Citation Nr: 21025384 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 18-18 229 DATE: April 28, 2021 ORDER Entitlement to service connection for a hysterectomy is denied. FINDING OF FACT The preponderance of the evidence is against a finding that the Veteran’s hysterectomy is etiologically related to her active service, to include by means of any in-service event, injury, or disease; or that it was caused or aggravated by her service-connected oophorectomy. CONCLUSION OF LAW The criteria for entitlement to service connection for a hysterectomy, including as secondary to service-connected oophorectomy, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from September 1989 to September 2010. This issue comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), which reconsidered and continued to deny the Veteran’s service connection claim for a hysterectomy. This issue was previously before the Board in May 2019. The Board denied entitlement to service connection for a hysterectomy at that time. Following the May 2019 denial, the Veteran appealed this matter to the United States Court of Appeals for Veterans Claims (Court). In April 2020, the Court granted a March 2020 Joint Motion for Remand (JMR), which vacated the Board’s May 2019 decision denying the Veteran’s claim for service connection for a hysterectomy Board’s, and remanded the matter to the Board for further proceedings consistent with the JMR. In November 2020, the Board, in turn, remanded the matter to the Agency of Original Jurisdiction (AOJ) for further evidentiary development. Service Connection - Hysterectomy The Veteran seeks entitlement to service connection for a hysterectomy that was performed as a result of fibroids. She reported in her March 2018 VA Form 9 that her understanding was that fibroids grow slowly, and she noted her belief that her fibroids began growing during the latter part of her active service. The Veteran reported that she began having heavy menstrual cycles during service, which became routine for her, and gradually became heavier, more prolonged, and painful. She indicated that her gynecologist recommended a hysterectomy and indicated that there may be some correlation between her in-service ovarian cyst, which led to her undergoing an oophorectomy, and her later hysterectomy. She further noted that later requested that the same gynecologist provide an opinion as to this correlation, but that the gynecologist then indicated that there was no correlation between the two operations. The record confirms that the Veteran underwent a hysterectomy in June 2015, and review of her service treatment records (STRs) indicates that she was noted to have heavy menses during service and that she underwent an oophorectomy in 2001 because of an ovarian cyst. As for the matter of a nexus between the Veteran’s hysterectomy and her active service, and/or her service-connected oophorectomy, following the Board’s November 2020 remand, new etiology opinions were obtained from a VA-contracted examiner in December 2020. With respect to the oophorectomy, the examiner noted that the Veteran underwent right ovary removal secondary to an ovarian cyst. There was no evidence of complaints of pelvic pain following her separation from service, however, until 2015. The examiner noted that the Veteran began complaining of pelvic pain, often of the right lower pelvic area, to her gynecologist in 2015. At that time, she underwent an ultrasound showing uterine fibroids, and she was recommended to undergo a hysterectomy. The surgical pathology report came back showing uterine fibroids. The examiner concluded that an ovarian cyst with ovary removal does not cause uterine fibroids and does not cause pain 14 years later. The examiner further noted that there was no evidence on the operative or pathology reports of any abnormality where the right ovary once was, and that the Veteran’s reported symptoms resolved post hysterectomy, supporting the finding that her pelvic pain in 2014-15 was secondary to the fibroids. The examiner further explained that aggravation of the condition was not plausible as the Veteran no longer had the ovary at the time of the hysterectomy, and there was no evidence of residuals of the oophorectomy. The December 2020 VA-contracted examiner provide a further explanation addressing conflicting evidence of record. While noting that there was no evidence that the Veteran had fibroids during her active service, the examiner explained that the Veteran first reported symptoms in 2015 which was 14 years after her separation in 2001. This is not factually accurate, where Veteran did not separate from service until 2010. Thus, the examiner findings were partly based on an inaccurate reading of the Veteran’s military service; and therefore, the examiner’s opinion is rendered inadequate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (an opinion based on an inaccurate factual premise has no probative value). Pursuant to a request from the Veteran and her representative, a new opinion was obtained from another VA-contracted examiner in March 2021. Notably, the examiner was an OBGYN physician with 30+ years of experience. In the opinion report, the examiner noted that he reviewed the Veteran’s file including prior VA examinations as well as information submitted by the Veteran specifically related to fibroids. Upon a complete review the examiner found, with a confidence level of 100 percent, that the fibroids and hysterectomy were completely unrelated to service, events in service, or the oophorectomy in service, for which service connection was later granted. The examiner first explained that the Veteran’s right oophorectomy with scar played no role in her subsequent hysterectomy. The examiner stated that this finding was unequivocal. He noted that the Veteran underwent a laparoscopic oophorectomy with lysis of adhesions in October 2001, then later had a successful pregnancy in 2007 and subsequent tubal ligation in 2008. The intervening normal pregnancy confirmed the absence of impact of the prior oophorectomy. The examiner noted that there was no evidence of any impact whatsoever on the pelvic organs or the pregnancy, as the pregnancy records in her STRs showed no fibroids identified during the pregnancy, including during ultrasound, and where fibroids were not noted at the time of the tubal ligation. The examiner further noted that there was no pathologic or physiologic connection between the prior right oophorectomy and uterine fibroids. The examiner explained that while the Veteran, as a black female, would have a genetic predisposition to forming fibroids, it was evident that she did not have a fibroid condition through 2008 and through a prior compensation and pension (C&P) examination in December 2010. While various disorders were discussed at that examination, symptoms/history consistent with fibroids were specifically denied. Further, there was no evidence of care for this condition prior to the events leading to the hysterectomy in 2015. Thus, the examiner concluded that it was less likely than not that the Veteran's uterine fibroids/status post-hysterectomy had their nexus in service or were in any way related to the 2001 oophorectomy. The examiner further noted that the same rationale applied directly to the question of aggravation. As there was no relationship between the ovary and the development of fibroids/hysterectomy, there could be no impact on the Veteran's hysterectomy/fibroids. The hysterectomy could not be aggravated, and 2001 operation did not have an impact on the Veteran's hysterectomy/residuals. In conclusion, there was absolutely no evidence of aggravation of the veteran's postoperative status beyond its natural course. The Board finds the March 2021 VA-contracted examiner’s opinion to be of significant probative value. The examiner clearly reviewed the Veteran’s medical history and considered her lay assertions of record, and provided a clear explanation that, based on review of the Veteran’s medical history, including her in-service treatment for oophorectomy, and subsequent pregnancy and gynecological treatment history, her hysterectomy was less likely than not related to her active service, to include her oophorectomy, and was not caused or aggravated by the service-connected oophorectomy or residuals. In short, there was no evidence of care for the Veteran’s fibroids prior to the events leading up to her hysterectomy in 2015. Most notably, neither the Veteran nor her representative have provided any evidence contrary to the examiner’s findings. As such, the Board accepts the examiner’s conclusion as probative evidence on matters upon which this claim turns. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Further, the Board finds that the examiner’s opinion adequately addressed the directives stated in the March 2020 JMR, by addressing the question of whether the Veteran’s fibroids were proximately due to or the result of the service-connected right oophorectomy, and whether her in-service symptoms were related to her post-service diagnosis of fibroids and the related hysterectomy. As the examiner noted, the Veteran did not have any noted history of fibroids following oophorectomy during subsequent, successful pregnancy in 2007, and subsequent tubal ligation in 2008, and the examiner noted that there was no evidence of any impact whatsoever from the oophorectomy on the pelvic organs or the pregnancy. The examiner further noted that there was no pathologic or physiologic connection between the prior right oophorectomy and uterine fibroids. Further, the examiner found that it was evident that the Veteran did not have a fibroid condition through 2008 and through a prior compensation and pension examination in December 2010, at which time a C&P examination addressed various disorders but any symptoms or history consistent with fibroids were specifically denied. As for the Veteran’s lay assertion that her fibroids and subsequent hysterectomy were related to symptoms experienced during service, the Board finds that her assertions lack probative value, especially in light of the fact that she has provided no evidence to support this assertion. Moreover, matters of etiology of complex medical diagnoses typically are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). Although lay persons are competent to provide opinions on some simple medical issues (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), the specific matter of the etiology of the Veteran’s fibroids leading up to hysterectomy is a complex medical matter that falls outside the realm of common knowledge of a lay person. See, e.g., Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As neither the Veteran nor her representative is shown to be other than a layperson, without appropriate medical training and expertise, neither is competent to render a probative (persuasive) opinion on any medical matter upon which this claim turns. See id. Hence, the lay assertions in this regard have no probative value. Overall, then, there is no competent, probative evidence of record to establish that the Veteran’s hysterectomy was at least as likely as not incurred during or as a result of her service, or that it was caused or aggravated by her service-connected oophorectomy or residuals. Rather, the abundant competent, probative evidence on these points weighs against the claim. For all of the foregoing reasons, the Board finds that the claim for service connection for hysterectomy must be denied. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Michael L. Wilson Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Andrew Ledman II 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.