Citation Nr: 21028600 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 18-25 525 DATE: May 11, 2021 ORDER Entitlement to service connection for hysterectomy associated with perforated portion, uterus is denied. FINDING OF FACT The Veteran's hysterectomy did not manifest in service and is not otherwise attributable to active duty service. CONCLUSION OF LAW The criteria for entitlement to service connection for a hysterectomy have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1981 to September 2001. In March 2020, the Veteran testified before the undersigned Veterans Law Judge at a Travel Board Hearing. A transcript of the hearing is associated with the claims file. This matter was previously remanded by the Board of Veterans' Appeals (BVA) in June 2020 for additional development. It now returns for further appellate review. While the appeal was on remand, the Regional Office granted service connection for tinnitus. See August 2020 Rating Decision. Thus, the service connection claim for tinnitus is no longer before the Board because a grant of service connection constitutes a full grant of benefits on appeal. Grantham v. Brown, 111 F.3d 1156 (Fed. Cir. 1997). 1. Service Connection The Veteran contends that her hysterectomy is related to active service. See March 2016 Notice of Disagreement (NOD). Specifically, she asserts that "I was seen and treated several times for irregular cycle, heavy bleeding, menstr[u]al period messed up, pelvis issues which lead [sic] to me getting a hysterectomy." Id. Legal Criteria Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained in the line of duty during active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may be granted for a disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Relevant Facts and Analysis The June 2015 VA examiner confirmed the Veteran's diagnosis of hysterectomy. See June 2015 VA Gynecological Conditions DBQ. Thus, the first element of service connection has been met. The second element of service connection, an in-service illness or occurrence, has also been met. The Veteran's service treatment records (STRs) reflect that the Veteran was treated for irregular menses in July 1986, heavy menses in June 1988 and June 1991, and underwent a bilateral tubal ligation in September 1996. See STR-Medical. During a December 1994 gynecological evaluation, the Veteran denied a history of uterine fibroids. Id. A September 1995 sonogram taking during her pregnancy did not indicate any fibroids. Id. The post-operative report for the Veteran's tubal ligation indicated the Veteran's uterus appeared normal and that she had a uterine perforation in her left uterine cornu. See September 1996 Post-Operative Report in STR-Medical. The Veteran testified during the March 2020 Board hearing that her fibroids led to her hysterectomy. See Hearing Transcript. She further asserted that she began experiencing symptoms of excessive bleeding and problems with her menstrual cycle in 1984 and that she was treated for anemia. She was diagnosed with fibroids following active service. Id. Thus, the issue is whether the Veteran's hysterotomy or residuals thereof, were caused by or related to active service, including the reported gynecological symptoms and complaints, to the documented in-service tubal ligation, and suture of perforated uterus as well as heavy and/or irregular menses, pelvic pain, and anemia. The record contains three negative VA medical nexus opinions. The June 2015 VA examiner opined that the Veteran's hysterectomy was less likely than not related to active service because the Veteran "underwent a hysterectomy due to uterine fibroids, which there is no evidence to suggest this was caused by the hole in the uterus during service. See June 2015 VA Medical Opinion Disability Benefits Questionnaire (DBQ). However, the Board remanded the claim in June 2020 because the June 2015 VA examiner did not address the Veteran's in-service complaints of gynecological symptoms such as abnormal vaginal bleeding, pelvic pain, anemia, and the Veteran's assertion that her fibroids led to a hysterectomy are related to her hysterectomy residual in providing a negative nexus opinion. Consequently, a VA examiner provided a negative nexus opinion in a July 2020 VA addendum medical opinion. See July 2020 VA Medical Opinion DBQ. Specifically, the examiner stated as follows: There is evidence that the Veteran underwent bilateral tubal ligation and suturing of the uterus secondary to a uterine perforation, but neither of these conditions cause uterine fibroids and no evidence that the Veteran's uterine perforation continued as a chronic condition following suturing of the uterus. Her 2011 ultrasound showed uterine fibroids without evidence of uterine residuals secondary to uterine perforation. It is less likely than not that her 1996 uterine perforation was [the] cause of her 2011 hysterectomy that was clearly documented as secondary to uterine fibroids. See July 2020 VA Medical Opinion (Opinion 1) DBQ. The July 2020 VA examiner provided a second addendum medical opinion. See July 2020 VA Medical Opinion (Opinion 2) DBQ. She addressed the Veteran's in-service symptoms. The examiner noted that the Veteran did not have uterine fibroids during service, "as the Veteran did have ultrasounds during that time due to multiple pregnancies and the ultrasounds were all negative for fibroids." Id. She further noted that the Veteran's uterus was inspected in 1991 during a C-section with no evidence of fibroids. Id. The examiner also stated that with "regard to the dysfunctional uterine bleeding during [active duty], it was documented several times that it was likely secondary to anovulation." Id. Although the Veteran provided a private gynecological evaluation related to her claim in February 2015. See Private Gynecological Conditions DBQ. The private examiner did not provide a nexus opinion. Therefore, it is not probative on the issue of nexus. The Board acknowledges the Veteran contention that she believes her hysterectomy is related to an undiagnosed fibroid condition which occurred during service. While the Veteran is competent to report her symptoms, as a lay person, she lacks the specialized medical training and expertise in the field of gynecology, to render diagnoses, etiological opinions, or theories of medical proximate causation. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Therefore, her lay statements on diagnosis and etiology are less probative. The Board assigns significant probative to the July 2020 VA medical opinions. The VA examiner reviewed the claims file; considered the Veteran's reports and provided adequate rationale for her conclusions. Importantly, the respective examiner rendered an opinion based on evidence and medical information. The earliest clinical indication of fibroids was in 2007, which is six years after the Veteran separated from service. See September 2007 Fort Benning Clinic Pelvic Ultrasound Report. Regarding the etiology of the Veteran's hysterectomy, the June 2015 and July 2020 VA examiner provided a negative nexus opinion as to direct service connection. Both examiners opined that the Veteran's hysterectomy was related to her uterine fibroids. The July 2020 VA examiner explained that bilateral tubal ligation and suturing of the uterus did not cause her hysterectomy and that there was no evidence of fibroids during service. See July 2020 VA Medical Opinion (Opinion 1) DBQ. Finally, the July 2020 VA examiner also attributed the Veteran's uterine bleeding during active service to anovulation rather than fibroids. See July 2020 VA Medical Opinion (Opinion 2) DBQ. Thus, based on the forgoing, the Board finds the weight of the evidence is against finding that the Veteran's hysterectomy was related to active service. The Board is sympathetic to the concerns that have been voiced by the Veteran. However, the medical evidence of record does not support that Veteran's contention that the Veteran's hysterectomy was incurred in service or was related to the in-service treatment she received for gynecological symptoms. (Continued on the next page) Therefore, because the VA examiner's opinion has more probative weight, the preponderance of the evidence weighs against finding the Veteran's hysterectomy is entitled to service connection. Thus, based on the foregoing, the preponderance of the evidence is against the Veteran's claim. The benefit-of-the-doubt rule does not apply and service connection for a hysterectomy is denied. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49,55 (1990). YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Lilly, 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.