Citation Nr: 21028299 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 16-28 753 DATE: May 10, 2021 REMANDED Entitlement to service connection for a gynecological disorder is remanded. Entitlement to service connection for a bladder disorder, to include overactive bladder and urinary tract infections (UTI), to include as secondary to a gynecological disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1999 to July 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in March 2012 by a Department of Veterans Affairs (VA) Regional Office. In June 2018, the Board remanded the case for additional development. In April 2020, the Board denied service connection for a gynecological disorder and remanded the claim for service connection for a bladder disorder for additional development, and, in November 2020, denied service connection for a bladder disorder. The Veteran subsequently appealed the April 2020 and November 2020 Board decisions to the U.S. Court of Appeals for Veterans Claims (Court). In February 2021 and March 2021, the Court granted the Veteran's and the Secretary of VA's (the parties') Joint Motion for Partial Remand (JMPR) and Joint Motion for Remand (JMR), respectively, which vacated such decisions. Both issues now return to the Board for further appellate review. 1. Entitlement to service connection for a gynecological disorder. 2. Entitlement to service connection for a bladder disorder, to include overactive bladder and UTI, to include as secondary to a gynecological disorder. In the April 2020 decision, the Board found the Veteran's current gynecological disorder, diagnosed as status post total vaginal hysterectomy bilateral salpingo-oophorectomy (TVHBSO), was unrelated to an in-service injury, event, or illness, to include her noted history of abnormal pap smears and daily spotting documented in May 2003. In such regard, the Board relied upon November 2018 and July 2019 VA opinions in which the examiners opined that the diagnosis of endometriosis could not be substantiated, and the Veteran's TVHBSO was performed due to her desire for sterilization, rather than as a result of her in-service dysfunctional uterine bleeding and abnormal pap smears, respectively. However, in the February 2021 JMPR, the parties found that the Board erred in failing to consider records reflecting a diagnosis of endometriosis, to include the July 2011 pre- and post-operation records, and address a May 2011 treatment record reflecting that a physician contradicted a previous resident's opinion that there was no indication for hysterectomy and instead agreed that she "can/should have a hysterectomy." In the November 2020 decision, the Board found that the Veteran's current bladder disorder, diagnosed as overactive bladder, was unrelated to an in-service injury, event, or illness, and she did not have a current diagnosis of chronic bladder and/or urinary tract infections. In this regard, the Board observed that, while she had an in-service history of UTIs, such had resolved, and a July 2020 VA examiner opined that her overactive bladder was less likely than not incurred in or caused by an in-service injury, event, or illness. Thus, the Board denied direct service connection. Further, while the examiner noted that a hysterectomy is a risk factor for an overactive bladder, the Board found that, as service connection for such had been denied in the April 2020 decision, secondary service connection was not warranted. However, in the March 2021 JMPR, the parties found that, as the April 2020 Board decision that denied service connection for a gynecological disorder was vacated and remanded in February 2021, the Veteran's claim for service connection for a bladder disorder was likewise remanded as inextricability intertwined with the former claim. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). As relevant to the Veteran's claim for service connection for a gynecological disorder, the Board finds that, while the November 2018 VA examiner found that the diagnosis of endometriosis could not be substantiated, other evidence of record suggests the presence of such a diagnosis. Specifically, an assessment in a May 2003 service treatment record included endometriosis. Further, as noted by the parties to the JMPR, records dated around the time of the Veteran's TVHBSO, to include those dated from June 2011 to October 2011, as well as subsequent treatment records reflect a diagnosis of endometriosis, which was, at least in part, the basis of her hysterectomy. However, in July 2012, the Veteran's physician noted that the Veteran was told she had endometriosis, but she had no prior laparoscopy and pathology was negative. Additionally, in September 2015, her physician noted that, while the Veteran reported that her hysterectomy was performed as a result of endometriosis, there was no evidence of endometriosis or any reason to explain her abdominal pain and instead noted that the hysterectomy and BSO was related to menorrhagia and dysmenorrhea. Furthermore, the October 2018 VA examiner noted that the Veteran's post-operative diagnosis included no pathological evidence of endometriosis, and she did not have a diagnosis of endometriosis. Thus, in light of the conflicting evidence as to whether the Veteran had endometriosis prior to her hysterectomy, the Board finds that an addendum opinion is necessary to resolve such matter. Furthermore, while the July 2019 VA examiner opined that the Veteran's TVHBSO was performed due to her desire for sterilization, rather than as a result of her in-service dysfunctional uterine bleeding and abnormal pap smears, the records such otherwise. Specifically, such demonstrate that her medical providers consistently cited endometriosis (although, as noted, it is unclear whether such is an accurate diagnosis), abdominal pain, menorrhagia, and dysmenorrhea as reasons for the Veteran's July 2011 hysterectomy, rather than her desire for birth control and, as noted by the parties to the JMPR, a May 2011 treatment record reflects that a physician contradicted a previous resident's opinion that there was no indication for hysterectomy and instead agreed that she "can/should have a hysterectomy." Thus, an addendum opinion addressing whether the Veteran's gynecological disorder, to include TVHBSO, is related to her in-service gynecological complaints, which include abnormal pap smears, dysfunctional uterine bleeding, and endometriosis (if accurate), without consideration of her desire for sterilization, is likewise necessary. Finally, in light of the fact that the July 2020 VA examiner noted that hysterectomy is a risk factor for an overactive bladder, the Veteran's claim for a bladder disorder is inextricably intertwined with her claim for service connection for a gynecological disorder and adjudication of such must be deferred pending the outcome of the latter claim. See Harris, supra. Nonetheless, in light of such indication, the Board also finds that an opinion addressing whether the Veteran's overactive bladder is caused or aggravated by her TVHBSO should be obtained. Accordingly, the matters are REMANDED for the following action: Forward the record, to include a copy of this remand, to an appropriate VA clinician for a medical opinion addressing the etiology of the Veteran's gynecological and bladder disorders. Following a review of the record, the examiner should address the following inquiries: (A) Offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran had a diagnosis of endometriosis prior to her TVHBSO. In offering such opinion, the examiner should reconcile the conflicting medical evidence of record, to include: A May 2003 service treatment record reflecting an assessment that include endometriosis. Treatment records contemporaneous to the Veteran's July 2011 TVHBSO, to include those from June 2011 to October 2011, and those thereafter that reflect a diagnosis of endometriosis, which was noted to be, at least in part, the basis of her hysterectomy. A July 2012 treatment record wherein the Veteran's physician noted that the Veteran was told she had endometriosis, but she had no prior laparoscopy and pathology was negative. A September 2015 treatment record wherein the Veteran's physician noted that, while the Veteran reported that her hysterectomy was performed as a result of endometriosis, there was no evidence of endometriosis or any reason to explain her abdominal pain and instead noted that the hysterectomy and BSO was related to menorrhagia and dysmenorrhea. The October 2018 VA examiner's opinion that the Veteran's post-operative diagnosis included no pathological evidence of endometriosis. (B) Identify all gynecological disorders that have been present proximate to the Veteran's June 8, 2011, claim, to include endometriosis (based on the response to (A)), abdominal or pelvic pain, dysfunctional uterine bleeding, ovarian cysts, menorrhagia and dysmenorrhea, and TVHBSO, even if such are asymptomatic or have resolved. (C) Offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any gynecological disorder identified in response to (B), to specifically include TVHBSO, had its onset in, or is otherwise related to, the Veteran's military service, to include her in-service gynecological complaints, which include abnormal pap smears, dysfunctional uterine bleeding, and endometriosis (if accurate), without consideration of her desire for sterilization. In offering such opinion, the examiner should consider a May 2011 treatment record reflecting that a physician contradicted a previous resident's opinion that there was no indication for hysterectomy and instead agreed that she "can/should have a hysterectomy." (D) Offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's diagnosed overactive bladder is caused or aggravated by her TVHBSO. For any aggravation found, the clinician should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology by the aggravation. In offering such opinion, the examiner should consider the July 2020 VA examiner's statement that hysterectomy is a risk factor for an overactive bladder. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dawn A. Leung, 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.