Citation Nr: 21076656 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 19-36 008A DATE: December 27, 2021 ORDER Revision of a prior rating decision based on clear and unmistakable error (CUE) is dismissed. Service connection for a traumatic brain injury (TBI) is granted. A disability rating in excess of 10 percent for a seizure disorder is denied. A 30 percent rating, but no higher, for chronic vaginitis, is granted. REMANDED Service connection for a bilateral heel injury. Service connection for bilateral fallen arches. Service connection for a disability characterized by chronic fatigue. Service connection for a psychiatric condition, to include as secondary to a seizure disorder or chronic vaginitis. Service connection for a gastroesophageal condition, to include as secondary to a seizure disorder. Service connection for a urinary tract disorder, to include as secondary to chronic vaginitis. Service connection for fibroids. Service connection for human papillomavirus (HPV). Service connection for chronic pain syndrome, to include as secondary to a seizure disorder. Service connection for memory loss. Service connection for loss of concentration. Service connection for migraine headaches, to include as secondary to a seizure disorder or TBI. A total disability based on individual unemployability (TDIU). FINDINGS OF FACT 1. The Veteran has not asserted that there was CUE in a prior rating decision with requisite specificity. 2. The Veteran's TBI, which clearly and unmistakably pre-existed service, was aggravated by service and resulted in her currently diagnosed TBI. 3. The Veteran has not experienced at least one major seizure in the last two years or at least two minor seizures in the last six months at any point during the appeal period. 4. The Veteran's chronic vaginitis has been manifested by symptoms that are not controlled by continuous treatment. CONCLUSIONS OF LAW 1. The Veteran's claim to revise a prior rating decision based on CUE is dismissed. 38 U.S.C. § 7105; 38 C.F.R. § 20.104. 2. The criteria for service connection for a TBI have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for a disability rating in excess of 10 percent for a seizure disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 8910. 4. The criteria for entitlement to a 30 percent rating, but no higher, for chronic vaginitis, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.116, DC 7611. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from May 1987 to December 1997. This matter comes before the Board on appeal from July 2017 and November 2018 rating decisions. In March 2021, the Veteran testified at a Board hearing. At the hearing, the record was held open for 90 days. Thereafter, the Veteran submitted additional evidence. 1. CUE. The Veteran has alleged that there is clear and unmistakable error, or CUE, in a prior rating decision. At the outset, however, the Board notes that she has not indicated which past decision she believes contains CUE or, for that matter, what error of fact or law she believes to be present. CUE is a very specific and rare kind of error. It is the kind of error, of fact or of law, that when called to the attention of later reviewers compels the conclusion, to which reasonable minds could not differ, that the results would have been manifestly different but for the error. See Bustos v. West, 179 F.3d 1378, 1380-81 (Fed. Cir. 1999); Hines v. Principi, 18 Vet. App. 227, 235 (2004). In Russell v. Principi, 3 Vet. App. 310, 313-14 (1992), the Court set forth a three-pronged test for determining when there is CUE present in a prior rating decision: (1) either the correct facts, as they were known at the time, were not before the adjudicator (i.e., more than a simple disagreement as to how the facts were weighed or evaluated) or the statutory or regulatory provisions extant at the time were incorrectly applied; (2) the error must be undebatable and of the sort which, had it not been made, would have manifestly changed the outcome at the time it was made; and (3) a determination that there was clear and unmistakable error must be based on the record and law that existed at the time of the prior adjudication in question. Claimants must plead allegations of CUE with specificity. Andre v. West, 14 Vet. App. 7, 10 (2000). This specific allegation must assert more than merely disagreement with how facts of a case were weighed or evaluated. In other words, to present a valid claim of CUE, the claimant cannot simply request the Board to reweigh or reevaluate evidence. Crippen v. Brown, 9 Vet. App. 412 (1996). This can never arise to the stringent definition of CUE. Similarly, neither can broad-brush allegations of "failure to follow the regulations" or "failure to give due process," or any other general, nonspecific claim of "error." Fugo v. Brown, 6 Vet. App. 40, 43-44 (1993). In addition, failure to address a specific regulatory provision involves harmless error unless the outcome would have been manifestly different. Id. at 44. Here, there are no statements in the record that allege that there has been CUE in a prior final rating decision with any specificity. Instead, the Veteran has merely alleged that the RO has thus far failed to adequately assist her in obtaining evidence to support her claims. The Board acknowledges its duty to read filings liberally when a claimant is either proceeding pro se or represented by a veterans' service organization. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). However, this is not the case here, as the Veteran is represented by a private attorney. Even when construed liberally, her filings do not contain clear, specific arguments as to why there is a legal or factual error in a specific prior decision. As such, the Board finds that the Veteran has not claimed with requisite specificity that there was CUE in a prior rating decision, and none is apparent at this juncture. As such, her appeal is dismissed without prejudice to refiling. See Simmons v. Principi, 17 Vet. App. 104 (2003). In the future, the Veteran is free to submit a CUE motion that alleges, with requisite specificity, which prior final rating decision she wishes to collaterally challenge. 2. Service connection for TBI. The Veteran contends that she is entitled to service connection for a TBI. She does not argue that her TBI was incurred during service; in fact, she has repeatedly disclosed that her TBI was the result of a violent assault in 1984 prior to enlisting in the Army. Rather, her contention is that her TBI was permanently aggravated during service, when she began having grand mal seizures and taking continuous anti-seizure medication to prevent them. Service connection may be granted if there is a disability resulting from personal injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish service connection, the evidence 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). Here, the evidence clearly indicates that the Veteran has been diagnosed with a TBI. The chief question for the Board is thus whether her TBI was incurred or aggravated during service. To that end, the Board notes that every veteran who served in the active military, naval, or air service after December 31, 1946, is taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment, and was not aggravated by such service. 38 U.S.C. § 1111. Only those conditions recorded in examination reports can be considered as "noted," 38 C.F.R. § 3.304(b), and a history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions. 38 C.F.R. § 3.304(b)(1). If the presumption of soundness attaches and is not rebutted, the Veteran's claim is simply an ordinary claim for service connection. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). To rebut the presumption of soundness for conditions not noted at entrance into service, VA must show by both clear and unmistakable (obvious and manifest) evidence that (1) the disease or injury existed prior to service, and that (2) the disease or injury was not aggravated by service. VAOPGCPREC 3-03 (July 16, 2003); 70 Fed. Reg. 23,027 (May 4, 2005); Wagner, 370 F.3d at 1096. In this case, the Veteran's February 1987 enlistment examination is absent of any notations of defects, infirmities, or disorders, including a TBI. Although she reported a previous head injury in the accompanying report of medical history, the Board finds that this is not enough to prevent the presumption of soundness from attaching. Moreover, the evidence is at least in equipoise that symptoms of the Veteran's TBI, such as seizures, manifested during service. As such, the presumption of soundness attached, and the Veteran was presumed to be in sound condition upon enlistment. 38 C.F.R. § 3.304(b). Because the presumption of soundness attached, the Board must next determine whether the presumption of soundness has been rebutted. In other words, the Board must decide whether there is clear and unmistakable evidence that her TBI occurred prior to service and clear and unmistakable evidence that her TBI was not aggravated during service. If the Board finds that there is clear and unmistakable evidence of both of these things, the presumption of soundness will have been rebutted and the Board must deny the claim for service connection. On the other hand, if the Board finds that there is clear and unmistakable evidence that her TBI occurred prior to service but also that it was aggravated during service, the Board will treat her claim like an ordinary claim for service connection. Notably, the in-service element of the service connection framework will have been satisfied in such a situation. Having carefully reviewed the evidence in the record, the Board finds that there is clear and unmistakable evidence that the Veteran's TBI was incurred in 1984, prior to service. To that end, the most competent, credible evidence of record undebatably shows that the Veteran was assaulted during service, which resulted in head trauma and a loss of consciousness. Conversely, no head injuries resulting in loss of consciousness occurred during service, nor has the Veteran alleged that she incurred such an injury during that timeframe. The Board thus finds that her TBI obviously and manifestly existed prior to service. With respect to the second question, whether there is clear and unmistakable evidence that her TBI was not aggravated during service, the government may show a lack of aggravation by establishing clear and unmistakable evidence that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. Wagner, 370 F.3d at 1096. This burden of proof must be met by affirmative evidence demonstrating that there was no aggravation. The burden is not met by finding that the record contains insufficient evidence that there was aggravation. Horn v. Shinseki, 25 Vet. App. 231, 236-37 (2012). Temporary or intermittent flare-ups during service of a pre-existing injury or disease will not be sufficient to be considered "aggravation in service" unless the underlying condition, as opposed to the symptoms, is worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The occurrence of symptoms, in the absence of an increase of the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002). Evidence that a veteran was asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). If the disorder becomes worse during service and then improves due to in-service treatment to the point it was no more disabling than it was at entrance into service, the disorder has not been aggravated by service. Verdon v. Brown, 8 Vet. App. 529 (1996). Here, the most competent and credible evidence of record illustrates that there is not clear and unmistakable evidence that the Veteran's disability was not aggravated by military service. In this regard, the Veteran was asymptomatic at entry to service but soon thereafter began having nocturnal grand mal seizures in 1988. As a result of her seizures, she had to begin taking Tegretol, an anti-seizure medication, multiple times a day. As a result of her seizures, she was given physical profiles that prohibited her from driving vehicles or carrying weapons. At her separation examination, the examiner noted a history of nocturnal seizures, which she continued to have after she was discharged from service. Ultimately, the evidence suggests that the Veteran's pre-service TBI was exacerbated beyond its natural progression during military service because she developed worsening symptoms that were caused by her TBI and that required continuous medication to treat. In other words, the evidence indicates that the underlying disability, the TBI itself, had worsened. Indeed, a VA examiner opined that the Veteran's pre-service TBI was aggravated beyond its natural progression by an in-service event, injury, or illness in an October 2018 VA examination report, because she began having post-traumatic seizures during service. Given the evidence in the record, it cannot be said that there is clear and unmistakable evidence that the severity of her pre-service TBI did not increase during service. As such, the presumption of soundness has not been rebutted. When VA fails to carry its burden as to either preexistence or lack of aggravation, whether and to what extent a veteran is entitled to compensation for the injury is determined upon the assumption that the injury was incurred during service. However, the Veteran must still demonstrate a current disability and a nexus between the current disability and the injury or disease in service. Horn, 25 Vet. App. 231, 233. In this case, that nexus has been established. Indeed, although the Veteran's TBI occurred prior to service, it was aggravated during service to the extent that she began exhibiting manifestations such as seizures, and she continues to require medication to treat the symptoms of her TBI (i.e., her seizure disorder) at present. As such, there is evidence demonstrating a causal connection between her current TBI and her service, and service connection is warranted. Increased Rating Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Where, as here, entitlement to service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the Veteran argues that she is entitled to higher ratings for a seizure disorder, which is currently rated at 10 percent disabling under DC 8910, and chronic vaginitis, which is currently noncompensable under DC 7611. 3. A higher rating for seizure disorder. The Veteran's seizure disorder is currently rated under the criteria in DC 8910 for grand mal epilepsy. This DC indicates that grand mal epilepsy should be rated under the General Rating Formula for Major Seizures. According to this formula, a 10 percent rating is awarded for a confirmed diagnosis of epilepsy with a history of seizures, while a 20 percent rating is assigned for at least one major seizure in the last two years or at least two minor seizures in the last 6 months. 38 C.F.R. § 4.124a, DC 8910. A 40 percent rating is assigned for at least one major seizure in the past six months or two in the last year, or averaging at least five to eight minor seizures weekly. A 60 percent rating is assigned for averaging at least one major seizure in four months over the last year, or nine to 10 minor seizures per week. An 80 percent rating is warranted for averaging at least one major seizure in three months over the last year, or more than 10 minor seizures weekly. Last, a 100 percent rating is available for averaging at least one major seizure per month over the past year. Note (1) indicates that when continuous medication is shown to be necessary for the control of epilepsy, the minimum evaluation of 10 percent will be assigned. Note (2) indicates that where there are both major and minor seizures, the predominating type will be rated, while note (3) clarifies that there is no distinction between diurnal and nocturnal major seizures. The relevant period on appeal here is the period beginning one year prior to the Veteran's claim for an increased rating for her seizure disorder. Records from during this timeframe indicate that she requires continuous medication called Tegretol to control her seizure disorder. However, at no point do the records indicate that she has had any seizures during this period. Moreover, the Veteran has affirmatively stated that she has not had any seizures in approximately 20 years. As such, a rating in excess of the minimum 10 percent rating is not warranted under DC 8910. In so finding, the Board acknowledges that the Veteran has raised the issue of whether various conditions, such as a psychiatric condition or a gastrointestinal condition, are secondary to her seizure disorder. More specifically, she has argued that the medication she uses to control her seizure disorder has caused or aggravated various other disabilities. As set forth further below, the Board has remanded several of these claims for additional development. 4. A higher rating for chronic vaginitis. The DC for injury or disease of the vagina, DC 7611, is found within the schedule of ratings for gynecological conditions and disorders of the breast in 38 C.F.R. § 4.116. DCs 7610 through 7615 are rated under the General Rating Formula for Disease, Injury, or Adhesions of Female Reproductive Organs. Under the general rating formula, a noncompensable rating is assigned for symptoms which do not require continuous treatment, while a 10 percent rating is warranted for symptoms that require continuous treatment and a 30 percent rating for symptoms that are not controlled by continuous treatment. 38 C.F.R. § 4.116, DC 7611. At a September 2017 VA examination, the Veteran reported that she began having recurrent vaginitis while on active duty, which was treated with Diflucan and Monistat. The VA examiner indicated that she continued to have recurrent vaginitis at a similar rate and that it was treated episodically. In a treatment record dated November 14, 2017, the Veteran complained of a thick, white, odorless vaginal discharge with perineal swelling and irritation. She indicated that she had been treated with Diflucan and probiotics repeatedly by her primary care provider and gynecologist without improvement in the past, and that for the past year or so she had only been treating her recurrent yeast infections with over-the-counter Monistat and probiotics because they were better at mitigating her symptoms, although without complete resolution. Because using over-the-counter medications had become cost prohibitive for her, her doctor prescribed probiotics. An April 2018 post-service treatment record indicates that she had been prescribed probiotic tablets to prevent recurrent episodes of vaginitis. In a medical treatment note dated June 6, 2018, medical treatment record, her provider noted that she had a 28-year history of chronic vaginitis and recommended that she try weekly suppressive therapy with large, regular doses of Diflucan for six months to deter recurrences. In a follow-up note from later that month, the provider noted that the Veteran had treated her recurrent vaginal yeast infections with over-the-counter creams with good results, although she usually had to treat herself several times a year. She had recently started suppressive therapy and indicated that her symptoms had not yet recurred. In an October 2018 VA examination report, the examiner noted that the Veteran had recurrent vaginitis six times in the past two years which had successfully been treated with Diflucan each time, as well as 8 recurrences of bacterial vaginosis in the same interval that was successfully treated with Flagyl. Her recurrent vaginitis had made sexual intercourse painful for her and reduced her desire to be intimate with her husband. At her March 2021 Board hearing, the Veteran testified that she had been experiencing symptoms of chronic vaginitis approximately every three weeks since she was in the Army, with vaginal or valvular itching and white discharge. Although she had been continuously treating her symptoms, she reported that her symptoms were not relieved by treatment. She also stated that many of the medications she had been prescribed, like Diflucan, negatively interacted with Tegretol. Here, the evidence is at least in equipoise to demonstrate that the Veteran was continuously treating her chronic vaginitis with probiotics and other medications throughout the entire period on appeal, including prior to the beginning of the period starting one year before filing her claim. The evidence also indicates that her recurrent yeast infections and symptoms of itchiness and discharge had continued despite continuous treatment. For instance, her records illustrate that she had been used over-the-counter medicines and prescription probiotics to control her chronic yeast infections in the past before being placed on large, regular doses of Diflucan in June 2018, but that she continued to have regular symptoms despite these treatments. As such, the evidence indicates that her vaginitis was being treated continuously with probiotics and other medications but that her symptoms were not controlled. A rating of 30 percent is therefore warranted. REASONS FOR REMAND 1. Service connection for bilateral heels and fallen arches. The Veteran has argued that she is entitled to service connection due to a bilateral heel injury and fallen arches, which she contends that she has experienced since service. At her March 2021 hearing, she testified that she went to sick call during service due to pain in her feet from her boots. She also stated that she was given orthotic devices to lift her arches, which she had been wearing since 1988. VA's duties to assist claimants in the development of claims also may include scheduling a medical examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). Here, the evidence indicates that the Veteran has a current disability with respect to her feet. Additionally, the Veteran's testimony and service treatment records establish that she complained of fallen arches in 1988. This suggests that her current problems could be related to her in-service complaints of foot pain. To date, however, the RO has not afforded her a VA examination regarding the nature and etiology of her foot condition. Remand is thus warranted to obtain a VA examination and opinion. 2. Service connection for a disability characterized by chronic fatigue. The Veteran argues that she is entitled to service connection for chronic fatigue syndrome (CFS) and anemia. The Board notes that previous VA examiners have stated that she does not have current diagnoses of anemia or CFS, but her records indicate that she has been diagnosed with anemia via laboratory findings. As such, the Board will recharacterize her claim as a claim for a disability characterized by chronic fatigue, however diagnosed, to recognize this fact. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). At her March 2021 hearing, the Veteran reported that her anti-seizure medication makes her feel sleepy, drowsy, and sluggish, which raises the possibility that her claimed condition could be caused or aggravated by her seizure disorder. She also reported that she continues to experience anemia symptoms due to iron deficiencies, such as weakness and tiredness. When VA undertakes to provide an examination or obtain a medical opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To date, the RO has obtained VA examinations with respect to the etiology of the Veteran's condition in September 2017 and October 2018. However, the VA examiners did not provide any opinions regarding the etiology of the condition. More specifically, the September 2017 VA examiner indicated that no medical opinion was necessary because the Veteran did not have anemia. On the other hand, the October 2018 VA examiner acknowledged that she had been previously diagnosed with anemia in 2011, but because she had not been diagnosed with chronic fatigue syndrome at any point, the examiner rendered no medical opinion. In the interest of assembling clear and reliable findings, remand is warranted to obtain a medical opinion regarding the nature and etiology of the Veteran's condition, to include whether her condition is caused or aggravated by the treatment for her service-connected seizure disorder. 3. Service connection for a psychiatric condition. The Veteran claims that she is entitled to service connection for various mental health conditions, such as post-traumatic stress disorder (PTSD), major depressive disorder, anhedonia, anxiety, sexual dysfunction (also known as female sexual arousal disorder, or FASD), and a sleep disorder. The record suggests that she does not have a current diagnosis of PTSD, but that she has other mental health conditions, such as unspecified insomnia disorder and FASD. As such, the Board has broadened the characterization of her claim on appeal to entitlement to service connection for an acquired psychiatric condition, however diagnosed, to recognize this fact. With respect to sleep issues, the Veteran has indicated that she began having problems with insomnia while she was in the military because she was scared that she would have a nocturnal seizure while she was sleeping. The record also suggests that the Veteran's acquired psychiatric condition could be related to the treatment for her service-connected seizure disorder, as well as secondary to her chronic vaginitis. To that end, the Veteran testified at her March 2021 hearing that she feels sluggish and unmotivated due in part to the medication she uses to treat her seizures, which has caused or exacerbated symptoms of depression and anhedonia. Additionally, she has indicated that she has no interest in sexual activity in part due to the symptoms of her vaginitis, which include itchiness, pain, and discharge. Although the RO obtained a VA examination in October 2018 regarding PTSD, the VA examiner did not render a sufficient opinion because the examiner did not find that she had a current diagnosis of PTSD. Although the VA examiner diagnosed an unspecified insomnia disorder, the examiner did not render any opinions regarding whether it was related to service or secondary to a service-connected condition. Additionally, the examination did not address her contentions regarding sexual dysfunction, anxiety, depression, or anhedonia. The Board also notes that the Veteran reported a history of FSAD at an October 2018 VA gynecological examination, but the examiner did not render any opinion regarding FSAD. As such, the Board finds that remand is warranted to obtain another VA examination that adequately clarifies which mental health conditions, if any, are currently present and their etiology. 4. Service connection for a gastroesophageal condition. The Veteran also contends that she is entitled to service connection for gastroesophageal reflux disease (GERD) and gastritis. As with other claims, it is somewhat unclear from the record whether the Veteran has current diagnoses of gastritis or GERD. However, the Veteran reported at her March 2021 hearing that she has had issues with chronic acid reflux and bacterial stomach infections and was diagnosed with esophagitis in 2019. As such, the Board has recharacterized her claim as a claim for service connection for a gastroesophageal condition, however diagnosed. Because her most recent VA examination regarding a gastroesophageal condition was conducted in October 2018, it appears that she would not yet have been diagnosed with esophagitis. The probative weight of the VA examination report is therefore reduced. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As such, remand is warranted to obtain a new VA examination to clarify the nature and etiology of her gastroesophageal condition. In doing so, the Board notes that the Veteran suggested at her hearing that her seizure medication negatively interacted with her medications for reflux, which could be aggravating her gastroesophageal condition. On remand, the examiner is asked to address this theory of entitlement as well. 5. Service connection for a urinary tract disorder. Additionally, the Veteran argues that she is entitled to service connection for a urinary tract disorder secondary to her chronic vaginitis. More specifically, she reports that she has had several urinary tract infections since service and that she experiences symptoms such as pain during urination when she has a recurrence of vaginitis. The Veteran was afforded a VA examination in October 2018. The examination indicates that she was diagnosed with an overactive bladder in 2017 when her voiding pattern changed. She had increased urinary frequency every two to three hours with marked urgency and nocturia twice a night. The urgency caused leakage. However, the VA examiner opined that the Veteran's urinary tract disorder was less likely than not incurred or caused by an in-service injury, event, or illness because her symptoms began in 2017 and were not related to any vaginal discomfort during active duty. The Board finds that this opinion is inadequate, as the examiner failed to provide a sufficiently detailed opinion that fully considered all raised theories of entitlement. To that end, the examiner's opinion that her urinary tract disorder was not related to vaginal discomfort during active duty is conclusory and not supported by a detailed rationale. An opinion that is conclusory or that does not provide a sufficiently detailed rationale is inadequate. Stefl v. Nicholson, 23 Vet. App. 320 (2007). Moreover, the VA examiner failed to address whether the Veteran's vaginitis aggravated her urinary tract disorder. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (indicating that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b)). Remand is therefore warranted to obtain a new VA medical opinion. 6. Service connection for fibroids. The Veteran contends that she was first diagnosed with fibroids during service after experiencing urinary pressure, pain, and bleeding during her period. She testified that although her fibroids shrank after she was first diagnosed with fibroids, her fibroids have since returned and gotten bigger. The Veteran's service treatment records from August 1996 reflect that leiomyoma (i.e., fibroids) were found on her uterus. To date, however, the RO has not obtained any medical opinions regarding the etiology of her current fibroids and whether they are related to service. Accordingly, the Board finds that remand is warranted to obtain a VA examination and opinion. McLendon, 20 Vet. App. at 83-86. 7. Service connection for HPV. The Veteran claims that she is entitled to service connection for HPV because she was diagnosed with cervical dysplasia in 1993, which caused her to develop HPV. Her HPV was not diagnosed until 2004, but she indicated that she was told that her HPV was related to her cervical dysplasia, because one condition causes the other. In September 2017, the Veteran attended a VA examination regarding the severity of her vaginitis and the nature of her HPV. In the examination report, the VA examiner provided an opinion as to whether the HPV was caused by her recurrent vaginitis or was a separate condition. The VA examiner clarified that HPV was a separate condition. However, the VA examiner did not opine as to whether HPV had its onset during or was otherwise directly related to an injury or disease incurred during service. As such, remand is warranted to obtain a medical opinion regarding this theory of entitlement. Stefl, 23 Vet. App. at 320. 8. Service connection for chronic pain syndrome. At the Veteran's March 2021 hearing, she testified that she had chronic pain throughout her entire body in all her joints and muscles and that she experienced body aches all the time. The Veteran reports that this condition is exacerbated by the side effects of her seizure medication, which cause her to feel fatigued. The RO has not yet obtained a VA examination regarding the nature and etiology of the Veteran's full-body muscle and joint pain or obtained an opinion regarding whether it is secondary to the treatment for her seizure disorder. As such, remand is warranted to obtain a VA examination. McLendon, 20 Vet. App. at 83-86. 9. Service connection for memory loss, loss of concentration, and migraine headaches. The Veteran indicated at her hearing that while she was still working, she had begun to forget computer skills and struggled with reading comprehension. Additionally, she stated that she had experienced issues such as difficulty concentrating and migraine headaches. She suggested that her migraines, which were not diagnosed until 2002, were related to her seizure medications. At this juncture, however, is unclear whether the Veteran's symptoms of memory loss and loss of concentration are symptoms of a separate condition, or whether they are instead subjective manifestations of her now service-connected TBI. Additionally, it appears that the Veteran's migraines could be secondary to her TBI as well. The Veteran was previously provided with a VA examination regarding the etiology of her migraine headaches in September 2017. At that time, however, the VA examiner stated that it was less likely than not that her migraines were secondary to her Tegretol use because migraines were a primary headache syndrome that were not caused by treatments for nocturnal seizures. However, the VA examiner failed to address whether her Tegretol use aggravated her migraine headaches. An adequate medical opinion regarding secondary service connection must address causation and aggravation separately. See El Amin, 26 Vet. App. at 140. As such, the September 2017 VA examiner's opinion is of limited probative value. Additionally, the VA examiner did not address whether the Veteran's migraines were related to her service-connected TBI. The Board acknowledges that the Veteran underwent a VA examination regarding the etiology of her TBI in October 2018. In the examination report, the VA examiner did not indicate that she had symptoms such as memory loss or problems concentrating as a result of her TBI. However, the VA examiner did not perform neuropsychological testing, nor did she consider evidence such as the Veteran's hearing testimony. For these reasons, remand is warranted to obtain a new VA examination regarding the nature and etiology of these disabilities. On remand, the VA examiner should consider whether the Veteran's migraines are either caused or aggravated by her seizure medication, as well as whether they are caused or aggravated by her TBI. Additionally, the examiner should clarify whether her memory loss and concentration problems are manifestations of her service-connected TBI. 10. A TDIU. The Veteran has argued that she is unable to work beginning in 2017 because of various disabilities, such as her seizure disorder, migraines, feelings of depression, and her issues with memory and concentration. Because resolution of the claims for these disabilities could potentially impact the resolution of the claim for TDIU, and in light of the Board's grants above, the Board will also remand this issue. Accordingly, the matters are REMANDED for the following action: 1. Ask the Veteran to identify any relevant and outstanding treatment records and, after obtaining appropriate authorization, request the records. 2. Schedule the Veteran for a VA examination regarding the nature and etiology of her claimed bilateral heel and foot disabilities. The examiner(s) must be provided with a copy of the entire claims file, which the examiner(s) must review in its entirety. All necessary tests and studies must be performed. After reviewing the claims file and examining the Veteran, the VA examiner(s) is asked to do the following: (a.) Identify all relevant heel and foot conditions that have been present at any time during the pendency of this appeal, including conditions that have since resolved. If the Veteran does not have any diagnosable conditions, but has pain only, determine whether the pain causes functional loss. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). (b.) For each identified condition, opine as to whether it is at least as likely as not (approximately 50 percent or greater probability) that it was caused by or otherwise etiologically related to service. A complete rationale is required for any opinion rendered by the examiner(s). All opinions should be based on examination findings, historical records, and medical principles. The examiner(s) should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner(s) is reminded to consider all relevant evidence of record, including the Veteran's hearing testimony, lay statements, service treatment records, and post-service treatment records. 3. Schedule the Veteran for a VA examination regarding the nature and etiology of her claimed disability characterized by chronic fatigue. The examiner must be provided with a copy of the entire claims file, which the examiner must review in its entirety. All necessary tests and studies must be performed. After reviewing the claims file and examining the Veteran, the VA examiner is asked to do the following: (a.) Identify all relevant conditions characterized by chronic fatigue that have been present at any time during the pendency of this appeal, including conditions that have since resolved. In doing so, the examiner is asked to clarify whether she has a diagnosis of anemia or CFS. (b.) For each identified condition, opine as to whether it is at least as likely as not (approximately 50 percent or greater probability) that it was caused by or otherwise etiologically related to service. (c.) For each identified condition, opine as to whether it is at least as likely as not (approximately 50 percent or greater probability) that it is (1) due to, or (2) aggravated by a service-connected disability or its treatment, such a seizure disorder. The examiner is reminded that causation and aggravation are distinct legal concepts that must be addressed separately. "Aggravation" is defined as worsening beyond the natural progression of the disability. If a condition is aggravated by a service-connected disability, to the extent possible, the examiner is requested to provide an opinion as to the approximate baseline level of severity of the condition before the onset of the aggravation. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner is reminded to consider all relevant evidence of record, including the Veteran's hearing testimony, lay statements, service treatment records, and post-service treatment records. 4. Schedule the Veteran for a VA examination regarding the nature and etiology of her claimed psychiatric condition. The examiner must be provided with a copy of the entire claims file, which the examiner must review in its entirety. All necessary tests and studies must be performed. After reviewing the claims file and examining the Veteran, the VA examiner is asked to do the following: (a.) Identify all relevant acquired psychiatric conditions that have been present at any time during the pendency of this appeal, including conditions that have since resolved. In doing so, the examiner is asked to clarify whether she has a diagnosis of PTSD, depression, anhedonia, anxiety, a sleep disorder, or FASD. (b.) For each identified condition, opine as to whether it is at least as likely as not (approximately 50 percent or greater probability) that it is (1) due to, or (2) aggravated by a service-connected disability or its treatment, such a seizure disorder or chronic vaginitis. The examiner is reminded that causation and aggravation are distinct legal concepts that must be addressed separately. "Aggravation" is defined as worsening beyond the natural progression of the disability. If a condition is aggravated by a service-connected disability, to the extent possible, the examiner is requested to provide an opinion as to the approximate baseline level of severity of the condition before the onset of the aggravation. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner is reminded to consider all relevant evidence of record, including the Veteran's hearing testimony, lay statements, service treatment records, and post-service treatment records. 5. Schedule the Veteran for a VA examination regarding the nature and etiology of her claimed gastroesophageal condition. The examiner must be provided with a copy of the entire claims file, which the examiner must review in its entirety. All necessary tests and studies must be performed. After reviewing the claims file and examining the Veteran, the VA examiner is asked to do the following: (a.) Identify all relevant gastroesophageal conditions that have been present at any time during the pendency of this appeal, including conditions that have since resolved. In doing so, the examiner is asked to clarify whether she has a diagnosis of GERD, gastritis, or esophagitis. (b.) For each identified condition, opine as to whether it is at least as likely as not (approximately 50 percent or greater probability) that it was caused by or otherwise etiologically related to service. (c.) For each identified condition, opine as to whether it is at least as likely as not (approximately 50 percent or greater probability) that it is (1) due to, or (2) aggravated by a service-connected disability or its treatment, such a seizure disorder. The examiner is reminded that causation and aggravation are distinct legal concepts that must be addressed separately. "Aggravation" is defined as worsening beyond the natural progression of the disability. If a condition is aggravated by a service-connected disability, to the extent possible, the examiner is requested to provide an opinion as to the approximate baseline level of severity of the condition before the onset of the aggravation. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner is reminded to consider all relevant evidence of record, including the Veteran's hearing testimony, lay statements, service treatment records, and post-service treatment records. 6. Schedule the Veteran for a VA examination regarding the nature and etiology of her claimed urinary tract disorder. The examiner must be provided with a copy of the entire claims file, which the examiner must review in its entirety. All necessary tests and studies must be performed. After reviewing the claims file and examining the Veteran, the VA examiner is asked to do the following: (a.) Identify all relevant urinary tract disorders that have been present at any time during the pendency of this appeal, including conditions that have since resolved. (b.) For each identified condition, opine as to whether it is at least as likely as not (approximately 50 percent or greater probability) that it is (1) due to, or (2) aggravated by a service-connected disability or its treatment, such a chronic vaginitis. The examiner is reminded that causation and aggravation are distinct legal concepts that must be addressed separately. "Aggravation" is defined as worsening beyond the natural progression of the disability. If a condition is aggravated by a service-connected disability, to the extent possible, the examiner is requested to provide an opinion as to the approximate baseline level of severity of the condition before the onset of the aggravation. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner is reminded to consider all relevant evidence of record, including the Veteran's hearing testimony, lay statements, service treatment records, and post-service treatment records. 7. Schedule the Veteran for a VA examination regarding the nature and etiology of her claimed fibroids. The examiner must be provided with a copy of the entire claims file, which the examiner must review in its entirety. All necessary tests and studies must be performed. After reviewing the claims file and examining the Veteran, the VA examiner is asked to do the following: (a.) Identify all relevant conditions that have been present at any time during the pendency of this appeal, including conditions that have since resolved. (b.) For each identified condition, opine as to whether it is at least as likely as not (approximately 50 percent or greater probability) that it was caused by or otherwise etiologically related to service. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner is reminded to consider all relevant evidence of record, including the Veteran's hearing testimony, lay statements, service treatment records, and post-service treatment records. 8. Obtain an addendum VA medical opinion regarding the nature and etiology of her claimed HPV. The examiner must be provided with a copy of the entire claims file, which the examiner must review in its entirety. All necessary tests and studies must be performed. After reviewing the claims file, the VA examiner is asked to opine as to whether it is at least as likely as not (approximately 50 percent or greater probability) the Veteran's HPV was caused by or otherwise etiologically related to service. In doing so, the examiner should address her contentions regarding in-service cervical dysplasia. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner is reminded to consider all relevant evidence of record, including the Veteran's hearing testimony, lay statements, service treatment records, and post-service treatment records. 9. Schedule the Veteran for a VA examination regarding the nature and etiology of her claimed chronic pain syndrome. The examiner must be provided with a copy of the entire claims file, which the examiner must review in its entirety. All necessary tests and studies must be performed. After reviewing the claims file and examining the Veteran, the VA examiner is asked to do the following: (a.) Identify all relevant conditions that have been present at any time during the pendency of this appeal, including conditions that have since resolved. (b.) For each identified condition, opine as to whether it is at least as likely as not (approximately 50 percent or greater probability) that it is (1) due to, or (2) aggravated by a service-connected disability or its treatment, such a seizure disorder. The examiner is reminded that causation and aggravation are distinct legal concepts that must be addressed separately. "Aggravation" is defined as worsening beyond the natural progression of the disability. If a condition is aggravated by a service-connected disability, to the extent possible, the examiner is requested to provide an opinion as to the approximate baseline level of severity of the condition before the onset of the aggravation. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner is reminded to consider all relevant evidence of record, including the Veteran's hearing testimony, lay statements, service treatment records, and post-service treatment records. 10. Schedule the Veteran for a VA examination regarding the nature and etiology of her claimed migraine headaches, memory loss, and loss of concentration. The examiner must be provided with a copy of the entire claims file, which the examiner must review in its entirety. All necessary tests and studies must be performed. After reviewing the claims file and examining the Veteran, the VA examiner is asked to do the following: (a.) Identify all relevant conditions that have been present at any time during the pendency of this appeal, including conditions that have since resolved. In doing so, the examiner should clarify whether the Veteran's memory loss and loss of concentration are manifestations of her service-connected TBI or manifestations of a separate disability. (b.) For each identified condition, opine as to whether it is at least as likely as not (approximately 50 percent or greater probability) that it is (1) due to, or (2) aggravated by a service-connected disability or its treatment, such a seizure disorder or TBI. The examiner is reminded that causation and aggravation are distinct legal concepts that must be addressed separately. "Aggravation" is defined as worsening beyond the natural progression of the disability. If a condition is aggravated by a service-connected disability, to the extent possible, the examiner is requested to provide an opinion as to the approximate baseline level of severity of the condition before the onset of the aggravation. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner is reminded to consider all relevant evidence of record, including the Veteran's hearing testimony, lay statements, service treatment records, and post-service treatment records. 11. After completing the above development, and any other development reasonably raised by the record, readjudicate the issue of whether the Veteran is entitled to TDIU. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Rademacher, Associate 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.