Citation Nr: 21002573 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 16-54 352 DATE: January 14, 2021 ORDER New and material evidence having been received, the application to reopen the claim of entitlement to service connection for tinnitus is granted. Service connection for tinnitus is denied. Service connection for chronic sinusitis/rhinitis is denied. Service connection for pes planus is denied. Service connection for an acquired psychiatric disorder is denied. Service connection for hypertension (HTN) is denied. Service connection for ulcers is denied. REMANDED Service connection for endometriosis. Service connection for hysterectomy. Service connection for ovarian/uterine cysts. Service connection for pulmonary embolism (PE). Service connection for chronic fatigue syndrome (CFS). FINDINGS OF FACT 1. The Veteran served on active duty from February 1988 to February 1993. 2. An unappealed January 2017 rating decision denied service connection for tinnitus; evidence received since the January 2017 rating decision is new and raises a reasonable possibility of substantiating the claim. 3. Tinnitus was not shown during service, was not shown to a compensable degree within one year of service, symptoms were not continuous since service, and tinnitus is not otherwise caused by or related to any incident of service. 4. Chronic sinusitis/rhinitis has not been shown. 5. Pes planus preexisted service entry but did not increase in severity during service. 6. An acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), has not been shown; a psychiatric disorder other than PTSD was not shown in service and is not causally or etiologically related to service. 7. HTN was not shown in service or to a compensable degree within one year of service and symptoms of hypertension were not continuous since service; the current diagnosis of HTN is not causally or etiologically related to service, and is not caused or aggravated by a service-connected disability. 8. Ulcers were not shown in service and are not otherwise causally or etiologically related to service or service-connected disability. CONCLUSIONS OF LAW 1. The January 2017 rating decision, which denied service connection for tinnitus, is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.156, 20.302, 20.1103 (2020). 2. Evidence submitted to reopen the claim of entitlement to service connection for tinnitus is new and material, and the claim is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156(a) (2020). 3. Tinnitus was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2020). 4. Chronic sinusitis/rhinitis was not incurred in service. 38 U.S.C. §§ 1110, 1131, 5103, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2020). 5. Preexisting pes planus was not aggravated by service. 38 U.S.C. §§ 1101, 1111, 1112, 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309 (2020). 6. A psychiatric disorder, to include PTSD, was not incurred service. 38 U.S.C. §§ 1110, 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2020). 7. HTN was not incurred in service nor may it be presumed to have been incurred in service and is not secondary to a service-connected disability. 38 U.S.C. §§ 1110, 1112, 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2020). 8. Ulcers were not incurred in service nor are they proximately due to or aggravated by a service-connected disability. 38 U.S.C. §§ 1110, 1131, 5103, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In December 2018, the Board remanded the appeal for additional development. The case has now been returned to the Board for further appellate action. New and Material Evidence to Reopen Claim for Tinnitus Prior unappealed rating decisions may not be reopened absent the submission of new and material evidence warranting revision of the previous decision. 38 U.S.C.§ 5108; 38 C.F.R. § 3.156. “New” evidence means evidence “not previously submitted to agency decisionmakers.” “Material” evidence means “evidence that, by itself or when considered with previous evidence of record, related to an unestablished fact necessary to substantiate the claim.” 38 C.F.R. § 3.156(a). Service connection for tinnitus was initially denied in a January 2017 rating decision on the basis that it was not related to service. The Veteran filed a timely notice of disagreement with the January 2017 rating decision and a statement of the case (SOC) was issued in February 2018. However, she did not file a substantive appeal and new and material evidence was not received within one year of the rating action. Therefore, the January 2017 rating decision is final. The evidence added to the record since the January 2017 rating decision is new and material. In this regard, the evidence added to the record includes the Veteran’s statements contending that tinnitus began during service and has been ongoing since service. This new evidence raises a reasonable possibility of substantiating the claim. The credibility of this evidence is presumed for purposes of reopening the claim. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Accordingly, the claim is reopened and will be considered on the merits. Service Connection Claims Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Tinnitus A review of the record reflects that the Veteran has a diagnosis of tinnitus. Specifically, a November 2016 VA treatment record noted that she reported ringing in the ears and the June 2018 VA audio examination reflected that she reported recurrent tinnitus. Based upon this medical evidence, as well as the fact that tinnitus is a disability for which self-diagnosis is appropriate, Charles v. Principi, 16 Vet. App. 370 (2002), a current disability has been shown. As to inservice incurrence, the Veteran’s military occupational specialty (MOS) was yeoman, which has a low probability of noise exposure. However, in her September 2016 claim and in a June 2020 written argument, she reported that she was assigned to an aircraft squadron. As such, noise exposure is conceded. As to a medical nexus, at the June 2018 VA examination, the Veteran reported that tinnitus began during service; however, the examiner opined it was less likely than not caused by or a result of military noise exposure because there was no evidence of tinnitus in service, the Veteran’s MOS had a low probability of noise exposure, there were no threshold shifts in service, and the Veteran’s hearing was normal on current examination. There is no contradictory medical evidence of record. While the Veteran has argued that tinnitus can be present despite a normal audiogram, as noted above, there is no dispute that the Veteran has a current diagnosis of tinnitus and noise exposure in service is conceded. However, she has not submitted any medical evidence in support of the claim that the currently-diagnosed tinnitus is related to noise exposure during service and the only medical opinion of record weighs against the claim. Next, service connection is not warranted based on presumptive service connection. In this regard, the Veteran had no complaints or treatment for tinnitus while in service and the medical evidence does not document complaints of tinnitus until November 2016, after she filed the initial claim. At that time, she did not report any ongoing tinnitus. Moreover, a May 2014 VA general medical examination report specifically reflected that she did not report tinnitus when given the opportunity. Further, while she reported in a December 2019 written argument and at the June 2018 VA audio examination that tinnitus had its onset during service, the service treatment record (STR) do not support this contention. In this regard, the STRs do not reflect any complaints of tinnitus and the February 1993 separation Report of Medical History indicated that she specifically denied ear trouble. Therefore, the evidence does not support a chronic disorder in service or continuity of symptomatology after service. Next, tinnitus was not shown to a compensable degree within one year after service separation does not support the claim. Notably, the objective evidence of record establishes that the Veteran did not have tinnitus within one year of separation from service. As indicated above, the first evidence of any complaint of tinnitus was in November 2016, over 20 years after separation from service. Importantly, although given the opportunity to report tinnitus at the May 2014 VA general medical examination, she did not do so. Moreover, the medical evidence as discussed above undermines the Veteran’s report of continuity of symptomatology. As such, the Board finds the Veteran’s report of ongoing tinnitus since service to not be credible and the medical evidence does not support the claim on any basis. Chronic Sinusitis/Rhinitis The Veteran claims that service connection is warranted for chronic sinusitis or rhinitis. She has not provided any details regarding the basis for this claim except to say that it was present in service. A review of the record does not reflect a current diagnosis of a chronic sinusitis or rhinitis disorder. In this regard, the VA treatment and private treatment records are completely silent for any complaints or findings with respect to chronic sinusitis or rhinitis. In fact, at the May 2014 VA general medical examination, the Veteran was given the opportunity to report sinus problems and did not do so. The Board places significant probative value on the clinical records, which do not show a diagnosis of chronic sinusitis or rhinitis. Further, there is no contradicting medical evidence of record. As such, there is no basis on which to grant service connection for chronic sinusitis or rhinitis. Pes Planus In addition to the laws and regulations outlined above, a veteran is presumed to be in sound condition upon entrance into service, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service, or where evidence or medical judgment is such as to warrant a finding that the disease or injury existed before acceptance and enrollment. 38 U.S.C. § 1111. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). If a disorder is noted, the question is whether it was aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any “increase in disability [was] due to the natural progress of the” preexisting condition. 38 U.S.C. § 1153. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b); Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Moreover, “temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered aggravation in service unless the underlying condition, as contrasted to symptoms, is worsened.” Crowe v. Brown, 7 Vet. App. 238, 247-48 (1994); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). However, the increase need not be so severe as to warrant compensation. Browder v. Derwinski, 1 Vet. App. 204, 207 (1991). As an initial matter, the Veteran was noted to have pes planus upon her initial entry into service. In this regard, a review of the STRs reveals that moderate pes planus was noted on the May 1988 entrance examination. Accordingly, pes planus was noted upon entry into service, the presumption of soundness does not attach, and the claim may only be considered on the basis of aggravation. The STRs are silent as to further complaints, treatment, or diagnoses of pes planus. Further, her feet were found to be clinically normal at the February 1993 separation examination and the Report of Medical History at separation reflected that the Veteran denied foot trouble. Therefore, worsening pes planus was not noted at the time of separation from service. At a May 2017 VA examination, the Veteran reported current foot complaints but did not report any relation to service or any symptoms, complaints or aggravation during service. Specifically, her main complaint was medial arch pain and pain with ambulation. She had orthotics that did not help. The examiner opined that the pre-existing pes planus was not aggravated beyond its natural progression during service. The examiner indicated that the Veteran never complained about her feet during service and the current foot pain was related to improper shoe wear, not pes planus. The examiner also noted that there were no post-service records to indicate any aggravation during service. Based on the above, the medical evidence does not support a finding that pes planus was aggravated by service. While pes planus existed prior to enlistment, it did not worsened in-service. As it did not increase in severity during service, the medical evidence does not support the appeal. Acquired Psychiatric Disorder, to Include PTSD With specific regard to PTSD claims, three elements must be present: (1) a current medical diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a); (2) medical evidence of a causal nexus between current symptomatology and a claimed in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128 (1997). For a disability to be service connected, it must be present at the time a claim for VA disability compensation is filed or during or contemporary to the pendency of the appeal. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). As to the claim for PTSD, the record does not show that the Veteran had been diagnosed with PTSD. To that end, a May 2020 VA examiner specifically found that she did not meet the full criteria for a diagnosis of PTSD. Similarly, VA and private treatment records do not reflect a diagnosis of PTSD. As noted, service connection may only be granted for a current disability. As there is no current diagnosis of PTSD, the medical evidence does not support the appeal. As to an acquired psychiatric disorder other than PTSD, VA treatment records, the VA examination report and private treatment records reflect diagnoses of depressive disorder, anxiety disorder, panic disorder, mood disorder, and insomnia. As such, a current psychiatric disorder other than PTSD has been met. As to in-service incurrence, while there is a single indication of a complaint of anxiety in 1992, there is no psychiatric diagnosis in service, the separation examination noted normal psychiatric examination, and the Report of Medical History for separation purposes indicated that the Veteran denied nervous trouble of any sort, frequent trouble sleeping, and depression or excessive worry. As such, the STRs do not reflect a chronic acquired psychiatric disorder. As to a medical nexus, the Veteran contends that she was raped in service and a buddy statement from her roommate confirms that she reported the rape to her shortly after it occurred. Moreover, the May 2020 VA examiner opined that it was more likely than not that the Veteran experienced military sexual trauma (MST) during service. Thus, the requirement of in-service incurrence has been met. While the Veteran has alleged that her psychiatric disorder is due to this in-service sexual assault, it has not been found to be related to any current psychiatric disorder. Importantly, the medical evidence reflects that the Veteran was not diagnosed with or treated for a psychiatric disability for many years following service. When she began treatment, she did not report any MST until years later, and when she did, she specifically denied experiencing any problems due to the MST. As such, the weight of the medical evidence is against the claim. Notably, the VA and private treatment records showing a current diagnosis do not reflect any nexus to service. Instead, at the May 2020 VA examination, the Veteran denied any problems related to the MST. In this regard, she indicated that she did not feel that her insomnia was related to the trauma because she was able to sleep after the trauma until 2005. Further, the examiner noted that the Veteran’s self-reports for potential etiology of her current mental health symptoms varied considerably over time, with attribution of her mental health problems directly toward MST being a relatively recent development. Previously, she attributed symptoms to her 2008 hysterectomy. Further, the examiner indicated that over time, various life stressors contributed to the fluctuations in the state of her mental health. Based on a thorough review and recitation of the VA treatment records in the claims file and examination of the Veteran, the VA examiner opined that it was less likely than not that the Veteran’s acquired psychiatric diagnoses were related to service. There is no contrary medical opinion of record. A review of the VA treatment record dating from 2013 to the present specifically reflected multiple stressors contributing to depression, anxiety and insomnia, including the death of her mother, the death of her brother, relocation/moving, falling out with her family, and being a single mother of three children. Importantly, a February 2013 VA treatment record indicated that the Veteran reported that her anxiety began in 2008 after her hysterectomy and insomnia began in 2005. She specifically denied any problems related to the MST she had experienced in service, stating that she did not feel that her insomnia was related to the MST because she was able to sleep fine after it occurred up until 2005. A March 2013 VA treatment record indicated that she did not know where her anxiety and insomnia came from except that it had been since 2003 that she had been able to sleep. In addition, private treatment records dated in November 2005 reflected that the Veteran was diagnosed with insomnia and generalized anxiety disorder. It was indicated that she complained of difficulty sleeping and difficulty getting rest after a night sleep. It was also noted that she was going to donate kidney to her brother, and her insomnia was mainly due to her preoccupation with the household and taking care of her three children. An October 2007 private treatment record reflected that the Veteran had seasonal affective disorder. Further private treatment records dating through July 2010 show ongoing anxiety and depression symptoms and treatment, but no indication of any relationship to service. Importantly, when she began seeking treatment for her mental health conditions, she did not relate any problems related to service and when asked, she generally denied any problems related to MST, as she stated she had no problems sleeping after the MST until 2003. Additionally, she related her mental health concerns to other stressors. Finally, there is no evidence in the medical record that she has any mental health diagnosis related to MST. Consequently, the medical evidence tends to undercut any argument that she has experienced ongoing psychiatric symptoms since her MST in service. Her post-service statements to medical professionals as described above are highly probative and have the hallmarks of truthfulness as they were made for purposes of receiving medical treatment. These records, coupled with the May 2020 VA examiner’s opinion, are highly probative. Therefore, the medical evidence weighs against the claim. HTN The Veteran contends that HTN is secondary to her acquired psychiatric disorder to include PTSD. While the VA and private treatment records reflect a current diagnosis of HTN, in this decision service connection has been denied for an acquired psychiatric disorder to include PTSD. As such, there is no basis on which to award service connection for HTN on a secondary basis. As to presumptive service connection, HTN was not shown in service. Review of the STRs fails to show complaints of, treatment for, or diagnosis of hypertension, or any symptoms reasonably associated with high blood pressure in service. Notably, blood pressure readings were normal and at service separation the blood pressure reading was 98/62. The Report of Medical History at separation reflected that the Veteran denied high blood pressure. There is also no medical evidence indicating that HTN was present within one year of separation from service. Instead, the medical evidence reflects that blood pressure was normal until August 2007. The private treatment records reflected that HTN was not diagnosed until 2008. Therefore, the evidence does not support service connection on a chronic in-service basis or within one year of service basis. Next, continuity of symptomatology has not been shown. Importantly, private treatment records do not reflect any evidence of high blood pressure until August 2007 and HTN was first diagnosed in 2008, some 15 years after discharge. At that time, there was no evidence or complaint of ongoing symptoms since service. Based on these considerations, the evidence does not support service connection on a presumptive basis. Further, as indicated above, the medical evidence does not reflect complaints of, treatment for, or a diagnosis of HTN in service and a February 2014 Gulf War Registry examination report indicated that hypertension was not related to Gulf War exposure. In sum, the medical evidence does not support service connection on any basis. Ulcers The record reflects a diagnosis of ulcers. In this regard, the May 2014 VA examination report contains a diagnosis of gastritis and ulcer, unknown type. As such, the first element of service connection has been met. As to inservice incurrence, the STRs do not reflect any complaints, findings or diagnoses related to ulcers/gastritis. Therefore, the second element of direct service connection has not been met. To the extent that the Veteran asserts a medical nexus between ulcers and service, the May 2014 VA general medical examination report indicated that she reported experienced epigastric distress during service and being diagnosed with ulcers shortly after service. The examiner noted that the STRs did not reflect any symptoms associated with gastritis or ulcer. The examiner stated that because the Veteran stated that she had symptoms in service and was diagnosed shortly after service, but there is no documentation of such, it was difficult to ascertain whether ulcers occurred during service. The examiner indicated that additional treatment records, especially the EGD or other studies conducted to diagnose ulcers, would be helpful. In a July 2020 VA addendum opinion, the clinician opined that the Veteran’s gastritis/ulcer were less likely than not to have been incurred during service. The clinician indicated that there were no studies/labs/procedures or other objective findings to confirm a diagnosis of gastritis or ulcers in the STRs. Moreover, there were no related complaints, evaluation or treatment in service and the separation examination report was silent for esophageal, stomach, liver, or intestinal troubles. The clinician reasoned that ulcers were diagnosed through endoscopy or X-ray series and laboratory tests for H. Pylori. Further, the clinician stated that even though the term gastritis is often used to describe “stomach discomfort,” the medical term gastritis was made by a pathologist when there was evidence of inflammation and damage to the stomach lining when seen in a biopsy during an upper endoscopy. This evidence weighs against the appeal. To the extent that the Veteran asserts ulcers are related to an acquired psychiatric disorder, to include PTSD, the psychiatric appeal has been denied. As such, there is no basis on which to grant service connection for ulcers on a secondary basis. As such, the medical evidence does not support the claim. Persian Gulf War VA regulations provide for relaxed evidentiary requirements in cases for veterans with military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War era, if they develop a qualifying condition during such service or within a certain time period thereafter. See 38 C.F.R. § 3.317. The Board notes that specific presumptive service connection is available to Veterans who served during the Persian Gulf War and exhibit objective indications of a qualifying chronic disability that manifested during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. See 38 U.S.C. § 1154 (2012); 38 C.F.R. § 3.317 (a)(1). For the purposes of presumptive service connection based upon the Persian Gulf War, Southwest Asia refers to Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 U.S.C. §§ 1117, 1118 (2012); 38 C.F.R. § 3.317(e). The Veteran served during the Persian Gulf War Era. She had no foreign service but did have seven months of sea service, and she received a Southwest Asia service medal. In her February 2017 claim for service connection for pes planus and sinusitis/rhinitis, she indicated that she served in Diego Garcia. The RO indicated that Diego Garcia was in the Indian Ocean and not the Southwest Asia Theater of Operations. In any event, 38 C.F.R. § 3.317 only applies to qualifying diseases. Because the Veteran’s claimed disabilities (tinnitus, HTN, ulcers, acquired psychiatric disorder to include PTSD, pes planus and sinusitis/rhinitis) were diagnosed diseases with at least partially understood etiology and pathophysiologies, they do not qualify as an undiagnosed illness or medically unexplained chronic multi symptom illness (MUCMI) to allow for consideration under these provisions. See 38 C.F.R. § 3.317 (a)(2). Further, a February 2014 VA Gulf War Registry examination report indicated that the Veteran did not have any health conditions which were related to Gulf War exposure. Therefore, the claims cannot be granted under this theory. As to all the appeals, the Board has considered the Veteran’s lay statements that her disorders were caused by service. She is competent to report symptoms because this requires only personal knowledge as it comes to her through her senses; however, she is not competent to offer an opinion as to the diagnosis of any claimed disorder or the etiology of her current disorders due to the medical complexity of the matter involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to her statements. In light of the above, the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (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). REASONS FOR REMAND CFS. Post-service VA and private treatment record contains various diagnoses of fatigue or chronic fatigue related to insomnia and depression/anxiety and a July 2014 VA treatment record noted a diagnosis of chronic fatigue related to use of Xanax; however, there is only a single diagnosis of CFS, which was noted in a May 2008 private treatment record. The Veteran filed her claim for service connection for CFS in 2013 and as such, there is no current diagnosis during the period of the claim. Nonetheless, given the unclear nature of whether the Veteran has a confirmed current diagnosis of CFS, further development is needed to ascertain whether her sea service qualified as service in the Southwest Asia theater of operations. In this regard, while the RO has already determined that her service in Diego Garcia does not qualify as such service, the record reflects that she served in Diego Garcia from late 1992 to early 1993 yet her DD-214 reflects 7 months of sea service. Therefore, additional development is needed to make a formal determination as to whether the Veteran qualifies as a Persian Gulf veteran. If the Veteran is found to qualify as a Persian Gulf veteran under 38 C.F.R. § 3.317(e), an examination is needed to determine whether she has a diagnosis of CFS or whether her chronic fatigue symptoms can be attributed to a known diagnosis (and if so, whether such disability is related to service) or, if they represent manifestations of an undiagnosed illness or a MUCMI. Endometriosis, Hysterectomy, Ovarian/Uterine Cysts, PE. The Veteran claims that endometriosis and uterine/ovarian cysts were manifested during service as vaginal infections, abnormal pap smears, and cramping, that a hysterectomy was a result of endometriosis, and that the PE was secondary to the hysterectomy. In support of her claims she submitted a medical article which indicated that endometriosis symptoms include painful periods, pelvic pain, gastrointestinal symptoms, urinary tract problems, and overall fatigue. Furthermore, it stated that endometriosis sufferers tend to have frequent vaginal yeast infections. A May 2014 VA examination reflected there was no diagnosis of endometriosis in the record; however, diagnoses were noted in April 2005 and surrounding her December 2007 hysterectomy. In a May 2019 addendum opinion stated that endometriosis was not incurred in service or caused by an in-service event, injury or illness. The clinician found that there was no evidence of endometriosis by history or review of the service records, and even if there was endometriosis could not be caused by injury, event, or illness. However, the clinician did not provide a thorough rationale nor address the numerous STRs showing various gynecological complaints and explain why those various in-service complaints and findings were not indicators or early symptoms of endometriosis or uterine/ovarian cysts. Further, the clinician incorrectly stated that there was no evidence of cervical cancer in the record. Therefore, a remand for another opinion is required. In addition, in the June 2013 claim the Veteran indicated that endometriosis, hysterectomy and uterine/ovarian cysts were due to environmental hazards during the Persian Gulf War. Therefore, while on remand, if the RO determines that the Veteran qualifies as a Persian Gulf veteran, an opinion should be obtained as to this theory of the claim. The matters are remanded for the following: 1. Make a determination as to whether the Veteran’s sea service qualifies as service in the Southwest Asia theater of operations pursuant to 38 C.F.R. § 3.317(e). 2. If and only if the Veteran qualifies as a Persian Gulf veteran pursuant to 38 C.F.R. § 3.317(e), schedule her for an examination in order to determine whether she has a diagnosis of CFS. The examiner should review the claims file, to include a copy of this remand. After review and examination of the Veteran the examiner should provide an opinion as to whether the Veteran has a current diagnosis of CFS. If the Veteran’s chronic fatigue symptoms cannot be attributed to a known clinical diagnosis such as CFS, the examiner is asked to address the follow: • whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s symptoms are the result of an undiagnosed illness or medically unexplained chronic multi-symptom illness etiologically related to service in Southwest Asia. A complete rationale for all stated opinions must be provided. 3. Provide the claims file, to include a copy of this remand, to a clinician in order to obtain an addendum gynecological opinion. The clinician is asked to review the claims file, to include review and discussion of the STRs showing extensive complaints/findings vaginal infections, painful periods/dysmenorrhea, cramping, possible urinary tract infections and diagnoses of gonorrhea, as well as the medical article submitted in November 2015 (entitled The Link Between Candida and Endometriosis), stating that endometriosis sufferers tend to have bloating, constipation, diarrhea, CFS, urinary ailments, and vaginal yeast infections. The examiner should then provide an opinion as to the following: • whether it is at least as likely as not that the Veteran’s endometriosis and/or uterine/ovarian cysts had their onset in service (manifested as the gynecological symptoms noted above as being present in service), or • whether the endometriosis and/or uterine/ovarian cysts are otherwise causally or etiologically related to service, to include the gynecological symptoms noted above as being present in service. If the RO determines that the Veteran qualifies as a Persian Gulf veteran pursuant to 38 C.F.R. § 3.317(e), the clinician is asked to address the following: • whether it is at least as likely as not that the Veteran’s endometriosis and/or uterine/ovarian cysts are the result of an undiagnosed illness or medically unexplained chronic multi-symptom illness etiologically related to her service in Southwest Asia. A complete rationale for all opinions stated must be provided. 4. If the clinician determines that an examination is necessary in order to provide the requested opinions, then one should be scheduled. L. HOWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Redman, 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.