Citation Nr: 21077570 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 16-31 781 DATE: December 30, 2021 REMANDED Entitlement to service connection for cervicitis is remanded. Entitlement to service connection for endometriosis is remanded. Entitlement to service connection for residuals of a hysterectomy is remanded. Entitlement to service connection for hypothyroidism is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for a bilateral leg disability, claimed as gait dysfunction is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for bilateral shoulder disability is remanded. Entitlement to service connection for diabetes mellitus, type II is remanded. Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for a lower back disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. REASONS FOR REMAND The Veteran served in the Army Reserves from February 1, 1975 to January 31, 1978 with active duty for training from May to June 1975. In April 2019, the Veteran testified before the undersigned Veterans Law Judge via video conference. A transcript of the hearing is associated with the claims file. This appeal has an extensive procedural history that includes several remands by the Board and the U.S. Court of Appeals for Veterans Claims (Court). Most recently, in September 2020, the Board denied the Veteran's claims for service connection for cervicitis, endometriosis, residuals of hysterectomy, and hypothyroidism. The Veteran appealed the September 2020 decision to the United States Court of Appeals for Veterans Claims (Court). In July 2021, the Court granted a Joint Motion for Remand (JMR) wherein the parties agreed that the decision should be vacated, and those issues remanded to the Board for further consideration. In March 2021, the Board remanded the Veteran's claims for service connection for diabetes mellitus, hypertension, GERD, a bilateral leg disability, right shoulder disability, bilateral shoulder disability, neck disability, lower back disability, and left and right knee disabilities for further development. The claims have returned to the Board for further consideration but, for reasons explained below, the Board finds an additional remand is needed. 1. Entitlement to service connection for cervicitis is remanded. 2. Entitlement to service connection for endometriosis is remanded. 3. Entitlement to service connection for residuals of a hysterectomy is remanded. 4. Entitlement to service connection for hypothyroidism is remanded. With respect to the claims for cervicitis, endometriosis, and residuals of hysterectomy, in the July 2021 Joint Motion, the parties agreed that the Board failed to address the evidence of record that may have indicated the Veteran's symptoms began in June 1975 while in service. In this regard, the parties specifically noted that a 1976 record reflects that the Veteran's hair began to fall out the previous June. The Board observes that this record does not link the Veteran's hair loss to reproductive issues. Instead, the record documents the Veteran's complaint of "hair falling out since June (rhinoplasty preceded this) weight problem, menses are irregular." It was noted that her menses have always been irregular. In light of the Joint Motion, and because the medical opinions of record that address the Veteran's gynecological conditions do not address if the Veteran's hair loss in 1976 was related to a gynecological condition the Board will remand the Veteran's claims in order to obtain a medical opinion. In the July 2021 Joint Motion, the parties also agreed that the Board failed to address the adequacy of the January 2020 VA opinion that addressed the Veteran's hypothyroidism, as the opinion was based solely on the absence of a thyroid diagnosis in the service treatment records. In this context, the Board notes that neither the January 2020 nor December 2019 VA opinion addressed whether the Veteran's hair loss in June 1975 was an early sign, symptom, or indicator of the thyroid problem that was eventually diagnosed after service, particularly given the December 2019 clinician's notation that the Veteran was prescribed thyroid medication at that time for "unclear reasons" possibly due to hair loss. The Board observes that a December 1977 treatment record noted that her thyroid was within normal limits, but she was gaining weight despite her efforts to lose weight. The following month she called her clinician asking if she could "start thyroid meds." Therefore, the Board finds an additional medical opinion is also needed with respect to the hypothyroidism claim. 5. Entitlement to service connection for hypertension is remanded. In support of this claim, the Veteran submitted a private medical opinion that purports to establish a nexus between the Veteran's hypertension and service-connected PTSD. In that opinion, the clinician noted several studies that supported several findings, including that hypertension and mental health diagnoses are co-morbid conditions and that stress-related increases in blood pressure can be dramatic. However, the clinician failed to identify evidence that shows or supports a finding that this Veteran experiences stress-related increases in blood pressure or that her PTSD caused or aggravates her hypertension. Nevertheless, the clinician also stated that obesity is a risk factor for hypertension, noting that the Veteran's PTSD and resulting anxiety and agoraphobia make exercise very difficult which hinders her from losing weight. She also noted the Veteran has been prescribed medication that causes weight gain and inhibits a person's ability to perform activities, such as operating heavy machinery. See April 2021 statement L. Bucholz, PA-C. While the opinion purports to establish a causal relationship between the Veteran's hypertension and obesity caused by PTSD, the clinician's statement does not adequately establish that the Veteran's PTSD caused her to become obese or aggravated her obesity and, if so, whether her obesity or aggravation thereof was a substantial factor in causing her hypertension, and whether hypertension would not have occurred but for the obesity caused by PTSD. Notably, each of the foregoing factors must be addressed when attempting to establish obesity as an intermediate step to establish service connection between hypertension and service-connected PTSD. See e.g., Walsh v. Wilkie, 32 Vet. App. 300 (2020). The April 2021 VA opinion that was obtained following the September 2020 JMR & March 2021 Board decision notes that the Veteran has not been diagnosed with an eating disorder, but does not address the Veteran's statements that eating clams her or that PTSD makes exercise difficult. Therefore, the Board finds an additional medical opinion is needed with respect to the hypertension claim. 6. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. 7. Entitlement to service connection for a bilateral leg disability, claimed as gait dysfunction, is remanded. 8. Entitlement to service connection for a right shoulder disability is remanded. 9. Entitlement to service connection for bilateral shoulder disability is remanded. 10. Entitlement to service connection for diabetes mellitus, type II is remanded. 11. Entitlement to service connection for a neck disability is remanded. 12. Entitlement to service connection for a lower back disability is remanded. 13. Entitlement to service connection for a left knee disability is remanded. 14. Entitlement to service connection for a right knee disability is remanded. The Veteran has asserted and the evidence of record indicates that each of the foregoing disabilities is due to her obesity. The Veteran has asserted that her obesity is secondary to service-connected PTSD. In April 2021, a VA physician opined that the Veteran's PTSD did not cause or aggravate her obesity; however, the rationale provided does not account for the Veteran's assertions that her PTSD and resulting symptoms make exercise very difficult and hinder her ability to lose weight. The evidence of record also, now, suggests that the medications the Veteran is prescribed for PTSD causes weight gain. Given the foregoing deficiencies, the Board finds the April 2021 VA opinion is inadequate and another opinion is needed that addresses the foregoing. Additionally, while the Veteran has asserted that the foregoing disabilities are secondary to obesity caused by her service-connected PTSD, the evidence of record suggests that her obesity is due to hypothyroidism. As such, these claims are inextricably intertwined with the hypothyroidism claim be remanded herein. The matters are REMANDED for the following action: 1. Obtain an medical opinion regarding the Veteran's claimed gynecological disabilities. Following a review of the complete record, the examiner is asked to address the following: (a) Is at least as likely as not (50 percent or more probability) that the Veteran's gynecological conditions, to include cervicitis, endometriosis, and residuals of hysterectomy, had their onset during or are otherwise related her period of active service? In answering the foregoing, the examiner must address whether the Veteran's hair loss that began in June 1975 was related to or indicative of the gynecological condition, i.e., polycystic ovary syndrome, that was treated as early as 1976 and thereafter. If the examiner finds the Veteran's gynecological conditions existed prior to her period of active service, the examiner must address the following: (b) Is there clear and unmistakable (undebatable) evidence that a gynecological condition existed prior to service? If so, identify the evidence. (c) If there is clear and unmistakable evidence that a gynecological condition pre-existed service, is there clear and unmistakable (undebatable) evidence that the gynecological condition was not aggravated during service? In other words, is there undebatable evidence that there was no increase in the gynecological condition during service or that any increase in disability was due to the natural progress of the pre-existing condition? A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 2. Obtain an medical opinion regarding the Veteran's thyroidectomy. Following a review of the complete record, the examiner is asked to address the following: Is at least as likely as not (50 percent or more probability) that the Veteran's hair loss in June 1975 was a sign, symptom, or indicator of the thyroid problem that was diagnosed after service? In answering the foregoing, the examiner must address the fact that the Veteran was prescribed thyroid medication in the 1970s. The examiner must also consider the other service treatment records, post-service medical evidence, and lay statements of record. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. Obtain an medical opinion regarding the Veteran's PTSD and obesity. 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 service-connected PTSD, to include any medications prescribed and taken therefor, caused or aggravated the Veteran's obesity? In answering the foregoing, the examiner must address the Veteran's assertions that: (1) PTSD and resulting anxiety and agoraphobia make exercise very difficult which hinders her from losing weight, (2) that eating food is calming, and (3) that her medication for PTSD causes her to gain wait. (b) If the answer to (a) is yes, is it as likely as not that the Veteran's obesity or the aggravation of obesity as a result of service-connected PTSD was a substantial factor in causing hypertension, diabetes mellitus, GERD, bilateral leg, right shoulder, bilateral shoulder, neck, lower back, and/or right and left knee disabilities; and (iii) whether diabetes mellitus, hypertension, GERD, bilateral leg, right shoulder, bilateral shoulder, neck, lower back, and/or right and left knee disabilities would not have occurred but for the obesity caused or aggravated by service-connected PTSD. An answer must be provided with respect to each of the foregoing. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 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.