Citation Nr: 21001002 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 16-42 314 DATE: January 6, 2021 REMANDED Service connection for a disability manifested by dysfunctional uterine bleeding is remanded. REASONS FOR REMAND The Veteran served on active duty from May to November 2002, January to October 2003 and April to August 2005. The Veteran testified before the undersigned Veterans Law Judge in August 2020. A transcript of the hearing is in the record before the Board. In October 2020 correspondence, the Veteran’s representative stated that 2014 surgical treatment of the Veteran’s claimed disability rendered her sterile and she is accordingly entitled to special monthly compensation (SMC) due to the loss of a creative organ. This claim has not been adjudicated and the Board refers it to the Agency of Original Jurisdiction. Service connection for a disability manifested by dysfunctional uterine bleeding (claimed as a gynecological condition) is remanded. This issue is remanded to obtain a VA examination and medical opinion. Treatment records from the Veteran’s private gynecologist reflect an assessment of pelvic pain – pelvic pressure in January 2016. In a September 2020 statement, the Veteran’s private gynecologist stated that the Veteran’s history was significant for irregular menses starting mid-2002, which the Board observes is during the Veteran's active duty. The Veteran was treated with multiple hormonal manipulation medications until 2013, which failed. She continued to have ongoing difficulties with activities of daily living (due to unpredictable and uncontrollable bleeding and pain). In order to manage her diagnosis of abnormal uterine bleeding, the private physician recommended an endometrial ablation and tubal ligation. The Veteran underwent this surgery in June 2014. Subsequent to the ablation, she continued to have significant cramping with menses. As the criteria set forth in in McLendon v. Nicholson, 20 Vet. App. 27 (2006), have been met, a remand is warranted for a VA examination and opinion. The matter is REMANDED for the following action: 1. Obtain any outstanding VA and non-VA treatment records relevant to the Veteran’s claimed disability. 2. After the action in #1 is complete, schedule the Veteran for an examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) for a disability manifested by abnormal uterine bleeding and a medical opinion. The clinician must review the eFolder. The clinician is asked to provide the following opinions: (a.) Has the Veteran carried any diagnosis related to her abnormal uterine bleeding at any time since March 2013? The September 2020 statement from Dr. Knight indicates that abnormal uterine bleeding is a diagnosis. Please explain. (b.) Has the Veteran had any functional impairment in earning capacity related to her dysfunctional uterine bleeding with pain and cramping at any time since March 2013? If so, please specifically identify such impairment. (c.) If the opinion provider identifies any disability/ies in response to (a) and (b), as to each disability identified, is it at least as likely as not that such disability is related to service? The clinician is asked to consider and address as necessary the September 2020 statement from the Veteran’s private gynecologist that the Veteran’s history was significant for irregular menses starting mid-2002 (while in service); was treated unsuccessfully with multiple hormonal manipulation medications until 2013; continued to have ongoing difficulties with activities of daily living (due to unpredictable and uncontrollable bleeding and pain); in order to manage her diagnosis of abnormal uterine bleeding, the private physician recommended an endometrial ablation and tubal ligation, which the Veteran underwent in June 2014; subsequent to the ablation, the Veteran continued to have significant cramping with menses. The Board specifically highlights the following evidence from the current appeal period, which began in March 2013: (a) an April 2014 Gynecological Conditions Disability Benefits Questionnaire (DBQ) completed by the Veteran’s private gynecologist provides a diagnosis of irregular menses, pelvic pain, atypical glandular cells on PAP and ovarian cysts. The Veteran’s pertinent medical history was irregular menses with multiple clinic visits and emergency room visits for heavy and irregular menses from 2003 to 2013; pelvic pain with multiple clinic and emergency room visits from 2007 to 2012; and abnormal PAPs in 2003 and 2004. The Veteran’s conditions impacted her ability to work, resulting in chronic recurring dysmenorrhea and menometrorrhagia refractory thus far to hormonal management (and the Veteran was intolerant of the side effects of various hormone options); (b) VA treatment records dated in May 2014 show that the Veteran was diagnosed with AUB (abnormal uterine bleeding) and a laparoscopic tubal ligation and endometrial ablation were scheduled which she underwent in June 2014; (c) treatment records from the Veteran’s private gynecologist reflect an assessment of pelvic pain – pelvic pressure in January 2016 A complete rationale must be provided for any opinion(s) expressed. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Davitian, 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.