Citation Nr: 21032771 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 08-07 226 DATE: May 27, 2021 ORDER Entitlement to service connection for a gynecological disorder, including uterine fibroids and heavy menstrual periods, is granted. Entitlement to service connection for anemia, to include as secondary to service-connected gynecological disorder, is granted. FINDINGS OF FACT 1. The most probative evidence reflects that uterine fibroids and heavy menstrual periods caused by the Veteran's uterine fibroids began during service. 2. The most probative evidence reflects that the Veteran's anemia was caused by her service-connected uterine fibroids. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a gynecological disorder, including uterine fibroids and heavy menstrual periods are met. 38 U.S.C. §§ 1101, 1110, 1112, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.317. 2. The criteria for entitlement to service connection for anemia, as secondary to service-connected uterine fibroids, are met. 38 U.S.C. §§ 1101, 1110, 1112, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1990 to June 1990 and from November 1990 to June 1991. She served in Southwest Asia during the Persian Gulf War. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision of a Department of Veteran's Affairs (VA) Regional Office of the Veteran's Benefits Administration, which is the Agency of Original Jurisdiction (AOJ). This matter was previously before the Board in February 2013, October 2015, September 2016, June 2017, and March 2019, at which times it was remanded for additional development. This matter was most recently before the Board in December 2020 at which time it was again remanded. Service Connection 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, 1131, 5107; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In general, service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). A disability that is proximately due to, or results from, another disease or injury for which service connection has been granted, will be considered part of the original disorder. 38 C.F.R. § 3.310(a). Service connection may also be granted on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on qualifying chronic disability, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Notably, laypersons are considered competent to report objective signs of illness. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location, or symptomatology are similar. 38 C.F.R. § 3.317 (a)(5); Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A "qualifying chronic disability" for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (1) an undiagnosed illness, (2) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (3) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a), (c). Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). 1. Entitlement to service connection for a gynecological disorder, including uterine fibroids and heavy menstrual periods, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness The Veteran seeks service connection for a gynecological disorder, including fibroids and heavy menstrual periods. As an initial matter, because medical records indicate and VA examiners have consistently opined that the Veteran's heavy menstrual periods were caused by uterine fibroids, the Board finds that 38 C.F.R. § 3.317 does not apply to this diagnosed disorder. The Veteran was diagnosed with premenopausal menorrhagia in December 1992 and with uterine fibroids in October 1993 pursuant to a pelvic ultrasound. Therefore, the first element required to establish service connection is met. The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Evidence pertaining to the second and third element required to establish service connection will be discussed together. The Board notes that it has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim being decided. A VA treatment record from December 1992 notes menorrhagia (heavy menstrual periods). A treatment record from January 1993 noted that the Veteran reported that her menstrual periods were lasting about nine days with 4-5 days of "heavy" flow. The Veteran underwent a pelvic ultrasound which diagnosed uterine fibroids in October 1993. Her uterus was noted to be enlarged, "6-8 week size." Menorrhagia and hematuria (blood in urine) were noted. An August 1996 treatment record indicates that the Veteran reported she usually has heavy periods. The Veteran underwent a second pelvic ultrasound in June 1997 that indicated uterine fibroids. Subsequent treatment records include complaints of heavy bleeding during periods. In July 2004, a VA physician noted the need to reduce the size of the Veteran's uterine fibroids. A May 2005 pelvic ultrasound revealed a 3 x 4 cm myoma. The Veteran's last menstrual cycle was in October 2006, with the onset of natural menopause. The Veteran was afforded several VA examinations. In May 2013, the examiner noted premenopausal menorrhagia related to uterine fibroids, resolved since 2007. The examiner found the Veteran's uterine fibroids were the cause of the Veteran's premenopausal menorrhagia. An October 2016 VA examiner opined that the Veteran's menstrual disorder likely resulted from fibroids diagnosed after active duty. A June 2017 examiner opined that the Veteran's gynecological condition is more likely to be the result of fibroids diagnosed more than one year following military service. During an October 2019 VA examination, the Veteran stated that she has always had heavy menstruation, starting at 12 years of age. She stated that after joining military at 34 years of age, menstruation became worse due to vigorous physical training and ruck marching. The examiner stated fibroids are known to cause heavy menstrual periods, which was a pre-existing condition, and the development of the uterine fibroids aggravated the heavy menstrual periods. An April 2020 addendum opinion noted that the Veteran's fibroids developed in October 1993. The examiner noted that fibroids are known to cause heavy menstrual periods. The examiner stated that the Veteran's heavy menstrual periods were a pre-existing condition, and the development of uterine fibroids aggravated the heavy menstrual periods. The examiner opined that the Veteran's gynecological disabilities were not aggravated beyond natural progression by any in service event, injury or illness. In December 2020, the Board remanded for an addendum opinion addressing whether the Veteran's gynecological disorders, including uterine fibroids and heavy menstrual periods, clearly and unmistakably pre-existed her active service, and, if so, whether they were clearly and unmistakably not aggravated beyond their natural progression by the Veteran's active service. The Board found that there was no other competent medical evidence in the claims file that adequately addresses those questions. The Veteran was afforded a VA examination in February 2021. The examiner diagnosed uterine fibroids with menometrorrhagia (prolonged or excessive uterine bleeding occurring irregularly and more frequently than normal). The examiner noted the Veteran reported heavy menstrual flow, resolved. The examiner noted that the Veteran has undergone natural menopause. The examiner noted that an October 1993 pelvic ultrasound showed a uterine leiomyoma. The examiner noted a July 1997 pelvic ultrasound showed enlargement with a heterogenous echogenicity consistent with a leiomyoma. The examiner also noted May 2005 pelvic ultrasound results indicated the uterus appeared bulky and heterogenous, with an apparent myoma 3 x 4 cm on right side of uterus. The examiner found no evidence that the Veteran's gynecological disorder preexisted service and no evidence that her gynecological disorder was aggravated by service. The Board finds this opinion is entitled to significant probative weight. The Board notes that there is no evidence, much less clear and unmistakable evidence, supporting any medical diagnosis of, or treatment for, medically significant heavy menstrual periods prior to service. Whatever menstrual symptoms the Veteran may have had prior to service, there is no indication of a gynecological disorder that required medical attention, nor does the Veteran claim so. As noted, the Veteran first sought treatment for heavy menstrual periods, lasting about nine days with 4-5 days of "heavy" flow, in January 1993. The Veteran reported that these heavy menstrual periods requiring medical attention began during service. The Board notes that the Veteran is considered competent to report her symptoms. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran attributed the heavy menstruation that began during service to vigorous physical training and ruck marching. However, VA medical examiners who addressed the issue have consistently opined that the Veteran's heavy menstrual bleeding was instead due to the development of uterine fibroids. The Board finds the VA examiners' opinions are entitled to higher probative weight on the issue of medical causation. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Board notes that while the February 2021 gynecological examiner stated that the Veteran was not found to be anemic until July 1997, during a concurrent February 2021 VA examination for hematologic and lymphatic conditions, the same examiner found that the Veteran's anemia had its onset in 1990. The Board notes that the medical record includes an October 1991 bloodwork result record that indicated low red blood cell count. Further, an October 1992 VA medical note indicates a history of anemia. The Board therefore finds the hematologic and lymphatic examination to be more probative on the issue of the onset of the Veteran's anemia and that the onset was, as stated therein, in 1990. As noted, VA examiners consistently opined that the Veteran's heavy menstrual periods were caused by uterine fibroids. These opinions and the medical documentation supporting them, along with the VA examiner's finding that the Veteran's anemia began in 1990, and the Veteran's statements, support a finding that the Veteran's medically significant heavy menstrual periods began during service and were diagnosed shortly after service as caused by uterine fibroids. Contrary to findings otherwise, the Veteran's uterine fibroids did not "develop" in October 1993; that is when her fibroids were diagnosed. Although the Veteran was not diagnosed with uterine fibroids until after her separation from active service, her statements reflecting in-service symptoms of heavy menstrual periods, in conjunction with the VA examiners' opinions linking those heavy menstrual periods to the Veteran's uterine fibroids, indicate that the fibroids were present during service. The absence of a diagnosis during service is not dispositive of a finding of service connection. 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). Accordingly, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran's gynecological disorder including uterine fibroids and heavy menstrual periods had its onset during her active service. The benefit of the doubt is resolved in the Veteran's favor, and the Board finds that entitlement to service connection for a gynecological disorder including uterine fibroids and heavy menstrual periods is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for anemia, to include as secondary to service-connected disabilities To establish secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or the result of service-connected disease or injury, or that service-connected disease or injury has aggravated the nonservice-connected disability for which service connection is sought. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Veteran was afforded a VA hematologic and lymphatic examination in February 2021. The examiner noted a diagnosis of iron deficiency anemia in 1991, with a date of onset of 1990. The examiner noted that the Veteran experienced anemia associated with her menometrorrhagia and she was treated with iron supplements. The cause of the Veteran's anemia was noted as heavy menstrual periods. The Board notes that the file includes an October 1991 bloodwork result record that indicated low red blood cell count. Further, an October 1992 VA medical note indicates a history of anemia and that the Veteran was taking over the counter Geritol. The Board finds the hematologic and lymphatic examination to be highly probative on the issue of the onset of the Veteran's anemia and that the onset was, as stated therein, in 1990. Medical records indicate that the Veteran has not had a menstrual period since 2007 at which time she underwent spontaneous menopause. Her blood count was normal on in May 2008 and VA records from October 2009 stated that the anemia was resolved. Nonetheless, the requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As VA examiners have attributed the Veteran's anemia to her now service-connected gynecological disorder, including uterine fibroids and heavy menstrual bleeding, the Board finds that secondary service connection is also warranted for anemia. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Debra B. McLoughlin, 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.