Citation Nr: 21042201 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 14-07 302A DATE: July 12, 2021 ORDER Service connection for a gynecological disorder is denied. FINDING OF FACT The gynecological disorder of a right ovarian cyst is not shown to be causally or etiologically related to any disease, injury, or incident during service, and clear and unmistakable evidence establishes that the Veteran's endometriosis, manifested by dysmenorrhea, preexisted service and was not aggravated beyond its natural progression therein. CONCLUSION OF LAW The criteria for service connection for a gynecological disorder have not been met. 38 U.S.C. §§ 1110, 1111, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 2001 to April 2005. This matter comes to 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 (RO). In April 2017, the Veteran and her mother testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In May 2018 and September 2020, the Board remanded the instant claim for additional development and it now returns for further appellate review. Entitlement to service connection for a gynecological disorder, to include a right ovarian cyst, dysmenorrhea, and endometriosis. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Therefore, where there is evidence showing that a disorder manifested or was incurred in service, and this disorder is not noted on the veteran's entrance examination report, this presumption of soundness operates to shield the veteran from any finding that the unnoted disease or injury preexisted service. Gilbert v. Shinseki, 26 Vet. App. 48 (2012); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991); 38 C.F.R. § 3.304 (b). Such presumption is only rebutted where the evidence clearly and unmistakably shows that the veteran's disability (1) existed before acceptance and enrollment into service and (2) was not aggravated by service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby, 1 Vet. App. at 227; VAOPGCPREC 3-2003 (July 16, 2003). The two parts of this rebuttal standard are referred to as the "preexistence prong" and the "aggravation prong." Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). To satisfy this second-prong requirement for rebutting the presumption of soundness, the government must show by clear and unmistakable evidence either that there was no increase in disability during service or that any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845, 847 (Fed. Cir. 2006). Under 38 U.S.C. § 1153, a preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. The occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a). Evidence of the veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). If the disorder becomes worse during service and then improves due to in-service treatment to the point that it was no more disabling than it was at entrance into service, the disorder has not been aggravated by service. Verdon v. Brown, 8 Vet. App. 529 (1996). As an initial matter, the Board notes that relating a current gynecological disorder to symptoms experienced during service is a complex matter, requiring related medical expertise. As the Veteran has no known or reported medical expertise, her own lay assertions regarding causation cannot serve to substantiate her claim, and probative medical evidence is required to decide her claim. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (holding that a lay person is not considered competent to testify regarding medically complex issues). As such, the Board will set forth this medical evidence and assess its probative value herein. As referenced above, the Veteran served on active duty from April 2001 to April 2005, and while she did not undergo a pelvic examination in conjunction with her February 2001 induction medical examination, she reported a history of "bad cramps" and a related hospitalization at age 18 (i.e.,, in approximately 2000). During her subsequent four years of active service, the Veteran sought treatment on numerous occasions for continued severe menstrual cramps, assessed as dysmenorrhea without a noted underlying etiology, as documented in service treatment records from May 2001 (at which time she clarified that her pre-service hospitalization for menstrual cramping was in January 2001), July 2001, January 2002, May 2002, and October 2002. The Veteran was prescribed birth control medication in February 2002 and, while her symptoms initially persisted, after some adjustments to the type and dosage of her medication, such apparently subsided or at least decreased in severity, as no subsequent related complaints were documented in service treatment records dated after October 2002. Prior to her discharge from service in April 2005, the Veteran underwent a VA medical examination in March 2005, at which time she reported her history of experiencing menstrual cramps during service, which had been treated with various forms of birth control medications, but nonetheless persisted. The Veteran also reported being informed that she might have endometriosis (a gynecological disorder which is only diagnosed surgically). The examiner diagnosed dysmenorrhea. In an August 2007 private diagnostic laparoscopic surgical report, the Veteran was diagnosed with pelvic pain and endometriosis. September 2010 private treatment records reflect a diagnosis of a right ovarian cyst in June 2010 after seeking emergent treatment for related pain, and a September 2010 operative report notes diagnoses of both endometriosis and a right ovarian cyst. In August 2019, the Veteran underwent a VA gynecological examination, at which time her diagnoses of dysmenorrhea, endometriosis, and a right ovarian cyst were confirmed. In an accompanying medical opinion, the VA examiner stated that the Veteran's right ovarian cyst, initially diagnosed in 2010, was unrelated to service, as the record failed to indicate that such disorder, detected approximately five years after service, had its initial onset during service. Indeed, the Board finds that this medical opinion is consistent with the Veteran's medical history, which reflects that the ovarian cyst was initially detected in June 2010 when she was experiencing symptoms and received emergent care related to the acute onset of this condition, and which fails to reflect any findings of an ovarian cyst on a December 2006 ultrasound or during an August 2007 laparoscopic surgery. As such, the Board finds that the examiner's opinion that this ovarian cyst, first detected several years after service, is unrelated to service, to be supported by the record, as well as unequivocally stated and supported by a cogent rationale. As such, the Board finds that this August 2019 VA medical opinion regarding the etiology of the Veteran's right ovarian cyst should be accorded great probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Further, there is no medical opinion to the contrary. However, as set forth when remanding this claim in September 2020, the Board found that the August 2019 VA medical opinions regarding the etiology of the Veteran's dysmenorrhea and endometriosis are legally inadequate, as they failed to adequately address the evidence of record indicating that her dysmenorrhea, and perhaps endometriosis (a disorder manifested by dysmenorrhea), preexisted service. As such, a new medical opinion was obtained in December 2020, which applies the appropriate legal standard. In this regard, after review of the record, the VA examiner (who conducted a contemporaneous VA examination) opined that the Veteran's endometriosis clearly and unmistakably preexisted her service and was not aggravated beyond its normal progression therein. Specifically, he found that the Veteran's reported pre-service significant dysmenorrhea on entrance to service established that her endometriosis, a disease most tellingly manifested by significant dysmenorrhea, also preexisted service. Further, while the Veteran continued to experience significant dysmenorrhea during service, these symptoms represent a continuation of the disease per its natural progression and not an aggravation of them. The Board finds this medical opinion is consistent with the medical evidence of record, which reflects that the Veteran experienced menstrual cramps of sufficient severity to warrant hospitalization prior to service and, while she continued to report experiencing significant menstrual cramps during service, none were of sufficient severity to warrant in-patient treatment, thereby failing to suggest that her in-service symptoms were worse than those she experienced prior to service. Further, the medical opinion employs the correct legal standard, is unequivocally stated, and supported by a cogent rationale. As such, the Board affords this December 2020 medical opinion concluding that the Veteran's endometriosis, which was manifested by dysmenorrhea prior to and during service, clearly and unmistakably preexisted service and was not aggravated beyond its natural progression during service, great probative value. Id. Notably, there is no medical opinion to the contrary. In this regard, the Board notes that, in her May 2021 Appellant's Post-Remand Brief, the Veteran's representative cites medical literature indicating that women who participate in activities that require rigorous training (such as performing military service) may find their menstrual cycles interrupted, i.e., amenorrhea; however, as noted previously, the condition at issue in the instant case is dysmenorrhea, which existed prior to service. Thus, such medical literature and argument are irrelevant to the instant matter. In sum, the probative evidence of record establishes that the Veteran's right ovarian cyst is unrelated to service and her endometriosis, manifested by dysmenorrhea, clearly and unmistakably preexisted service and was not aggravated therein. As such, service connection for a gynecological disorder is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for service connection for a gynecological disorder. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Northcutt, 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.