Citation Nr: 21013889 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 17-20 306 DATE: March 10, 2021 ORDER Service connection for status post hysterectomy is denied. REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for migraine headaches is remanded. FINDING OF FACT The weight of the evidence is against finding the Veteran’s hysterectomy and precipitating gynecological issues are related to service. CONCLUSION OF LAW The criteria for service connection for status post hysterectomy have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from October 1984 to September 1987. 1. Service connection for status post hysterectomy Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service” – also known as the “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When there is an approximate balance of positive and negative evidence regarding any material issue, all reasonable doubt is resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran is competent to describe symptoms observable to her senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Unfortunately, however, based on the evidence of record, the Board finds the criteria for service connection for status post hysterectomy have not been met. 38 C.F.R. § 3.303. The Veteran has a current disability. The August 2019 VA examiner noted the Veteran underwent a hysterectomy. The examiner noted that VA treatment records in 2011 showed chronic pelvic pain, fibroids with calcification, and ovarian cyst. Removal of the uterus establishes the first element of service connection. See Holton, 557 F.3d at 1366. Next, the evidence shows an in-service illness. Service treatment records show diagnosis of pelvic inflammatory disease in June 1983 and a pelvic ultrasound report with left tubo-ovarian or pelvic abscess and diagnosis of pelvic inflammatory disease in September 1985. The Veteran has also reported having pelvic inflammatory disease during service. Thus, the evidence satisfies the second element of service connection. See Holton, 557 F.3d at 1366. Finally, however, the weight of the evidence is against finding a connection between the pelvic inflammatory disease and abscesses in service and the current hysterectomy. During the Board hearing, the Veteran asserted that she had recurrences of the pelvic inflammatory disease that began in service. Unfortunately, records of the Veteran’s treatment during the time between separation from service and 2011 are unavailable. The August 2019 examiner opined that the Veteran’s hysterectomy is less likely than not related to service. The examiner explained that peer-reviewed medical literature shows pelvic inflammatory disease is caused by untreated sexually transmitted infections, is acute and episodic in nature, and resolves with treatment. The examiner noted that if pelvic inflammatory disease is left to advance, it can cause toxic/septic shock, hypovolemia and death, and can warrant emergency hysterectomy. However, the examiner opined that in the Veteran’s case, the service treatment records show the Veteran was treated for pelvic inflammatory disease with complete resolution of symptoms in service and the post-military infections were separate episodes and not a chronic infection festering for over 20 years. Instead, the examiner explained that the most common reasons for hysterectomy are heavy periods that can be caused by fibroids, pelvic pain, prolapse of the uterus, and cancer. Additionally, the examiner noted that ultrasounds during service used to diagnose pelvic inflammatory disease did not show ovarian cysts or uterine fibroids, and there is no peer-reviewed, accepted medical literature that endorses pelvic inflammatory disease as a cause or significant risk factor for developing uterine fibroids or ovarian cysts. The Board has considered the Veteran’s assertions of continuous infection. However, neither the Board nor the Veteran has the requisite medical knowledge to determine the cause of an infection or complex gynecological diagnosis. See Jandreau, 492 F.3d at 1377. The Board must rely on competent medical evidence to determine whether the Veteran’s current disability is related to the disease she had in service. The August 2019 examiner’s opinion is the only competent medical evidence to address that question; therefore, the Board finds it is the most probative evidence on nexus. As the weight of the evidence is against finding a causal relationship between the hysterectomy and service, service connection cannot be granted. See Holton, 557 F.3d at 1366. REASONS FOR REMAND 1. Entitlement to service connection for a low back disability is remanded. In the March 2019 remand, the Board requested an opinion on the back claim. The August 2019 examiner opined that the Veteran’s current low back disability is less likely than not due to service. The examiner’s reasoning relied on the lack of documentation of a back disability without further rationale for the conclusion. Thus, the Board finds an additional opinion is needed to adequately address the Veteran’s claim. See Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). 2. Entitlement to service connection for migraine headaches is remanded. In the March 2019 remand, the Board requested an opinion on the headache claim. The August 2019 examiner provided a negative opinion relying mainly on the lack of documentation of treatment for headaches in service and after, until 2011. The examiner noted the statements of the Veteran and her mother providing evidence of headaches but concluded that she was unable to establish a nexus without documented treatment. The Board finds this opinion inadequate because it is based solely on the lack of documented treatment despite the favorable evidence in lay statements. See Dalton, 21 Vet. App. at 39. A new opinion is needed. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records. 2. Obtain an addendum medical opinion for the Veteran’s back and headache claims. The medical expert(s) should review the claims file and address the following: (a.) Is the Veteran’s current degenerative arthritis of the lumbar spine at least as likely as not related to her service, including a fall and injury in 1986 when refueling a fuel tank? (b.) Are the Veteran’s current migraine headaches at least as likely as not related or concurrent with the Veteran’s service? Consider all relevant lay and medical evidence, including the reports of injury, onset, and ongoing symptoms. All opinions must be supported by detailed rationale, including if possible, alternate etiologies for the conditions if found to be other than service. If the opinions cannot be provided without resort to speculation, the expert should explain why, and state whether the inability is due to lack of evidence or limits of scientific/medical knowledge. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.P. Armstrong 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.