Citation Nr: 21012444 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 12-11 515A DATE: March 4, 2021 REMANDED Entitlement to service connection for a disability of the uterus characterized as status post vaginal hysterectomy for uterine prolapse remanded. REASONS FOR REMAND The Veteran served in the United States Marine Corps from January 1994 to October 1997. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran testified before the undersigned in a July 2014 Board hearing, a transcript of the hearing is of record. The Board remanded the case to the Agency of Original Jurisdiction (AOJ) in March 2015 and April 2018. In October 2019, the Board denied the Veteran’s claim for service connection for a disability of the uterus. The Veteran appealed the decision to the United States Court of Appeals for Veterans’ Claims (Court). In August 2020, the Court effectuated a Joint Motion for Partial Remand (JMPR) which vacated the Board’s decision denying the Veteran’s service connection claim for a disability of the uterus characterized as status post vaginal hysterectomy for uterine prolapse.   1. Service connection for disability of the uterus is remanded. The Veteran contends that her disability of the uterus is related to her service. The JMPR vacated the Board’s decision because it relied on an inadequate VA medical opinion for its decision. In December 2018, a VA examiner opined that it is highly unlikely that the Veteran has a disability of the uterus resulting in post service hysterectomy. The examiner reasoned that an operative note dated July 2009 lists the indication for total vaginal hysterectomy as symptomatic uterine prolapse. That only contributing factors to uterine prolapse that could be found in the Veteran’s record was a history of prior spontaneous vaginal deliveries with 2 births in 1990 and 1998. The examiner further found that abnormal pap smear in the military did not play a role in hysterectomy and a disability of the uterus would not be considered service related. The examiner reasoned that at the time the Veteran was in the military, routine HPV testing was not used for cervical cancer screen. HPV co-testing is also not used in screening in patients under the age 30 as it is very common and often clears spontaneously. The Veteran had documented normal pap smears after separation from service. The examiner concluded that HPV is known to be associated with cervical dysplasia and is sexually transmitted. The JMPR found this opinion inadequate because the examiner did not accurately reflect the record. Notably the examiner stated that the Veteran only had a pap smear screening testing with no cervical biopsy or endocervical curetting in military to document dysplasia in the military; however, a December 1996 service treatment record showed the Veteran underwent a cervical biopsy that revealed mild dysplasia. The December 1996 service treatment record also noted fragments of endocervical curettings with glandular atypia favored dysplastic metaplasia. Further, the examiner did not address the Veteran’s October 1996 notation of a history of “LGBIL ON PAP” despite the examiner’s finding of only finding one abnormal pap smear in service. The December 2018 examiner further noted that the only contributing factors to uterine prolapse was the Veteran’s vaginal deliveries. However, a July 2009 consent form listed three diagnoses requiring a hysterectomy, notably, one of the diagnosis was dysplasia, which was also diagnosed through biopsy after the Veteran’s inservice fall in December 1996. Finally, the JMPR noted that the December 2018 examination failed to comply with the Board’s April 2018 Board remand directives. Specifically, the Board directed a VA examiner to consider and discuss the significance of the December 1996 service treatment record, the August 2008 private treatment records, the July 2009 treatment records, and the Veteran’s statements regarding the symptoms of her disability. The December 2018 examiner did not mention the July 2009 private treatment records or the Veteran’s statements concerning her symptoms. Further, the JMPR noted that it was unclear whether the August 2008 medical record noted was same record referenced in the Board’s April 2018 remand order. Thus, the Board finds a remand is required to obtain an adequate medical opinion. Upon remand, a VA examiner must address the October 1996 abnormal pap smear, December 1996 service treatment record, the August 2008 private treatment records, the July 2009 treatment records, and the Veteran’s statements regarding the symptoms of her disability. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion to ascertain the nature and etiology of the Veteran’s disability of the uterus from an appropriate clinician. The examiner must review the claims file including the December 2018 VA medical opinion and August 2020 JMPR. The examiner must provide the following opinion: (a.) Whether it is at least as likely as not that the Veteran disability of the uterus resulting in a post-service hysterectomy for uterine prolapse manifested during service, or is otherwise causally or etiologically related to a period of active duty service, to include the Veteran’s fall during service; the diagnosis of dysplasia during service in 1996, the bleeding which occurred in service, and/or the diagnosis of HPV. (b.) The examiner must address the following: i. The October 1996 treatment note that indicates a history of “LGBIL ON PAP” ii. the December 1996 service treatment record, which reflects that the Veteran underwent a cervical biopsy, which revealed mild dysplasia and viral effect (grade 1 cervical intraepithelial neoplasia (CIN I), low grade squamous intraepithelial lesion (LSIL) involving squamous metaplasia and endocervical glands, chronic cervicitis; and fragments of endocervical curetting with glandular atypia favor dysplastic metaplasia; iii. the August 2008 private treatment records which reflect a diagnosis of high grade squamous intraepithelial lesion (HSIL) and that the Veteran underwent a loop electrosurgical excision procedure (LEEP) iv. The July 2009 consent form that indicates that dysplasia was one of three diagnosis for the hysterectomy and whether it relates to the Veteran’s diagnosis of dysplasia in service. v. The July 2009 private treatment record, which reflects a diagnosis of uterus with cervix, hysterectomy: cervix: squamous metaplasia and chronic cervicitis, and endometrium: proliferative phase. vi. The Veteran’s statements concerning her disability and the onset in-service. (c.) The examiner must provide a complete medical rationale for all opinions proffered. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Robert Batten 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.