Citation Nr: 20060768 Decision Date: 09/15/20 Archive Date: 09/15/20 DOCKET NO. 15-46 268 DATE: September 15, 2020 ORDER Entitlement to service connection for hyperthyroidism to include as secondary to service-connected hyperprolactinemia is denied. FINDING OF FACT The Veteran’s hyperthyroidism is not secondary to service-connected hyperprolactinemia, and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for entitlement to service connection for hyperthyroidism to include as secondary to service-connected hyperprolactinemia 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 served on active duty from April 2002 to April 2006. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In May 2019 the Veteran and her mother testified at a Board hearing before the undersigned Veterans Law Judge. The transcript is of record. In October 2019, the Board remanded the issue on appeal in order to obtain an addendum opinion addressing whether the Veteran’s hypothyroidism was directly related to service or was aggravated by the Veteran’s hyperprolactinemia. The Board finds there has been substantial compliance with the directive. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for hyperthyroidism to include as secondary to service-connected hyperprolactinemia The Veteran contends that her hyperthyroidism is secondary to her service-connected hyperprolactinemia. The Veteran expressed that before she joined the Army, she was a healthy young woman. She stated that everything started in 2005 when she was on active duty. She expressed that she noticed milk discharge from her nipples followed by a migraine. The Veteran stated that she was diagnosed with a benign tumor. At her board hearing, the Veteran testified to having symptoms of tiredness and constipation in service. The Veteran stated that she was diagnosed with hyperprolactinemia in 2005 and hypothyroidism in 2013. Service connection may be granted for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, there must be (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) evidence, generally medical, of a causal relationship between the claimed in service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). A disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. 38 C.F.R. § 3.310(a). With regards to a current disability, the Veteran has established that she has hyperthyroidism, and therefore the first element of service connection has been met. The Board notes that the Veteran is also service-connected for hyperprolactinemia. Turning to the evidence of record, the Veteran’s service treatment records showed that the Veteran had milky nipple discharge in May 2005, and that her TSH was 0.65. The Veteran’s service treatment records are absent of any hyperthyroidism diagnosis. In a July 2006 treatment note, it was recorded that the Veteran had hyperprolactinemia and that the Veteran’s prolactin level will be checked to rule out hyperthyroidism as a cause of elevated prolactin. The Veteran was afforded a VA examination in October 2013. The Veteran was diagnosed with hyperthyroidism with a date of diagnosis in June 2013. A negative opinion was provided when the examiner opined that the Veteran’s mild hypothyroidism, which was corrected at present with medication, is less likely a primary or secondary condition related to military service. In an addendum opinion from July 2014, the examiner stated that based on chart reviews, compensation and pension examinations, service treatment records, and treatment records from government facilities, the Veteran is suffering from pituitary microadenoma causing hyperprolactinemia. The examiner noted that the VA examination in October 2013 revealed that the Veteran had a normal palpable thyroid gland without any thyromegaly or nodules, no exophthalmos, normal pulse, and a non-focal neurological examination. The examiner reported that the Veteran’s last TSH done on October 29, 2013 was 1.13, within normal limits. The examiner reported that the Veteran is currently on levothyroxine for mild hypothyroidism. The examiner also noted that the Veteran was diagnosed with galactorrhea with normal serum prolactin level. The examiner stated that the Veteran had a MRI of the brain that showed a 4 mm pituitary microadenoma, and a repeat MRI in 2008 that showed a 5 mm pituitary microadenoma without any mass effect. The examiner noted that the Veteran was treated with bromocriptine which was changed to cabergoline in May 2005. The examiner expressed that hyperprolactinemia results almost exclusively from diseases that cause hypersecretion of by lactotroph cells. The examiner provided a negative opinion when the examiner opined that since the Veteran’s hypothyroidism predisposes to hyperprolactinemia, hypothyroidism is less likely than not proximately due to or the result of or aggravated by the Veteran’s service-connected condition. In a private medical opinion received in March 2015, Dr. Inzerillo stated that there was an increased risk/association of hypothyroidism with pituitary tumors. The Veteran was afforded another VA examination in May 2017 for the Veteran’s thyroid; however, no opinion was provided. In an August 2017 private opinion, Dr. Krishtul stated that past medical records indicated that the Veteran was diagnosed in 2004 with elevations in prolactin. Dr. Krishtul noted that a MRI done privately in 2005 showed a 4 mm prolactinoma and a MRI done in May 2008 showed a 5 mm lesion in the right aspect of the pituitary gland (prolactinoma). Dr. Krishtrul reported that hypothyroidism was diagnosed in June 2013 and that hypothyroidism is a secondary diagnosis caused by the pituitary tumor. In a January 2018 VA endocrine examination, with a May 2018 addendum opinion, the examiner stated that the Veteran has asymptomatic microadenoma, which is not causing any compression of surrounding structures, meaning not causing hypopituitarism, hypothyroidism, or visual problems. The examiner stated that the Veteran’s comorbid condition is hypothyroidism, which is of primary type caused by the hormonal problem related to the main thyroid gland in the neck. The examiner noted that it is based on the Veteran’s TSH levels. The examiner expressed that the TSH level is high in primary hypothyroidism as opposed to low or normal levels in secondary hypothyroidism caused by pituitary macroadenoma. The examiner noted that the Veteran has asymptomatic microadenoma, not macroadenoma. The examiner stated that the Veteran’s currently diagnosed hypothyroidism is not secondary to or caused by a pituitary gland compression problem. The examiner opined that the Veteran’s hypothyroidism is not a secondary type, not caused by or secondary to hypopituitarism and hyperprolactinemia. The examiner opined that the Veteran has two independent, separate endocrine conditions not related to one another, and therefore there is no need to determine which symptoms are due to the already established hyperprolactinemia. In a September 2018 VA opinion, the examiner stated that the Veteran was diagnosed with primary hypothyroidism in June of 2013, while the Veteran was pregnant. At that time, the examiner noted that the Veteran’s TSH was elevated (10.69). The examiner noted that the elevated TSH at the time of diagnosis means that there is an issue with the actual thyroid gland itself and not secondary to the pituitary microadenoma, also known as prolactinoma. The examiner stated that if the Veteran’s hypothyroidism was secondary to a problem with the pituitary microadenoma, the TSH would have been decreased at the time of diagnosis. The examiner expressed that in 2017, the Veteran was found to have anti-thyroglobulin antibodies. The examiner reported that these antibodies are present in almost all patients with primary hypothyroidism due to a primary problem with the thyroid gland itself. The examiner expressed that these antibodies may also be present in a small number of healthy adults as well. Regardless, the examiner noted that these antibodies are not caused by the prolactinoma in which the Veteran was diagnosed to have then. Further, the examiner discussed that these antibodies are not unique to or caused by military service. The examiner stated that the presence of these antibodies, however, taken with the elevated TSH at the time of the hypothyroidism diagnosis confirms that that the Veteran has primary hypothyroidism, a problem with the actual thyroid gland itself, and not secondary hypothyroidism due to a pituitary process. The examiner noted that the Veteran has asymptomatic microadenoma, which is not causing any compression of surrounding structures, meaning not causing hypopituitarism, hypothyroidism, or visual problems. Therefore, the examiner stated that the Veteran’s hypothyroidism is not secondary hypothyroidism and is only primary hypothyroidism which is not related to or caused by her prolactinoma, or pituitary microadenoma. The examiner stated that the previous diagnosis and current diagnosis was and is still primary hypothyroidism. The examiner expressed that once diagnosed and established, primary hypothyroidism is a permanent, lifetime diagnosis, distinct from the Veteran’s pituitary adenoma (prolactinoma). The examiner concluded that primary hypothyroidism, which the Veteran has should not qualify for service connection because of the rationale given. The examiner reported that in the US, the most common cause of primary hypothyroidism is destruction of the thyroid gland by the immune system, a condition called Hashimoto’s thyroiditis which is not caused by incident, illness, injury, or exposure related to military service. The Veteran was afforded a VA medical opinion in March 2020. The examiner stated that the Veteran’s hypothyroidism was diagnosed in June 2013, seven years after leaving military service. The examiner noted that lab tests during the Veteran’s military service confirm normal thyroid function. The examiner reported that the Veteran’s service treatment records show that, on December 8, 2004, the Veteran’s thyroid stimulating hormone (TSH) was 1.43, which was normal, and in May 2005, her TSH was 0.65 which was normal, ruling out hypothyroidism. The examiner opined that the Veteran’s hypothyroidism did not have its clinical onset during military service or is otherwise related to military service. The examiner noted that it is critically important to differentiate between primary hypothyroidism, which the Veteran has, from secondary hypothyroidism which this Veteran does not have. The examiner expressed that primary hypothyroidism means that the condition is an independent, separate disease, unrelated to any other condition while secondary hypothyroidism means that the condition is caused by other conditions. The examiner stated that the Veteran clearly has primary hypothyroidism, based on objective evidence of diagnostic tests. The examiner reported that primary hypothyroidism is not caused by or is secondary to the Veterans’ pituitary microadenoma. Further strengthening the diagnosis of primary hypothyroidism, the examiner noted that the Veteran has anti-thyroglobulin antibodies, which is strongly associated with primary hypothyroidism. The examiner stated that these antibodies are not caused by pituitary microadenoma, also known as prolactinoma. The examiner stated that these antibodies are not unique to or caused by military service. The examiner expressed that microadenoma does cause secondary hypothyroidism. Finally, the examiner noted that if the Veteran’s hypothyroidism were secondary to her pituitary microadenoma, the TSH would have been decreased at diagnosis. However, the Veteran has elevated levels of TSH, ruling out secondary hypothyroidism. The examiner stated that the Veteran was diagnosed with primary hypothyroidism in June of 2013, with an elevated TSH of 10.69, supporting the diagnosis of primary hypothyroidism and ruling out secondary hypothyroidism. Therefore, the examiner concluded that the development of primary hypothyroidism in this Veteran is unrelated to her pituitary microadenoma. In conclusion, the examiner expressed that the correct diagnosis is primary hypothyroidism that was not caused by an incident, illness, injury, or exposure related to military service. With regards to secondary service connection, the examiner stated that the Veteran’s well-established diagnosis of primary hypothyroidism is an independent disease, which is not caused by or aggravated by the Veteran’s service-connected hyperprolactinemia, also known as pituitary microadenoma. The examiner noted that there is no evidence to support that her primary hypothyroidism is in any way affected by her hyperprolactinemia, also known as pituitary microadenoma. The examiner expressed that the question of aggravation does not even arise, because the Veteran’s pituitary condition has no influence of any kind on her thyroid function and her primary hypothyroidism, and because the Veteran’s pituitary condition is, in fact, stable and well controlled per the endocrinology clinic visit in November 29, 2019. The examiner opined that the Veteran’s primary hypothyroidism is not caused by or aggravated by the Veteran’s service-connected hyperprolactinemia. The examiner noted that one does not aggravate the other and that the Veteran unfortunately has two independent, separate endocrine conditions not caused by or related to one another. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the preponderance of the evidence is against the claim. It is to be noted that the Board is not free to substitute its own judgment for that of a medical expert. Colvin v. Derwinski, 1 Vet. App. 171 (1991).Where the record contains both positive and negative evidence, it is the responsibility of the Board to weigh the credibility and probative value of the evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998). The Board is mindful that it must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In this case, the Board finds that the May 2018 VA addendum opinion, the September 2018 VA opinion, and the March 2020 examination report, are adequate for the purposes of adjudication. The examiners addressed the contentions of service connection, but opined that the Veteran’s hypothyroidism was not related to service, or caused or aggravated by the service-connected hyperprolactinemia. The examiners, particularly the March 2020 examiner, based their conclusions on an examination of the claims file, the Veteran’s diagnostic reports, and provided adequate rationale. The March 2020 examiner provided a plausible explanation as to why the Veteran’s hyperthyroidism was not directly related to military, to include a lack of diagnosis in service, lab tests confirming normal thyroid function during military service, and the lapse of 7 years between service and a diagnosis of hyperthyroidism. With regards to whether the Veteran’s hyperthyroidism was caused or aggravated by the Veteran’s service-connected hyperprolactinemia, the March 2020 VA examination report noted that the Veteran’s diagnosis of primary hypothyroidism is an independent disease, which is not caused by or aggravated by the Veteran’s service-connected hyperprolactinemia. It was reported that if the Veteran’s hypothyroidism was secondary to a problem with the pituitary microadenoma, the TSH would have been decreased at the time of diagnosis. The March 2020 examiner expressed that the question of aggravation does not even arise, because the Veteran’s pituitary condition has no influence of any kind on her thyroid function and her primary hypothyroidism, and because the Veteran’s pituitary condition is, in fact, stable and well controlled, per the endocrinology clinic visit in November 29, 2019. To the extent that the March 2015 private medical opinion from Dr. Inzerillo and the August 2017 private opinion from Dr. Krishtul support the claim, the opinions are of low probative value. Both opinions provided little to no rationale for their conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Both private medical opinions merely provided a statement of a conclusion with no rationale. The Board finds the VA opinions more persuasive because they contain greater detail and provide a rationale as to why the examiner and reviewer reached the opinions that they did. The Veteran’s private physician’s opinion contains no supporting rationale. As such, the Board finds the VA examination reports more persuasive and outweighs that of the private medical opinions. With regards to the Veteran’s lay statements, the Board notes that the question of whether the Veteran’s hyperthyroidism is related to her active service or caused or aggravated by a service-connected disability falls outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The intricacies in opining the etiology of hyperthyroidism is an issue that requires the expertise of a medical professional. Therefore, the Veteran is not competent to provide an opinion on the etiology of her hyperthyroidism. While the Veteran can report symptoms that she experiences, she does not have the necessary training to make medical opinions. Thus, the Board finds that the Veteran’s lay assertions in the present case are outweighed by the medical evidence of record. The Board finds the VA examiner’s opinion more persuasive than the lay statements regarding the etiology. Considering the record, including post-service medical evidence, the VA examiner’s and private medical opinions, and lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater evidentiary weight. In conclusion, the preponderance of the evidence is against the claim. Thus, the benefit-of-the-doubt rule does not avail the Veteran. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.D. 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.