requirement of a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” 38 C.F.R. § 3.303(b). In these types of cases the disease may be presumed under the law to have had its onset during service even though there is no evidence of that disease during service. 38 C.F.R. § 3.307(a). This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. §§ 3.307(d), 3.309(a). Pursuant to 38 C.F.R. § 3.303(a) if a disease is not shown to be chronic during service or the one-year presumptive period, then service connection may also be established by showing a continuity of symptomatology after service. 38 C.F.R. § 3.303(b). Continuity of symptomatology may be established by demonstrating: (1) that a condition is shown in service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Nevertheless, when service connection cannot be granted on a presumptive basis, the Veteran may still establish service connection on a direct basis. See Combee v. Brown, 34 F.3d 1039,1042 (Fed. Cir. 1994). In evaluating service connection claims, the Secretary shall consider all information and lay and medical evidence of record in a case and make appropriate determinations as to competence, credibility, and weight. 38 U.S.C. § 5107; Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); 38 C.F.R. § 3.303. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. See Barr v. Nicholson, 21. Vet. App. 303 (2007). VA must consider all favorable lay evidence of record. 38 U.S.C. § 5107. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a 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. 1. The claim of entitlement to service connection for multiple menstrual disorders, to include pelvic organ prolapses, hysterectomy, and resulting bowel and bladder issues is denied. The Veteran contends that she has multiple menstrual disorders, to include pelvic organ prolapses, hysterectomy, and resulting bowel and bladder issues (hereafter, menstrual disorders), that are related to her active military service. Specifically, she contends that her current menstrual disorders and related symptoms are attributable to the hyperemesis gravidarum (HG) she experienced in service. See Veteran’s October 2017 Brief in Support of Appeal, at 11-14. The Board concludes that, while the Veteran has a current diagnosis of pelvic organ prolapse and has experienced additional menstrual disorders, the preponderance of the evidence weighs against finding that the Veteran’s menstrual disorders, began during service or are otherwise related to an in-service injury, event, or disease, including HG. The Board acknowledges at the outset that the Veteran sought treatment for a variety of symptoms related to her reproductive system during her active duty, especially during periods of time when she experienced unmanageable hyperemesis gravidarum and underwent therapeutic abortions. Further, the Board notes that the Veteran has been service connected for the tubal ligation she received as a residual of the HG experienced during active service. Given that medical history, in August 2018 the Board directed the RO to provide the Veteran a medical examination to assess whether it was at least as likely as not that any diagnosed menstrual disorder was related to the Veteran’s service, including her treatment for hyperemesis gravidarum, her terminated pregnancies, or her tubal ligation. The evidence of record shows that the Veteran received an in-person VA examination in August 2019. The Board notes that the medical examiner conducted a thorough review of the Veteran’s medical history, including her service treatment records as well as decades of post-service medical records. The examiner opined that it was “less likely than not that any diagnosed menstrual disorder is related to an in-service injury, event, or disease, including [the Veteran’s] treatment for hyperemesis gravida or her abortions during service.” The examiner further concluded that there was no medical, clinical, or significant research evidence to support the contention that the Veteran’s diagnosed menstrual conditions were caused by or aggravated by her service-connected tubal ligation. The Board finds this medical opinion highly probative. The examiner’s rationale was based on an accurate medical history and provided an explanation that contained clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). It is clear from the examiner’s report that she reviewed, considered, and discussed the Veteran’s extensive treatment records and corresponding lay statements in forming her medical opinion. For example, the examiner thoroughly noted the Veteran’s history of HG while in active service and her history of full-term pregnancies, as well as the reason for the Veteran’s eventual tubal ligation. The VA examiner also summarized the Veteran’s post-service menstrual disorders to have been diagnosed as “uterovaginal prolapse, rectocele, and cystocele [status post] laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and anterior and posterior repair [in August 2012] with residual scarring.” The examiner reviewed and considered decades of post-service medical records, including the Veteran’s April 1993 enlistment medical examination for the Air Force Reserves, which showed (among other things) that the Veteran denied frequent or painful urination, and denied dysmenorrhea at that time. The VA examiner noted that according to the 1993 enlistment examination, the Veteran had undergone a laparoscopy in 1984 to assess abdominal pain, but that the procedure did not identify any causal condition. Based on her review, the VA examiner determined that the Veteran’s claimed menstrual conditions were not noted until approximately 20 years after her military service and her in-service HG condition and abortions. The Board finds the VA examiner’s opinion additionally persuasive as it includes a review of relevant medical literature of the identified causes of conditions such as the Veteran’s. The VA examiner explained that “uterovaginal prolapse, cystocele, and rectocele [were] all noted to be consistent with pelvic organ prolapse (POP) which is the herniation of the pelvic organs to or beyond the vaginal walls[.]” The examiner noted that the condition is common, with established risk factors for POP to include parity, advancing age, and obesity. The Board understands the term “parity” here to mean the status of having borne one or more children. The VA examiner noted that according to medical research, the “risk of POP increases with increasing parity.” The examiner noted that a study that followed 17,000 women for 17 years found that as compared to women who had not given birth, “the risk of hospital admission for POP increased markedly after the first (fourfold) and second birth (eightfold), and then increased less rapidly for subsequent births (third: ninefold; fourth: 10-fold).” The examiner noted that among women who had given birth, an estimated 75 percent of prolapse could be attributed to pregnancy and childbirth.” Further still, the VA examiner noted that “[e]pidemiologic studies have generally reported an increased risk of POP with advancing age.” The examiner noted that one study of 1000 women reported a progressive increase in the rate of prolapse in that “every additional 10 years of age conferred an increased risk of prolapse of 40 percent.” A study of over 27,000 women identified “a small, but statistically significant, progressive increase in the prevalence of rectocele with age (50 to 59 compared to 60 to 69 and 70 to 79 years).” The Board notes that the Veteran would have been in her early 50’s when identified with POP. The examiner noted that another risk factor for POP, was the status of being overweight (with a body mass index (BMI) of 25 to 29.9), but the examiner did not specifically identify this to be a significant factor for the Veteran. The Board notes that during a gynecology consultation in November 2011, when the Veteran reported symptoms of cervical prolapse and vaginal pressure, the Veteran’s BMI was recorded as be 24.5. Overall, the Board finds the VA examination report and opinion to weigh against the Veteran’s claim. The Board notes that the evidence of record does not contain an adequate opinion to the contrary and the examiner’s opinion is consistent with the medical evidence of record. The Board acknowledges the Veteran’s assertion, through her representative, in her October 2017 Brief that a May 2011 VA examination supports her claim. On review of this examination, the Board concludes otherwise. The May 2011 VA examiner did record the Veteran’s lay statements that she had felt a “bulge between her legs” that had been worsening, especially in the prior year or so. The examiner noted the Veteran’s complaints of dysuria, urgency, frequency, incomplete emptying and incontinence.” The examiner assessed the Veteran with “pelvic organ prolapse grade I” that was “more likely than not causing the patient’s current symptomatology.” The examiner assessed the Veteran with “grade II cystocele and rectocele” that was “more [likely] than not related to the patient’s current symptomatology.” Essentially, the Board understands this examiner’s opinion to be that the Veteran’s pelvic organ prolapse was causing her then complained of genitourinary symptoms, which in turn caused or were related to her cystocele and rectocele. This examiner’s report did not provide a clear rationale for the cause of the POP or identify a link between the Veteran’s in-service conditions and those assessed during the examination. The Board further acknowledges that the Veteran considers her menstrual disorders to be attributable to her HG, the tubal ligation she underwent, or to otherwise be related to service. When assessing the Veteran’s contentions, the Board notes that the Veteran is competent to report having experienced symptoms of POP and other genitourinary symptoms as noted above, however, she is not competent to provide an etiology opinion in this case or determine that her symptoms were manifestations of her HG or tubal ligation. These issues are medically complex, as they require knowledge of the interaction between multiple organ systems in the body and the interpretation of medical research. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Therefore, it is outside the competence of the Veteran or her representative in this case because the record does not show them to have the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the August 2019 VA medical opinion. In sum, the Board finds that the preponderance of the competent, credible and probative evidence weighs against finding that the Veteran’s current menstrual disorders, began during service or are otherwise related to an in-service injury, event, or disease, including HG or the Veteran’s tubal ligation. As such, the benefit of the doubt does not apply, and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. The claim of entitlement to service connection for migraine headaches is granted. The Veteran contends that her headache condition, to include migraine headaches, is related to her active duty service. Review of the medical evidence of record reflects that the Veteran has received treatment for and a diagnosis of chronic headaches, including migraines. See August 2019 VA medical examination. As such, the Board finds that the Veteran has a current disability. Next, review of the Veteran’s service treatment records (STRs) reveals that she complained of headaches on numerous occasions during her active service. See, e.g., October 1995, February 1987, October 1987, August 1990, and December 1990. Additionally, the Veteran testified credibly before the Board that she suffered more frequent headaches than are reflected in her STRs as she would not seek medical attention each time. The Veteran’s medical records reflect her consistent lay report that she experienced her first “bad” headache during her active service during a deployment. The Board interprets the Veteran’s descriptive term to indicate that she likely suffered her first migraine headache during service, although a formal diagnosis was not assigned. The Veteran also reported “frequent or severe headaches” on her April 1993 Report of Medical History form for enlistment into the Air Force Reserve. While a lay person is “not competent to opine as to medical etiology,” a lay person is competent “to establish the presence of observable symptomatology[.]” Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The Board therefore finds the Veteran’s statements and testimony regarding her in-service experiences and symptoms to be competent. The Board finds the statements to be credible, as they are internally consistent and consistent with the medical evidence of record. Moreover, lay evidence can be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Accordingly, the Veteran is also competent to report experiencing continuing headache symptoms during and since her active service, as the onset, frequency, and duration of such symptoms as pain are certainly capable of lay observation. The Board acknowledges that the August 2019 VA examiner opined that it was less likely than not that the Veteran’s condition was related to her service, however, it appears to the Board that the examiner relied on the lack of formal migraine diagnosis until approximately three years after the Veteran’s active service in concluding that the migraines were unrelated to service. The Board finds this examiner’s reliance misplaced in light of the additional competent and credible lay evidence of record regarding the Veteran’s symptomatology. Significantly, lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (“[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence.”). After review of the evidence of record and resolving reasonable doubt in favor of the Veteran, the Board finds the evidence to be in equipoise to show chronic in-service symptoms of headache and continuous post-service symptoms relating to headaches and migraines. As such, the Board finds that the evidence establishes that the Veteran’s current headache disability had its onset in service and that it has been continuous since. Therefore, resolving reasonable doubt in favor of the Veteran, service connection for headaches, to include migraines, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. The claim of entitlement to an initial evaluation of 10 percent, but no higher, prior to June 23, 2017, for irritable bowel syndrome (IBS) is granted. See Section 4 below. 4. The claim of entitlement to an initial rating of 30 percent, but no higher from June 23, 2017, for IBS is granted. The Veteran contends that she is entitled to higher initial compensable ratings for her IBS. Because the Veteran’s appeal relates to the initial ratings assigned to her during the entire period on appeal, the Board will address these matters together. The Board notes at the outset of this discussion that it finds staged ratings to be appropriate in this case. Disability ratings are determined by application of a ratings schedule which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In general, the degree of impairment resulting from a disability is a factual determination and generally the Board’s primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Staged ratings are appropriate for initial rating and increased rating claims when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. However, pyramiding – the evaluation of the same disability or the same manifestation of a disability, under different diagnostic codes – is to be avoided when evaluating a Veteran’s service-connected disability. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Disabilities of the digestive system are rated in accordance with 38 C.F.R. § 4.114, Diagnostic Codes 7200-7348. Section 4.114 provides that ratings under codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. In this case, the Veteran’s service-connected IBS has been rated under the provisions of Diagnostic Code 7319, irritable colon syndrome (spastic colitis, mucous colitis, etc.). Under this Diagnostic Code, a rating of 0 percent is warranted where the condition is considered mild, with disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is warranted for a moderate condition, with frequent episodes of bowel disturbance and abdominal distress. A 30 percent rating is warranted for a severe condition, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. Additionally, the Veteran’s condition may be rated by analogy under DC 7346, for hiatal hernia, which permits a maximum 60 percent evaluation for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. January 26, 2011 to June 22, 2017 Procedurally, the RO granted the Veteran service connection for IBS, effective January 26, 2011, the date the RO received her claim. The RO assigned a zero percent, or noncompensable, rating. See September 2011 Rating Decision. In August 2012, the Veteran filed a Notice of Disagreement (NOD) with the assigned rating, contending that “the narrative portions of the rating decision describe symptoms for higher ratings of [her IBS condition].” The Board notes that the description included in the Rating Decision was that “frequent episodes of bowel disturbance with abdominal distress” warranted a 10 percent rating. No higher rating criteria was described in the decision. According to a March 2011 VA examination, the Veteran reported experiencing lower gastrointestinal conditions, including alternating diarrhea and constipation which occurred every few weeks and lasted for one to two days. The Veteran reported that between these episodes, she would experience alternating soft and hard stools with constipation. She utilized stool softeners and a high-fiber diet to regulate her bowel movements. Resolving all doubt in her favor, the Board considers the examiner’s recitation of the Veteran’s symptoms, along with the Veteran’s own endorsement of the level of symptomatology described in the September 2011 Rating Decision, to more closely align with a 10 percent disability rating. The Board considers the occurrence of the described symptoms every few weeks and lasting for one to two days to be “frequent.” As such, the Board finds that an increased rating of 10 percent, but no higher, from the period of January 26, 2011 to June 22, 2017, is warranted, based on frequent episodes of bowel disturbance. 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7319. An initial rating in excess of 10 percent during this period is not warranted. The evidence of record during this period does not support a finding that the Veteran’s IBS was manifested by more or less constant abdominal distress. The Veteran’s own lay statements, including her NOD, reflect that her disability was primarily manifested by symptoms every few weeks, which the Board finds to clearly not approach severe IBS, or be representative of more or less constant distress. June 23, 2017 to Present Following the Board’s August 2018 remand, the RO provided the Veteran an updated VA examination and issued a May 2020 Rating Decision in which it assigned a 30 percent rating for the Veteran’s IBS from the date of the August 21, 2019 VA examination. The RO determined that the next highest analogous rating of 60 percent was not warranted. See May 2020 Rating Decision and Supplemental Statement of the Case (SSOC). As that award did not represent a total grant of benefits sought on appeal, the claim of entitlement to higher initial ratings throughout the period on appeal remained before the Board. AB v. Brown, 6 Vet. App. 35 (1993). Having considered the evidence of record, the Board finds that from June 23, 2017, that a 30 percent rating, but no higher, is warranted for the Veteran’s IBS. On June 23, 2017, the Veteran testified before the Board that she had “at least frequent episodes” of bowel disturbances that were more or less constant and very unpredictable. According to the Veteran’s August 2019 VA examination, the Veteran reported fluctuating between going three days without having a bowel movement, to having one to three movements per day, “alternating between constipation and diarrhea[.]” The Veteran described significant pain, bloating, and abdominal distension. The examiner determined that the Veteran had “more or less constant abdominal distress.” The Board finds that the VA examiner’s report and the Veteran’s lay statements regarding her symptoms during this period align with a 30 percent rating. Based on the Veteran’s lay statements and credible VA examination evidence, and resolving all reasonable doubt in her favor, the Board finds it factually ascertainable that as of June 23, 2017, the Veteran’s IBS symptoms most closely approximated a 30 percent rating. To this extent, the appeal is granted. 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7319. The Board further finds, however, that at no point during this period on appeal, did the Veteran’s symptoms entitle her to a higher, 60 percent rating under DC 7346. According to the August 2019 VA examiner, the Veteran did not experience weight loss, malnutrition, serious complications or other general health effects attributable to her intestinal condition. The Veteran’s medical treatment records do not reflect more severe symptoms or health complications than this VA examination. Additionally, the Veteran has not identified or described symptoms that could be construed as comparable to the next higher 60 percent rating. For example, the Veteran affirmed that she experienced “pain and cramping” in relation to symptoms of diarrhea, bloating and bowel movements, but did not indicate that she suffered additional symptom combinations productive of severe impairment of health, such as weight loss, blood in her stool, or malnutrition. Thus, the Veteran’s IBS did not more nearly approximate a combination of symptoms productive of severe impairment of health during this period. A higher 60 percent rating under DC 7346 is not warranted. REASONS FOR REMAND 1. The claim of entitlement to service connection for chronic laryngitis, also claimed as pharyngitis, is remanded. The Veteran contends that her laryngitis is related to her active service. Although regrettable, additional remand is required for full compliance with the Board’s previous remand instructions. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998). Specifically, the Board directed the RO to obtain a medical opinion as to the nature and etiology of the Veteran’s laryngitis or pharyngitis, and to consider the Veteran’s multiple in-service complaints of a chronic sore throat and hoarseness. The examiner was to opine whether the Veteran’s condition could also be secondarily related to or aggravated by her service-connected GERD. The Board finds the examination opinion inadequate to accurately adjudicate the claim because the examiner failed to fully consider evidence that the Veteran was exposed to excessive dust and/or other environmental hazards known to be associated with her service in Southwest Asia during the Gulf War. Further, the examiner failed to address whether the Veteran’s collective symptoms of throat pain, hoarseness, and recurrent loss of voice, could nevertheless result in functional impairment at any time during or approximate to the pendency of the claim. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, an addendum etiological opinion is required. The matter is REMANDED for the following action: 1. Obtain an addendum opinion regarding the nature and etiology of the Veteran’s claimed recurrent laryngitis or pharyngitis throat condition, to include pain on swallowing and after speaking for extended periods. 2. The examiner is to conduct a review of all relevant service treatment records, and all lay statements made by the Veteran. The examiner is asked to do the following: (a.) Provide an opinion as to whether the Veteran has a current throat disability, to include a functional impairment due to pain or other symptoms. The RO and examiner are reminded that pain, even without a formal diagnosis, can constitute a disorder warranting service connection where such pain causes a functional impairment of earning capacity. See 38 C.F.R. §§ 3.102, 3.303; Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018); Wait v. Wilkie, No. 18-4349, 2020 U.S. App. Vet. Claims LEXIS 1609 (Aug. 26, 2020). (b.) For any identified disability and/or functional impairment, provide an opinion as to whether the condition is at least as likely as not directly related to the Veteran’s active military service, specifically to include as due to her conceded exposure to environmental irritants (including excessive dust and other environmental hazards known to be associated with service in Southwest Asia). (c.) For any identified disability and/or functional impairment, please provide an opinion as to whether the condition is distinct from, and/or secondarily related to, the Veteran’s service-connected GERD. 3. Following adequate completion of the foregoing, the Agency of Original Jurisdiction (AOJ) should review the record, perform any necessary development, and readjudicate the claim on appeal. If the appeal is denied, the AOJ should issue an appropriate Supplemental Statement of the Case (SSOC), afford the Veteran and her representative an opportunity to respond, and return the case to the Board. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Hart, 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.