Citation Nr: 21015379 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 16-07 206 DATE: March 17, 2021 REMANDED Entitlement to service connection for a hysterectomy is remanded. Entitlement to service connection for a temporomandibular joint (TMJ) disability is remanded. REASONS FOR REMAND The Veteran had active duty service from January 1999 to January 2004. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an August 2014 rating decision. This matter was previously before the Board in September 2018. 1. Entitlement to service connection for a temporomandibular joint (TMJ) disability is remanded. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives regarding the issue of service connection for a TMJ disability. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). In this regard, prior Board remand instructions of September 2018 clearly instructed that an addendum opinion be obtained, in order for an examiner to opine as to whether a) the TMJ disability was clearly and unmistakably not aggravated by service, including the installation and removal of braces during service and b) if not, whether it is at least as likely as not related to an in-service injury, event, or disease, including the installation and removal of braces during service. In addition, the Board made clear that adequate explanation and rationale is necessary. An addendum opinion was obtained in October 2020. The examiner made conclusory statements without rationale. The Board finds the 2020 VA examination to be inadequate for adjudication purposes for the aforementioned reasons, and a new VA opinion is warranted. 2. Entitlement to service connection for a hysterectomy is remanded. The Veteran underwent a hysterectomy in March 2008, approximately four years after separation from service. The Veteran contends that her hysterectomy is a result of gynecological problems that had their onset during active service. See February 2019 Substantive Appeal. The Veteran’s service treatment records reflect the Veteran had a pap smear in December 1999 which was within normal limits. In September 2000, the Veteran was noted to be pregnant. An August 2001 treatment note reflects that her last Depo Provera shot was in May 2001 and was being given another one. An August 2001 hospital triage note reflects that she reported left lower quadrant pain, and that it was painful to wear tampons as well as painful urination. Bleeding was also reported, as well as pain and pressure. She was diagnosed with vaginal bleeding and prescribed Naproxen. In another August 2001 treatment note, the Veteran was assessed to have vaginal bleeding, identified as probable resumption of menstrual cycle. She reported continued vaginal bleeding since the birth of her son. In a September 2001 follow up, the Veteran indicated that vaginal bleeding had resolved, but that there is abnormal uterine bleeding. In February 2002, the Veteran was noted to be doing well on OCP, and there was no more abnormal bleeding. In an August 2003 treatment note, the Veteran was noted to have delivered a baby in June 2003. No abnormal Pap smear was noted. Uterine tenderness and endometriosis were noted. In October 2003, the Veteran was assessed to have dyspareunia and urinary loss of control. She reported wanting to see a gynecologist due to pain and complications from childbirth. Post-service treatment records indicate that the Veteran began complaining of gynecological problems in June 2004, five months after separation, including pelvic inflammatory disease, endometriosis, dyspareunia and cervicitis shown as active problems. In addition, she complained of uterine bleeding in November 2004. In August 2004, the Veteran reported experiencing dyspareunia and unusual white discharge since 2003. In December 2004, the Veteran inquired about correcting the position of her uterus. She continued to suffer from endometriosis, cervicitis, pelvic pain and dyspareunia into 2006. The Veteran reported that she underwent a bilateral tubal ligation in 2007 as a means to solve her gynecological problems and, when her problems persisted, she opted for a hysterectomy. The Veteran was afforded a VA examination in July 2014, which was found by the Board in a September 2018 decision to be inadequate for adjudication purposes as it was based on an inaccurate factual premise. When VA undertakes to obtain an examination/opinion, it must ensure that the examination/opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion/examination is considered adequate “where it is based on consideration of the veteran’s prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one.” Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). An addendum opinion was obtained in September 2020. Pertinently, the VA examiner opined that the Veteran’s hysterectomy was less likely than not caused by or a result of her military service. The examiner reviewed the Veteran’s medical gynecological history and noted in particular that while the Veteran had a diagnosis of endometriosis in medical records, there is no evidence of diagnostic laparoscopy to confirm said diagnosis. Further, the examiner noted that the Veteran had been offered more conservative management for her uterine bleeding, and she refused further medical management which could have resulted in avoidance of a hysterectomy. Finally, the examiner cited a study stating that women with tubal ligation have more menstrual irregularity than those without. The Board finds this examination inadequate for adjudication purposes. Specifically, the examiner’s rationale is not responsive to the opinion requested. In this regard, the examiner’s dispute of the Veteran’s endometriosis diagnosis and speculation that alternate, more conservative treatment may have resulted in avoidance of hysterectomy does not address the origin of the Veteran’s gynecological issues which ultimately led to the hysterectomy. The Board finds the 2020 VA examination to be inadequate for adjudication purposes for the aforementioned reasons, and a new VA opinion is warranted. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA and private treatment records pertinent to the hysterectomy and TMJ disability claims. 2. Thereafter, obtain an addendum opinion from an appropriately qualified VA examiner regarding the Veteran’s TMJ disability. The examiner should answer the following questions: (a.) For any disability diagnosed, the examiner must opine whether the Veteran’s disability clearly and unmistakably preexisted service and, if so, whether it was clearly and unmistakably not aggravated by service, including the installation and removal of braces during service. (b.) If the examiner finds that it either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the installation and removal of braces during service. 3. Obtain an addendum opinion from an appropriately qualified examiner regarding the Veteran’s hysterectomy disability. The examiner should answer the following questions: (a.) The examiner must opine whether the Veteran’s hysterectomy was at least as likely as not related to service, including the multiple gynecological problems she experienced during service. The examiner should specifically address abnormal the uterine bleeding and pain after the birth of the Veteran’s first child during service in 2001, and the endometritis, pelvic pain, and dyspareunia she suffered after the birth of her second child during service in 2003. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. (Continued on the next page)   If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). If the examiner cannot provide answers because further information is required, all reasonable steps to obtain this information should be exhausted before concluding that the answer cannot be provided. Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs 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.