Citation Nr: 21022776 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 13-09 668A DATE: April 19, 2021 ORDER Entitlement to service connection for uterine fibroids, status post total hysterectomy, to include as secondary to service-connected Hodgkin’s disease, is denied. Entitlement to special monthly compensation (SMC) based on anatomical loss of a creative organ is denied. FINDINGS OF FACT 1. The Veteran’s uterine fibroids, status post total hysterectomy, are not secondary to a service-connected disability, and are not otherwise related to an in-service event, injury, or disease. 2. The Veteran’s anatomical loss of a creative organ is not due to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for uterine fibroids, status post total hysterectomy, have not been satisfied. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for SMC based on anatomical loss of use of creative organ are not satisfied. 38 U.S.C. § 1114(k); 38 C.F.R. §§ 3.102, 3.350(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1986 to January 1992. This matter comes before the Board of Veterans’ Appeals (Board) from a September 2012 rating decision of the Department of Veteran’s Affairs (VA) Regional Office (RO). The issues were previously before the Board in January 2018, May 2019, and August 2020, where they were remanded for additional development. They now return for further appellate review. Service Connection for Uterine Fibroids The Veteran seeks service connection for diagnosed uterine fibroids, status post total hysterectomy. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. By way of background, the Veteran originally filed a claim for service connection for uterine fibroids in June 2008. It was denied in an unappealed June 2009 rating decision based on the findings of an October 2008 VA examiner who opined that it was less likely than not that the Veteran’s uterine fibroids were incurred as a result of her active service. The Board notes that the Veteran’s service treatment records (STRs) indicate in-service anemia associated with irregular menstrual flow and abdominal pain and cramping. There were no other complaints, diagnosis, or treatment related to any gynecological disability, to include fibroids, although the Board notes that the Veteran was pregnant at the time of her separation. While a report of medical history just prior to separation noted the Veteran reporting a history of menstrual pattern changes, a corresponding physical examination was negative for any gynecological condition. The Veteran has not contended, however, nor does the record suggest, that her uterine fibroids, when at issue, were directly due to her active service. Rather, the Veteran asserts that they were due to her service-connected Hodgkin’s disease and its chemotherapy treatment. Of note, the October 2008 examiner opined that there might be a contributing factor concerning the fact that Hodgkin’s disease with chemotherapy could cause abnormal bleeding, and that the Veteran was later found to have abnormal bleeding and uterine fibroids. No further rationale in support of the negative opinion was provided. Additionally, VA treatment records from March 2011 indicate that the Veteran underwent a total hysterectomy due to continuing abnormal bleeding, and pathology indicated that she had several fibroids at the time. At an additional VA examination in June 2011, the examiner noted that the Veteran’s symptoms had subsided since her total hysterectomy, which was also corroborated by VA treatment records from May and June 2011. The Veteran relayed to the examiner that, after the completion of chemotherapy, her menstrual flow became heavier and more painful. The examiner noted CT scans conducted between April 1998 and May 2004, which were all negative for fibroids. While the examiner opined that the Veteran’s uterine fibroids were less likely than not related to her Hodgkin’s disease and chemotherapy treatment, no rationale was provided. The Board reopened the Veteran’s claim in January 2018, finding that new and material evidence had been received since the RO’s June 2009 denial (see 38 C.F.R. § 3.156(a)), and remanded the claim for an opinion that provided an adequate rationale as to whether the chemotherapy treatments for her Hodgkin’s disease caused or aggravated her uterine fibroids on a secondary basis. In January 2019, a VA examiner opined that it was less likely than not that the Veteran’s chemotherapy caused or permanently aggravated her uterine fibroids, explaining that there was no objective medical evidence or reputable medical literature to support a causal relationship. The January 2019 examiner further cited to the previous opinions provided in October 2008 and June 2011. The Board, upon the appeal’s return in May 2019, found the examiner’s rationale to be incomplete, as the opinion did not address the Veteran’s history of heavier and more painful menstrual flow following her chemotherapy treatment, or her theory that hormonal changes caused by chemotherapy led to the development of uterine fibroids. Thus, the Board again remanded the claim for a new opinion, which was obtained November 2019. The examiner noted the Veteran’s relevant medical history of irregular menstrual flow with abdominal pain and cramping, diagnosis and treatment for Hodgkin’s disease beginning in 1996 which temporarily stopped her menstrual pattern, and the return of irregular menstrual flow and severe anemia. It was noted that she was then diagnosed with fibroids in 2005 and underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) in 2011, with biopsies confirming fibroids. The examiner opined that the Veteran’s condition was less likely than not proximately due to or the result of the service connected Hodgkin’s disease, as the examiner was unable to confirm a current chronic diagnosis of female sexual arousal disorder and therefore, there is no nexus or plausible secondary relationship. The examiner also opined that there is no medical literature to support a causal relationship or aggravation beyond the natural progression of the Veteran’s uterine fibroids by her Hodgkin’s disease, to include treatment of the disease. The examiner indicated that the Veteran had several known risk factors supported by medical literature, to include race and age. The examiner also addressed the Veteran’s contentions regarding hormonal changes caused by chemotherapy that led to uterine fibroids. See, e.g., April 21, 2019 Correspondence. The examiner indicated that the Veteran’s chemotherapy concluded in 1996 and she was not diagnosed with uterine fibroids until 2005, with normal gynecological examinations in between such time, and that medical literature did not support a connection between the two. As to the medical literature, the examiner stated that the epidemiology of leiomyomas parallels the ontogeny and life cycle changes of estrogen and progesterone (the reproductive hormones), and that although fibroids are responsive to gonadal steroids, these hormones are not necessarily responsible for their genesis. With regard to the history of heavier and more painful menstrual flow following chemotherapy, the examiner indicated that their onset was not until the 2005 diagnosis of fibroids, many years following completion of chemotherapy. In addition, there were no reports of menorrhagia and heavier menstrual flow during follow up oncology examinations between 1999 and 2001. In the Board’s most recent remand in August 2020, however, it found the November 2019 examination was also incomplete. Specifically, and with regard to proximate causation, the Board was unclear on the examiner’s rationale citing to the inability to confirm a current chronic diagnosis of female sexual arousal disorder and what the correlation is to uterine fibroids. With regard to aggravation, the Board was also unclear about the relationship between chemotherapy and gonadal steroids as it relates to the development of uterine fibroids. As the cited medical literature tended to indicate that the epidemiology of fibroids parallels the life cycle changes of reproductive hormones, and the examiner concluded that gonadal hormones are not necessarily responsible for the genesis of the tumors, further clarification regarding hormonal changes resulting from chemotherapy and uterine fibroids was necessary. Additionally, the examiner did not discuss the possible correlation between chemotherapy treatments, which can cause some bleeding, and the Veteran’s subsequent uterine fibroids, as originally suggested by the October 2008 VA examiner. As such, a lengthy addendum opinion was provided in October 2020 by a Board Certified OB/GYN. As with the previous examiners, the examiner opined in the negative regarding the Veteran’s secondary service connection theory, finding that it was less likely than not that her current disability was proximately due to, the result of, or aggravated beyond its natural progression, by the Veteran’s service-connected condition. The examiner explained that it is accepted medical knowledge and practice that Hodgkin’s lymphoma and chemotherapy do not cause fibroids, and the possible relationship between chemotherapy and fibroids suggested by the VA examiner in 2008 is not supported by medical facts and documentation. The examiner explained that the Veteran was treated for Hodgkin’s lymphoma in 1996 with the chemotherapy regimen “ABVD” (Adriamycin, Bleomycin, Vinblastine, and Dacarbazine), and while chemotherapy may cause irregular cycles or bleeding secondary to hematologic effects, this does not cause or necessarily relate to fibroids. Any bleeding from 1996 until the developmental of fibroids was more likely than not due to the absence or irregular production of hormones to regulate the endometrium, or direct hematologic effects. The effects of chemotherapy on the uterus would be to inhibit growth of fibroids or be neutral, were they present. Therefore, it is more likely than not that the Hodgkin's lymphoma and chemotherapy are moot with respect to the cause or aggravation of the Veteran’s fibroids and subsequent hysterectomy. Although the Veteran reported an irregular uterus with her 1991 pregnancy, there is no evidence of a fibroid at the time of her pregnancy at separation, which was in its tenth week, and the Veteran carried this pregnancy successfully. Therefore, any menstrual irregularities that may have arisen during service would be considered moot, and she essentially had a “physiologic reset” at the end of her pregnancy in 1992. As to an internet article submitted by the Veteran in April 2019, the examiner stated that it does not represent widely accepted, peer-reviewed research, and is instead a general, broad discussion of effects of chemotherapy by non-medical personnel. Instead, the examiner explained, the mechanisms by which chemotherapy can cause irregular bleeding includes effects on the ovaries, suppressing normal function and the production of estrogen and progesterone, and also direct hematologic effects, including thrombocytopenia. While estrogen and progesterone can, and do, commonly impact fibroid growth, in the Veteran’s case they were not evident until at least 2005. Thus, it is less likely than not that chemotherapy was involved in her fibroids identified nine years later, including irregular bleeding. Pregnancy, the examiner noted, is considered a high-risk time for fibroid growth due to the large amounts of estrogen, progesterone, and other hormonal factors that can cause rapid growth. If the Veteran had fibroids during either pregnancy, the likelihood is they would’ve been identified, as sonography was routine during pregnancies in the 1990s. As the Hodgkin’s was diagnosed subsequent to her pregnancies and no abdominal imaging identified uterine fibroids, it is less likely than not that the fibroids were present in service or even as late as 1996. Additionally, and as to the November 2019 VA examiner’s discussion of the absence of female sexual arousal disorder (FSAD), there is no mention of such on the two prior VA examinations or in any records preceding the claim. However, even if conceded, the examiner continued, the origin cannot be determined. The prevalence of FSAD arises in the perimenopause and postmenopausal states. As the Veteran underwent a TAH-BSO for her fibroids, she was rendered surgically menopausal, and it is unclear if the Veteran was treated with post-hysterectomy hormone therapy. Although a TAH-BSO for any reason has been associated with FSAD, with or without hormone replacement therapy, this does not bear any relationship to the Veteran’s Hodgkin’s lymphoma and chemotherapy treatment, with respect to both cause and aggravation. Any FSAD is more likely than not due to her postmenopausal state. The Board finds the above opinions, as a whole, and particularly the more recent opinion by an OB/GYN, to be highly probative as they were made by medical professionals with consideration of the specific facts in this case and after examination of the Veteran. There is no medical opinion or competent and credible evidence in significant conflict with the VA medical opinions. For the above reasons, the preponderance of the evidence is against the claim and service connection is denied. The Board has considered the Veteran’s statements, to include her assertions that her uterine fibroids are related to her service-connected disability. As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., changes in her menstruation; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent, however, to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. Thus, her lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the multiple opinions rendered by a trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). SMC The Veteran also seeks entitlement to SMC due to her uterine fibroids. SMC is a statutory award, in addition to awards based on the schedular evaluations provided by the diagnostic codes in the VA Rating Schedule. Claims for SMC, other than those pertaining to one-time awards and an annual clothing allowance, are governed by 38 U.S.C. § 1114(k)(s); 38 C.F.R. §§ 3.350, 3.352. Under 38 U.S.C. § 1114(k) and 38 C.F.R. § 3.350(a)(1), SMC is payable at a specified rate if the Veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organs. Here, however, as the Board has denied the above service connection claim, a grant of SMC cannot be awarded as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Scarduzio, 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.