Citation Nr: 21061343 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 09-18 419 DATE: October 1, 2021 ORDER Entitlement to service connection for a cardiovascular disability, to include Long QT Syndrome, claimed as Gulf War Illness (GWI), is denied. Entitlement to service connection for a disability manifested by neuropsychological symptoms (also described as dysthymia with anxiety and physical symptoms), to include somatoform disorder, is denied. Entitlement to service connection for chronic fatigue syndrome (CFS) or chronic fatigue immune dysfunction syndrome (CFIDS), also claimed as GWI, is denied. Entitlement to service connection for fibromyalgia, also claimed as GWI, to include the claim of entitlement to service connection for disability manifested by muscle and joint pain and/or wasting, is denied. Entitlement to service connection for cytomegalovirus (CMV) and Epstein-Bar virus (EBV) is denied. Entitlement to service connection for hypothyroidism, to include as secondary to CFS or CFIDS, is denied. Entitlement to service connection for mycoplasma, to include as secondary to CFS or CFIDS, is denied. Entitlement to service connection for headaches (as a primary diagnosis), to include migraines, is granted. Entitlement to service connection for a disability manifested by pituitary dysfunction, also claimed as GWI, is denied. Entitlement to service connection for a disability manifested by deficiencies or imbalances in growth hormone, progesterone, estrogen, DHEA, testosterone, and pregnenolone, also claimed as GWI, is denied. Entitlement to service connection for a disability or disabilities manifested by low natural killer cell function, elevated RNA-S-L, also claimed as GWI, is denied. Entitlement to service connection for a disability or disabilities manifested by hypercoagulation state, systemic fungus, hypoglycemia, elevated angiotensin II, skin symptoms, neurological symptoms, sleep disturbances, and abnormal weight loss, also claimed as GWI, is denied. Entitlement to service connection for a respiratory disability, to include chlamydia pneumonia, to include as secondary to CFS or CFIDS, is denied. Entitlement to service connection for a disability manifested by menstrual disorders/vaginitis, also claimed as GWI, is denied. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. Entitlement to special monthly compensation based on the need for regular aid and attendance or at the housebound rate is remanded. FINDINGS OF FACT 1. The Veteran did not serve in the Southwest Asia theatre of operations during the Persian Gulf War. 2. The Veteran does not have a cardiovascular disability, to include Long QT Syndrome, that is related to service, to include in-service vaccinations. 3. The Veteran does not have a current disability that is manifested by neuropsychological symptoms, dysthymia with anxiety and physical symptoms, or a somatoform disorder. 4. The Veteran did not have CFS or CFIDS during service and neither diagnosis is related to service to include in-service vaccinations. 5. The Veteran did not have fibromyalgia during service, to include disability manifested by muscle and joint pain and/or wasting, and it is not related to service to include in-service vaccinations. 6. CMV and EBV were not manifested during service or for several years after and are not shown to be related to service or any incident therein, to include in-service vaccinations. 7. Hypothyroidism did not manifest during service and the Veteran does not have a current diagnosis of hypothyroidism that is related to service to include in-service vaccinations, and CFS or CFIDS are not primary disabilities related to service. 8. Mycoplasma did not manifest during service and the Veteran does not have a current diagnosis of mycoplasma that is related to service to include in-service vaccinations, and CFS or CFIDS are not primary disabilities related to service. 9. After resolving reasonable doubt, the Veteran has recurrent headaches since she separated from service in April 1991. 10. The Veteran does not have a disability manifested by pituitary dysfunction that began in service or is related to service, to include in-service vaccinations. 11. The Veteran does not have a disability manifested by deficiencies or imbalances in growth hormone, progesterone, estrogen, DHEA, testosterone, and pregnenolone, that began during service or is related to service to include in-service vaccinations. 12. The Veteran does not have disability manifested by low natural killer cell function or elevated RNA-S-L that began in service or is related to service, to include in-service vaccinations. 13. The Veteran does not have a disability manifested by hypercoagulation state, systemic fungus, hypoglycemia, elevated angiotensin II, skin symptoms, neurological symptoms, sleep disturbances, and abnormal weight loss that began in service or is related to service, to include in-service vaccinations. 14. The Veteran does not have a current respiratory disability, to include chlamydia pneumonia, that is related to service to include in-service complaints or vaccinations, and CFS or CFIDS are not primary disabilities related to service. 15. The Veteran does not have a disability manifested by menstrual disorders/vaginitis that began in service or is related to service, to include in-service vaccinations. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a cardiovascular disability, to include Long QT Syndrome, have not been met. 38 U.S.C. §§ 1110, 1131, 1117, 5107(b); 38 C.F.R. §§ 3.303, 3.317. 2. The criteria for entitlement to service connection for a disability manifested by neuropsychological symptoms (also described as dysthymia with anxiety and physical symptoms), to include somatoform disorder, have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303. 3. The criteria for entitlement to service connection for CFS or CFIDS have not been met. 38 U.S.C. §§ 1110, 1131, 1117, 5107(b); 38 C.F.R. §§ 3.303, 3.317. 4. The criteria for entitlement to service connection for fibromyalgia, to include the claim of entitlement to service connection for disability manifested by muscle and joint pain and/or wasting, have not been met. 38 U.S.C. §§ 1110, 1131, 1117, 5107(b); 38 C.F.R. §§ 3.303, 3.317. 5. The criteria for entitlement to service connection for CMV and EBV have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303. 6. The criteria for entitlement to service connection for hypothyroidism, to include as secondary to CFS or CFIDS, have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310. 7. The criteria for entitlement to service connection for mycoplasma, to include as secondary to CFS or CFIDS, have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310. 8. The criteria for entitlement to service connection for headaches, as a primary diagnosis, to include migraines, have been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310. 9. The criteria for entitlement to service connection for a disability manifested by pituitary dysfunction have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310. 10. The criteria for entitlement to service connection for a disability manifested by deficiencies or imbalances in growth hormone, progesterone, estrogen, DHEA, testosterone, and pregnenolone have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310. 11. The criteria for entitlement to service connection for a disability or disabilities manifested by low natural killer cell function, elevated RNA-S-L have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310. 12. The criteria for entitlement to service connection for a disability or disabilities manifested by hypercoagulation state, systemic fungus, hypoglycemia, elevated angiotensin II, skin symptoms, neurological symptoms, sleep disturbances, and abnormal weight loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310. 13. The criteria for entitlement to service connection for a respiratory disability, to include chlamydia pneumonia, to include as secondary to CFS or CFIDS, have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310, 3.310. 14. The criteria for entitlement to service connection for a manifested by menstrual disorders/vaginitis have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the Reserve and had periods of active duty from April 1989 to September 1989 and from November 1990 to April 1991. This appeal to the Board of Veterans' Appeals (Board) is from a September 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran had a hearing before a Veteran Law Judge in October 2009; a transcript of the hearing is in the record. These matters were before the Board several times before a decision that denied 12 issues and remanded four was issued in March 2014. Regarding the 12 issues that were denied, the Veteran appealed the denials to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a March 2015 Joint Motion for Partial Remand (JMPR), the Court vacated the portion of the decision that denied 12 of the Veteran's claims and remanded them to the Board for additional development. After the case was returned to the Board, the Veteran was notified that the Veterans Law Judge who held her October 2009 hearing was no longer employed at the Board and she given the opportunity to have another hearing, which she accepted. The case was remanded in July 2015 to schedule a hearing. In April 2016, the Veteran testified during a Travel Board hearing that was held before the undersigned; a transcript is of record. During the April 2016 Board hearing, the Veteran suggested that the issues on appeal be recharacterized. As the Board noted in the previous March 2014 decision and remand, a full explanation as to the reorganization and recharacterization of the issues on appeal was provided in the January 2013 Board remand. Moreover, the Board reiterates that each of the disabilities on appeal is characterized in broad and inclusive terms, and consideration has been given to all diagnoses raised on the record. Following the April 2016 hearing, the Board remanded the case in July 2016 and November 2020. The Board also reiterates what was stated in the July 2016 remand regarding the Veteran's suggestion that the issues should include "service connection for gastrointestinal signs or symptoms" and "service connection for abnormal weight loss." The Board noted that irritable bowel syndrome (IBS) is already service connected and that pyramiding of disabilities is to be avoided under 38 C.F.R. § 4.14. The Board noted that since gastrointestinal signs or symptoms, including weight changes appeared to be contemplated in rating IBS, the rating of which is not before the Board, no issues will be added at this time relating to gastrointestinal signs or symptoms of weight loss. Service Connection: Law Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest 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. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. For purposes of section 3.317, there are two types of qualifying chronic disabilities: (1) an undiagnosed illness, and (2) a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2). A MUCMI is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome, (2) fibromyalgia, and (3) functional gastrointestinal disorders (excluding structural gastrointestinal disease). The term MUCMI means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2). A Persian Gulf veteran is defined as a veteran who served on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War. See 38 U.S.C. § 1117(f); 38 C.F.R. § 3.317(e). Pursuant to 38 C.F.R. § 3.310(a), service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. at 448 (1995). The Board, as fact finder, must determine the probative value or weight of the admissible evidence. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005) (citing Elkins v. Gober, 229 F.3d 1369, 1377 (Fed. Cir. 2000)). Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the Board discuss every piece of evidence in the record. Rather, the Board will summarize the relevant evidence, as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). JMR Errors Prior to addressing the merits of the claims, the Board will address errors that were noted in the March 2015 JMPR to show compliance. The parties noted that the Veteran reported undergoing blood tests in 1995 or 1996 as part of a clinical trial conducted by Dr. Frederick Petty at the "VA Dallas Healthcare Center." She believed these records would be pertinent to her claims. The JMPR also pointed out that the Veteran reported receiving disability retirement from a U.S. Navy civilian position. The Veteran also identified private treatment records from Dr. Mehdi and Dr. Gerge. The Board was directed to obtain authorization from the Veteran to obtain these records. The JMR found the Board also erred by not addressing the Veteran's request to obtain a specialist opinion from Dr. Nancy Klimas. See March 2015 CAVC Decision. In the July 2016 remand, the Board addressed the above deficiencies by requesting the VA medical records associated with the clinical trial in the 1995/1996 timeframe, the Navy civilian disability retirement records, signed releases for identified private treatment records, and inviting the Veteran to solicit a specialist opinion from Dr. Klimas. See July 2016 BVA Decision. April 2020 correspondence laid out the efforts VA made to obtain the VA Medical Center records; these efforts were unsuccessful. See April 2020 Correspondence. Attempts were also made to obtain the records directly from Dr. Petty. In May 2020, the Veteran stated that the participants of the 1995/1996 clinical trial were anonymous and the results of the trials were published in the form of abstracts in peer-reviewed publications. Thus, the Board finds that despite the efforts to obtain her lab work as part of the trial, they were not and could not be obtained. With regard to the disability retirement records, a March 2018 response informed the Veteran that she had to provide the name and address of the physician of her choice who would receive the records, as they were not permitted to release them to anyone other than a physician. In her March 2018 correspondence to VA, which included the aforementioned letter, she indicated that she expected VA to provide a doctor's signature and make the request. See March 2018 Correspondence. The record shows VA made multiple attempts to obtain her disability retirement records from OPM; however, all were unsuccessful. See June 2020 and August 2020 Correspondence. In February 2021, the Veteran stated she first submitted these records in December 2006 and then twice in 2016, and that she would make no further requests to OPM for records. Regarding Dr. Klimas, the Veteran has not responded to the invitation to obtain a medical opinion from this specialist. The Board recognizes that the Veteran asked the Board to obtain an opinion, but such a request is outside the scope of the Board's authority to request development of the claim. Under 38 U.S.C. § 7109, the Board has authority to obtain an independent medical opinion from a medical expert outside of the Department; however, subsection (b) specifically provides that any such arrangement shall provide that the actual selection of the expert or experts to give the advisory opinion in an individual case shall be made by an appropriate official of such institution. Hence, the Board is not authorized to hand pick the expert from whom the opinion is sought. Finally, August 2016 correspondence asked the Veteran to complete and submit releases for the private providers identified in the JMR; however, the Veteran has not returned the completed releases. The Board notes that during her April 2016 hearing, the Veteran stated that she did not necessarily want VA to get her private records unless she has seen them because she did not know what they said. She stated that she would get the records first and then submit them. Contentions regarding applicability of 38 C.F.R. § 3.317 The Veteran has submitted many statements during the course of her appeal and with regard to her contentions, her assertions have been that while she was not deployed to the Persian Gulf, she received vaccinations in preparation for such deployment and handled equipment that was returned from the Persian Gulf, and as a result she believes many of her diagnoses are a direct result of either or both events and fall within the scope of a Gulf War Illness (GWI). See January 2007 Correspondence, June 2007 Hearing Testimony, October 2009 Hearing Testimony, September 2012 Correspondence, and April 2016 hearing Testimony. The Veteran has also repeatedly referred to "Public Law 107-103" as the basis for her claim and that all of her disabilities are presumptive. See January 2007 Correspondence and June 2007 Hearing Transcript, August 2008 NOD, and October 2008 Correspondence. This is a reference to the Veterans Education and Benefits Expansion Act of 2001, Public Law N. 107-103, 115 Stat. 976, which contains, among other things, new provisions relating to Persian Gulf veterans. The implementing regulation, 38 C.F.R. § 3.317, was amended to include presumptive service connection for medically unexplained chronic multi-symptom illnesses. The Veteran's service personnel records show she did not serve in the Southwest Asia theater of operations as defined by law and regulation, and this is a fact that she does not dispute. See April 1992 Certificate of Release or Discharge From Active Duty, October 2016 Medical Treatment Record Government Facility, and December 2016 Correspondence; 38 U.S.C. § 1117(a)(1)(A); 38 C.F.R. § 3.317(e)(1), (2). As such, she does not meet the definition of a Persian Gulf veteran and, despite her reported exposure to equipment that came from the Southwest Asia theatre of operations, she still does not fit the definition. There is no presumption for "secondary exposure" to those who served in the Southwest Asia theatre of operations as defined per law and regulation. As the Veteran is not a Persian Gulf veteran, service connection cannot be considered under 38 C.F.R. § 3.317. See 38 C.F.R. § 3.317(a)(1), (e). Additionally, the Board notes that there are references to "Gulf War Illness/GWI" and "Gulf War Syndrome/GWS" in this decision. However, the terms recognized by VA for compensation and pension purposes pertaining to disability that may be related to service in Southwest Asia theater of operations are defined as qualifying chronic disability including an undiagnosed illness and medically unexplained chronic multisymptom illness. 38 C.F.R. § 3.317(a)(2). References to GWI and GWS were maintained in this decision to more accurately reflect the Veteran's contentions and to more accurately report findings made by medical providers. Statements Regarding the Evidence and Records The Veteran has also made many statements to the effect that a multitude of errors exist in service treatment records, VA medical records, and even some private treatment records that include, but are not limited to, incorrect information, misdiagnoses, and falsified information. Some of these statements are found in June 2008, May 2009, September 2009, and April 2011 correspondence where she identified what she believed was incorrect information in VA examination reports, to include a September 1992 VA examination that she indicates did not convey what was said because the report was written in "Ebonix;" a misdiagnosis of panic attacks by Dr. Grandjean; and the Medical Evaluation Board (MEB) was deficient in kind and excluded physician notes on her weekly physical training profiles. She also stated in September 2012, that most Army and VA C&P physicians lie for their own convenience. To a large extent, the Veteran has not provided any support for her assertions. While she has strong opinions as to what the evidence shows and appears to have done a lot of research based on the number of articles and excerpts she refers to, she is not a physician and not competent to "correct" the diagnoses of medical professionals. Regarding symptoms, the Veteran is competent to report them. Layno v. Brown, 6 Vet. App. 465 (1994). However, the Board does not find her statements regarding such widespread errors and the falsification of documents regarding her symptoms to be credible. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). There is no probative evidence of record to support her allegations of widespread errors and falsification of documents. Thus, her statements regarding misdiagnoses and falsifications are not probative. Regarding her assertion that VA and the Board, in particular, have acted in self-interest and have lied, there is no support for her assertion. The Board is charged with the principal functions to make determinations of appellate jurisdiction, consider all applications on appeal properly before it, conduct hearings on appeal, evaluate the evidence of record, and enter decisions in writing. The Board is bound by applicable statutes, regulations of the Department of Veterans Affairs, and precedent opinions. See 38 C.F.R. §§ 19.4, 19.5. She has offered no evidence that the Board has been remiss in performing its duty. The Board notes that the Veteran asserts that no VA clinician or fee-based physician is qualified to offer opinions for her case. In November 2011, she stated that the VHA specialist relied upon old government propaganda and that none of the Army, VA, or VHA physicians know how to read specific tests. During her April 2016 hearing, she also stated that VA doctors relied on studies that were outdated and obsolete. See November 2011 Third Party Correspondence and April 2016 Hearing Testimony. Along with his August 2011 expert VHA opinion, Dr. Casillas provided a summary of his education, experience, and training. See June 2011 Third Party Correspondence. There is nothing in his background to suggest that he was not qualified to provide the requested opinion. With regard to VA examiners, the Veteran's blanket assertion that all VA clinicians, in general, are incompetent is not sufficient to challenge any particular examiner's qualifications to offer an opinion with regard to her claims. Thus, to the extent each clinician identified themselves as a psychologist, psychiatrist, physician, etc., the Board finds this is sufficient qualification to provide the requested opinions. The Veteran also requested during her April 2016 Board hearing that the opinions of her private physician, Dr. Kippels should be afforded greater probative value than the opinions VA obtained. A broad application of a treating physician rule (giving greater weight to opinions of treating physicians) has been explicitly rejected as applying to VA claims. See White v. Principi, 243 F.3d 1378, 1381 (Fed. Cir. 2000). The Board is tasked with taking a more objective approach by weighing the evidence and considers multiple factors in weighing the evidence. A medical opinion is afforded substantial weight when it is factually accurate, fully articulated, and has sound reasoning for the conclusion; it is not just the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), Stefl v. Nicholson, 21 Vet. App. 120 (2007). The probative value of medical evidence is based on the examiner's knowledge and skill in analyzing the data, and the medical conclusion the examiner reaches; as it true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). Factual Background A July 1988 applicant medical pre-screening form shows the Veteran's weight was 103 pounds with a maximum weight of 134 pounds. See August 2015 STR Medical The July 1988 enlistment medical history report for Reserve service shows the Veteran only reported having ENT problems, hay fever, and an adverse reaction to serum, drugs, or medicine. She offered an explanation by listing the medications she was allergic to, noting a tonsillectomy at age 16, and reporting seasonal hay fever. She had no treatment for any female disorder and no change in menstrual patterns. The date of her last menstrual period was in July 1988, and her last pregnancy with elective abortion was one year earlier with no complications. See August 2015 STR Medical. Her August 1988 Reserve enlistment exam shows that under the category for body marks and scars, there is a notation of left arm vaccine. She had a recorded weight of 102 pounds and the rest of her examination was negative for any findings. See August 2015 STR Medical. During her first period of active duty from April 1989 to September 1989, she received vaccines on May 3, 1989 that consisted of oral poliovirus, rubella, and smallpox. A June 1989 treatment record shows she reported having problems with her feet, ankles, and knees and that she had extremity pain for three weeks. The assessment was probable muscle strain, PFS (patellar femoral syndrome), and plantar fasciitis. Later in June 1989, she complained of difficulty breathing, chest congestion, productive yellow phlegm, bilateral knee pain, and fever. The symptoms had been present for one day and the assessment was bronchitis. In August 1989, she reported having upper abdominal pain with diarrhea and one episode of vomiting. She also had body chills for one week. The diagnosis was viral syndrome. See August 2015 STR Medical. An April 1990 note from Dr. C. Rutherford stated the Veteran was under his care and that she was restricted from running, sit-ups, or push-ups for three weeks. Although the problems she was being treated for are not shown, the Board notes that he was in an orthopedic practice. A May 1990 note from Dr C. Rutherford says the Veteran had a knee contusion and effective that day she was not able to participate in an upcoming running test due to her knee injury. See August 2015 STR Medical. A May 1990 treatment record from Dr. L. Robinson states she underwent a dilation and curettage and a laparoscopic tubal ligation. The findings revealed a normal uterus. A tissue sample that was taken from her uterus showed proliferative endometrium; there was no evidence of endometrial hyperplasia, endometritis, or malignancy. See May 2014 Medical Treatment Record Non-Government Facility. A September 22, 1990 Statement of Medical Exam from the Medical Brigade to Fort Hood shows that she was admitted on this date with a history of illness that consisted of a mild upper GI bleed from Mallory Weiss tear and a possible staph of food poisoning. The Veteran was on inactive duty for training (INACDUTRA) on September 22, 1990 and had eaten at the mess facility on the day of admission. After finishing her duty for the day, she vomited a lot of the water she had consumed since lunch as well as the remainder of her meal. After she went home, she vomited each time she attempted to drink water. She began to notice increased amounts of blood and less food and water. When her temperature began to rise, she went to the ER where she vomited more blood and water. Her temperature and white blood count rose, and explosive uncontrolled diarrhea set in. She was admitted overnight due to dehydration and was given an IV and medicine to stop pain and nausea. The last of her vomiting consisted of blood clots, and diarrhea ended a few days later. She was discharged three days later. She missed 3 days of Reserve duty and 6 days of civilian work. See October 2016 Military Personnel Record. During her private hospitalization, Dr. Rasheed ordered X-rays and an ultrasound of the abdomen that were unremarkable and an upper GI endoscopy that revealed upper GI bleeding secondary to a Mallory-Weiss tear; Adson-Clark lesion; and symptoms consistent with food poisoning secondary to staph; the pyloric channel, duodenal bulb, and second portion of the duodenum were normal and unremarkable. An iron profile would be obtained in view of the low serum iron. An abdominal sonogram would be obtained to rule out the possibility of cholelithiasis. September 1990 lab work for the Veteran's stool showed that no ova or parasites were found. See August 2015 STR - Medical. A September 1990 note from Dr. Rasheed states that the Veteran had been admitted with severe gastroenteritis probably secondary to food poisoning. She had improved but still felt weak, so he advised that her physical training be postponed for the current month and that she could attend the next month. He also ordered lab work and the report shows that with the exception of glucose, all values were within the reference ranges. See October 2016 Medical Treatment Record Non-Government Facility. The Veteran had a second period of active duty from November 1990 to April 1991. During that time Dr. Rasheed wrote a note dated in November 1990 that states the Veteran had IBS and was symptomatic from constipation and diarrhea. She was also quite sensitive to some food and might not tolerate M.R.E. foods. See September 1992 Third Party Correspondence. She had medical in-processing on November 21, 1990 and her weight was recorded as 100 pounds. On that same day she was given the tetanus-diphtheria toxoids vaccine, Influenza vaccine, and hep#1 vaccines. Five days later, on November 26, 1990, the Veteran reported having a three month history of GI dysfunction and that she had problems ever since she had food poisoning. She reported having nausea and diarrhea three days earlier and constipation the day before. A November 29, 1990 record shows she was seen as follow-up for complaints of GI distress and diarrhea and extreme nausea since the previous night. The Veteran reported having chills and sweats after taking medication given to her. The assessment was IBS. She was sent to quarters for 48 hours. See August 2015 STR Medical. A December 4, 1990 physical profile notes a medical condition of rule out IBS and that she was very symptomatic. The temporary profile was in effect until the end of January 1991 and it did not restrict her from various exercises including jogging in place. She was unable to deploy at that time. A December 13, 1990 service treatment record notes her nausea had improved and that she had been without diarrhea for five days before it returned. She could not perform PT. See August 2015 STR Medical. In February 1991, the Veteran complained of sinus infection; her symptoms were nasal congestion, sore throat, and greenish discharge from nose. The assessment was acute rhinitis with sinusitis. See August 2015 - STR Medical. A February 13, 1991 summary from the Medical Evaluation Board (MEB) includes a past medical history that indicates that as an adolescent the Veteran had problems with severe diarrhea, weight loss, and constant nausea. The history of her present illness notes she was healthy until September 22, 1990 when, during her monthly drill for the Reserve service, she developed food poisoning. Since coming out of the hospital she continued with constant nausea that increased with food intake. She stated it was accompanied by cramps and chronic low back pain and intermittent diarrhea and constipation. She denied history of hepatitis, fevers, or sweats. The Veteran lost approximately 10 pounds since this had started. On physical examination, she was slightly underweight, and her heartbeat was regular without murmur or S3. There is laboratory data from outside the military system, as well as data from the military system, and she had been worked up by Dr. Rasheed. Stools for ova and parasites were also negative in October 1990. Abdominal ultrasound and X-rays were normal. An endoscopy revealed a Mallory-Weiss tear without evidence of peptic ulcer disease and symptoms consistent with food poisoning secondary to staph on that occasion. Upper GI with small bowel follow-through showed an unremarkable study except for a rapid transit time throughout the small bowel. The final diagnosis was IBS. See August 2015 STR Medical. The Veteran's February 14, 1991 separation medical history report shows the Veteran wrote "I'm in fair health." She also provided negative responses for frequent or severe headaches; dizziness or fainting spells; thyroid trouble; pain or pressure in chest; frequent trouble sleeping; depression or excessive worry; and nervous trouble of any sort. Her history was positive for swollen or painful joints; ENT trouble; chronic or frequent colds; sinusitis; hay fever; skin disease; shortness of breath; frequent indigestion; stomach or intestinal trouble; adverse reaction to serum, drugs, or medicine; recent gain or loss of weight; arthritis, rheumatism or bursitis; and recurrent back pain. The explanations she gave for the positive responses were tonsillectomy in 1974, tubal ligation in May 1990, hospitalization for vomiting and diarrhea in December 1971, hospitalization for abdominal pains in December 1978, hospitalization for dehydration due to food poisoning in September 1990, follow-up visits and lab work for IBS from September to October 1990, left knee injury in basic in June 1989, right knee injury in April 1990, sinus infection in February 1991, three colds and two flu-like viruses since food poisoning in September 1990, sinus infection in February 1991, symptoms controlled with OTC drugs in the fall and spring, pregnancy symptoms in August 1988, intermittent stomach problems since food poisoning in September 1990 to the present (February 1991), allergic to penicillin and sulfa, occasional bladder infections, bleeding from bladder infections in 1977, continuous loss of weight since food poisoning in September 1990, arthritis symptoms in both knees in 1981, low back pain that precedes diarrhea IBS in September 1990. The February 14, 1991 separation examination, pending MEB records, shows the Veteran's weight was 101 pounds and notes multiple things including bronchitis symptoms with URI, nausea and diarrhea (diarrhea alternating constipation since September 1991), UTI in 1987, recurrent lower back pain, and bilateral knee pain after running. It was negative for cardiovascular and thyroid disorders. See August 2015 STR Medical. Subsequent to her period of active duty, the Veteran was seen in April 1991 by Dr. Grandjean who recorded her weight as 109 pounds. She had a possible bladder infection and no fever since Sunday. She also reported having some low back pain. She was observed to be anxious and the assessment noted UTI and anxiety. The Veteran also completed a Hamilton anxiety rating scale and she scored a 29, which was interpreted as evidence of anxiety. Some of the areas in which she reported complaints were being sweaty, tension headaches, hot/cold flashes, depression, unsatisfying sleep, tired on waking, and nightmares. She indicated she did not have respiratory symptoms, aches/pains, and initially indicated no cardiovascular symptoms. See August and September 1992 Medical Treatment Record Non-Government Facility. A follow-up record in 1991 regarding a Buspar prescription from Dr. Grandjean is partially illegible but refers to insomnia, hot flashes, weakness, IBS symptoms, and headaches. The assessment included much improved anxiety. A June 1991 follow-up on Buspar medication indicated she still had fatigue and referred to insomnia. Dr. Grandjean also noted that Buspar was still helping/working. See May 2014 Medical Treatment Record Non-Government Facility. In July 1991, Dr. Grandjean saw the Veteran for anxiety and IBS. She had almost daily diarrhea and was stressed. She was observed to be anxious and the assessment included anxiety. An October 1991 private treatment record notes a history of bronchitis. The Veteran complained of having a cough and the assessment was acute bronchitis, sinusitis, and allergic rhinitis. See August 1992 Medical Treatment Record Non-Government Facility. On October 30, 1991, the Veteran had a one day TDY for follow-up care. A service treatment record on this date by Dr. Vajdos notes complaints of nausea, bowel symptoms, weight loss, and decreased appetite. The Veteran also reported "depression and nightmares." She felt generally weak and reported a "lack of strength." She was unable to perform PT tests. She requested blood tests for giardia and the physician noted multiple stool samples had been negative for this. The physician agreed with the diagnosis of IBS. A consult request shows she had a one year history of intermittent symptoms consistent with irritable bowel and that it was initiated by food poisoning. She was concerned about giardiasis but stool tests for ova and parasites were negative. An independent history and physical were requested and an MEB was on hold pending evaluation. On November 12, 1991 consultation, she had another one day TDY for follow-up care and final determination for retention. The November 12, 1991 evaluation by Dr. Yamamoto states intermittent episodes of abdominal pain and diarrhea with normal stools in between was suggestive of IBS but a significant weight loss or anorexia was not a characteristic feature of IBS. Inflammatory bowel disease, colitis, or chronic giardiasis were to be ruled out. It was also noted that dietary factors to include lactose intolerance may be contributing to diarrhea. The history notes the Veteran was well until September 1990 when, after eating at a local restaurant, she developed food poisoning three to four hours later. She was admitted to a civilian hospital and after recovering she had recurrent episodes of loose stools/diarrhea that occurred seven to fourteen days at a time four to five times a day. During periods of normal stools, she continued to have nausea, anorexia, and an occasional gagging sensation when swallowing. She was positive for day and night sweats, occasional fevers, which were not documented, with chills. She claimed she could tolerate milk/milk products. Work-ups were normal, and an ultrasound was normal. Ova and parasite stool tests were normal (x6). Of note, she carried a diagnosis of depression/anxiety. See August 2015 STR Medical. In November 1991, Dr. Yamamoto requested a consult to rule out a gynecological etiology for abdominal pain, but the Veteran declined a gynecological examination, indicating she had a complete exam and treatment by a civilian gynecologist. See August 2015 STR Medical. In December 1991, the Veteran had an annual gynecology examination with Dr. L. Robinson. She reported having bleeding two to three days that was heavy with pain. She refused a urine sample and blood test. The examination was within normal limits for her thyroid, lungs, heart, CVA, vagina, cervix, and uterus. Her uterus was noted to be small A/U (at umbilicus). Her weight was recorded at 102 pounds. A pap smear cytologic report notes there were no abnormal cells and that severe inflammation was present. In a letter to the Veteran, Dr. Robinson wrote that her exam was essentially normal and that the pap smear was also normal. The Veteran had reported irregular bleeding and the physician stated he would not be surprised if some of the bleeding was not related to her IBS. See May 2014 Medical Treatment Record Non-Government Facility. A March 12, 1992 treatment record from Dr. Musso notes possible bronchitis. She had a cough with discolored mucus, reported feeling very tired, and had a possible fever. The impression was bronchitis/URI. See August 1992 Medical Treatment Record Non-Government Facility. A March 1992 ER record from St. Paul Medical Center noted the Veteran's complaints of abdominal pain/diarrhea; the diagnoses were dehydration and IBS. The ER record shows an 18 month history of IBS and that she arrived with complaints of severe nausea, diarrhea, and dehydration. Two days earlier she developed cold symptoms that included laryngitis, some lower chest bilateral wall pain, and a cough productive of greenish and yellow sputum. She had gone to a doctor earlier in the day and was given chest X-rays; she was told she had a respiratory infection and took one erythromycin before going back to work. She later became increasingly nauseated and sick and was near syncope when she stood; she eventually laid down. An ambulance was called and EMTs said she had low but normal blood sugar. She reported having a fever of 99.4 the day before and continued to complain of severe nausea and diarrhea consistent with her IBS. The clinician noted that her history was complicated, and she had several different physicians. In November 1991, a mildly inflamed duodenum was noted. She had been under treatment by Dr. Grandjean for depression and anxiety that the Veteran said was consistent with PTSD secondary to a tour of duty in Desert Storm. On exam, she was somewhat lethargic but in no acute distress. She demonstrated orthostatic tilt. The cardiovascular examination was normal, temperature was 98.6, and her chest was clear. Her skin was somewhat pale and dry. Lab work on admission showed white blood cell (WBC) count was 18,600 (18.6) and by the next day it was 10,100 (10.1). The urinalysis was negative for any infection. She was admitted and had diagnoses of dehydration and IBS. The discharge diagnoses were near syncope, IBS, and bronchitis. On discharge she was also noted to have mild anemia and told to follow-up with a gynecologist. In April 1992, the Veteran complained of a yeast infection and possible UTI. She reported having a bloated feeling, feeling crampy, and some bleeding/yellow discharge. Her weight was 100 pounds. See August and September 1991 Medical Treatment Record Non-Government Facility. In May 1992, she was seen to recheck for vaginitis and complaints of lethargy and a "crampy feeling." The clinician commented that she had persistent vaginitis. See September 1992 Medical Treatment Record Non-Government Facility. A September 1992 general medical VA examination notes the Veteran was seeing Dr. Grandjean for depression and anxiety. She currently suffered from insomnia, frequent awakening with an inability to return to sleep, and chronic fatigue. On Saturdays she was so tired it was very difficult to get out of bed. She worked full-time and went to school four times a week. She also reported having had vaginal infections several times during the past year and that she gained weight from 94 pounds to 104 pounds. On examination, her thyroid was not palpable, lungs were clear, heart was normal size to percussion with regular rhythm and no murmurs, and the rate was 72 beats per minute. The examination was unremarkable, and she had a diagnosis of IBS. The Veteran reported that her condition improved considerably since she had stopped taking medications and placed herself on an intense nutritional program recommended by her nutritionist. Her vaginal infections could not be attributed to IBS. See September 1992 VA Examination An October 1993 gynecology record shows she complained of occasional chest pain, stress, and shoulder pain. Her weight was 104 pounds. In June 1994, her weight was 115 pounds. She reported having severe menstrual cramps and abdominal pain. The assessment was pelvic pain and rule out endometriosis. August 1994 gynecological records note her complaints of cramping, increased swelling, pain all the time, and back ache. An operative report contains pre- and post-operative diagnoses of menorrhagia and dysmenorrhea. She underwent a diagnostic hysteroscopy, endometrial biopsy, suction curettage. She had a history of menorrhagia and significant dysmenorrhea over the past several months that was unresponsive to hormonal manipulation and usual and customary pain medication. She also had a long history of IBS. The pathology report for the uterus revealed secretory endometrium without hyperplasia or malignancy. See May 2014 Medical Treatment Record Non-Government Facility. In September 1994, Dr. Rasheed noted that approximately three weeks before the Veteran had surgery for endometriosis at St. Paul Hospital and since then she had multiple infections, but the details were not available. She had been given antibiotics, but she continued to run a low grade infection with fatigue, some low back pain, and occasional loose stools. Lab work showed her WBC, neutrophils, lymphocytes, monocytes, eosinophils, basophils, neutrophils, lymphocytes, monocytes, eosinophils, and basophils were within the reference range. IgM was interpreted as positive. See August 2015 STR Medical. An October 1994 treatment record from Dr. Rasheed noted that the Veteran continued to be fatigued. She had returned back to work and by late evening she was exhausted. She still had generalized aches and pains with severe fatigue and denied any systemic symptoms except for occasionally running a low grade fever. He stated she had CMV Viraemea. She continued to work no more than 40 hours a week. November 1994 correspondence from Dr. Rasheed confirmed the Veteran had acute CMV viraemia and he stated that it would make her feel fatigued and occasionally run a low grade fever. The Veteran had multiple tests in December 1994. An ECG showed rare supraventricular ectopics, but no etiology for syncope seen. An MRI of the head and EEG/EMG report were normal. December 1994 correspondence from Dr. Rasheed states that the Veteran had multiple investigations to determine the cause of episodes of syncope (fainting) and they were all normal. He saw no connection between her fainting episodes to her recent surgery or chronic virus condition. She was able to resume a 40 hour work week. See October 2016 Medical Treatment Record Non-Government Facility. A January 1995 treatment record shows the Veteran complained of headaches and dizziness. In July 1995, she complained of muscle pain. See October 2016 Medical Treatment Record Non-Government Facility. A May 1997 treatment record from the Institute for Molecular Medicine shows testing was done for mycoplasma fermentans and that two tests were positive for blood leukocytes. An accompanying statement from Dr. G. Nicolson notes, among other things, that mycoplasmal infections have also been documented in patients with GWI and patients have been successfully treated for these infections. See August 2015 Medical Treatment Record Non-Government Facility. A July 1999 treatment record from Dr. McClean shows the Veteran reported having several health problems, but he did not elaborate on what she reported. He did indicate she had CFIDS. Lab tests were requested for EBV acute infection antibodies, thyroid panel with TSH, torch panel, CBC with differential/platelet. Results showed WBC was high. Normal ranges for neutrophils, lymphocytes, monocytes, eosinophils, basophils, platelet count, RBC were reported. Thyroid tests were within normal limits. EBV antibody tests showed EBV-VC IGG and EBV-nuclear AG IGG were above the reference ranges and EBV-VC IGM was within the reference range. In August 1999, she complained of general muscle weakness, loss of appetite, of headache/borderline migraine, lethargy, and severe fatigue. The assessment was CFIDS. Lab work ordered by Dr. McClean showed EBV-VC IGG and EBV-nuclear AG, IGG were above the reference ranges. CMV IGG was noted to be high. See October 2016 Medical Treatment Record Non-Government Facility. In September 1999, Dr. Garza and Dr. McClean referred the Veteran for a stress echocardiogram due to complaints of chest pain. Her resting EKG was within normal limits. The exercise test lasted 2.25 minutes and terminated due to fatigue. During that time, there was no evidence of arrhythmias or significant ST changes. The stress echocardiogram was normal. Dr. Tasian commented that there were no symptoms to suggest angina pectoris. In correspondence dated that month to Dr. Garza, he stated that Dr. McClean had been treating her for infections and he apparently heard an S3 gallop and told her she could conceivably have an enlarged heart, possibly leaky heart valves. He recommended an echocardiogram. She complained of dyspnea on exertion and tightness in her chest when climbing stairs that was relieved by sitting. A review of systems noted migraines associated with temporary vision loss, dyspnea on exertion and a cough productive of brown sputum. She complained of an irregular heartbeats and occasional palpitations. She had pain in her calves when walking and reported pain in some of her joints. She also reported having chills and night sweats and losing seven to ten pounds. She was scheduled to start cytovene for CMV. The physician noted that a stress echocardiogram showed no evidence of myocardial ischemia and ventricular function was normal. She had very mild mitral and tricuspid regurgitation. The impression was chest pain and dyspnea of uncertain etiology but non-cardiac in nature. The data did not suggest the presence of heart disease to explain her symptoms. It was further noted that she may need pulmonary workup for dyspnea. See October 2016 Medical Treatment Records Non-Government Facility. An October 1999 treatment record notes her complaints of burning in her lungs and labored breathing with dry non-productive cough. The assessment was viral syndrome. In January 2000, the Veteran complained of swollen glands in her neck and under her arms, flushed cheeks, and a low grade fever. She reported an onset of symptoms a week and a half earlier. Her current weight was 104 pounds and her temperature was 98.3. The assessment was viral syndrome. See May 2014 Medical Treatment Record Non-Government Facility. A December 2002 treatment record shows she was status post a laparoscopy. See December 2009 Medical Treatment Record Non-Government Facility. In January 2003, Dr. Garza requested lab work and a notation indicates it was good except for slightly elevated calcium. See December 2009 Medical Treatment Record Non-Government Facility. In March 2003, Dr Busco ordered lab work that revealed her cortisol level was within the reference range and her cortisone level was above the reference range. See December 2009 Medical Treatment Record Government Facility. In March 2003, the Veteran reported that Dr. Busco referred her for hormonal level testing, she also complained of AUB (abnormal uterine bleeding) for two weeks duration. She had recurrent weight loss and currently weighed 97 pounds. Lab work did not indicate that her testosterone level was high, TSH was within normal levels, cortisol was in the reference range and cortisone was above the reference range. See December 2009 Medical Treatment Record Government Facility. An April 2003 treatment record shows the Veteran discontinued Provera after the second dose secondary to bone/joint pain, chest pain, and leg cramps. A May 2003 treatment record shows the Veteran reported having a three day history of left lower quadrant pain. The record includes an assessment of Gulf War Syndrome. She went to the ER later that month due to complaints of shortness of breath and general weakness. Her lab work was normal for WBC, gran percent, lymph percent, mono percent, eos percent, baso percent, gran number, lymph number, and BASO number. Due to complaints of chest pain and shortness of breath she had chest X-rays, which were normal. See August 2015 Medical Treatment Record Non-Government Facility. A January 2004 treatment record from Dr. Garza shows the Veteran presented for fever and chills. She stated she was still very exhausted and could barely walk; she indicated that she needed a handicap sticker. The impression included CFS/weakness, tachycardia, and fatigue. In April 2004, she had a follow-up with Dr. Garza for fatigue, chronic sinusitis, and abnormal lab work. The impression was fatigue/fibromyalgia. She was stable and her last "viral" relapse was seven days earlier. She had a one day history of weakness/sweats. An August 2004 record shows the impression included migraines and sebaceous dermatitis of the scalp. See December 2009 Medical Treatment Record Government Facility and August 2015 Medical Treatment Record Furnished by SSA. September 2004 correspondence from Dr. B Tasian shows that the Veteran complained of her heart speeding up at times without dizziness or syncope and reported being treated for Gulf War Syndrome. She also reported having occasional sharp chest pain that radiated and was unrelated to exertion or meals. She had been on Adderall to increase her energy. She had normal muscle strength and tone, and her heart had regular rhythm and no murmur or gallop. An EKG was performed due to her concern about endocarditis even though there were no clinical signs or symptoms suggesting it. It revealed sinus tachycardia with a prolonged QT interval. There was no evidence of valvular heart disease. See June 2006 Medical Treatment Record Non-Government Facility. The interpretation on the September 2004 echocardiogram report was concentric left ventricular hypertrophy, E to A reversal suggestive of abnormal relaxation, and normal mitral valve with trace mitral regurgitation. See June 2008 Medical Treatment Record- Non-Government Facility. A November 2004 treatment record from Dr. Garza shows she reported having a virus, headaches, weakness, fatigue, swelling on and off, and was achy all over but mostly in her elbows, knees, and joints. Her employer wanted her to medically retire. The impression was fatigue, frequent illness, and work stress. See August 2015 Medical Treatment Record Furnished by SSA. November 2004 lab work noted her IgD was very low. See August 2015 Medical Treatment Record Non-Government Facility. In December 2004, Dr. Garza noted diagnoses of dermatitis to scalp and CFS/GWS. In January 2005, she had impressions of seborrheic dermatitis with staph infection and extremely low IgD. See December 2009 Medical Treatment Record Government Facility. Private treatment records show that Dr. Kippels first saw the Veteran in April 2005. The initial history and physical noted her complaints were poor sleep and feeling unrefreshed. There was notation of a possible coagulation problem and that she had treatment for CMV in the past. The examination noted she had a rapid pulse, but the physician also noted that the Veteran had taken Adderall that morning. Her thyroid, skin, muscles, and abdomen were normal. A tender points evaluation was 14/21. She was positive for sleep, mitochondria enhancement, pain, and bowel dysfunction. The assessment was supplements for energy, GI, sleep, and pain. The diagnoses were CFIDS (CDC defined) and fibromyalgia (ACR defined). See August 2015 Medical Treatment Records Furnished by SSA. A report of April 2005 lab work ordered by Dr. Kippels states that the sample was received two days after the blood was drawn, which might be a factor for having low NK activity. Repeat testing was suggested to verify the results. The Veteran's B12 was 379 and the record noted that it has been reported that between five and ten percent of patients with values between 200 and 400 PG/ML may experience neuropsychiatric and hematologic abnormalities due to occult B12 deficiency. See January 2007 Medical Treatment Record Non-Government Facility. A treatment record from Dr. Kippels dated two days later indicates the Veteran was given an IV on the date of her initial visit and that changes since then were in the back and muscle, twitching around eyes, sweating, spasms in back. Her subjective complaints were headache, chills, severe pain in all muscles, body began to swell and loss of appetite. The physician considered infections. See August 2015 Medical Treatment Record Furnished by SSA. In April 2005 correspondence from Dr. Garza, he stated that he first met the Veteran in the fall of 1996 when she presented with a complaint of fatigue. Since then, she continued to suffer from this symptom, and by definition suffered from CFS with fibromyalgia. Since 1996, he had treated her for her condition and that several physicians believe that CFS may be induced by bacteria. She had worsening CFS since an operation in November 2002 and had to rely on a flexible work schedule since her symptoms might have been exacerbated by her surgery. She was weak and often unable to lift heavy items such as law books or income tax publications. The more she tried to exert herself, the worse her CFS became. Her symptoms can be categorized by chronic multi-symptom illness, which included but was not limited to chronic fatigue, IBS, unexplained dermatitis, frequent headaches, myalgias, arthralgias, neuropathies, frequent respiratory disturbances, cardiovascular disturbances, and menstrual disturbance. See January 2007 Medical Treatment Record Non-Government Facility. An October 2005 treatment record from Dr. Kippels contains an assessment of probable thyroid dysfunction. In January 2006, the Veteran reported having migraines, overall weakness, and shortness of breath, and that all of these symptoms started when she began taking an increased dose of T3; she was advised the medication was causing the symptoms and to discontinue. See December 2008 Medical Treatment Record Furnished by SSA. In correspondence from Dr Kippels to Dr. Garza dated in January 2005 (the Board notes this date is likely incorrect since he did not start seeing the Veteran until April 2005), Dr. Garza stated his clinic specialized in fibromyalgia and CFS and that it is generally accepted that these diseases are included in the condition referred to as GWI. He first saw the Veteran at his clinic in April 2005 and she met the CDC criterion for CFIDS and the rheumatology society diagnosis for fibromyalgia. Extensive laboratory tests were done that revealed multiple hormone deficiencies and evidence of chronic infections, both of which are consistent with GWI. In his opinion, she was currently disabled from any work. She had central hypothyroid with suboptimal free T4 and free T3 and elevated reverse T3. The IGF-1 measurement of growth hormone was below 95 percent, also showing deficiency. Her cortisol level was suboptimal as was often the case in patients who have "burned out" the adrenal function by relying on forcing themselves to function despite overwhelming fatigue. Estradiol and progesterone levels were low for someone in their 40's and her testosterone level was very low as was DHEA and pregnenolone. Tests in the first round suggested a chronic infection or infections was present and further testing revealed evidence of those infections. Mycoplasma Pn, EBV, CMV were all present and mycoplasma is a chronic active infection in over 80 percent of patients with GWI. In summary, he concluded she had fibromyalgia, chronic fatigue and GWI. She had multiple hormone deficiencies caused by hypothalamic dysfunction, her immune system was dysfunctional and had led to several chronic infections and she was unable to work. She was totally disabled, and the physical stress of working would interfere with her recovery. See January 2007 Medical Treatment Record Non-Government Facility. In February 2006 correspondence, Dr. K. Kippels wrote that the Veteran had been disabled since November 21, 1990. Her diagnoses were CFS and/or fibromyalgia, and the likely triggering event was multiple vaccines given to her on her deployment to the Persian Gulf that resulted in immune and pituitary dysfunction. The immune dysfunction then resulted in further reactivation of other viruses, intracellular bacterial infections, and a systemic fungal infection. Her pituitary dysfunction was worsened by the neurotoxins as well as a coagulation defect that limited oxygen diffusion into the cells. The pituitary dysfunction resulted in multiple hormonal deficiencies that also contributed to her symptoms. She was noted to have thinning lateral eyebrows and a slow relaxation phase of her ankle reflex, which were signs of low thyroid. Initial blood work was drawn to uncover any hormonal and metabolic defects. Her thyroid panel was consistent with secondary hypothyroidism with a thyroid resistance. Her free Cortisol and ACHTH levels were indicative of adrenal insufficiency usually associated with her condition and were also consistent with an abnormally low insulin level. The HgbA1c was in the lowest quartile indicating hypoglycemia. Her white blood count was below reference range for the population and a subsequent low natural killer cell function indicated immune dysfunction and a significant chronic infection. Her insulin like growth factor level and testosterone levels were in the lowest 10 percent of the population and consistent with pituitary dysfunction. IGF-1 (growth hormone) was below the reference range, which indicated pituitary failure and adult growth hormone deficiency. She also had a high lipoprotein (a) putting her at risk for coagulation defect that was revealed at a later time. A November 2005 lab panel demonstrated a pattern of multiple infections often seen with immune dysfunction. She had a positive IgG serial testing for CMV, EBV, chlamydia pneumonia, and mycoplasma. An elevated RNA-s-L activity was present on the original testing that also indicated immune dysregulation and chronic active infection. She had multiple physiological abnormalities that resulted in disability and were listed as follows: hypothyroidism, pituitary dysfunction, immune dysfunction, RNAse-L activity, elevated angiotensin converting enzyme, EBV infection, HHV6 infection, fungal infection, and other infections. See January 2007 Medical Treatment Record Non-Government Facility. An April 2006 treatment record from Dr. Kippels provides a history of illness that notably began after military vaccination for deployment to Gulf in November 1990, when the Veteran began to have fatigue and pain and unrefreshed sleep, gastrointestinal dysfunction, and impaired concentration. Her current symptoms and complaints and functional impairment were severe sleep disturbance, chronic severe fatigue, unrelenting pain, impaired concentration, and cognition. Her diagnoses were CFIDS and fibromyalgia. See January 2007 Medical Treatment Record Non-Government Facility. An August 2006 treatment record notes the Veteran was on medication for headaches. See December 2009 Medical Treatment Record Government Facility. A November 2007 VA treatment record shows the Veteran stated that she had a hepatitis cocktail in service that caused her medical problems. She reported having irregular vaginal bleeding for three months every time the weather changed, and she took enzymes or carnivora from Venus flytrap plants to control her hypercoagulability. Dr. Kippels was her treating gynecologist and gave her an IV every two weeks to control her bleeding. She denied having any other gynecological problems. Her medical history indicates she had a laparoscopy and endometrial ablation in August 1994 and was diagnosed with endometriosis. A second ablation and laparoscopy was performed in 2002. The physical examination was normal, and her uterus was a normal size. See December 2009 Medical Treatment Record Government Facility. In November 2007, the Veteran had a general medical VA examination with Dr. Horne. She reported that in and around 1998 her weight was down to 66 and that she regained weight to 114 pounds and had since maintained her weight. In a copy of the report the Veteran submitted, she crossed out the portion regarding her weight. During the same period, she was diagnosed in the early to mid-1990's with CFS and fibromyalgia; both of these were in 1996. In the Veteran's copy, she indicated the year was 1994. She had tests and was thought to have pituitary dysfunction and to have antibodies against CMV, TB, chlamydia, mycoplasma, and candida. She developed chest pain and was seen by a cardiologist at St. Paul who said that the CMV virus might damage her coronary arteries, but she had no specific treatment for that; apparently no condition was found that required treatment. She had insomnia and attributed this and all other complaints to Gulf War Syndrome (GWS). She claimed muscle wasting due to GWS and said lab tests suggested thyroid dysfunction, pituitary dysfunction (growth hormone deficiency hypothyroidism), and antibodies showed previous exposure to chlamydia, mycoplasma, EBV, CMV. She reported low blood sugar, shortness of breath, and chest pain but not exertional as well as abnormal levels of enzymes in the blood. She reported having had blue fingers due to blood clots but there was no swelling or pain. She reported having back pain and stopped working in 2004 due to shortness of breath, dyspnea on exertion, syncope, dizziness, weight loss, and exhaustion. She was treated for endometriosis and uterine adenomyosis. She reported having abdominal pain and frequently migratory pain in the back but did not describe it in the joints and limbs. She described ongoing severe fatigue that varied from day to day and that she walked her dog daily for exercise. She used to walk three miles but stopped after 2002 due to fatigue. The diagnoses included undifferentiated somatoform disorder, chronic low back strain, allergic rhinitis, insomnia, uterine fibroid, status post endometrial ablation for menorrhagia, dysthymia with anxiety and migraines. The physician commented that the Veteran no longer had symptoms of IBS. He added that the myriad of diagnoses and complaints could not be explained by CFS or fibromyalgia and that the medical evidence did not support these diagnoses. The Veteran currently did not have many of the features necessary for a fibromyalgia diagnosis. There were no clinical findings of hypothyroidism, heart or chest disease, or pituitary disease. There was no evidence of muscle wasting, immune deficiency (i.e., no unusual infections), and her weight was stable. The examiner noted that "GWI" had not been shown by medical authorities to exist. She did receive vaccines in preparation for deployment to the Persian Gulf, but she described no side effects known to occasionally accompany vaccination. Her physical activities would be limited by lack of stamina due to fatigue, low back pain, and poor concentration. See November 2007 Compensation Checklist and November 2007 VA Examination. In June 2008 correspondence, the Veteran requested numerous changes be made to the November 2007 VA examination report. Changes were made in July 2008 as follows: Paragraph one should read that she was treated by various physicians and had testing over several years with a negative colon examination. Paragraph two should delete "During that period of time she had loss to 66# she subsequently regained up to 124# and after the Metronidazole in 1998 regained and maintained her weight." Paragraph three, line two should read "Chronic fatigue in 1994." Line four should say EB virus instead of TB virus. Line 7 should read "cardiologist at St. Paul Med Center, but it is not clear what was found." Lines eight and nine should be deleted. See July 2008 Medical Treatment Record Government Facility. On November 2007 mental health VA examination, the Veteran asserts she was ill from GWI. She was in the Reserve and was medically boarded out due to IBS. She had been prepared to go to the Gulf War, but she had a bad reaction to the vaccines in preparation for deployment. VA records did not show mental health problem or medication. The psychologist consulted with Dr. Horne who had also examined her, and he indicated there were no medical findings to support her having the claimed medical problems, especially but not limited to 23 illnesses and problems. She took Adderall that was designed for use for ADD, and she reported it helped with concentration. She stated she believed she did not have mental problems and that her physician said she was just angry about being physically ill. She saw a psychologist for nine months and Dr. Garza gave her antidepressants for one to two years. She said the medication was designed to address her fatigue. She stated that she started to have physical problems in 1990 and that she had become physically ill after being given various inoculations in preparation of going to the Gulf War. She indicated that she had pain at the 8/10 level at times and that it was usually 4-5/10 and that she was on pain medication. She worked until 2006. Her only trauma was her divorce and that her husband got GWI from her because it was communicable. She was also traumatized by her father's death. The Veteran engaged in a normal range and variety of ADLs without interruption of typical daily routine. A review of psychological symptoms resulted in endorsement by the Veteran of Medication Induced Anxiety. She indicated having some depression and insomnia. She believed she was thinner than normal due to muscle atrophy associated with GWI and reported being socially active. The Axis I diagnosis was undifferentiated somatoform disorder and mood disorder. Both diagnoses represented separate issues. The Veteran showed some of the signs and symptoms of bipolar disorder according to the MMPI, however, the examiner did not make a diagnosis because the Veteran was overall denying she had any sort of mental problem. She spent a great deal of time pursuing her strong conviction that she had a variety of physical problems. She may have been experiencing delusions of grandeur, paranoid delusions, and/or somatic delusions. The current evaluation did not indicate any service connected mental illness. See November 2007 Compensation Checklist. While in the process of seeking disability benefits from the Social Security Administration (SSA), the Veteran was evaluated by Dr. Bellah in January 2008. At that time, the Veteran complained of distractibility, forgetfulness, indecisiveness, and general malaise. Based on the examination, her memory overall appeared to be within normal limits and concentration was apparently intact. Abstract thinking was moderately impaired, and the Veteran had limited insight and judgment. The Veteran's chief complaints were cognitive dysfunction/ GWS and the Axis I diagnosis was cognitive disorder NOS. Elsewhere, the clinician also listed somatoform, cognitive disorder and ADD as medically determinable impairments present that do not precisely satisfy the diagnostic criteria. See August 2015 Medical Treatment Record Furnished by SSA. A March 2008 treatment record from Dr. Kippels states that the Veteran's blood hypercoagulation problem was causing shortness of breath on exercise. Muscle pain was also secondary to hypercoagulation. Her migraines were prominent and secondary to something that is illegible but related to her scalp. The assessment was that the thyroid was as expected for someone on T3 and her adrenal was still low. Her viruses were still troublesome. See December 2008 Medical Treatment Record Furnished by SSA. In April 2008, Dr. Garza evaluated the Veteran for CFS. She described current, severe fatigue. The symptoms complex had been rapid and was aggressively worsening. Tender spots included shoulders, hands, fingers, and feet and associated symptoms included difficulty falling asleep, staying asleep, and fever. Aggravating factors included lack of sleep and anxiety. She did not have any chest pain, dizziness, palpitations, respiratory symptoms, arthralgias, or myalgias. Her weight was 110 pounds. The assessment was CFS. See August 2015 Medical Treatment Records- Furnished by SSA. In August 2008, the Veteran had another clinical evaluation by Dr. Bellah as part of her evaluation for disability benefits from SSA. No records were reviewed, and her chief complaints were GWS and cognitive dysfunction. The Veteran complained of distractibility, forgetfulness, indecisiveness, and general malaise. Her memory overall appeared to be within normal limits and concentration was apparently intact. Abstract thinking was moderately impaired, and she had limited insight and judgment. The Axis I diagnosis was cognitive disorder NOS. See August 2015 Medical Treatment Record Furnished by SSA. In October 2008 correspondence, Dr. Kippels wrote that the Veteran's original complaints included muscle pain and stiffness, insomnia and unrefreshed sleep, daytime fatigue of severe degree, gastrointestinal disorder, impaired concentration and memory, headaches, and multiple chemical sensitivities. She had diagnoses of CFS and fibromyalgia. Her symptoms were caused by physiologic abnormalities and the triggering event was multiple vaccines given to her on her deployment to the Persian Gulf War that resulted in immune and pituitary dysfunction. See November 2008 Medical Treatment Record Non-Government Facility. In December 2008 correspondence from Dr. Tasian to Dr. Kippels, he stated that he saw the Veteran in September 2004 due to concerns about possible myocarditis from multiple viral infections including cytomegalovirus. She reported a history of chronic EBV, fibromyalgia, CFS and stated she lost her immune system when she received hepatitis b vaccine in service. In September 2004, her EKG showed Q-T prolongation, but she had nothing to suggest she had long QT syndrome. It was conceivable that the QT prolongation was secondary to medications she was taking at the time. She has been complaining of rapid heartbeats and chronic chest pain which apparently were attributed to pericarditis. The pain was chronic and constant. The examination showed she weighed 101 pounds with a BMI of 18.47. Her heart had a regular rhythm, PMI was within the mid-clavicular line, S4 gallop, and no murmur. She showed good muscle strength and tone. An EKG revealed a sinus rhythm with normal QT interval. She was scheduled for an echocardiogram to assess her ventricular function and to look for possible vegetations because of her concern that she may have endocarditis and possible myocarditis from her viral infections. If echo were to show abnormal ventricular function she would be considered for a cardiac MRI. A December 2008 treatment record shows that Dr Tasian requested the study due to a fever. The echocardiogram showed normal left and right ventricular size and function and trace tricuspid regurgitation. No vegetations were seen. Atria, mitral, and aortic valves were normal. See July 2015 Correspondence. A January 2009 treatment record shows the Veteran was referred for possible myocarditis. The MRI was incomplete due to an inability to insert an IV and the Veteran's request to terminate the exam prior to obtaining all noncontrast images; however, based on what they could complete the chamber sizes were normal and there was trace tricuspid regurgitation. See August 2015 Medical Treatment Record Furnished by SSA. In October 2009, the Veteran and Dr. Kippels testified during a hearing before a Veterans Law Judge. She stated that during Desert Storm she had tests at Fort Hood, specifically an ovarian endoscopy/barium enema, and a "rapid transit" was discovered, but that during the Medical Board Evaluation they said there was nothing significant. The second omission was an EGD. She returned to the Reserve after a TDY and her problem was so severe that she lost 20 pounds, 10 of which had been since her vaccines. A September 1992 record shows she complained of chronic fatigue and was unable to get out of bed. Her symptoms were present while she was still on active duty. She stated that the day after she received the vaccines, she found out she was no longer able to run. She had persistent, chronic symptoms within 48 hours of the vaccine, so she asked for medical attention and was placed in quarters within eight days of the vaccines. They were not told what vaccines they were given. The Veteran believed that if a person contracted CFS from vaccines then they would have to get treatment within two years, or they could continue to decline. She suffered from back to back pneumonia and other infections. They are never cured and almost every one of them could be linked to a vaccine. She had aluminum and mercury in her brain from vaccines and she was exposed to depleted uranium at Fort Hood. Dr. Kippels stated the Veteran had a "sadamugulavum" (as spelled in the hearing transcript) virus that comes from vaccines. (The Board notes that the word "sadamugulavum" is most likely a transcription spelling error since none of Dr. Kippels' statements or medical records refer to it and it is not found in publicly available information.) Dr. Kippels stated this virus comes from vaccines that use kidney tissue from the green African monkey. This virus attacks and weakens the heart. She also had a sleep disorder; she had difficulty falling asleep and woke unrefreshed. The Veteran had muscle pain with 11 of 18 tender points, which qualifies as fibromyalgia. She was also fatigued for longer than six months. Her CFS symptoms were multiple joint or muscle pain, sore throat, headache, unrefreshed sleep, and memory and cognition difficulties. She had extreme fatigue when she exercised. She had numerous tests that revealed thyroid problems, cortisol problems, infections, a hyper coagulation state. Dr Burress, a VA doctor, reported that she had chronic fatigue in September 1992. The Veteran testified that her heart went from racing and skipping a beat and passing out two or three times a year to passing out on a weekly basis. She was found to have long QT syndrome on an echocardiogram. She had several forms of pneumonia and now had asthma. See October 2009 Hearing Testimony. A March 2010 VA examination shows the Veteran reported she could prepare meals, protect herself from ordinary hazards, drive to the grocery store and appointments, and climb ladders to install shelves at home, but needed assistance with bathing and hygiene because it was too exhausting. Her weight was 141 pounds and there were no signs of malnutrition. Regarding her claim that her medical issues were caused by her vaccinations in service, the examiner noted that there was no medical evidence of this and it was considered unlikely. See March 2010 VA Examination. In August 2011, the Board obtained a specialist opinion from Dr. Casillas, an Associate Professor who specializes in the practice of Allergy and Immunology. The physician reviewed medical records and literature in the form of publications of scientific information and textbooks. The physician stated that there are numerous disability/disease that are claimed but not substantiated in the medical records, to include objective evidence of muscle wasting disease or true destructive joint disease. There is no evidence of any hormonal deficiency to growth hormone, thyroid, DHEA, testosterone, or pregnenolone. There is no substantial evidence of any natural killer cell function defect. The NK cells are involved in some aspect of natural immunity to various organisms that are encountered daily and might be problematic if completely absent. Such deficiencies are extremely rare and are associated with disease in early childhood. The test report indicated that the sample was received under suboptimal conditions "2 days after blood drawing," which is the reason that there appeared to be lower function. Even the reported "flagged" value of 19 units is suspect with regard to any clinical implications. There is no definitive level of NK cell activity that is specific for a clinically relevant immune deficiency, and there is no consensus view among clinical immunologists about the significance of NK cell defects for any condition. Her value of 19 units with a normal value of 20 units is also hardly worth mentioning, especially in light of the fact that the sample was not properly processed. There is no evidence that RNAse-L activity has any clinical significance, as has been claimed. This laboratory test may be valid for specific research in the area of molecular biology and RNA, but it has no use in the diagnosis or treatment of patients. Furthermore, the methods of the laboratory that performed this test, Immunosciences Laboratories, is subject to a great deal of scrutiny. The laboratory that provided some of the data that Dr. Kippels relied on did not meet standards of the scientific community with regard to methods and reporting of data. Immunosciences Laboratory (ISL) has been cited by the California Department of Health Services (CDHS) due to major irregularities in its scientific validation of tests. The CDHS recommended that sanctions be imposed on ISL due to failure to comply with California Laboratory Improvement Amendment (CLIA) Requirements. The ISL CLIA certification was revoked due to noncompliance secondary to highly questionable and unverifiable laboratory practices. Dr. Casillas noted that there is a claim of EBV and CMV infection and that the evidence only supports that there was an old infection, the timing of which cannot be determined by routine clinical laboratory testing. Furthermore, the immunological response shown by the laboratory tests suggests a perfectly normal immune response to two very common viruses which most individuals are exposed to early in life. Also, the CMV is not a contaminant of vaccines as Dr. Kippels alluded to in his testimony. The Veteran indicated the hepatitis B virus vaccination and other vaccines, in general, caused her problems. The allegation was that the vaccine(s) were contaminated with SV40, a monkey virus derived from the cells in which some vaccines are produced. Hepatitis vaccine is NOT produced in this type of system and cannot be contaminated with SV40 on that basis. Contamination with SV40 has been reported only in polio vaccines administered in the late 1950's and early 1960's. It is possible the Veteran could have been inoculated with such a vaccine, but this would have been during her infancy. Moreover, patients who were inoculated with the SV40-containing vaccines have been monitored since the discovery of the contamination, and no untoward effects have been documented or verified. Hepatitis B vaccines have been subject to study by the CDC, the Institute of Medicine as well as other scientific groups for evidence of associated disease states that may be attributed to the vaccine. Extensive epidemiological evidence has been reviewed and the recommendations favor rejection of a causal link between hepatitis vaccine and specific disease states and syndromes. To date, no evidence of a causal link to any specific disease states has been proven. It is still a recommended vaccine for all children in the United States, and it is felt to be effective in safely decreasing the risk of hepatitis infection causes. The Veteran allegedly has CFIDS as a diagnosis made by her physician Dr. Kippels, but there is no evidence that there is any immune deficient state that the Veteran suffers from. In fact, the very tests that were ordered to survey for a variety of infections such as EBV and CMV prove that she is able to mount a normal immune response by producing antibodies that are positive. Dr. Casillas also questioned Dr. Kippels' practice since claims to be certified in aging and restorative medicine by a board that is not recognized by the American Board of Medical Specialists. The physician also mentioned that Dr. Kippels was sanctioned by the Texas Medical Board in November 2007. Dr. Casillas opined that based on the evidence and research, the Veteran does not have any evidence of an immune deficiency, chronic viral infections, endocrine dysfunction, immune deficiency syndrome, or adverse effect of hepatitis or other vaccines. There are no specific disease syndromes identified by numerous batteries of tests that have been performed for the purpose of identifying any defect in immune function or immune deficiency syndromes or adverse vaccine effects such as those claimed by the Veteran. See August 2011 Third Party Correspondence. In October 2011 correspondence to the Board, Dr. Kippels wrote that he had treated the Veteran for more than six years. She volunteered to fight in the Persian Gulf and quickly developed GWI. GWI has been well documented in the medical literature to be the result of the vaccines given in preparation for deployment. A book by Dr. Roizman states that EBV, CMV, HHV-6 establish "latent" infection in B-lymphocytes, monocyte-macrophage precursors, or T - lymphocytes respectively. This means that after initial infection these viruses hide in a dormant state inside the cells of the immune system that are responsible for clearing the body of infection. HHV-6 and EBV are rarely present in the serum. Cultures and polymerase chain reactions (PCR) are usually not sensitive enough to detect chronic or reactivated infections. Brain or heart biopsies are not possible in living patients. Thus, physicians must rely on immunoglobulin tests, the main ones are IgM, IgG, IgA, IgD, IgE. These are measured in the serum and quantified by the "titer." High titers of IgG indicate a "reactivated" infection. A Wagner study in 1996 found that in CGS patients, 89 percent with high titers to HHV-6 had active cultures. Dr Montoya's research shows that reactivation of a latent virus infection that once was an acute infection does occur and cause infirmity. He also shows that a high titer of immunoglobulin G is a reliable indicator of the presence of this reactivate viral infection. Contrary to other opinions, the Veteran has evidence of hormonal deficiency to human growth hormone, thyroid, DHEA, testosterone, and pregnanolones if laboratory tests are read as intended. There is a common misconception that reference range (RR) as reported is the "normal" range and that nothing can be further from the truth. Each laboratory analyses their own test numbers and provides the physician with the "reference range" for that lab. RR is intended to represent two standard deviations from the mean for that test. Dr. Kippels continued that there is a body of evidence in literature concerning the relationship between the vaccines the Veteran received and the development of what is known as GWI. Dr. Hotopff et al. states that "[a]mong veterans of the Gulf War there is a specific relationship between the multiple vaccinations given during deployment and later ill health." Researchers also found that "traditional stresses of war, however, did not modify the effect of multiple vaccines and there were no interactions between vaccines and the use of pesticides." It is the vaccine exposure not the stress of war that caused the illness. Rook and Zumla suggested the same relationship in their 1997 "Lancet" article. Dr. Kippels concluded by stating Miller and Goldman found a direct relationship between the number of vaccines mandated to be given to infants and infant mortality rate. They state that vaccinated babies die at a higher rate than non-vaccinated babies. While the Veteran is not an infant, in preparation for deployment to the Persian Gulf, she received many vaccines all at once and at doses calculated for an adult male's weight, a dose much higher than she required. Based on military records, those vaccinations immediately overwhelmed her immune system and allowed the reactivation of viruses that now cause her illness. This illness is service related. There is no doubt she had CFS despite a murky reference to her ability to mount "a normal immune response" eliminating this diagnosis. See November 2011 Third Party Correspondence. In May 2012 correspondence to VA Secretary Shinseki, Dr. Kippels wrote that the Veteran's dysfunctions and disorders are service connected and that she had vaccine-induced diseases and had been diagnosed as terminally ill. The basis for the conclusion was blood work from the VA examination in November 2007 (CBC and metabolic panel). At that time her heart damage/disease associated with viral and bacterial infections had not responded to medication. Due to her age and history of vaccines, she was too young to suffer from SV40. Dr. Kippels stated that the VAH physician did not know how to interpret lab results and was not qualified or sufficiently educated to address treatment for vaccine poisoning or vaccine toxicity. He believed the physician was a vaccine proponent who misguided medical students into the campaign for mandatory, mass vaccination and relied on medical literature abundant in mainstream medical practice. He claimed Dr. Casillas missed 30 pages of labs ordered by three different treating physicians at almost a dozen commercial laboratories and bypassed other physician statements regarding her antibiotic and antiviral treatment for CFS. The Veteran's rebuttal shows she cited to three civilian physician specialists opinions, interviews, and peer-reviewed published medical journals. Dr. Kippels asserted the VA PTSD clinic psychiatrist's assistant falsified medical records with fabricated diagnoses and treatment of depression. He emphasized that the Veteran's claim was for Gulf War Illness not Gulf War Syndrome. He noted that "Cocktail" vaccines are multiple vaccines administered simultaneously without regard to soldier's gender, weight, or health status for past 90 days, allergies from birth that might indicate a "hiccup" in the immune system, Reserve or active duty status, medications taken in the 90 days prior, or whether vaccines were administered in the private sector within prior 90 days. Dr. Kippels asserted that the truth only came out when the Veteran requested numerous tests and procedures to disclose parasites, highly communicable infections of the digestive tract such as H Pylori, and vast differences between procedures her civilian doctors produced after food poisoning, and scope procedures her Army GI seemed to "cover up" a year after vaccine poisoning. She was 10 pounds too light to receive adult doses of vaccines even if administered one at a time. In less than one year Army physicians and radiologists trimmed her down to 88 pounds. BMI indicates she should weigh a median weight of 120 pounds. He claims that Army records were full of mistakes because they were written by untrained medical technicians. He added that her military records are deficient and plagued with oversimplified symptoms and diseases. See May 2012 Third Party Correspondence. On March 2013 Gulf War VA examination, the claimed conditions the Veteran reported having related to an undiagnosed illness or unexplained multisymptom illness were respiratory conditions, gallbladder and pancreas conditions, infectious intestinal conditions, stomach and duodenal conditions, endocrine disorder, fibromyalgia, CFS, and infectious diseases. Regarding the conditions identified, the clinician indicated that there were no diagnosed illnesses for which any etiology was established. The Veteran also reported having fatigue, upper and lower respiratory system signs and symptoms, gastrointestinal signs or systems, cardiovascular signs or symptoms, and abnormal weight loss. The physical examination was normal. See August 2016 CAPRI records. On June 2013 VA examination, Dr. Rees stated that, according to Up To Date, the diagnosis of Chronic Fatigue Syndrome (CFS) is one of exclusion. It is generally made if the patient has a typical history, and no abnormality can be detected on physical examination or in the screening tests. Well under 10 percent of patients with chronic fatigue have CFS. CFS represents a small subset of those who complain of chronic fatigue, accounting for one to nine percent of patients in a population with fatigue of at least six months duration. Medical or psychiatric diagnoses can explain fatigue in approximately two-thirds of patients with complaints of chronic fatigue. Psychiatric illness is present in 60 to 80 percent of patients with chronic fatigue. In one study, for example, a psychiatric diagnosis was found in 74 percent of over 400 patients who presented to a chronic fatigue clinic with at least one month of fatigue. Harrison's Textbook of Medicine, 17th edition, also emphasizes the need to exclude other medical conditions before considering the diagnosis of CFS. Harrison's states "No laboratory test can diagnose this condition, or measure its severity. In most cases elaborate, expensive workups are not helpful . . . CFS has no pathognomonic features and remains a constellation of symptoms and a diagnosis of exclusion." Dr. Rees stated that since CFS is a diagnosis of exclusion, and the Veteran has an alternative diagnosis to explain her symptoms (i.e. somatoform disorder), the diagnosis of CFS/CFIDS is not plausible or tenable. Basically, this Veteran does not meet the criteria necessary to establish a diagnosis of Chronic Fatigue Syndrome. Therefore, it was the opinion of this the examiner that the Veteran did not have the medical condition of Chronic Fatigue Syndrome. Dr. Kippels' presentation of October 2011 was noted. However, it was noted that he did not address the issue that CFS is a diagnosis of exclusion, and that the Veteran had an alternative diagnosis to explain her symptoms. According to the medical reference UpToDate: "The diagnosis of fibromyalgia is based primarily on the patient's symptoms of widespread pain. Patients report chronic myalgias and arthralgias, but have no evidence of joint or muscle inflammation on physical examination or laboratory testing. The physical examination reveals multiple tender points at specific soft tissue locations. There is no diagnostic laboratory test, or radiographic or pathologic finding, and testing should be kept to a minimum. The diagnostic evaluation is usually straightforward and should never be a 'fishing' expedition to exclude every potential cause of pain and fatigue." Dr. Rees noted Dr. Kippels' October 2011 presentation, but opined based on history, physical exam, chart review, and medical literature review, the Veteran did not meet the diagnostic criteria sufficient to establish a diagnosis of fibromyalgia. The history and physical exam were not consistent with fibromyalgia. There was no tenderness on palpation of at least 11 of the 18 "tender points" important for the diagnosis of fibromyalgia.; therefore, it was considered less likely than not that the Veteran had fibromyalgia. Regarding whether she had a current valid medical diagnosis of CMV or EBV, he stated that the positive titers noted in her file indicated past exposure, but it did not mean that she had an active ongoing infection. Her history and physical exam were not consistent with an active ongoing infection. Despite Dr. Kippels' assertion, it was the examiner's opinion that it was unlikely that the Veteran had a valid medical diagnosis of CMV or EBV. Concerning whether she had a current valid medical diagnosis of any chronic cardiovascular disease, Dr. Rees stated that a review of the records, as well as the history and physical exam failed to support any chronic cardiovascular disease, including infection, hypercoagulable state, prolonged QT, and soluble fibrin monomer. Her cardiovascular evaluations have been negative. Despite Dr. Kippels' assertion, it was the examiner's opinion that it was unlikely that the Veteran has a valid medical diagnosis of any chronic cardiovascular disease. Regarding whether the Veteran had a current valid medical diagnosis of hypothyroidism, respiratory disease (including Chlamydia pneumonia), mycoplasma, or any chronic headache pathology, she reported a history of chronic daily headaches. There was no valid medical evidence that she had any chronic thyroid or respiratory conditions; therefore, he opined that it was unlikely that the Veteran had a valid medical diagnosis of any thyroid or respiratory disease. Her service treatment records were negative for chronic headaches and there was no credible peer reviewed medical reference that supported the contention that chronic daily headaches were related to vaccinations. Therefore, it was less likely than not that the Veteran's headaches were etiologically related to military service. The physician was also asked if the Veteran had a current valid medical diagnosis of any disability or disabilities manifested by menstrual disorders/vaginitis, pituitary dysfunction, deficiencies or imbalances of various hormones, low natural killer cell function, elevated RNA-S-L, hypercoagulation state, systemic fungus, hypoglycemia, elevated angiotensin II, skin symptoms, neurologic symptoms, sleep disturbances, and/or abnormal weight loss. Dr. Rees commented that based on review of the records, as well as the history and physical exam the evidence did not support the contention that she had a physical disability manifested by menstrual disorders/vaginitis, pituitary dysfunction, deficiencies or imbalances of various hormones, low natural killer cell function, elevated RNA-S-L, hypercoagulation state, systemic fungus, hypoglycemia, elevated angiotensin II, skin symptoms, neurologic symptoms, sleep disturbances, and/or abnormal weight loss. Despite Dr. Kippels' assertions, it is was the examiner's opinion that the most likely etiology of the Veteran's complex myriad symptomatology was her previously noted somatoform disorder. Regarding somatoform disorder, there was no credible peer reviewed medical reference that supports the contention that it was related to vaccinations. It was unlikely that her somatoform disorder was etiologically related to her military service. See August 2016 CAPRI records. On September 2013 VA respiratory examination, Dr. Rees addressed whether it is at least as likely as not that any current chronic respiratory disability manifested during the Veteran's active duty service or is otherwise etiologically related to such service. The Veteran's service treatment records include a June 1989 report showing she sought treatment for difficulty breathing, chest congestion, cough with productive yellow phlegm; the medical assessment was bronchitis. The Veteran's February 1991 medical examination report indicates that the Veteran's "Defects and Diagnoses" included an upper respiratory infection that was under treatment, and the notes on the Veteran's history refer to respiratory and bronchitis symptoms with upper respiratory infections. The Veteran's own index of her medical history, documented on an attachment to her February 1991 medical history questionnaire, indicates that she had come down with relatively frequent symptoms of colds, flu, and sinus infections. The Veteran's February 1991 medical history questionnaire endorsed a number of symptoms, including "Chronic or frequent colds" and "shortness of breath." A March 1992 private hospitalization report, less than a year after the conclusion of active duty service, also shows that the Veteran's discharge diagnoses included bronchitis. The physician reviewed the file to include the above mentioned service treatment records. The history of several URI's ("cold/sinus/bronchitis") was noted. There was no diagnosis of a chronic disability related to these symptoms, i.e., no chronic bronchitis, no chronic sinusitis, no COPD, etc. The discharge physical exam recorded a normal ENT and lung exam. The examiner opined that it was most likely that these in-service URI's were acute transient conditions which resolved without permanent residual disability. He further opined that it was less likely than not that any current chronic respiratory disability was etiologically related to her military service. See August 2016 CAPRI records. In October 2013, at VA's request, Dr. Murray offered opinions regarding the Veteran's claimed disabilities. The physician reviewed the record and opined that fibromyalgia was less likely than not related to service. The Veteran did not deploy to SW Asia. She was diagnosed with IBS in service after thorough evaluation and as a result received an MEB and was discharged. In the MEB history dated in February 1991, she provided a positive history of swollen or painful joints, ENT trouble, hearing loss, chronic or frequent colds, sinusitis, hay fever, skin diseases, shortness of breath, frequent indigestion, stomach liver or intestinal trouble, adverse reaction to medicine, frequent or painful urination, kidney stones or blood in urine, recent gain or loss of weight, arthritis, rheumatism or bursitis, recurrent back pain, history of operation, hospitalization, and treatment by a physician. The Veteran also provided an explanation for her positive responses to include tonsillectomy at age 16; tubal ligation at age 32; hospitalization for vomiting, diarrhea in 1971; hospitalization for abdominal pains in 1978; hospitalization for dehydration due to food poisoning in September 1990; follow-up visits and lab tests for IBS from September to October 1990; injured left knee during basic training that swells after running; an injured right knee due to a fall in April 1990, swelling that sometimes occurred when reinjured; sinus infection in February 1991; symptoms controlled with OTC drugs in the fall and spring (hay fever); acne treated with topical solutions; symptoms of pregnancy in August 1988; intermittent problems with stomach and intestine since food poisoning; allergic to penicillin and sulfa; occasional bladder infections with bleeding; continuous loss of weigh it since food poisoning; arthritic symptoms in both knees; lower back pain preceding diarrhea - IBS. The exam showed she weighed 101 pounds (her enlistment weight was 102). A subsequent progress note in October 1991 shows she was seen for intermittent gas/abdominal pain/and diarrhea after an episode of food poisoning in September 1990. She had an extensive evaluation and February 1991 MEB and continued to have symptoms of nausea and alteration of bowel habits that lasted two weeks at a time. She had weight loss and decreased appetite. Also noted were "depression" and "night mares." She requests blood test for giardia and multiple stool samples were negative for giardia. The exam was unremarkable, and the assessment was IBS. Regarding Dr. Kippels' written statements, Dr. Murray concluded that the Gulf War vaccinations did not cause the Veteran to develop Gulf War illness pathologies to include fibromyalgia. Dr. Murray noted that the scientifically based medical literature had not yet confirmed the causal relationship between vaccination and fibromyalgia as noted in the article "Chronic widespread pain and fibromyalgia: could there be some relationships with infections and vaccines?" The November 2011 article states "There is no clear-cut evidence of FM or CWP due to infections or vaccinations, no correlations with persistent infection, and no proven relationship between infection, antimicrobial therapies and pain improvement." The article does acknowledge that "some unconfirmed evidence and case reports suggests that vaccinations may trigger FM or chronic pain." The reference article, "Etiology of fibromyalgia: the possible role of infection and vaccination," published in October 2008, notes "There is some evidence for the possible role of vaccinations in triggering the development of FMS and related syndrome; however, this association remains to be established." Service treatment records show that the Veteran was extensively worked up for her gastrointestinal symptoms that persisted following a hospital admission for severe gastroenteritis, likely due to food poisoning. She was diagnosed with irritable bowel syndrome (based on a totally negative work-up) and was ultimately discharged from military service following an MEB for IBS. The Veteran suffered a documented right knee injury and was seen for extremity pains with complaints of pain in her feet, ankles, and knees in June 1989. In addition, she was seen for acute self-limited minor upper respiratory illness. There were no complaints or medical evaluations for symptoms of chronic fatigue syndrome. Even in her diffusely positive medical history for her February 11, 1991 MEB, there was no complaint of fibromyalgia in the Veteran's provided explanation of symptoms. It was noted that Dr. Grandjean, a private physician, who cared for the Veteran around the time of her discharge from the military had begun treatment with Buspar and commented "still fatigue" on Buspar and that she had diffuse mild tenderness with a drawing indicating that it was especially slightly below the umbilicus in the right lower abdomen. This was not suggestive of the onset of fibromyalgia. Dr. Murray also opined regarding whether the Veteran had a diagnosis of CFS or CFIDS and, if so, its etiology to service. Dr. Murray wrote that the Veteran had not been diagnosed by VA with CFS or CFIDS. Most recently, she was under the care of Dr. Kippels, a private physician who had treated her since 2005. In October 2011 and May 2012 letters, Dr. Kippels offered his theories on why he believed the Veteran had CFS/CFIDS due to exposure to other Veterans returning from the Gulf War theater of operations and receiving "cocktail" vaccines. Prior to Dr. Kippels, she was diagnosed with CFS by Dr. Garza. Dr. Murray stated that Dr. Rees offered a reasonable rebuttal to Dr. Kippels diagnoses in June 2013 and that he agreed. He opined that the claimed CFS/CFIDS was less likely than not incurred in or caused by or aggravated by service. Service treatment records show that the Veteran was extensively worked up for her gastrointestinal symptoms that persisted following a hospital admission for severe gastroenteritis, likely due to food poisoning. She was diagnosed with irritable bowel syndrome (based on a totally negative work-up) and was ultimately discharged from military service following an MEB for IBS. The Veteran suffered a documented right knee injury and was seen for extremity pains with complaints of pain in her feet, ankles, and knees in June 1989. In addition, she was seen for acute self-limited minor upper respiratory illness. There were no complaints or medical evaluations for symptoms of chronic fatigue syndrome. Even in her diffusely positive medical history for her February 11, 1991 MEB, there was no complaint of chronic fatigue in the Veteran's provided explanation of symptoms. There were no complaints of chronic fatigue and no evidence of evaluation for any complaints related to chronic fatigue within a year of leaving active military service. Dr. Murray also opined regarding whether the Veteran had a diagnosis of CMV or EBV and, if so, its etiology to service. He stated that it would be mere speculation to provide an opinion as to whether the Veteran had a valid medical diagnosis of CMV or EBV on the basis that VA had no laboratory results on the Veteran and that she declined to report for any more examinations. A laboratory result collected in September 2004 had a result for CMV IgM antibody of 1.46, which is considered positive according to the lab's ranges. The Veteran's EBV VCA-IgM antibody value was 0.15, which was negative according to the lab's ranges. Dr. Garza, who provided care prior to Dr. Kippels diagnosed the Veteran with CFS, and chronic EBV and CMV. A previous expert had provided an opinion that the CMV result would be consistent with convalescence. A February 2008 lab result showed DBV IgG of 3.53 H, which was positive (and remains positive for life after exposure); EBV nuclear antigen of 5.00H, which was positive (and also does not differentiate between active and past infection). Dr. Murray opined that CMV and EBV were less likely than not incurred in or caused by or aggravated by service. His rationale was that there was no testing for CMV or EBV in service and no complaints by the Veteran to provide a basis to order testing for them. There was also no evidence of blood testing for them within one year of active duty. Dr. Murray also opined regarding whether the Veteran had a diagnosis of cardiovascular disorder and, if so, its etiology to service. He stated that it would be mere speculation to provide an opinion as to whether the Veteran had a valid diagnosis of chronic cardiovascular disease. Dr. Garza received a letter from Dr. Tasian in September 2004 that he evaluated the Veteran for complaints of her heart speeding up at times. There was no associated dizziness or syncope and occasional complaints of sharp chest pain were relieved by "ginko biloba and Cat's claw." An echocardiogram showed "no evidence of valvular heart disease." A December 2008 EKG showed sinus rhythm and normal QT interval and an echocardiogram was normal. There was no evidence upon review of the claims file to provide basis for a current diagnosis of chronic cardiovascular disease other than the Veteran's symptoms. Dr. Murray opined that the claimed heart disorder was less likely than not incurred in or caused by or aggravated by service. His rationale was that there are no service treatment records indicating evaluation or complaint by the Veteran related to her heart and no evidence of evaluation for complaints related to her heart within one year of leaving active duty service. Dr. Murray stated it would be speculative to provide an opinion on whether the Veteran had a valid medical diagnosis of hypothyroidism, respiratory disease, mycoplasma, or any chronic headache pathology and, if so, its etiology to service. He noted that Dr. Kippels and Dr. Garza were the source of these diagnoses and that the Veteran chose them to be her primary care providers. They had examined her and obtained a history from her, evaluated lab tests and special studies for her, as well as asked for consultations for other specialists. On this basis, they made these diagnoses and prescribed treatment and, as an independent medical examiner, Dr. Murray may not agree with every diagnosis or treatment option, but without an opportunity to examine the Veteran and obtain this history and current lab tests and special studies, the diagnoses have to be considered valid. Mr. Murray did, however, opine that these disorders are less likely than not incurred in or caused by or aggravated by service. There are no service treatment records indicating evaluation or complaint by the Veteran related to any of these conditions. There was no evidence of evaluation for complaints related to any of these conditions within a year of leaving active military service. Dr. Murray stated it would be speculation to provide an opinion as to whether the Veteran had a valid diagnosis of menstrual disorder, pituitary dysfunction, deficiencies or imbalances of various hormones, low natural killer cell function, elevated RNA-S-L, hypercoagulation state, systemic fungus, hypoglycemia, elevated angiotensin II, skin symptoms, neurologic symptoms, sleep symptoms, and/or abnormal weight loss. She had an active diagnosis by VA of unspecified disorders of menstruation and other abnormal bleeding. This diagnosis was based on a November 2007 VA examination which noted a history that she was being treated by Dr. Kippels "who administers IVs of 'hydrogen peroxide and dextrose and Myer's Cocktail"' every two weeks that helps control her bleeding problems." Dr. Brooks diagnosed a "History of vaginitis with no evidence of it at the time on wet prep; perimenopausal on multiple "natural" compounded hormonal formulations and was asymptomatic; s/p endometrial ablation x 2 with good control of menstrual flow." VA had not diagnosed her with pituitary dysfunction, deficiencies or imbalances of various hormones, low natural killer cell function, elevated RNA-S-L, hypercoagulation state, systemic fungus, hypoglycemia, elevated angiotensin II, skin symptoms, neurologic symptoms, sleep symptoms, and/or abnormal weight loss and she declined new exams. Dr. Kippels and Dr. Garza are the sources of all of these diagnoses, and, in some cases, it is clear that abnormal lab values are the consequences of his treatment. A lab report in February 2008 has normal Ferritin at 67, FSH in the mid-cycle peak range at 10.8, LH in the mid-cycle peak range at 13. Insulin at <2 in the normal range. Normal angiotensin-1-converting enzyme value of 45. Progesterone in the luteal or mid-luteal phase range at 12.9, Low T-4 Free at 0.3 and low TSH at 0.02 and high T3 at 628 (consistent with treatment with Triioldo-l-thyronine by Dr. Kippels), Thyroglobbulin antibodies were negative at <20, thyroid perozidase antibodies were negative at <10. DHEA sulfate was elevated at 201 (this was consistent with Dr. Kippels' treatment with Testosterone troches and DHEA capsules). Dr. Kippels also had her taking cortisol, a form of hydrocortisone, which could cause a number of side effects when taken for a prolonged period such as thin skin, bruising, high or increased blood pressure, susceptibility to infections including fungal, build-up around the face, osteoporosis, fluid retention, and diabetes. Dr. Kippels' diagnosis of pituitary dysfunction was based on a low free cortisol level and ACTH this testing and diagnosis required adherence to proper methodology, there was no indication in his discussion that he obtained these values on more than one occasion or at the proper time. The Veteran's CBC with differentials from September 2008 was unremarkable, making his discussion of immune dysfunction with "low killer cell function of doubtful significance given a normal white cell count, including both granulocyte and lymphocyte counts." However, the Veteran had chosen Dr. Kippels and Dr. Garza as her primary providers, and they had examined her and obtained history from her, evaluated lab tests and special studies for her, as well as asked for consultation from other specialists. On this basis they made these diagnoses and prescribed treatment, so Dr. Murray, as an independent medical examiner, might not agree with every diagnosis or treatment option, but without an opportunity to examiner her and obtain history, current lab tests, and special studies, the diagnoses had to be considered valid. Regarding the etiology of these disorders, Dr. Murray opined that they were less likely than not incurred in or caused by or aggravated by service. He stated that there are no service treatment records indicating evaluation or complaints by the Veteran related to these disorders or findings. He noted that the Veteran weighed 102 pounds when she entered active duty and 101 pounds when her MEB physical was performed. There was no evidence of evaluation or complaints related to the claimed disorders and findings within a year of leaving active service. See October 2013 Medical Treatment Record Government Facility. A December 2016 DBQ for heart disabilities completed by Dr. Kippels states the Veteran had diagnoses of congestive heart failure (CHF) with dyspnea, supraventricular arrhythmia ectopics, valvular disease, hypertensive heart disease, infectious heart conditions, diastolic failure/dyspnea, and long QT syndrome with syncope. Several cardiac diseases above consisted of multiple organic cardiac diagnoses. He asserted that pre-deployment vaccines on November 21, 1990 triggered diastolic/congestive heart failure common in CFS. Diastolic failure became apparent after the Hepatitis B cocktail vaccines on November 21, 1990. Exercise intolerance due to diastolic heart failure or "defective cardiac filling" began November 27, 1990. Diastolic failure causes severe chest/heart pain. She could not complete her treadmill stress test in September 1999 for diastolic failure, dyspnea, chest/heart pain. Additional diagnoses were bradycardia (below 60 heart rate) noted on March 12, 1992; chest pain, fast or slow heartbeat, irregular heartbeat, palpitations, skipped beats (ectopics) on June 19, 1991; lightheadedness on April 30, 1991; shortness of breath (dyspnea on exertion) on April 30, 1999; sweating on April 30, 1991; tachycardia (sinus above 100) on September 14, 1999; CHF (includes buildup of fluids in body tissue, edema/swelling, tiredness, shortness of breath) on September 14, 1999, diastolic heart failure on September 20, 2004, E to A reversal on September 20, 2004; CMV on September 20, 1994; EBV on July 1, 1999, left ventricular hypertrophy and Long QT Syndrome on September 20, 2004, organic heart disease and syncope on June 17, 1991, S2 gallop on March 12, 1992 and S3 gallop on January 11, 2000, short PR sinus rhythm, supraventricular ectopics on December 5, 1994. Indications of additional or underlying organic cardiac disease valvular disease were mitral and tricuspid valve regurgitation and nonrheumatic tricuspid valve insufficiency on September 14, 1999. He noted that on September 14, 1999 she was started on cytovene oral antiviral to control the spread of CMV and that this relieved 50 percent of her cardiac symptoms. Dr. Kippels also commented that the Veteran was never admitted to any hospital largely because mainstream cardiologists, internists, and ER physicians do not treat organic heart disease as they do ischemic heart disease. He stated that the cardiologist Dr. Tasian was not involved in the Veteran's chronic, progressive illness until September 4, 1999 and that many of his statements were conjecture. Dr. Tasian does not treat organic heart disease and was not familiar with the Veteran's history of organic heart disease, which was supported by him not recognizing "E to A reversal suggesting relaxation" as a diastolic failure that is common in CFS patients. He stated that Dr. Tasian was uninvolved in organic heart disease except for periodic testing. Dr. Tasian reported his findings via EKG and echo in 1999, 2004, and 2008. During these same tests, UTSW, where the physician worked, had cardiac tests that discovered additional organic heart diseases detailed in echo charts/graphs and all were excluded from Dr. Tasian's letter. Dr. Kippels stated that pre-deployment vaccines on November 21, 1990 triggered all of the Veteran's organic diseases: vaccines reactivated viruses that negatively impact the heart. He identified CMV as a green African monkey virus found in live injectable polio vaccines, which were administered during basic training in April/May 1989. Once their immune systems are impaired, humans are unable to mount an immune response to CMV infections. He opined that military grade vaccines administered too many at one time and too close together plus post-vaccination infections damaged her immune system on active duty. The Army's lack of ordinary healthcare caused more damage. The Army's February 4, 1991 blood tests proved acute viral infection and a December 2, 1991 pathology report proved she had a chronically inflamed duodenum. Her civilian blood tests and pathology reports prove she was healthy prior to active duty and pre-deployment vaccines. Vaccine Adverse Events Reporting System (VAERS) proves women suffer CFS, pancreatitis, and colitis as adverse effects after Hepatitis B vaccines. Hepatitis B vaccines were never clinically tested for administration simultaneously with other vaccines, including flu, tetanus, and diphtheria. Dr. Kippels stated that more recent research from Canadian Medical Associations Journal 2007 shows hepatitis B vaccines negatively impact physically fit men with healthy BMI. The Veteran was 10 pounds underweight at 100 pounds for her age and height. Together CMV and EBV cause massive cardiac damage beginning with diastolic heart failure in four stages. Since the Veteran exhibited symptoms of diastolic heart failure, chest/heart pain, and exercise intolerance from onset of November 21, 1990 vaccines, her heart damage appears to be irreversible at stages 3 and 4. Valve conditions include mitral valve regurgitation, tricuspid valve regurgitation, left ventricular hypertrophy, supraventricular ectopics. Fatigue onset as a prerequisite for a CFS diagnosis was simultaneous with organic heart disease, immediately after pre-deployment vaccines on November 21, 1990. The Veteran was denied blood tests eight times, civilian hospitalization three times, and Army physician consult with civilian physician four times. She did not receive treatment for multiple infections or heart disease on active duty or within a year thereafter. In the remarks section, Dr. Kippels wrote that the Veteran visited hospital ERs at least a dozen times for syncope associated with organic heart disease/CFS. However, she had never been admitted to any hospital largely because mainstream cardiologists, internists, ER physicians do not treat organic heart disease as they do ischemic heart disease. Also, most hospitals did not recognize women's heart disease or women's heart attacks prior to 2013. CMV is slightly transmissible by body fluids, and most civilian hospitals are not willing to quarantine a patient with CRS/organic heart disease due to viral infection that is not recognized as HIV positive of AIDs. See December 2016 Ischemic Heart Disease Disability Benefits Questionnaire. Dr. Kippels completed a DBQ for CFS in December 2016. He noted diagnoses of fatigue, coagulation defect, fibromyalgia, hypoglycemia, lack of strength, migraines, tinnitus, tiredness, and muscle weakness and the dates they were diagnosed, which ranged from muscle weakness in December 1990 to hypoglycemia diagnosed in November 2005. Biomarkers for virus profiles in CFS are chronic CMV, HHV-5 and chronic EBV, HHV-4. Under CMV in CFS the diagnoses were CMV infection HHV-5, chytomegaloviral disease, cytomegaloviral vireme, other cytomegaloviral disease, chlamydia pneumonia, mycoplasma bacterial infection, mycoplasma fermentans (found in GWI), and mycoplasma pneumonia (bronchitis). Cognitive dysfunction in CFS were ADD, cognitive deficit in attention or concentration, cognitive changes due to medical disorder, confusion NOS, disorientation unspecified involving cognitive, and memory loss. Sleep disorders in CFS are insomnia, nonorganic sleep disorder unspecified, sleep disorder NOS, and sleep disorder organic. Diagnoses of Hypothalamic/pituitary/adrenal in CFS were hypothalamic dysfunction, hypothyroiditis, adrenal insufficiency, pituitary dysfunction, unspecified endocrine disorder, ovarian dysfunction, or menopause syndrome. Nutritional deficiencies in CFS are diagnoses of bacterial overgrowth syndrome (August 1998), B12 deficiency (April 4, 2005). Other diagnoses for CFS were bilirubin metabolism disorder, hypoglycemia, malabsorption, malabsorption specified NEC, mitochondrial metabolism defect, small intestine bacterial overgrown, vitamin D deficiency, and wasting disease (emaciation July 1, 1999). Dr. Kippels also listed numerous gastrointestinal diagnoses related in immune dysfunction, and hypotension diagnoses in CFS. In his review of the medical evidence, Dr. Kippels detailed everything he believed the Army MEB report and VA examiners excluded. Dr. Kippels noted that signs and symptoms of CFS are debilitating fatigue, low grade fever, non-exudative pharyngitis, palpable lymph nodes cervical and axillary, generalized muscle aches, fatigue lasting 24 hours or longer after exercise, headaches, migratory joint pain, sleep disturbance, weakness, and lack of strength. Under the 24 hour fatigue category he stated that the Veteran had not been able to exercise aerobically since her pre-deployment vaccines due to diastolic failure described to Army physicians. Other mild activity such as spot cleaning or mild yard maintenance resulted in a "bedfast" state form one or more days. Regarding headaches, they were of a severity, type, or pattern different than headaches in her pre-morbid state. Her neuropsychological symptoms specifically did not include mental illness and were described as cognitive dysfunction in disability letters. Under findings, signs, and symptoms Dr. Kippels wrote that chronic CMV includes inflamed, swollen salivary glands rather than sore throat or pharyngitis. Her symptoms were so severe as to restrict routine daily activity almost completely and that she could not drive to doctor appointments or anything else pre-scheduled since live polio vaccine reactivated in 2011, before leaky gut syndrome in 2010, before fecal incontinence resumed in 2010. Most physical activity required two days of bed rest and being in a bedfast state. Her bedfast state began in August 1994 and has substantially worsened. She missed 45 days of work in 1994 due to elevated IgM in reactivated CMV and she missed 21 days in 1995 due to recurring infections, which were biomarkers for CFS. Even when working full-time she resorted to bedrest on weekends and holidays. He stated that no VA examiner reviewed any medical records or diagnoses from Dr. Rasheed, Dr. McClean, Dr. Garza, or Dr. Tasian and that VA had fabricated mental illness and fabricated claims. He stated the Army's and VA's fabrications and repetitive denials were for the sake of "denial bonuses." The Veteran volunteered twice to deploy to Desert Storm. See December 2016 Disability Benefits Questionnaire (DBQ). In September 2020, Dr. Kulkarni, a VA psychiatrist, provided an opinion to address whether the Veteran had a diagnosis of a somatoform disorder and whether it was related to service. Based on a review of the record, the psychiatrist opined that the claimed disability was less likely than not incurred in or caused by service. The psychiatrist noted that the February 1991 MEB noted a final diagnosis of IBS. A summary of the defects and diagnoses noted on the MEB exam dated in February 1991 did not document any complaints, findings, symptoms, signs, diagnosis, or treatment consistent with a somatoform disorder or any other psychiatric disorder. The Veteran was given a normal psychiatric score of S1 on the physical profile in the MEB exam in February 1991. Service treatment records were silent for complaints, findings, symptoms, signs, diagnosis, or treatment of the claimed condition; therefore, the available evidence was insufficient to show that the claimed condition was incurred in or caused by the active duty military service. Based on above findings and rationale, the psychiatrist opined that it was less likely as not that the Veteran's in-service symptoms were related to any current psychiatric disorder, to include somatoform disorder, or otherwise demonstrated a somatoform disorder. See September 2020 C&P Exam. In a May 2021 supplemental opinion, Dr. Kulkarni noted that the Veteran's in-service symptoms consisted of an October 1991 service treatment record that notes her complaints of depression and nightmares and the November 1991 service treatment record that notes she carried a diagnosis of depression/anxiety. According to a document the Veteran provided that was received on December 7, 2016: "Patient already knew that she suffered atypical heart disease/gut infections instead of "anxiety" by the time Dr. Grandjean started treating her UTI on April 30, 1991." Therefore, it appeared that the Veteran's in service symptoms noted above could not be attributed to any mental or psychiatric disorder because they were accounted for by non-psychiatric conditions of atypical heart disease/gut infections. So, there was insufficient evidence to show that any psychiatric condition was noted in service. According to a document the Veteran provided that was also received on December 7, 2016: "Dr. Grandjean left Lake Highlands Medical Clinic shortly after patient's last office visit on July 15, 1991. Late in September or early in October, patient requested her medical files be returned to Lake Highlands Medical Clinic for future healthcare with a different doctor, Dr. Grandjean's medical records end on July 15, 1991. All civilian/Army physicians continued Dr. Grandjean's "treatment for nightmares and depression" through 8 months after the patient /physician relationship ended, that is, 8 months after the patient stopped taking BuSpar, which was prescribed for "fatigue" and "cardiac arrhythmias." The Veteran sought medical care from Muzzathr Mehdi, MD, PA on October 5, 1991. Dr. Mehdi's writing is illegible for the most part. However, Dr. Mehdi noted on Oct. 18, 1991 that his patient "has not taken chiordiazepoxide" (did not know what chiordiazepoxide was) and had stopped taking BuSpar" before end of July 1991." Therefore, there was insufficient evidence to establish continuity of any of the Veteran's in-service symptoms noted above, after active duty military service. According to another document the Veteran provided received on December 7, 2016: "All regulatory agencies list depression, anxiety, panic attacks, mental illness BS, and fibromyalgia as diseases that cannot be confirmed by diagnostic laboratory testing. All agencies urge physicians to pursue those diagnoses as "separate" or "in addition to" (CFS, which excludes mental illness by CDC definition). Researchers for CFS raised concern that Family Practitioners like Dr. Grandjean and psychologists that VA contracts for Comp & Pen are mis-diagnosing CFS patients with mental illness. Many were prescribing harmful anti-depressants/anti-anxiety prescriptions without blood tests to determine "root" cause of CFS. VA examiners chose Somatoform Disorder to the exclusion of all other diagnoses this patient had accumulated over the course of 20 years. No one at VA has experience diagnosing or treating CFS or GWL." Per the Veteran's statement dated on February 22, 2016: "Neither CFS nor organic heart disease involves mental illness or PTSD. VA is responsible for all references of non-existent mental illness. Army and VA falsified treatment for nightmare and depression for a full 8 months after patient physician relationship ended on July 1,1991. VA is also responsible for failure to "expunge" those mental illness records as I have repeatedly requested in writing. Most of the symptoms on Hamilton Anxiety Rating Scale duplicate CDC's regulatory lists for CFS symptoms." Therefore, VA examiner Dr. Kulkarni found it was unclear why the Veteran was claiming a psychiatric condition because it appeared that the Veteran's position on the issue was exactly the opposite. Here, the Veteran was trying to assert that she had the non-psychiatric condition of CFS, which was being misdiagnosed as mental illnesses, such as depression, anxiety, and Somatoform Disorder. Per Social Security records dated on May 19, 2009, the Veteran's primary and only disability diagnosis was CFS. The Social Security examination dated in June 2015 by Dr. Takach noted that the Veteran's disability diagnosis was CFS. Under the federal law of "Avoidance of pyramiding," VA C&P providers are prohibited from attributing symptoms already accounted for by one condition to a different condition. Therefore, there was insufficient evidence to establish the presence of a current psychiatric disorder. There was insufficient evidence to establish that the noted in-service symptoms arose from a psychiatric disorder. Additionally, there is insufficient evidence to establish a nexus between the noted in-service symptoms and any current psychiatric disorder, to include somatoform disorder or otherwise demonstrated the presence of a somatoform disorder. Also, there was insufficient evidence to establish the presence of a current psychiatric disorder, to include somatoform disorder or otherwise demonstrate the presence of a somatoform disorder. Based on above findings, it was determined that the Veteran's in-service symptoms were less likely than not related to any current psychiatric disorder, to include somatoform disorder or otherwise demonstrate the presence of a somatoform disorder. See May 2021 C&P Exam. In June 2021, the Veteran's claims file was made available to a VA examiner for the purpose of providing an opinion for the Veteran's claimed menstrual disorder. Based on his review, Dr. Dykes opined that it was less likely as not incurred in or caused by service. The Veteran was treated for UTI and she also claimed cycles Q3 to four months. Her service spanned only five months for two separate periods. No pattern of irregularity was established or could be established to assess etiology or true onset. No records reflect treatment for amenorrhea or prolonged cycles. Otherwise, there were no gynecologic references. No vaginitis was diagnosed. The separation exam dated in February 1991 was negative and also reported a normal menstrual cycle in January 1991 (contradictory and somewhat supports an indefinite, unassignable timeline or etiology). An exam dated in September 1992 was also negative, and no signs or symptoms of endometriosis or more frequent irregular bleeding were noted at separation. The Veteran underwent the ablations in 1998 and 2002. It was highly unlikely that a combined 10 months of active duty from April 1989 through April 1991 led to any significant gynecologic condition. The Veteran had noted less frequent cycles at separation. There was no evidence of care proximate to service. Dr. Dykes was unable to locate records within a year of service or even longer and the first gynecology records appear in or around 1994. The Veteran reported undergoing an endometrial ablation in August 1994, along with a diagnostic laparoscopy and was diagnosed with endometriosis. A second procedure was performed in 2002, with adenomyosis and endometriosis being diagnosed. Only IBS was reported proximate to service and there were no gynecologic complaints on the notes dated in September 1992. The Veteran claims, "Military vaccines caused all my problems got a hepatitis cocktail" - a medically unsubstantiated theory. There was no hepatitis cocktail other than a three-injection hepatitis B vaccine, 2 months apart, which does not cause vaginitis or menstrual irregularities. They have no hormonal impact nor do any other vaccines administered while in military service. There were no significant OB/GYN conditions noted while in service. The separation exam was negative for gynecologic conditions. There was nothing other than a reported occasional bladder infection/UTI. The last menstrual period was noted within the last month prior to separation. A letter from Dr. Rasheed dated in September 1994 noted the patient to be three weeks post-op from the first ablation. The Veteran was seen by Dr. Kippels and his opinions appeared to be predicated on the Veteran's history which was not supported by objective information. A progress note dated in November 2008 documented the Veteran's gynecologic history and there was a consistent error in the medical records regarding the dates of military service. It seems the Veteran had informed individuals of service into 1992. This had an impact on the rationale based on timing. She was seen by Dr. Kippels with some interesting, non-standard treatment options as described by the Veteran and somewhat substantiated in his treatment records. Nonetheless, all of these records are post-service and do not suggest a relationship to service. Even conceding a 1994 ablation and laparoscopy for apparent endometriosis and bleeding, it is more likely than not that the Veteran developed symptoms and signs post-service. The onset was more likely than not in or around 1994. It was unlikely that a condition arising in service would not have manifest sooner than three years. There was no evidence supporting a diagnosis while in service. The symptoms the Veteran was treated for 1994 and 2002 would include heavy irregular bleeding, natural pain, and pelvic pain. There was nothing to support such a claim the medical records. Dr. Dykes continued that the opinion by Dr. Kippels was broad and apparently without review of service treatment records/medical records. His rationale was not substantiated on the basis of an absence of the conditions in service. It was more likely than not that the Veteran's complaints developed after service, as evidenced by the negative separation exam. This included a history, physical and Veteran reported RMH, which was negative for gynecologic conditions with a normal menstrual cycle one month prior. This was documented. The only treatments were for urinary tract infections which are unrelated to irregular uterine bleeding or endometriosis. Additionally, the Veteran had a tubal ligation in 1990, with no evidence of endometriosis. Therefore, it was less likely than not that her current gynecologic conditions are due to or incurred in service. Dr. Dykes noted that he is a Board-certified OB/GYN with 30 plus years of experience. See June 2021 C&P Exam. Analysis As an initial matter, the Board will start by addressing one the Veteran's main assertions that her in-service vaccines caused her to develop her claimed disorders. Dr. Kippels is the only medical provider who offered a favorable opinion on this contention. The Board finds that Dr. Kippels' opinion that the vaccines the Veteran received during service caused her to develop her claimed disorders is outweighed by the other more probative evidence of record. Specifically, the Board finds Dr. Casillas' August 2011 opinion more probative. As outlined above, the Board finds Dr. Casillas' opinion more probative, in part, because he is specializes in the practice of clinical immunology and allergy. He has extensive training and expertise in immunology, the study of the body's reaction to infectious agents and vaccines as well as inflammation resulting from immunologic processes in the body. He has conducted research in the field of immunology and has treated multiple patients with conditions stemming from inflammation and disorders of the immune system. He is board certified by the American Board of Allergy and Immunology. Dr. Casillas had published approximately 30 peer-reviewed scientific papers in the field of allergy, asthma, and immunology. By contrast, Dr. Kippels does not specialize in the field of clinical immunology, nor is he Board certified in the field. Dr. Kippels identified himself as Board certified in obstetrics and gynecology and in anti-aging and restorative medicine. Further, as outlined above Dr. Casillas provided detailed reasoning for his conclusions. He noted that hepatitis B vaccines, in particular, have been subject to study by the Centers for Disease Control, the Institute of Medicine, as well as other scientific groups for evidence of associated disease states that may be attributed to the vaccine. Extensive epidemiological evidence has been reviewed and the recommendations favor rejection of a causal link between hepatitis vaccine and specific disease states and syndromes. Thus, due to Dr. Casillas' expertise and experience, his conclusions are afforded more probative value. Additionally, the Board affords Dr. Casillas' opinions more probative value because he based his conclusions on an accurate account of the Veteran's medical history. The Board finds that the most probative evidence is that contemporaneous to when it was recorded, as it was created closer in time to the actual evaluation or report of the claimed illness or injury. For example, the service treatment records, to include the Veteran's reports of symptoms and examiners' findings, are more probative than history the Veteran reported at a later date. This is because a person seeking treatment has an incentive to report symptoms accurately to receive proper treatment. Despite allegations that military and VA providers recorded information inaccurately, there is no support for his in the record, besides the Veteran's and Dr. Kippels' bare assertions. The Board also affords Dr. Casillas' conclusions about the clinical significance of laboratory testing and interpretation of laboratory results more probative due to his expertise. Similarly, the Board affords more probative value to his conclusions about the composition of vaccines. In October 2011 correspondence, Dr. Kippels concluded that GWI has been well documented in the medical literature to be the result of the vaccines given in preparation for deployment. The Board does not find Dr. Kippels' opinion as probative as Dr. Casillas' opinion. Dr. Casillas based his opinion on a review of the relevant medical literature in the form of publications of scientific information and text books and determined there was no evidence of a causal link between vaccines and the Veteran's claimed disorders. The Board finds Dr. Casillas' interpretation of the literature on the topic of vaccinations and their effects more probative than Dr. Kippels' interpretation, as Dr. Casillas has been shown to be an expert in the field and have more experience with the subject matter. 1. Entitlement to service connection for a cardiovascular disability, to include Long QT Syndrome. In a May 2012 statement, Dr. Kippels stated that that the Veteran had heart damage/disease associated with viral and bacterial infections. However, the evidence weighs against a heart disorder during service, or any such heart disorder related to service. In Dr. Kippels' December 2016 DBQ, he diagnosed the Veteran with multiple heart disorders. He stated that the November 1990 vaccinations triggered her congestive heart failure (CHF) and that the diastolic failure became apparent after the hepatitis B vaccine cocktails vaccines on November 21, 1990 and exercise intolerance due to diastolic heart failure that began on November 27,1990. However, he does not identify anything in particular on November 27, 1990 to support his opinion. Instead, he points to an exercise treadmill test in 1999 that she could not complete, which was nine years later. Regarding his diagnosis of bradycardia, he stated that this was noted on March 12, 1992 and was evidenced by a heart rate of below 60. The Board acknowledges that bradycardia is defined as a slow heartbeat. See www.mayoclinic.org; Pritchett v. Derwinski, 2 Vet. App. 116, 117 (1992). However, ER reports from St. Paul Medical Center on that date state her heart had a regular rate and rhythm. Her hospitalization records show her heart rate was 90 on admission and the discharge summary notes heart rates of 100 while lying down and 120 while sitting up. Furthermore, there was also no diagnosis of bradycardia. Dr. Kippels also stated the Veteran had organic heart disease, syncope, and irregular heartbeat and skipped beats (ectopics) on June 19, 1991; and lightheadedness and sweating on April 30, 1991, but the Board finds no evidence of a heart disorder. A Hamilton Rating scale questionnaire dated April 30, 1991 shows she reported being sweaty, but denied having any cardiac symptoms such as rapid heartbeat, palpitations/heart skipping beats, chest pain, and feeling faint. There is a second set of numbers that indicates she had cardiac symptoms but it was unclear when she was reevaluated, and no specific symptoms were identified. Her records from March 1992 note an episode of being near syncope, but no cardiac origin or diagnosis was found. She had a work-up for syncope again in 1994, but Dr. Rasheed found no evidence that it was related to a virus. As for the ectopics he noted in June 1991, the record shows that an ECG revealed rare supraventricular ectopics in December 1994. Dr. Rasheed appears to have been her physician in the early 1990's, but none of his or any other records contain a diagnosis or suspicion of a heart disorder. April 2005 correspondence from Dr. Garza states he has treated the Veteran since 1996 and while he makes a reference to the Veteran having cardiovascular disturbances, there is no specific diagnosis in his correspondence. However, a January 2004 record contains an impression of tachycardia, which is 14 years after her active duty service. Dr. Kippels' October 2009 hearing testimony states the Veteran had a virus that could damage the heart, but his treatment records do not contain any diagnosis of a heart disorder. When he first saw the Veteran in April 2005, the examination revealed a rapid pulse, but he also noted that the Veteran had taken Adderall that morning. Dr. Tasian, a cardiologist, saw the Veteran on multiple occasions but did not diagnose bradycardia or valvular disease. In 1999, he noted Dr. Garza suspected an enlarged heart or leaky heart valves and that the Veteran complained of dyspnea, chest tightness, irregular heartbeats, and palpitations, but after testing and an evaluation he stated the data did not suggest the presence of heart disease to explain her symptoms, the etiology of her dyspnea was unknown, and that her dyspnea was non-cardiac. Although the September 2004 EKG revealed concentric left ventricular hypertrophy, trace mitral regurgitation, and E to A reversal suggestive of abnormal relaxation and Dr. Tasian also found evidence of tachycardia, these findings were made 14 years after her in-service vaccinations. He also found no evidence of valvular disease. Dr. Kippels diagnosed the Veteran with having QT syndrome, but Dr. Tasian, who again evaluated her in December 2008, stated that the prolonged QT interval noted in 2004 was probably related to medication she was taking and that there was nothing to suggest QT syndrome. Furthermore, the current EKG showed a normal QT interval. Dr. Tasian did note there was trace tricuspid regurgitation in December 2008, but this was 18 years after receiving vaccinations in service and there is insufficient evidence to establish a nexus, particularly since Dr. Kippels indicates her heart disorder started almost immediately after she received the vaccinations. Dr. Kippels' DBQ attempted to minimize the value of Dr. Tasian's opinions and statements by noting the cardiologist did not become involved in the Veteran's care until 1999; however, the Board notes that this is five years before Dr. Kippels himself became involved in her care. Thus, Dr. Tasian's "late start" to the Veteran's treatment is no more damaging to the probative value of his opinions than Dr. Kippels'. He also comments that Dr. Tasian's statements are conjecture, he does not treat organic heart disease, and was not familiar with the Veteran's history or organic heart disease. Even though Dr. Tasian is a cardiologist and Dr. Kippels has identified some of the other physician's credentials, he essentially asserts Dr. Tasian is not qualified to diagnose any heart disorders that are present. The Board finds the reasons for Dr. Kippels' conclusions are not persuasive. Dr. Tasian, by virtue of his specialty as a cardiologist and experience, has adequate eduction and training to provide knowledgeable and informed opinions and diagnoses; therefore, he is qualified to evaluate and diagnose heart disorders. It is for these same reasons that the Board also finds Dr. Tasian more qualified to address this area of medicine than Dr. Kippels'. During the October 2009 Board hearing, Dr. Kippels identified himself as Board certified in obstetrics and gynecology and in anti-aging and restorative medicine. See October 2009 Hearing Testimony. While questioning the qualifications of Dr. Tasian, Dr. Kippels has offered nothing in the way of credentials that would lead the Board to believe that he is more capable of diagnosing cardiac disorders than an actual cardiologist. Thus, the Board assigns greater weight to Dr. Tasian's statements and diagnoses than Dr. Kippels'. Dr. Kippels also stated that CMV and EBV cause massive cardiac damage beginning with diastolic heart failure in four stages and that the Veteran exhibited symptoms of diastolic heart failure, chest/heart pain, and exercise intolerance since November 21, 1990. Even if this were true, as discussed below, the Board is denying service connection for CMV and EBV. Furthermore, the record does not show she had those symptoms since November 1990. Although he states she had exercise intolerance since 1990, she reported in 2007 that she walked her dog daily for exercise and that up until 2002 she had been walking three miles a day. Her February 1991 separation medical history report shows she denied having pain or pressure in her chest. She also had many evaluations after her November 1990 vaccinations but none of the records show she report any of the symptoms she is claimed to have had at that time. Thus, Dr. Kippels' statements regarding her cardiac symptoms are inconsistent with the more probative contemporaneous evidence of record. Dr. Murray also provided an opinion and while he declined to offer an opinion as to whether the diagnosed heart disorders were valid, he did opine that the claimed heart disorder was less likely than not related to service. He adequately explained his rationale and it is consistent with the record. Thus, his opinion is probative. For the reasons stated, the Board finds that the Veteran did not have a heart disorder that manifested during service or within one year of being discharged from active duty service. There is also insufficient evidence to establish a nexus between her claimed heart disorder and service, to include in-service vaccinations. Accordingly, a preponderance of the evidence is against the claim, so it must be denied. 2. Entitlement to service connection for a disability manifested by neuropsychological symptoms (also described as dysthymia with anxiety and physical symptoms), to include somatoform disorder. The Veteran contends she has a neuropsychological disorder related to service. See April 2016 Hearing Testimony. Private treatment records from Dr. Grandjean from April to July 1991 indicate the Veteran had anxiety and that he was treating her with Buspar. Her service treatment records show that during a one day TDY in October 1991 she reported having depression and nightmares, and the subsequent one day TDY in November 1991 notes she "carries a diagnosis of depression/anxiety." During a September 1992 VA examination she reported being told by a doctor she had panic attacks and depression, and based on the examination, the VA clinician gave an impression of dysthymia with anxiety. A later VA examination in November 2007 by Dr. Horne contains a diagnoses of undifferentiated somatoform disorder and mood disorder and the clinician opined that the current evaluation did not show a service connected mental disorder. Dr. Rees opined in June 2013 that despite Dr. Kippels' assertions, the most likely etiology of the Veteran's symptoms was somatoform disorder. He found no credible peer reviewed medical reference that supported the contention that the somatoform disorder was related to vaccines and opined that it was unlikely that somatoform disorder was etiologically related to service. Because the JMPR found that Dr. Horne's November 2007 opinion was conclusory and Dr. Rees' June 2013 opinion did not contain supporting rationale, the Board was directed to obtain another opinion to determine if the somatoform disorder was etiologically related to service and to discuss the in-service symptoms and determine whether they are related to somatoform disorder or demonstrate the presence of somatoform disorder. The Board notes that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). The Board obtained additional opinions from Dr. Kulkarni in September 2020 and May 2021, who, along with the January 2008 SSA examiner, found the Veteran did not have somatoform disorder. Dr. Kulkarni's opinion, as directed by JMPR, also addressed the in-service symptoms and whether they demonstrated a somatoform disorder or were related to a somatoform disorder. The psychiatrist opined that the in-service symptoms were not related to a somatoform disorder or any other psychiatric disorder and offered a rationale to support the opinions. The Board finds the opinion to be probative and, thus, finds that a preponderance of the evidence is against the existence of a somatoform disorder or any other mental health disorder being related to service. With regard to a neuropsychological disorder, Dr Kippels' February 2006 statement asserts the Veteran's in-service vaccinations in November 1990 resulted in immune dysfunction that reactivated infections in her body that produced neurotoxins that resulted in cognitive dysfunction. He specifically identified EBV and hypercoagulation state as causing cognitive dysfunction. The SSA examiner also diagnosed a cognitive disorder NOS, but also indicated that the full diagnostic criteria were not met. Thus, the medical evidence is conflicting. In February 2012, the Veteran stated only a neurologist could diagnose a neuropsychological disorder, yet in her statement she also stands by Dr. Kippels' diagnosis of cognitive disorder. Given that Dr. Kippels is not a neurologist, her objections to any examiner who is not a neurologist is without merit. Even if the Board found the evidence to be equally probative, Dr. Kippels etiologically linked the Veteran's cognitive dysfunction to EBV and hypercoagulation state. Since the Board's decision denies service connection for EBV and hypercoagulation state, the evidence, in turn, is unfavorable regarding establishing service connection on a secondary basis. Furthermore, there is no probative evidence that directly links a neuropsychological disorder to service, to include in-service vaccines. Service treatment records contain no complaints or findings of a neuropsychological disorder, to specifically include a cognitive disorder. Even when records show she was working full-time and going to school four times a week in September 1992, she did not have any complaints of a cognitive disorder or any other neuropsychological issues; those complaints did not come until many years after service. For the reasons stated, the Board finds that a preponderance of the evidence is against the claim, so it must be denied. 3. Entitlement to service connection for chronic fatigue syndrome (CFS) or chronic fatigue immune dysfunction syndrome (CFIDS). Dr. Garza first diagnosed the Veteran with CFS in 2004, which was followed by a diagnosis from Dr. Kippels in 2005. Dr. Garza indicated she had symptoms since he started treating her in 1996. In June 2013, Dr. Rees opined the Veteran did not meet the criteria for CFS because the physician attributed the Veteran's symptoms to other disorders, to include somatoform disorder. The Board notes that the weight of the evidence was against the presence of somatoform disorder and since he did not identify any other disorders the symptoms could be attributed to the opinion has limited probative value. The physician did, however, note that Dr. Kippels did not address other diagnoses to address whether the Veteran may have had other diagnoses to explain symptoms he attributed to CFS. Dr. Murray wrote that the Veteran has not been diagnosed by VA with CFS or CFIDS. He based his unfavorable opinion on evidence that the Veteran had extensive work-ups that revealed IBS and that she had known injuries in service and minor upper respiratory illness to explain her in-service symptoms. Most notably, she did not have the level of fatigue during active duty or within a year of completing active duty to warrant a diagnosis. In December 2016, Dr. Kippels stated the Veteran had many markers and diagnoses that he attributed to CFS, which he also opined was triggered by vaccines in service. He also listed a number of symptoms to include being "bedfast" after mild activity. Even when working full-time, he stated she resorted to bedrest on weekends and holidays. He stated that fatigue onset, as prerequisite for a CFS diagnosis, was simultaneous with organic heart disease, immediately after pre-deployment vaccines on November 21, 1990. In his 2008 statement, he opined that her CFS was likely triggered by the multiple vaccines she was given in preparation of deployment in November 1990. As discussed elsewhere in this decision and the record, Dr. Kippels' reasoning to support his opinion is that the Veteran's vaccines in November 1990 were the impetus for her CFS/CFIDS. Also discussed elsewhere, there is compelling evidence that the Veteran's vaccinations were not the cause of her multiple claimed disorders, which include CFS and CFIDS. Dr. Murray also offered an opinion, which the Board finds is very probative and more consistent with the record. For VA purposes, a CFS diagnosis requires: (1) new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months; and (2) the exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and (3) six or more of the following: acute onset of the condition, low grade fever, nonexudative pharyngitis, palpable or tender cervical or axillary lymph nodes, generalized muscle aches or weakness, fatigue lasting 24 hours or longer after exercise, headaches (of a type, severity, or pattern that is different from headaches in the pre-morbid state), migratory joint pains, neuropsychologic symptoms, sleep disturbance. See 38 C.F.R. § 4.88a. Regarding fatigue, there is no indication that the Veteran had the requisite severity of symptoms in service or within a year of discharge from active duty. During her October 2009 hearing, she stated that she had symptoms when she was still on active duty. In November 2011 Third Party Correspondence, the Veteran reported that within 48 hours of receiving vaccinations on November 21, 1991, she was twice confined to quarters and had debilitating fatigue. She also asserted in September 2012 Correspondence that her debilitating fatigue was noted within four Army physicians' written evaluations from 1990 to 1991, on every PT Profile that restricted physical training and mobility, and on orders to remain in quarters for 48 hours. She also stated that she immediately became sick from the vaccines and collapsed. She was so fatigued and exhausted that she did not leave the post over the Thanksgiving holiday. She asserts such debility indicates her chronic fatigue was more than 50 percent debilitating. The Veteran is competent to report her symptoms, but the Board finds her description of debilitating fatigue that began immediately after vaccines is not credible since it is inconsistent with the contemporaneous records. Despite many treatment records and work-ups since she received the vaccines on November 21, 1990, there is no indication of fatigue until April 1991 when she reported she was tired on walking. Although the absence of evidence is not always negative evidence, in this case it is. As noted, there are many records that document her complaints during active duty but not once is debilitating fatigue part of them. Furthermore, her February 1991 separation medical history report shows she wrote "I'm in fair health," which is not the comment one would expect for someone who had been experiencing debilitating fatigue. Even when complaints were first noted in April and June 1991, there was nothing that indicates any fatigue was extreme or debilitating. Similarly, the September 1992 treatment record that notes chronic fatigue also notes a lot of difficulty sleeping and only difficulty getting out of bed on Saturdays. The fact that the record also notes she was working full-time and going to school four times a week further dispels any idea that she had debilitating fatigue. Even in 1994 when she reported having severe fatigue, the Veteran worked full-time, so it does not indicate the level of fatigue to be consistent with CFS. In November 2007, she reported having severe fatigue, but also noted that she walked her dog every day for exercise and that up until 2002 she was walking three miles. Furthermore, November 1994 correspondence from Dr. Rasheed states that the Veteran's fatigue and low grade fevers were due to CMV Viraemia. Although there are other required symptoms for CFS, there is ample evidence to establish she did not have the requisite level of fatigue during service and the first several years after service to support a diagnosis of CFS at that time. Dr. Kippels also identified CFS and CFIDS as GWI and states there is a body of evidence in literature concerning the relationship between vaccines and GWI. One researcher indicated it was not the stress of war but the vaccine exposure that caused the illness. He also referred to literature that shows vaccinations are responsible for pertinent pathological phenomena. He states that because the Veteran received several vaccines at one time in doses calculated for an adult male, her immune system was overwhelmed and allowed for viruses to be reactivated in her body. He made a similar assertion in December 2016 when he states the Veteran was given military grade vaccines and that she was given too many vaccinations at once. However, he offers no support to his supposition that the vaccines she received on November 21, 1990 were any different from the standard vaccines given to the general public or that the doses were incorrect. He also has not provided evidence to support she has "GWI." As stated above, she was never deployed to the Persian Gulf and the types of vaccines administered (tetanus-diphtheria toxoids vaccine, Influenza vaccine, and hepatitis) are not unique to Persian Gulf veterans. It appears that Dr. Kippels is not an advocate of vaccines since he stated Dr. Casillas is a "vaccine proponent" who misguides medical students in the campaign for mandatory, mass vaccinations, but he has not provided persuasive evidence that the Veteran's vaccines either caused CFS/CFIDS, or that any of her other claimed disabilities is a "GWI." For these reasons, a preponderance of the evidence is against the claim and service connection is denied. 4. Entitlement to service connection for fibromyalgia to include the claim of entitlement to service connection for a disability manifested by muscle and joint and/or wasting. The Veteran was first diagnosed with fibromyalgia by Dr. Garza in April 2004. He stated he first saw the Veteran in the fall of 1996 and although the only symptom noted in his April 2005 correspondence regarding her symptomatology was fatigue, he stated her condition met the definition for fibromyalgia. In correspondence dated in January 2005, Dr. Kippels stated that it is generally accepted that fibromyalgia and CFS are included in the condition referred to as GWI and he attributed her fibromyalgia to vaccines she received in preparation for deployment to the Persian Gulf. During the October 2009 hearing, Dr. Kippels stated she had muscle pain with 11 of 18 tender points, which qualifies as fibromyalgia. Although the Veteran and Dr. Kippels have stated the Veteran has wasting, they offered no evidence of this. Dr. Horne and Dr. Casillas found no evidence of it. Dr. Tasian stated in September 2004 that she had normal muscle strength and tone. Based on his description, his observation is more consistent with Dr. Horne and Dr. Casillas, so the Board finds this evidence is more probative. Thus, the evidence tends to show the Veteran did not have muscle wasting. In June 2013, Dr. Rees noted that the definition of fibromyalgia, which is based primarily on the patient's symptoms of widespread pain, and found that she did not meet the diagnostic criteria based on her physical and examination. Unlike Dr. Kippels, he found that she did not have the requisite number of tender points. Dr. Murray did not question the diagnosis of fibromyalgia but opined that it was not related to service and stated scientifically based medical literature has not yet confirmed the causal relationship between fibromyalgia and vaccinations. Although Dr. Murray points out that some articles suggest vaccinations may trigger fibromyalgia or chronic pain, the scientifically based medical literature has not yet confirmed a causal relationship between vaccination and fibromyalgia. Dr. Murray also indicated, consistent with the record, that despite all of the work-ups and the MEB the Veteran had during active duty there were no complaints of fibromyalgia and that even with the many positive responses she offered on her separation medical history report, there was no complaint of fibromyalgia in the explanation of symptoms that she provided. In light of Dr. Murray's probative opinion and other evidence of record discussed in this decision regarding vaccine-induced illnesses and her disabilities, including fibromyalgia and GWI, the weight of the evidence is against the claim. Accordingly, a preponderance of the evidence is against service connection, so the claim is denied. 5. Entitlement to service connection for CMV and EBV. In December 2016, Dr Kippels indicated that EBV was diagnosed in July 1999 and CMV was diagnosed in September 2004. In February 2006, Dr. Kippels stated lab panels in November 2005 were positive for both. He also stated that the November 1990 vaccinations reactivated the viruses in the Veteran's system. In support of his conclusion, he noted that CMV is a green African monkey virus found in live injectable polio vaccines, which were administered during basic training in April/May 1989. Once their immune systems are impaired, humans are unable to mount an immune response to CMV infections. Since the Veteran's service treatment records clearly show the Veteran received an oral polio vaccine, his assertion that the Veteran's CMV is caused by a green African monkey virus found in an injectable polio vaccine is against the claim, rather than supporting it. Furthermore, there are three probative opinions that are against the claim. Dr. Casillas opined that CMV was not a contaminant of the Veteran's vaccines. He stated EBV and CMV are common viruses that most people are exposed to early in life. Lab work shows a normal immune response to both viruses and the evidence only showed past infection. Regarding a monkey virus, he stated that hepatitis B vaccines are not produced in this way and that contamination of SV40 with the polio vaccine was only reported in vaccines administered in the late 1950's and early 1960's. Dr. Rees agreed with Dr. Casillas in that that the positive titers noted in the Veteran's file indicate past exposure to CMV and EBV and added that this does not mean she has an active ongoing infection. Thus, he opined that despite Dr. Kippels' diagnoses, it is unlikely that the Veteran has a valid diagnosis for either virus. Dr. Murray declined to question the validity of the diagnoses and deferred to the diagnoses rendered by Dr. Garza and Dr. Kippels. He did, however, agree with the expert opinion that the CMV result would be consistent with convalescence. He noted the positive lab findings in February 2008 and stated that they remain positive for life after exposure. He opined that CMV and EBV are less likely than not incurred in or caused by or aggravated by service based on evidence that there was no testing for CMV or EBV in service and no complaints by the Veteran to provide a basis to order testing for either disability. There is also no evidence of any testing for them within one year of active duty. Although Dr. Kippels stated in May 2012 that Dr. Casillas does not know how to interpret lab results this statement appears to be merely conjecture on his part as he has offered no evidence to support his statement. Regarding his assertion that Dr. Casillas was not qualified or sufficiently educated to address treatment for vaccine poisoning or vaccine toxicity, the Board has already found the physician's credentials as a specialist in immunology and allergy medicine adequate. The Board finds his as well as the opinions of Dr. Rees and Dr. Murray to be probative and adequately supported by rationale. Despite Dr. Kippels' opinion to the contrary, he has offered no persuasive evidence to show that the Veteran's CMV and EBV were related to vaccines in service. The more probative evidence of record is against a finding that CMV and EBW are related to service. As a preponderance of the evidence is against the claim, service connection is denied. 6. Entitlement to service connection for hypothyroidism, to include as secondary to CFS or CFIDS. 7. Entitlement to service connection for mycoplasma, to include as secondary to CFS or CFIDS. The December 2016 DBQ indicates the Veteran's hypothyroidism was diagnosed in April 2005 and mycoplasma was diagnosed in May 1997. Based on a review of the record, the most probative opinions are against these claims. As with the other disorders, Dr. Kippels' February 2006 statement links these disorders to vaccines the Veteran received in service, which triggered an immune dysfunction that resulted in hypothyroidism and mycoplasma. Both Dr. Horne and Dr. Rees stated that they found no evidence of hypothyroidism. Dr. Murray, who declined to offer an opinion on the validity of the diagnoses without the opportunity to personally examine the Veteran, essentially opined they were less likely related to service on the basis that service treatment records contain no complaints or findings related to these disorders and there is no evidence she was evaluated for complaints related to them within one year of service. The record also contains a statement from Dr. Nicolson who stated that mycoplasmal infections have been documented in patients with GWI; however, he does not offer an opinion regarding the mycoplasma diagnosis made in May 1997. The Board also notes that this decision has already established that the Veteran does not have GWI. The Board finds Dr. Murray's opinion to be most probative. As previously discussed, the Board has found that the more persuasive evidence suggests the Veteran's in-service vaccines were not the cause of her disorders. Furthermore, there is no evidence of either disorder in service or for many years after service. Dr. Kippels' December 2016 DBQ also indicates he believes that both disorders fall within the broader diagnosis of CFS as he has identified them as biomarkers of CFS. Since the Board has denied service connection for CFS, service connection for any disorder claimed as secondary to it lacks legal merit. For the reasons stated, the Board finds a preponderance of the evidence is against the claims, so service connection for both disorders is denied. 8. Entitlement to service connection for headaches (as a primary diagnosis), to include migraines. The Veteran's service treatment records, to include the February 1991 separation examination and medical history report, are silent for complaints or findings of headaches. However, post-service records in April 1991 from Dr. Grandjean show she reported having headaches and there are additional references to headaches, to includes migraine headaches, that are scattered throughout her post-service medical records. She was also shown to be on medication for headaches. As to the etiology of her headaches, Dr. Garza opined in April 2005 that they were part of a chronic multi-symptoms illness. While the characterization of the disability and its etiology is suggestive of the type of disability found under 38 C.F.R. § 3.317 and is applicable only to Gulf War veterans, the Veteran is not, in fact, a Gulf War veteran as defined by VA regulations. During the October 2009 hearing, Dr. Kippels listed headaches as one of the symptoms associated with the Veteran's CFS; however, as discussed previously, the Board found the Veteran's CFS is not related to her military service. Dr. Rees notes the Veteran has a history of headaches but opines they were not etiologically related to service on the basis that there is no evidence of them during her service and there is no credible peer reviewed medical references that supports a relationship between chronic headaches and vaccinations. Similarly, Dr. Murray offered an unfavorable opinion on the basis that there is no evidence of the disorder in service or during the first post-service year. Although not all of the Veteran's headaches were diagnosed as migraines, many clinicians noted her complaints of headaches without diagnosing the specific type of headache. Given the close proximity to the onset of headaches to the end of her service in April 1991, and the recurrent complaints of headaches, reasonable doubt is resolved in the Veteran's favor regarding the onset of her headaches. According, service connection for headaches is granted. 9. Entitlement to service connection for a disability manifested by pituitary dysfunction. 10. Entitlement to service connection for a disability manifested by deficiencies or imbalances in growth hormone, progesterone, estrogen, DHEA, testosterone, and pregnenolone. 11. Entitlement to service connection for a disability or disabilities manifested by low natural killer cell function, elevated RNA-S-L. After review of the record, the Board finds that the evidence fails to adequately establish a relationship between these claimed disabilities and the Veteran's service. Dr. Kippels has diagnosed the Veteran with having each of these disorders and has opined that the vaccines she was given in preparation of her deployment triggered immune dysfunction, pituitary and hormone dysfunction, elevated RNA-S-L, and low natural killer cell function, which were discovered in testing and lab work conducted while treating her. He has discussed in great detail what specifically was shown in the lab results in his February 2006 statement along with the interplay between the disorders and their relationship to the Veteran's CFS and fibromyalgia. In a statement dated in January 2005, he states that the multiple deficiencies and infections are consistent with GWI and are related to hypothalamic and immune dysfunction. He also opined that these were all triggered by pre-deployment vaccines in service. Other evidence that addresses the etiology of these disorders is against the claim. As discussed previously, Dr. Casillas, a specialist in immunology and allergy medicine, offered a very probative opinion against an association between the Veteran's claimed disabilities and her vaccinations in service. Furthermore, based on his review of the record, he found "no evidence of any hormonal deficiency to growth hormone, thyroid, DHEA, testosterone, or pregnenolone. There is no substantial evidence of any natural killer cell function defect. The NK cells are involved in some aspect of natural immunity to various organisms that are encountered daily and might be problematic if completely absent. Such deficiencies are extremely rare and are associated with disease in early childhood. Dr. Casillas also points out that the initial lab results Dr. Kippels obtained to diagnose these disorders were based on samples evaluated under suboptimal conditions. Dr. Casillas stated there is no evidence that RNAse-L activity has any clinical significance and found no evidence that the Veteran suffered from an immune deficient state. Dr. Kippels countered the findings and opinions in October 2011 when he stated that "[c]ontrary to other opinions, the Veteran has evidence of hormonal deficiency to human growth hormone, thyroid, DHEA, testosterone, and pregnonolone if laboratory tests are read as intended." As shown, there is conflicting evidence whether the Veteran has the claimed disabilities and while Dr. Kippels suggested Dr. Casillas is not qualified to read lab results correctly, the Board has already found otherwise and determined Dr. Casillas' opinions have more probative value. Thus, the evidence weighs against the claimed disabilities being related to service, to include in-service vaccinations. For the reasons stated, the Board finds that a preponderance of the evidence is against service connection for the claimed disabilities, so the claims are denied. 12. Entitlement to service connection for a disability or disabilities manifested by hypercoagulation state, systemic fungus, hypoglycemia, elevated angiotensin II, skin symptoms, neurological symptoms, sleep disturbances, and abnormal weight loss. The Board notes that this group of disorders and lab findings were diagnosed by Dr. Kippels. He first suspected a coagulation problem on his initial evaluation in April 2005 and noted the blood work indicated hypoglycemia. In his December 2016 DBQ for CFS, he reported when some of these findings and symptoms were first noted at that time. With the exception of a sleep disturbances, which he indicated started in April 1991, he only noted diagnoses of hypercoagulation state in April 2005 and hypoglycemia in November 2005. The earliest evidence of a skin disorder was in August 2004 when Dr. Garza diagnosed sebaceous dermatitis. Dr. Kippels first referenced a systemic fungal infection and elevated angiotensin in February 2006. In that statement and in another statement in May 2012, he indicated that the November 1990 vaccines essentially compromised the Veteran's immune system and led to the fungal infection, hypoglycemia, and the other abnormal findings. In his October 2011 statement, he explained how viruses can remain dormant in the immune system and how blood tests reveal their reactivation. He believed the Veteran's immune system was overwhelmed by the vaccinations, which allowed the viruses to be reactivated and cause her subsequent illnesses. As previously noted, Dr. Casillas, a specialist in the field of immunology, reviewed the Veteran's records as well as publications, scientific information, and textbooks. He provided probative evidence as to why the Veteran's vaccines were not contaminated and did not lead to subsequent illnesses. Regarding the hepatitis B vaccine, in particular, he noted it has been the subject of studies by several different scientific groups and they have rejected a causal link to specific disease states and syndromes. He pointed out that the vaccine is still administered and is even considered safe enough to give to children. In short, based on the evidence and research, the Veteran does not have any evidence of an immune deficiency, chronic viral infections, endocrine dysfunction, immune deficiency syndrome, or adverse effect of hepatitis or other vaccines. There are no specific disease syndromes identified by numerous batteries of tests that have been performed for the purpose of identifying any defect in immune function or immune deficiency syndromes or adverse vaccine effects such as those claimed by the Veteran. Dr. Rees offered an opinion in June 2013 in which he opined that hypercoagulation state, systemic fungus, hypoglycemia, elevated angiotensin II, skin symptoms, neurologic symptoms, sleep disturbances, and/or abnormal weight loss were less likely related to service and more likely related to somatoform disorder, but since the Board has found there is not sufficient evidence of a somatoform disorder diagnosis, this opinion lacks probative value. Dr. Murray also addressed the matter and while he declined to offer an opinion regarding the validity of the diagnoses since they were made by the Veteran's treating physicians, he did state that it is clear that some of the Veteran's abnormal values were due to her treatment by these doctors and went on to support his statement with specific examples. He also noted in support of his unfavorable opinion that service treatment records did not indicate complaints or evaluations related to the disorders or findings and there was no evidence of such disorders or findings within a year of leaving service. Since Dr. Kippels indicated in the December 2016 DBQ that sleep disorders essentially fell within the scope of CFS, he further supports evidence that it is not a separate disorder apart from CFS. Dr. Kippels maintained his position in October 2011 and appeared to offer an explanation for contrary opinions by stating there is a common misconception that reference ranges, as reported, represent the "normal" range and that each laboratory has their own analysis and "reference range" for their particular lab. He also referenced material and resources to support his viewpoint. Although Dr. Kippels does not clarify whether this misconception is with laypersons or medical professionals, the Board agrees that laypersons are not qualified to interpret the meaning of lab report, which is why the Board limits itself to reporting the values and the refence ranges without interpreting their significance. To the extent that his comment is directed toward other medical professionals, he offers no sound basis for why he, and no other medical professionals, has the knowledge to accurately interpret the lab findings. The Board finds that the statements Dr. Kippels made in May 2012 and December 2016 suggest he does not hold the "mainstream" medical community in high regard; thus, his statements are viewed more as a personal opinions rather than ones based on facts or established scientific principles. While Dr. Kippels is a physician and competent to offer opinions on medical matters, the opinions of Dr. Casillas, who is a specialist in immunology, and Dr. Murray are more persuasive. Both offered good rationales to support their opinion and while Dr. Kippels is not an advocate of more mainstream medicine it is, at the moment, the commonly accepted practice. Thus, the Board is not inclined to disregard opinions that are supported by mainstream medicine and commonly accepted practice with supporting data. The Board has also documented the Veteran's weight since her second period of service and finds for the most part her weight has not frequently dropped below her in-service weight and that more often than not her weight was at or above her in-service weight. Thus, the evidence does not support a finding that she has a disability manifested by abnormal weight loss. For these reasons, the Board finds the preponderance of the evidence is against the claims, so service connection is denied. 13. Entitlement to service connection for a respiratory disability, to include chlamydia pneumonia, to include as secondary to CFS or CFIDS. Service treatment records during the Veteran's first period of service show she complained of difficulty breathing and other symptoms in June 1989; the assessment was bronchitis. During her second period of service, she complained of having a sinus infection in February 1991; the assessment was acute rhinitis with sinusitis. Her February 1991 separation medical history shows she reported having three colds, two viruses, and one sinus infection since September 1990, and the medical examination notes bronchitis symptoms with URI. In October 1991, she had an assessment of acute bronchitis, sinusitis, and allergic rhinitis. In March 1992, she had an assessment of bronchitis/URI. In October 1999, she had viral syndrome with symptoms of labored breathing and complaints of burning in her lungs. A January 2004 treatment record from Dr. Garza noted she had chronic sinusitis. In April 2003, she went to the ER for shortness of breath and general weakness. Chest X-rays were normal and there was no respiratory diagnosis made. According to Dr. Kippels, November 2005 lab tests show she had chlamydia pneumonia. She reported on November 2007 VA examination with Dr. Horne that she stopped working in 2004, in part, due to shortness of breath, and dyspnea on exertion. In October 2009, the Veteran testified she had several forms of pneumonia in the past and currently had asthma. In his December 2016DBQ, Dr. Kippels indicated chlamydia pneumonia fell within the diagnosis of CFS. In June 2013, Dr. Rees found there was no valid medical evidence that the Veteran had a chronic respiratory disorder and, therefore, opined she had no valid diagnosis of such. In September 2013, he offered an addendum that included an opinion that is unfavorable to the claim. Based on his review of the record, the physician found no chronic disability in service that related to the symptoms reported therein; the complaints and findings around the Veteran's period of service were acute transient conditions. The Board finds the opinion to be probative and consistent with the record. The Veteran had some complaints and findings during service and even shortly thereafter, but there is no evidence that she had a chronic or recurrent disorder. Dr. Garza did note that she had chronic sinusitis, but the use of the word chronic is not sufficient to establish chronicity. There is nothing in Dr. Garza's treatment records or the records of other physicians to show this has been a recurring problem. The Veteran also testified to having asthma, but her medical records do not show she actually has that diagnosis. Dr. Kippels has made few references to respiratory problems but has identified it as part of the Veteran's CFS, which is not a service-connected disability. As for it being related to GWI, the Board has already established that the Veteran does not have GWI. As a preponderance of the evidence is against the claim, service connection is denied. 14. Entitlement to service connection for a disability manifested by menstrual disorders/vaginitis. The service treatment records from the Veteran's first period of service are silent for any complaints, findings, or diagnosis of a gynecological problem. Subsequent to this, she was seen in May 1990 by Dr. Robinson. She had undergone tubal ligation and the records indicated that her uterus was normal. Her second period of service is also silent for complaints, findings, or diagnosis. The February 1991 examination was negative, and the medical history report indicates she had been treated for a female disorder and had a change in her menstrual pattern; however, her explanation referred to her tubal ligation and symptoms of pregnancy in August 1988. Records in December 1991 indicate she had some unusual bleeding, but her annual gynecological examination was normal. While hospitalized in March 1992 for other reasons, she was noted to have mild anemia and advised to see her gynecologist. An April 1992 gynecological record notes complaints of a possible yeast infection and other symptoms. A record the following month indicates she had vaginitis. She had surgery for endometriosis in 1994. In April 2005 correspondence, Dr. Garza noted she had menstrual disturbances, but he did not offer any opinion as to what they were or if they were related to service. In November 2007, she denied having any gynecological problem other than excessive bleeding and reported having ablations in 1994 and 2002. The examination indicated her uterus was a normal size. In June 2021, the Veteran's claims file was reviewed and based on that Dr. Dykes opined the Veteran less likely than not had a menstrual disorder related to service. He found it unlikely that her short service periods on active duty led to any significant gynecological disorder and that her periods of service were too short to establish any pattern or irregularity, or to assess an etiology, or to determine a true onset. He referred to specific evidence to support his opinion. He also stated that there was nothing to substantiate her theory that military vaccines caused her problems and that none of the injections she received would cause her gynecological disorders. All of her post-service records did not suggest a relationship to service and the onset of her problems was more likely than not in 1994. He added that a disorder would have manifested earlier than three years post-service if it were a result of her service. The physician provided a very thorough explanation to support his opinions, which the Board finds very probative. The claim is denied. REASONS FOR REMAND 15. Entitlement to a TDIU is remanded. As of this decision, the Veteran's only service-connected disabilities are IBS and headaches. Her headaches have not been addressed in a VA examination since November 2007 and for IBS since March 2010, and neither examination was specifically designed to fully evaluate each disability. In order to accurately determine the degree to which these disabilities impact her ability to engage in and maintain substantial gainful employment, examinations with current findings are needed. 16. Entitlement to special monthly compensation based on the need for regular aid and attendance or at the housebound rate is remanded. The Veteran last had a VA examination for Aid and Attendance in March 2010. During her hearing in 2016, the Veteran testified to her limitations to care for herself adequately, but she did not specifically identify which disabilities impacted her. Thus, another examination is needed. The matters are REMANDED for the following action: 1. Obtain any outstanding VA or private treatment records. 2. Thereafter, schedule the Veteran for a VA examination with an appropriate clinician to determine the severity of her IBS. The claims file and copies of all pertinent records should be provided to the examiner for review. A complete history should be obtained that goes back to at least March 2010 and all relevant complaints and findings should be noted. The clinician should also comment on what limitations or restrictions, if any, her disability would have on her ability to work. 3. After the development in #1 is completed, schedule the Veteran for a VA examination with an appropriate clinician to determine the severity of her headaches. The claims file and copies of all pertinent records should be provided to the examiner for review. A complete history should be obtained that goes back to at least November 2007 and all relevant complaints and findings should be noted. The clinician should also comment on what limitations or restrictions, if any, her disability would have on her ability to work. 4. After the development in #1 is completed, schedule the Veteran for a VA examination to determine housebound status and whether she is in need of regular aid and attendance for her service-connected IBS and headaches. The claims file and copies of all pertinent records should be provided to the examiner for review. All relevant complaints and findings should be reported. The examiner is asked to state whether the Veteran currently is in need of the regular aid and attendance of another person or is housebound as a result of his service connected disabilities. A complete rationale must be provided for any opinions expressed. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Bredehorst, 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.