Citation Nr: 21029078 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-36 855 DATE: May 12, 2021 ORDER Entitlement to service connection for status post total hysterectomy with history of uterine fibroids is granted. FINDING OF FACT The Veteran's uterine fibroids and subsequent hysterectomy began during active service. CONCLUSION OF LAW The criteria for service connection for status post total hysterectomy with history of uterine fibroids are met. 38 U.S.C. §§ 1110, 1131, 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 September 1983 to September 1998 and from October 2004 to April 2006. This matter comes to the Board of Veterans' Appeals (Board) from an October 2013 rating decision which, in pertinent part, denied entitlement to service connection for total abdominal hysterectomy with history of uterine fibroids. In March 2019, the Board remanded the matter for further development, to include obtaining a VA examination and/or medical opinion. The Board notes that in August 2020 and subsequent to the most recent July 2020 supplemental statement of the case (SSOC), the Veteran requested an additional 30 days to submit evidence before VA returned her case to the Board. Upon review, VA returned her case to the Board prior to expiration of this time. The Board further notes that a post-remand appellate brief from the Veteran's representative, the Disabled American Veterans, is not associated with the record. However, as the Board is granting her claim of service connection for status post total hysterectomy with history of uterine fibroids, which is a full grant of the benefit sought on appeal, there is no prejudice to the Veteran with the Board proceeding with a decision on this claim. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Entitlement to service connection for status post total hysterectomy with history of uterine fibroids. The Veteran contends that service connection is warranted for her hysterectomy with history of uterine fibroids. Specifically, she contends that her uterine fibroids, and subsequent hysterectomy due to heavy bleeding from the uterine fibroids, began during active service. The Board concludes that the Veteran has a current disability that began during active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Turning to the evidence of record, in February 1995, while the Veteran was on active duty, the Veteran underwent an emergency cesarean section. The operation report notes that intraoperatively, the ovaries and fallopian tubes were normal in appearance. However, the uterus contained multiple fibroids and her record of inpatient treatment lists a diagnosis of multiple fibroids. In March 1995, the Veteran reported moderate to heavy postpartum bleeding and she was diagnosed with anemia and subinvolution of the uterus. In September 1995, the Veteran underwent a bilateral salpingectomy for sterilization. The discharge summary shows that upon examination, the Veteran's uterus was slightly enlarged with a questionable posterior anteverted fibroid. On a June 1998 gynecological examination just prior to separation from her first period of active duty, the Veteran reported a history of heavy bleeding. Upon examination, the uterus was noted to be in the upper limits of normal and firmer than normal. A history of fibroids was noted by the examiner, but the examiner ultimately concluded the examination was normal. In November 2002, after her first period of active duty but prior to her second period of active duty, a pelvic sonogram revealed an enlarged uterus with a large posterior uterine fibroid. Her laboratory studies revealed profound anemia. She was diagnosed with anemia, menorrhagia, and fibroids, and underwent a series of Lupron injections. Subsequently, in January 2004, the Veteran underwent embolization of the posterior fibroid and a June 2004 follow-up imaging study revealed moderate reduction in the size of the fibroid. However, the Veteran continued to experience menorrhagia with fibroids. In January 2007, after the Veteran's second period of active duty, the Veteran underwent a hysterectomy due to fibroids and dysfunctional bleeding. In support of her claim, the Veteran submitted a May 2020 gynecological conditions Disability Benefits Questionnaire (DBQ) in which her treating clinician, Dr. F.P., noted the Veteran suffered from severe menometrorrhagia, abdominal pain, and severe anemia in service and was diagnosed with uterine fibroids and dysfunctional uterine bleeding. The clinician provided a diagnosis of dysfunctional bleeding in March 1995, uterine fibroids in September 1995, and hysterectomy in January 2007. In a September 2020 letter, Dr. F.P. indicated that the Veteran suffered from ongoing complications of uterine fibroids that began during service and were associated with heavy menses, abdominal pain, anemia, fatigue, and post-coital bleeding. Dr. F.P. explained that uterine fibroids are benign growths that develop from the muscle tissue of the uterus and may remain very small for a long time before suddenly growing rapidly or growing slowly over a number of years. Women who suffer from fibroids develop changes in menstruation, menstrual pain, and anemia. Dr. F.P. opined that the Veteran's uterine fibroids were symptomatic since March 1995 until a hysterectomy was performed in January 2007 and that during that time, the Veteran underwent several procedures and treatment, including with birth control pills, Lupron injections, and uterine embolization, to treat her anemia, stop the flow of blood feeding into the fibroid, and to prevent the fibroids growth. Ultimately, a hysterectomy was performed in January 2007, approximately six months after she separated from service, and was the only treatment left available to the Veteran. The Board finds the May 2020 and September 2020 letters and opinions of Dr. F.P. probative, as they are based upon long-standing treatment of the Veteran and provided an adequate rationale that considered the Veteran's medical history and medical literature. There are no competent and probative opinions to the contrary. While a February 2020 VA examiner opined that it was less likely than not that the Veteran's total abdominal hysterectomy with history of uterine fibroids was incurred in or caused by service, the Board finds the examiner's opinion inadequate. Specifically, the examiner indicated that although the Veteran was diagnosed with a questionable posterior fibroid while in service in 1995, it was not confirmed until 2002, when the Veteran was not on active duty. Thus, it is not clear whether the examiner considered that in February 1995, a visual inspection of the Veteran's uterus showed multiple fibroids and the diagnosis of fibroids was included on her record of inpatient treatment. Therefore, the Board gives no probative weight to the February 2020 VA opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Thus, the only probative evidence specifically addressing whether the Veteran's uterine fibroids and subsequent hysterectomy began during service are the letters and opinions of the Veteran's treating clinician. (Continued on next page) Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's uterine fibroids and subsequent hysterectomy began during service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for status post total hysterectomy with history of uterine fibroids is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Owen, 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.