Citation Nr: 21022720 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 17-62 837 DATE: April 19, 2021 ORDER Entitlement to service connection for endometriosis is denied. Entitlement to service connection for status post hysterectomy is denied. Entitlement to service connection for uterine fibrosis is denied. FINDING OF FACT The preponderance of the evidence is against finding that the claimed gynecological conditions of endometriosis; status post hysterectomy, uterine fibrosis began during active service, or are otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for endometriosis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for status post hysterectomy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for uterine fibrosis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty from November 1992 to August 1997. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a January 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In June 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge; a transcript is associated with the claims folder. The Board remanded the issues on appeal in March 2019, in addition service connection for female sexual arousal disorder (FSAD). In an August 2020 rating decision, the RO granted service connection for FSAD. This constitutes a full award of the benefits sought on appeal. This matter is no longer before the Board. SERVICE CONNECTION 1. Entitlement to service connection for endometriosis is denied. 2. Entitlement to service connection for status post hysterectomy is denied. 3. Entitlement to service connection for uterine fibrosis is denied. The Veteran contends that her gynecological disabilities had onset in service or are related to service. In the October 2016 VA Form 21-4138, the Veteran indicated that her symptoms in service included heavy menstrual bleeding, abnormal periods, and fibroids with abnormal pap smears. She indicated that her 2010 hysterectomy was a result of in-service symptoms. The Veteran noted the possibility that she contracted human papillomavirus (HPV) in service with manifestations and misdiagnosed as yeast infections, but eventually diagnosed in in 2006. In her November 2017 substantive appeal, the Veteran reported that she had cervical dysplasia and undiagnosed HPV in service. The Veteran contends that her hysterectomy was performed to prevent cervical cancer associated with HPV. Alternatively, the Veteran contends that her other gynecological disorders, to include endometriosis, are secondary to her hysterectomy. See September 2016 VA Form 21-4138. At the June 2018 Board hearing, the Veteran testified that she did not have any gynecological problems prior to service. She has testified that she experienced chronic pelvic pain, heavy bleeding and prolonged menses following a loop electrosurgical excision procedure (LEEP) procedure in December 1995. The Veteran testified that she frequently experienced heaving bleeding and irregular periods although she did not always seek treatment or report these symptoms when they occurred. She also testified that after service, she had an ectopic pregnancy in 1998, then was without a period for at least a year. Further, after the birth of her son in 1999, she continued to have heavy, irregular periods. Generally, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The dispositive question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The evidence of record shows that the Veteran had numerous gynecological complaints, abnormal test results, and procedures in service. In August 1993 and May 1994, the Veteran was noted to have yeast infections treated with medication. In December 1994, the Veteran’s cervical specimen was noted to have atypical squamous cell of undetermined significance. In November 1995, a cervical biopsy showed low grade squamous intraepithelial lesion (LGSIL). The December 1995 LEEP procedure noted a post-operative diagnosis of high grade SIL with HPV, multifocal LGSIL, low grade dysplasia, and chronic cervicitis with squamous metaplasia. After the procedure, the Veteran was noted to have excessive and prolonged bleeding in December 1995. A diagnosis of HPV was noted in an April 1996 service treatment record. A December 1996 examination with biopsy showed acute and chronic cervicitis with reactive squamous metaplasia. Likewise, a June 1997 cervical biopsy noted squamous metaplasia, inflammation reactive atypia, and unable to rule out LGSIL. In the July 1997 report of medical assessment, the Veteran indicated that her health was the same as her last medical assessment. The Veteran noted a December 1995 LEEP and indicated there were no problems. Post-service diagnoses include uterine fibroids, pelvic adhesive disease, vaginitis, endometriosis. See e.g. August 2010 private treatment records. She is also status post oopharectomy and status post hysterectomy. See July 2019 VA examination report. The Veteran previously underwent a general medical VA examination in September 1997 with a subsequent gynecological examination in October 1997. The examiner noted that the in-service history of abnormal pap in service, colposcopy and biopsy, December 1995 LEEP excision, monthly pap smears, and a last pap which indicated abnormality. However, the examiner noted that colposcopy and biopsy indicated no abnormality. Current examination showed normal vagina and cervix post LEEP; a pap performed. The results of that pap smear indicated severe inflammation. A subsequent April 1998 pap smear showed reactive changes associated with candida infection. The Veteran was also afforded a VA gynecological examination in October 2016, in connection with the current appeal. The examiner negatively opined on the matter of etiology between any gynecological disability to service, to include abnormalities noted on pathological or cytological report. In its March 2019 remand, the Board found that the medical nexus opinion obtained in October 2016 was inadequate because the examiner failed to adequately consider the Veteran’s contentions and offer a cogent rationale. Pursuant to the Board’s remand, the Veteran was afforded a gynecological examination in July 2019. The examiner noted diagnoses of uterine fibroids status post total abdominal hysterectomy; right adnexal mass, right endometrioma, pelvic adhesions, status post right salpingo oophorectomy; and HG-SIL status post LEEP. The examiner noted abnormal pap smears and LEEP procedure in service. The examiner also noted other gynecological issues in the Veteran’s whole medical history including oophorectomy, heavy menstrual bleeding, and abdominal hysterectomy for uterine fibroids, as well as reported cervical dysplasia and HPV. The examiner opined that the Veteran’s current gynecological disabilities are unrelated to service. Rather, the examiner noted that the in-service documentation of abnormal pap smear, cervical dysplasia, and candida vaginitis were insufficient evidence of the Veteran’s current disabilities. Notably, the Veteran’s hysterectomy was performed to treat uterine fibroids and uterine fibroids were not present during active service. In addition, in-service diagnosis of candida vaginitis is an intermittent condition which is not expected to recur as related to the clinical history during active service. Ultimately, the Veteran’s current disabilities occurred years after service, without sufficient evidence to relate the disabilities to service. VA obtained another addendum opinion in August 2020 from the same examiner who conducted the July 2019 examination. The examiner, a physician, indicated that she had reviewed the Veteran's service treatment records, lay statements, post-service treatment (records), and medical literature provided by the Veteran. The examiner opined that it is less likely than not that the currently claimed gynecological conditions were incurred in service or, related to or caused by the reported symptoms of pelvic pain, heavy bleeding, and irregular periods, abnormal PAPs and treatment for such during service. The examiner explained that the Veteran’s current conditions (uterine fibroids, pelvic adhesive disease, vaginitis, endometriosis, and status post oophorectomy) occurred several years after active duty service. The evidentiary record did not reveal symptoms or findings of these disabilities during active duty service. The examiner indicated that the Veteran’s reported heavy bleeding occurred after the LEEP procedure. After the LEEP procedure, however, subsequent gynecological examinations documented normal menstrual cycles and normal flow and there was no noted pelvic pain. The examiner explained that a one-time episode of heavy bleeding after a LEEP procedure does not justify a causal relationship to the gynecologic conditions that developed several years later. She also noted that the subsequent pelvic examinations in service were within normal limits and there were no adnexal masses. The post-service treatment records in 2006 documented normal flow, but not pelvic pain or adnexal mass. The examiner further explained that the Veteran’s oophorectomy was performed to treat endometriosis and her hysterectomy was performed to treat symptomatic uterine fibroids. The endometriosis and uterine fibroids were not, as the examiner indicated, of service origin. In addition, the examiner explained that there is no pathophysiological relationship of these conditions with abnormal PAP smears and related treatment in service. Based on review of the evidence, the Board concludes that the preponderance of the evidence weighs against finding that the Veteran’s gynecological conditions, to include endometriosis, uterine fibroids, and status post hysterectomy, began during service or are otherwise related to an in-service injury, event, or disease. Together, the July 2019 and August 2020 VA opinions establish that the Veteran’s gynecological conditions are less likely related to service, including the symptoms and findings noted therein. The examiner indicated that the medical knowledge regarding the development of these disabilities is inconsistent with the Veteran’s clinical history and reported symptoms. Rather, the evidence of record indicates that the Veteran’s gynecological conditions began after service and are unrelated to the events in service. The examiner’s collective July 2019 and August 2020 opinions are probative because they are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Although in the August 2020 examination report the VA examiner noted one reported instance of heavy bleeding in service and noted a history of heavy menstrual bleeding in the July 2019 examination report, the opinions are still probative. The examiner considered the evidence and has determined that regardless of whether there was one instance of heavy bleeding or a history of heavy bleeding in service, the current gynecological conditions did not onset in service and are not otherwise related to service. She considered the cumulative clinical history and lay statements in reaching this conclusion. Indeed, the August 2020 examination report reflects she had reviewed the Veteran’s service treatment records, lay statements, post-service treatment (records), and medical literature provided by the Veteran in formulating the opinion. Thus, the Board is satisfied that the collective examination reports considered the full extent of the Veteran’s reported symptoms. The examiner is competent to offer the nexus opinion. She is a physician, with the appropriate training, expertise, and knowledge to evaluate gynecological conditions. There are no competent medical opinions to the contrary. The Veteran has testified that she frequently experienced heaving bleeding, and other gynecological symptoms in service and thereafter. As the Board previously noted, she is credible in this regard. However, she is not competent to relate those symptoms or other symptoms to her later diagnosed gynecological conditions or offer an etiological opinion related to those diagnoses. The issue is medically complex, as it requires knowledge and understanding of complex internal gynecological processes not entirely discernable by the naked or untrained eye or other lay senses. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Moreover, some of the Veteran’s assertions are inconsistent with the more probative clinical records. Notably, the Veteran asserted that her hysterectomy was related to cervical cancer risks from HPV. Rather, the August 2010 operative reports show that the preoperative diagnosis was ‘symptomatic fibroid uterus,’ not HPV. Given the Veteran’s lack of competence in the ability to diagnose complex gynecological conditions, and her occasionally inaccurate recollection of her clinical history, the Board accords less probative weight to the Veteran’s lay opinion as to the etiology of the current gynecological conditions. (Continued on the next page)   In sum, the preponderance of the competent and probative evidence weighs against a nexus. Accordingly, there is no reasonable doubt to be resolved in this instance. Service connection for endometriosis, status post hysterectomy, and uterine fibrosis is not warranted. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Vuong, 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.