Citation Nr: 21067833 Decision Date: 11/05/21 Archive Date: 11/05/21 DOCKET NO. 13-09 566 DATE: November 5, 2021 ORDER Entitlement to service connection for a gynecological disorder, claimed as painful and heavy menstruation, is denied. REMANDED Entitlement to service connection idiopathic thrombocytopenic purpura is remanded. Entitlement to service connection for anemia is remanded. Entitlement to service connection for residuals of splenectomy is remanded. Entitlement to service connection for an immune system disorder, claimed as depressed immune system, is remanded. Entitlement to service connection for alopecia, claimed as hair loss, is remanded. Entitlement to service connection for a disability manifested by lack of well-being and fatigue is remanded. FINDINGS OF FACT 1. The competent, credible, and probative evidence weighs against a finding that the Veteran's current gynecological condition, including painful and heavy menstruation due to fibroids, ovarian cyst, and menorrhagia, was incurred in or is otherwise related to her military service. CONCLUSIONS OF LAW 1. The criteria for service connection for a gynecological disorder, claimed as painful and heavy menstruation, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1989 to December 1997, to include service in Southwest Asia from October 1990 to June 1991. The Veteran testified before the undersigned Veterans Law Judge via video conference in August 2019. This appeal was previously before the Board on two previous occasions, including most recently in February 2021, at which time the Board granted service connection for migraine headaches, denied service connection for fibrocystic breast disease, and remanded the remaining claims on appeal for further evidentiary development. The Board finds that all requested development has been completed with respect to the claim decided herein while further development is required for the claims discussed in the remand section below. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted on a presumptive basis for a Persian Gulf War veteran who exhibits objective indications of qualifying chronic disability that became manifest during either active 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, and cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on qualifying chronic disability, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1 (2004). A qualifying chronic disability means a chronic disability resulting from an (A) undiagnosed illness; (B) the following medically unexplained chronic multi-symptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) IBS; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi-symptom illness; or (C) any diagnosed illness that VA determines warrants a presumption of service connection under 38 U.S.C. § 1117(d). 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). 1. Entitlement to service connection for a gynecological disorder, claimed as painful and heavy menstruation The Veteran's DD Form 214 reflects that she served in Southwest Asia and received the Southwest Asia Service Medal. Therefore, the Veteran is considered a Persian Gulf War veteran with qualifying active service sufficient to trigger the application the laws and provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317(a)(1). The record reflects that this claim was initially adjudicated based upon the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317(a)(1) and the "undiagnosed illness" rubric. See July 2011 rating decision. However, the Board notes that the Veteran's claimed painful and heavy menstruation have been diagnosed as and attributed to uterine fibroid tumors, an ovarian cyst, and menorrhagia status post abdominal hysterectomy. See VA examinations and opinion dated March 2011, August 2020, and June 2021. As her claimed condition has been attributed to a clinical diagnosis, service connection based on the presumption concerning undiagnosed illnesses is not warranted in this case. While the presumption for undiagnosed illness is not applicable in this case, the Veteran is not precluded from establishing service connection on a direct basis. See generally Combee v. Principi, 34 F.3d 1039, 1043 (1994). Indeed, the Veteran has asserted that her painful and heavy menstruation condition started during service as a result of complications with the birth of her son in May 1992 and continued after service until she had a hysterectomy in 2015. See Veteran statement dated June 2010; August 2019 Board hearing transcript. The Veteran's service treatment records (STRs) contain a December 1988 record which reflects that the Veteran received an oral contraception assessment at a women's health clinic in December 1988, at which time she reported abnormal vaginal bleeding between periods. The Veteran did not otherwise describe the nature or severity of the "abnormal" vaginal bleeding, but the clinician noted that her last pap smear conducted in June 1988 showed inflammation and determined that she was a candidate for oral contraception (OC). During her August 1989 enlistment examination, the Veteran reported being treated for a female disorder and, in this regard, the examiner noted the Veteran was treated for chlamydia two years before but, otherwise, denied a history of gynecological problems. Notably, the Veteran specifically denied having a change in her menstrual pattern at that time. See August 1989 report of medical history. However, later in August 1989, the Veteran reported having vaginal bleeding for 48 hours, which the clinician noted was post-intercourse bleeding. The clinician also diagnosed the Veteran with vaginitis at that time and prescribed medication. Subsequent STRs show the Veteran complained of cramps in July 1991. While the Veteran reported a history of severe menstruation cramps, she stated that the pain she expereinced at that time did not feel like cramps. Clinical evaluation revealed discomfort around the umbilicus and, as a result, the clinician rendered a diagnostic assessment of abdominal muscle pain of an uncertain etiology. As noted, the Veteran delivered a healthy infant via cesarean section in May 1992. Thereafter, the Veteran reported having spotting occasionally with intercourse and within three days of menses. See May 1993 STR. In January 1995, she also sought treatment for dyspareunia (painful intercourse), spotting for one month, and passing blood clots at that time. The clinical assessment was post-coital bleeding and cramping of unknown etiology. Thereafter, in November 1995, the Veteran, again, denied having any change in her menstrual pattern. As shown above, the STRs show that the Veteran expereinced post-intercourse and intermenstrual bleeding, cramping, and other gynecological disorders, such as occasional passing of blood clots and vaginitis. However, the STRs do not reflect any complaints or treatment for heavy or painful menstruation, including after the Veteran gave birth in May 1992. In this case, the Veteran has consistently reported having painful and heavy menstruation during service and specifically after giving birth. See June 2010 Veteran statement; March 2011 VA examination. In fact, during the August 2020 examination, she reported that she "always" had painful menstruation, but these statements are not consistent with the symptoms and reports documented in her STRs. As the ultimate finder of facts, it is the Board's duty to assess the credibility and weight of conflicting evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc."). In this context, the Board finds probative that the STRs document the Veteran's various complaints of post-intercourse and intermenstrual bleeding, cramping, and passing of blood clots but there is not one occasion on which she reported heavy or painful menstruation. Indeed, when the Veteran reported having cramps during service, she stated that the cramps she was experiencing at that time did not feel like cramps and, while she endorsed a history of severe menstruation cramps, there is no evidence or indication that she expereinced such symptoms during service as opposed to prior to service. Similarly, while the STRs contain reports of bleeding, occasional reports of spotting, and passing of blood clots, these complaints are generally shown to occur between her menstruation cycle or post-intercourse, as opposed to during or as a result of her menstruation cycle, including after giving birth in May 1992. The Board notes the Veteran is competent to report the nature of her symptoms, but her statements regarding heavy and painful menstruation during service, including after giving birth, are inconsistent with the STRs, which weighs heavily against the credibility of her statements. The Board also finds probative that the post-service medical evidence reflects that, in 2003, the Veteran reported that she had regular menses until May 2003, at which time her menses was prolonged and subsequently heavy. At that time, she reported having increased clots after her cesarean section, but she specifically noted having heavy bleeding and menorrhagia for two to three months. See private treatment records dated July and July 2003. In this regard, the Board notes that the Veteran is shown to have endorsed passing blood clots in January 1995, which is after she gave birth, but the evidence does not reflect that this occurred during or as a result of her menstruation cycle or was otherwise consistent with a pattern of heavy and painful menstruation as reported by the Veteran. In evaluating this claim, the Board finds the Veteran's contemporaneous statements made to medical providers during and after service are significantly more credible and probative than subsequent statements made to VA for purposes of seeking compensation. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence); see also Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than subsequently reported history). Therefore, given that the Veteran's statements submitted in support of this claim are inconsistent with the other evidence of record, the Board finds that her statements of having heavy and painful menstruation during and since service are not credible and, thus, not probative evidence in this appeal. Nevertheless, because the STRs document a pregnancy and other gynecological complaints, the Veteran was afforded a VA examination and opinion. As noted, the Veteran has been diagnosed with uterine fibroid tumors, an ovarian cyst, and menorrhagia status post abdominal hysterectomy, to which her painful and heavy menstruation have been attributed. See VA examinations and opinion dated March 2011, August 2020, and June 2021. The Veteran submitted a medical opinion in support of her claim in which the physician opined that her menorrhagia is more likely than not related to military service. See September 2019 statement from Dr. Iftikhar. However, Dr. Iftikhar did not provide a supporting rationale for the opinion and, thus, the opinion does not have any probative value. Likewise, while the March 2011 VA examiner provided a negative nexus opinion, the opinion was based upon an inaccurate factual basis, i.e., that there was only one relevant complaint during service. Therefore, the VA opinion provided in March 2011 is also afforded no probative value. In June 2021, a Board-certified VA OBGYN with more than 30 years' experience reviewed the claims file, including the service and post-service medical records, previous VA examinations, and statements made by the Veteran. After reviewing the evidence, the VA physician opined that it is less likely than not that the Veteran's fibroids, which cause pain and heavy irregular bleeding, are due to events in service or connected to any events in service. The VA examiner noted the Veteran was diagnosed with fibroids and menometrorrhagia in 2004, which accounts for her heavy, irregular bleeding, painful intercourse, and pelvic pain. However, he noted the Veteran did not have problems with heavy, irregular bleeding chronically in service and also noted that the May 1996 GYN examination was negative for any gynecological conditions, including fibroids, as it specifically noted a normal uterus and pelvic exam. The examiner noted the Veteran was noted to have intermenstrual bleeding in 1988 which evidently resolved before service with oral contraceptives, and he further noted that additional episodes of bleeding noted in May 1993 and January 1995 were determined to be spotting from the cervix. The examiner also noted the Veteran was diagnosed with vaginitis in 1995 and 1997, but stated that, despite the Veteran's report of heavy periods historically, there is no evidence of heavy, irregular bleeding in service, clearly no evidence of fibroids, and the 1996 GYN examination is negative. Instead, the examiner noted that the Veteran's heavy, irregular bleeding represented a new condition arising in 2002 to 2003 with a subsequent hysterectomy in 2015. The June 2021 VA opinion is considered competent, credible, and probative evidence, as the examiner considered all relevant facts. In this regard, the examiner considered the Veteran's competent lay statements regarding having heavy, irregular bleeding and menstruation during service but noted that these statements were not consistent with the service or post-service records. The VA examiner also addressed each of the gynecological complaints and conditions shown during service but noted that these complaints were not due to or representative of heavy or irregular bleeding, which he noted is shown to be a new condition arising in 2002 or 2003. The Board notes that the June 2021 VA opinion is consistent with the medical evidence of record and is supported by a clear rationale. Therefore, the June 2021 VA opinion is afforded significant probative weight. The Board acknowledges that the Veteran believes her gynecological disorder began during service; however, to the extent that her lay assertions are intended to establish a nexus between her gynecological condition and service, the Board notes that her assertions are afforded lessened probative value because they are not consistent with the other evidence of record. Indeed, as noted, the preponderance of the medical evidence and opinions of record weighs against a finding that her gynecological condition, including heavy or painful menstruation due to fibroids, ovarian cyst, or menorrhagia, was incurred during or as a result of her military service. Further, the Veteran is not shown to have the medical expertise to opine on complex matters, such as the etiology of a gynecological condition. As such, the Veteran's purported nexus statements are not considered competent or probative evidence favorable to her claim. Therefore, based on the foregoing, the Board finds the preponderance of the most competent, credible, and probative evidence is against the grant of service connection for a gynecological condition. Because the evidence preponderates against the Veteran's claim, the benefit-of-the-doubt doctrine is not for application and her claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). REASONS FOR REMAND 1. Entitlement to service connection idiopathic thrombocytopenic purpura is remanded. In February 2021, the Board remanded this claim to obtain a medical opinion that address or discuss if the Veteran's in-service pregnancy caused or aggravated her ITP. In this regard, the Board noted that the opinion of record noted that medical literature showed that ITP can occur on its own or be triggered by chronic infection, medication, or pregnancy but did not discuss the Veteran's in-service pregnancy. See August 2020 VA opinion. In June 2021, a VA physician opined that it is less likely that the Veteran's ITP had its nexus in service or is due to events in service, including her 1992 pregnancy. While the physician noted there was no evidence of ITP in service and was not diagnosed until 2003, he also stated that pregnancy does not cause or aggravate ITP. The physician did not, however, provide a basis for this statement, particularly given the medical literature cited in the August 2020 VA opinion. Indeed, the physician did not attempt to distinguish the Veteran's in-service pregnancy and medical history or explain how or why the information provided in the medical literature was not applicable in this case. The Board has considered whether the evidence of record, inclusive of the VA opinions provided in August 2020 and June 2021, raises a reasonable doubt as to whether the Veteran's ITP is related to her in-service pregnancy; however, the Board is mindful that the Veteran gave birth in May 1992 and that ITP was diagnosed in 2003, more than 10 years later. Given the lapse of 10 years between the pregnancy and diagnosis, the Board finds a medical opinion is needed to determine the likelihood that a pregnancy can give rise to ITP more than 10 years later. Therefore, while the Board regrets the additional delay, the Board finds an additional remand is needed in order to for a fully informed decision to be rendered in this case. The Board also notes that, in May 2020, this claim was remanded to obtain a medical opinion that addresses whether the Veteran's ITP is a diagnosable but medically unexplained chronic multi-symptom illness (MUCMI), which must be considered when adjudicating the Veteran's claim based upon Gulf War exposures. Unfortunately, neither of the opinions provided in August 2020 or June 2021 was responsive to this question but, instead, focused on whether the Veteran's ITP was noted during service. Indeed, while the June 2021 VA physician stated there is no event in service that would cause ITP six years after service, the opinion did not discuss if the Veteran's ITP is a diagnosable but MUCMI. Therefore, on remand, an opinion addressing this question must also be obtained. See Stegall v. West, 11 Vet. App. 268 (1998). 2. Entitlement to service connection for anemia 3. Entitlement to service connection for a disability manifested by lack of well-being and fatigue is remanded. 4. Entitlement to service connection for residuals of splenectomy is remanded. The clinician who provided the August 2020 VA opinion noted that the Veteran's anemia was diagnosed in 2003 due to ITP and menorrhagia. See also private treatment records dated June and July 2003. Similarly, the August 2020 VA examiner opined that the Veteran's symptoms of lack of well-being and fatigue are likely the result of her ITP. The Veteran has also asserted that her splenectomy is related to her ITP and the post-service evidence shows that the splenectomy performed in 2004 was done as treatment to control the Veteran's ITP. See e.g., May 2007 private treatment record; August 2020 VA opinion. Therefore, the claims for anemia, a disability manifested by lack of well-being and fatigue, and residuals of splenectomy are inextricably intertwined with the ITP claim being remanded herein. Therefore, adjudication of those claims must be deferred. 5. Entitlement to service connection for an immune system disorder, claimed as depressed immune system, is remanded. The physician who provided the June 2021 VA opinion stated that ITP has an autoimmune component. This statement is in contrast with the other medical opinions of record which state that a chronic diagnosis could not be made for the claimed immune system disorder and that there were no signs or symptoms to support a findings of an undiagnosed condition. See VA opinions dated August 2020 and October 2020. Therefore, the Board finds the autoimmune disorder claim is inextricably intertwined with the ITP claim being remanded herein. 6. Entitlement to service connection for alopecia, claimed as hair loss, is remanded. In September 2014, the Veteran's VA primary care physician noted that the Veteran's alopecia may be genetic but could also have an autoimmune component. Unfortunately, the VA opinions of record that address the Veteran's alopecia do not rule out an autoimmune component to her hair loss condition and, as such, this claim is inextricably intertwined with the claim for an immune system disorder being remanded herein. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the Veteran's idiopathic thrombocytopenia. Following a review of the complete record, the examiner is asked to address the following: (a) Is it at least as likely as not (50 percent or more probability) that the Veteran's idiopathic thrombocytopenia is due to or aggravated by her in-service pregnancy and delivery in 1992? In answering the foregoing, the examiner must address the medical literature cited in the August 2020 VA opinion which is noted to state that ITP can occur on its own or be triggered by chronic infection, medication, or pregnancy. (b) If the answer to the foregoing question is no, the examiner is asked to state if the Veteran's idiopathic thrombocytopenia is (i) an undiagnosed illness; (ii) a diagnosable but medically unexplained chronic multisymptom illness; (iii) a diagnosable chronic multisymptom illness with a partially explained etiology and pathophysiology; or (iv) a disease with a clear and specific diagnosis, etiology, and pathophysiology. The term medically unexplained chronic multisymptom illness 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. Examples include, but are not limited to, the following: chronic fatigue syndrome; fibromyalgia; and functional gastrointestinal disorders. The response to this question must include a discussion of the pathophysiology and etiology of the Veteran's idiopathic thrombocytopenia and associated symptomology. Pathophysiology is defined as the physiology of abnormal states; specifically, the functional changes that accompany a particular syndrome or disease. Consideration of pathophysiology and etiology is a veteran-specific inquiry, as opposed to an inquiry regarding the general knowledge of the medical community. The examiner should note that the physician who provided the June 2021 VA opinion noted that ITP has an autoimmune component. (c) If the Veteran's idiopathic thrombocytopenia is deemed (iii) a diagnosable chronic multisymptom illness with a partially explained etiology and pathophysiology, or (iv) a disease with a clear and specific diagnosis, etiology, and pathophysiology, the examiner should also state whether it is at least as likely as not (50 percent or more probability) that the disability had its onset during or is otherwise related to the Veteran's military service, to include any exposures during her service in Southwest Asia. (d) A complete rationale must be provided for each opinion offered. The examiner must consider and address all lay and medical evidence of record with respect to the onset and progression of the Veteran's various symptoms. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Turnipseed, 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.