Citation Nr: 22014134 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 19-01 024 DATE: March 11, 2022 ORDER Entitlement to service connection for dizziness, as caused by service-connected left ear hearing loss, is granted. REMANDED Entitlement to service connection for a sleep disorder, to include obstructive sleep apnea (OSA), is remanded. Entitlement to service connection for a joint pain condition, joint arthritis, is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a sinus condition is remanded. Entitlement to service connection for residuals of uterine fibroids is remanded. Entitlement to service connection for a total hysterectomy due to uterine fibroids is remanded. Entitlement to service connection for depression, secondary to pain and fibroids/hysterectomy, is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, her symptoms of dizziness/lightheadedness are caused by her service-connected left ear hearing loss. CONCLUSION OF LAW The criteria for entitlement to service connection for dizziness, as caused by the service-connected left ear hearing loss, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the U.S. Navy from November 1983 to June 1989. The record also indicates that she has additional periods of active duty training (ACDUTRA). This matter comes on appeal before the Board of Veterans' Appeals (Board) from May 2013 (joint pain, low back, dizziness/balance, sinus, fibroids, hysterectomy, depression) and May 2018 (sleep disorder) rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2022, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the claims file. The Board notes that during the hearing, the Veteran testified that the name she used in service/the name on her DD Form 214 (Glenda) is not the name on her birth certificate (Linda). She requested that her name be changed to Linda R. Williams for VA purposes. The electronic record does not currently contain a copy of her birth certificate. As such, the Board has left the name Glenda Davis as the official name on this decision, but noted her additional "also known as" names to include the names discussed during the hearing. The Veteran is encouraged to provide a birth certificate showing her alternative ("correct") name. 1. Entitlement to service connection for dizziness, as caused by service-connected left ear hearing loss, is granted. During her January 2022 Board hearing, the Veteran reported that she was initially informed that her balance problems were likely due to high blood pressure or diabetes. However, after treatment she continued to have symptoms of lightheadedness that impacted her balance. She testified that it was possible her lightheadedness was due to "all the medication" but that "no one knows." She stated that her lightheadedness began in service, but that she did not seek treatment in service. The VLJ asked if anyone had ever associated her lightheadedness or balance with her hearing loss, and she said she "may have heard that once." The Board will consider the Veteran's contentions to include direct service connection (her dizziness began in service) and secondary service connection (her dizziness is caused by one of her other medical conditions). Service treatment records include several instances of her denying dizziness on forms for dental work, including in January 1990, October 1992, July 1993, and December 1994. She also denied dizziness was a problem on forms seeking birth control medication in 1984, 1986, 1987, and 1988. A November 1986 treatment record included the Veteran's complaint of stomach pain and dizziness for the past month. She noted that her prior period only lasted one day. A pregnancy test was negative; she was diagnosed with gastroenteritis. A July 21, 2008, VA primary care record included the Veteran's report of experiencing some lightheadedness/dizziness since the day before. She was being treated for heavy bleeding and anemia at the time. She also reported that the dizziness was relieved by lying down. A May 14, 2013, nursing progress note included the form question: "is patient on four or more antihypertensives, pain medications, or sedative hypnotics?" The answer was yes. The follow-up form question was if she had any symptoms associated with these medications, and she reported her medications made her dizzy and lightheaded. An April 24, 2014, VA cardiology clinic note included that the Veteran used a cane for ambulation due to "dizzy episodes she had without any orthostatic changes." Regarding her "chronic dizziness," she was referred to her primary care physician for further evaluation. In June 2017, the Veteran participated in a VA ear conditions examination in conjunction with her claim for dizziness. The examiner commented that there was "no record of her being treated for dizziness." She had diagnoses of chronic nonsuppurative otitis media and Eustachian tube dysfunction. In the "medical history" section it was noted that the Veteran reported the onset of dizziness symptoms in 1984. "She was a bus driver and as she stepped down from the school bus, she got dizzy and fell. She felt a spinning sensation. The condition had worsened over time." She reported vertigo more than once per week, lasting up to 24 hours. She did not have a benign neoplasm of the ear that caused any impairment or function. Her left tympanic membrane was retracted with middle ear fluid. On tympanometry exam, her left ear was a type C, showing evidence of negative middle ear pressure. She had obstructive sleep apnea (OSA) and had been using a CPAP machine for 8 years. She was also noted to have hearing loss. Her Romberg test was abnormal or positive for unsteadiness. Her Dix-Hallpike test for vertigo was normal. Her limb coordination test was normal. In the remarks section, the examiner wrote "she has Eustachian tube dysfunction with otitis media in the left ear which should be addressed by ENT and treated." The examiner noted that, "for the claimed condition of disability causing symptoms of dizziness, there is no diagnosis because there is no pathology to render a diagnosis." In the opinion section, the examiner again noted that there were no records present pertaining to dizziness/vertigo, and she had not been given any work-up or treatment for her dizziness. However, she reported a history of dizziness in her medical history. The examiner gave a positive opinion, noting that the Veteran had a history of "hearing loss related to military noise exposure," and that "noise trauma to the inner ear can also result in dizziness." Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current dizziness is proximately due to her service-connected left ear hearing loss. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for dizziness associated with hearing loss is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND Initially, the Board notes that the Veteran has periods of ACDUTRA and INACDUTRA, and she has testified of symptoms related to her fibroids, joint pain, back pain, and (by association) depression occurring during periods of ACDUTRA. Although the record contains a service treatment record from February/March 1993 wherein she was taken by ambulance to "Carswell AFB" due to the onset of back and right lower quadrant pain, the record does not contain the dates of her ACDUTRA service. On remand, those records must be obtained. Additionally, as the Veteran has also reported injury to her left ankle joint in-service while driving a school bus, but this record is not contained in the currently available service treatment records, the RO should also attempt to obtain any additional treatment records from the Veteran's National Guard/Reserve service. The Veteran has reported VA treatment from as early as 1992. Current VA treatment records only date back to 2008. An attempt should be made to locate and obtain any VA treatment records prior to 2008. Any negative responses must be added to the electronic record. 1. Entitlement to service connection for a sleep disorder, to include obstructive sleep apnea (OSA), is remanded. Regarding her claim for service connection for a sleep disorder, the Veteran testified that her OSA symptoms began in service. She also argued that her schedule in service, which she referred to as "2-2-2 and 80 shift" resulted in disordered sleep. She described this shift work as "coming in for a day shift, and coming back the same day for another shift." The following day she would get the morning off, but have to come in for a shift at night. The third day she would get the morning off, but 8 hours later she had to work a swing shift. She had 80 hours off, but had to do training and other service "stuff" during the time "off." She was unable to regulate her sleep. She also testified that her roommates in service complained about her snoring in service, and that it sounded like she stopped breathing in her sleep. She stated she was diagnosed with sleep apnea approximately 10 to 15 years ago, she was unsure of the year diagnosed. A July 22, 2008, VA History and Physical for a chief complaint of menorrhagia included the Veteran's report of feeling "depressed and sleeping pills help her sleep." A December 1, 2008, VA rheumatology included the Veteran's complaint of a "long history of loud snoring, excessive daytime fatigue, and witnessed apneic episodes." A February 6, 2009, VA record included the conclusion that there was "no evidence of OSA" based on home sleep monitoring. An April 13, 2009, addendum included the physician's review of a sleep screening study and the determination that it showed "minimal" sleep apnea; "however, sleep hypoventilation is significant." The Veteran has not been afforded a VA examination to determine the etiology of her OSA, or to determine if she has any other disordered sleeping associated with her shift work in service. Given that the record shows she has a current diagnosis of OSA, and her ongoing records include complaints of sleep symptoms, as well as her testimony regarding her in-service shift work, and the complaints of her roommates regarding her snoring, an examination is warranted. On remand, she must be afforded a VA examination. 2. Entitlement to service connection for a joint pain condition, joint arthritis, is remanded. During her Board hearing, the Veteran testified that she developed symptoms of joint pain/arthritis in her hands, fingers, wrists, and ankle in service. She noted her left ankle had the greatest pain. She argued that she developed her arthritis as a result of performing the physical training required by service. She also stated she did not enter service with any joint pain. A November 14, 2008, VA treatment record included the Veteran's complaint of swelling in both hands and joint pain. She had "multiple complaints." On examination, she did not have any swollen joints in her hands or feet, and no erythema. Her grip strength was normal. X-rays were ordered to rule-out arthritis. A December 2008 VA rheumatology record included the Veteran's complaint of "bilateral hand and foot pain and stiffness for 15 years while on active duty with the Navy." She stated she never sought medical treatment and managed with over-the-counter analgesics. Her symptoms were intermittent and not severe. However, symptoms became more severe about 1 week following her hysterectomy on 8/22/08. Since that time, she had at least 1 hour of morning stiffness in her hands and feet and "aching" in all the joints in her hands and forefeet. She denied symptoms in her toes, wrists, elbows, shoulders, or knees. She had chronic left ankle pain due to a remote injury. She was assessed with acute on chronic poly arthralgias, no clinical, serological, or radiological evidence of inflammatory arthropathy at this time. She had "very mildly elevated" CRP which "may cause arthralgias if untreated." Degenerative calcaneal spurring left ankle. She had bilateral pes planus which "may be contributing to mechanical forefoot pain." She was also assessed with depression, "likely contributing to chronic pain and may have been exacerbated following hysterectomy." An addendum included that the Veteran complained of a mild pain and stiffness in her hands and feet since the early 1990s (15 years prior), which increased since her hysterectomy in 2008. On examination, she had no swollen or tender joints. She had mild tenderness at insertion of left Achilles' tendon, mild pes planus. She was assessed with arthralgia without evidence of inflammatory arthropathy. A February 24, 2009, addendum noted that her RF factor was negative, and she had no joint swelling in December 2008. The Veteran's service treatment records do not contain any complaints of specific joint pain in her hands or ankles. However, her May 1989 separation medical history included complaint of cramps in her legs. The handwriting is difficulty but noted that her "legs fall asleep" for the past two months. Following discharge from active service, the Veteran continued to have ACDUTRA and INACDUTRA periods. The record contains a report from her that she was a bus driver in service and that she stopped down from a school bus, had an episode of dizziness, and injured her left ankle. Currently, the record does not contain any ACDUTRA, or private records related to this left ankle injury. The Board will remand in an attempt to obtain any outstanding service treatment records, and will request that the Veteran provide releases for any private treatment records not currently contained in the claims file. The Veteran has not been afforded a VA examination regarding her joint pain/arthritis claims. As she has argued her current joint pain began in service, and is associated with her physical training in service, a VA examination with etiology opinions must be afforded on remand. 3. Entitlement to service connection for a low back disability is remanded. During her Board hearing, the Veteran testified that she injured her back in service as a result of her physical training. She stated that the push-ups and sit-ups in the service resulted in her back condition. She stated that physical training always seems to fall during her period, and that she had problems with her stomach at the same time. During her runs, the pain from her stomach would "shoot" to her sides and back. She stated that she later found out that she had arthritis in the low back. Her representative noted that service treatment records included a notation of back pain during a run in 1993. She stated that her condition worsened from that date. She was unable to continue the physical training and she had to "give up [her] career" because "it became very painful." She was not receiving treatment for her back, but was on arthritis medication as medical professionals felt her back pain was due to arthritis. A July 21, 2008, VA History and Physical for menorrhagia and anemia included that the Veteran had pain in both lower quadrants and radiated to her back. She reported "joint stiffness and mild pain during menses." She was not assessed with any diagnosis related to her spine. A December 1, 2008, VA rheumatology record included the Veteran's report of chronic stable low back pain without radiculopathy. She was noted to have a prescription for Tramadol, but she had not used it yet. She was assessed with "polyarthralgias." A November 24, 2009, VA primary care record included the Veteran's complaint of back pain. She was seen in the emergency room and received an injection of Toradol. On examination, her back was tender on palpation of the left lower back. She was assessed simply with "back pain." Service treatment records include a March 14, 1993, record that the Veteran was taken by ambulance to the hospital due to abdominal pain following a run. She had pain and cramping during her physical training run, "no more than usual," but she was pushing to finish the run when she had the onset of back pain and right lower quadrant pain that was sharp, stabbing, and constant. She was 7 months post c-section with a history of uterine fibroids. She was on her period at the time of the note. She was assessed with an "acute overuse injury." She had moderate tissue tenderness of the lumbosacral region, with improvement in pain with Toradol. A statement in the record, dated February 14, 1993 (it is unclear if the incident occurred on the March or February date), noted that the Veteran was on her 13th of 19 laps of her timed physical training run when she sat down and developed pain in her side and back. The paramedics noted that the Veteran 'seemed fine now," but she was taken to Carswell AFB for observation. The Veteran has not been afforded a VA examination in connection with her back claim. As the Veteran had a complaint of back pain during, what appears to be, ACUDTRA service and she has additional post-service treatment and complaints regarding her low back. On remand, she must be afforded a VA examination. 4. Entitlement to service connection for a sinus condition is remanded. The Veteran testified that she felt her sinus condition began in service, and her representative noted she was treated for allergic rhinitis in December 1988. Her MOS was as a cryptologist, and she stated that "90 percent of the time, [they] had to clean out the bottom of the incinerators because [they] had destroy material." They did not wear masks for this task, and would have all the soot go up their noses. She felt that this then went to her "lungs" and she started getting sinus infections. She thought she had a cold at first, but went to "quick care" and was told she had an "upper respiratory sinus infection." She did not have sinus surgery. She had a "daily ritual" of using nose spray, and she had a diagnosis of asthma with an albuterol in case of an emergency. Post service treatment records included records from Dr. T.E.K. Family Medical Clinic began in November 2006. On November 1, 2006, she was assessed with acute sinusitis with complaints of cough, scratchy throat, nasal drainage/congestion. A November 19, 2007, record also had an assessment of sinusitis. An April 8, 2012, WK Urgent Care Center record included a chief complaint of sinus congestion. ENT medical history included "seasonal allergies." She was diagnosed with pneumonia. The Veteran participated in a Disability Benefits Questionnaire in June 2017. She was diagnosed with allergic rhinitis, but not sinusitis. She reported the onset of allergic rhinitis symptoms in the mid-1980s when working an incinerator detail. She also noted that the condition worsened with time. She reported she "began to get frequent sinus infections following allergy exacerbations." The examiner reviewed the Veteran's treatment records, and noted that she did not complaint of sinus/rhinitis symptoms at separation in 1989. She was treated for pharyngitis in May 1986 and August 1986. She was treated for cold symptoms in December 1988, with a diagnosis of allergic rhinitis. VA treatment records showed she was currently using medication to control her allergy symptoms. The examiner provided a negative nexus opinion, stating that the Veteran's service treatment records included only one visit, in December 1988, where she was diagnosed with allergic rhinitis. The examiner noted that, with 13 years of experience, if she truly had allergic rhinitis at that time, she would have been seen more than just that one visit. Her visits for pharyngitis were unrelated. "Additionally, December is an odd time for allergy symptoms, unless your main allergens are dust and mold." He noted that a logical step in caring for a patient with allergy symptoms would be allergy testing; however, the Veteran did not have allergy testing to confirm her diagnosis. "There is simply no documentation, in [her service treatment records] to support a chronic or debilitating problem with allergic rhinitis...no nexus can be established." Provided an opinion that it was less likely than not that her current allergic rhinitis began during service. The Board notes that the nexus opinion provided by the examiner did not address the Veteran's contentions that her symptoms were associated with her exposure to incineration materials in service. On remand, the Veteran should be afforded an additional examination with opinion. 5. Entitlement to service connection for residuals of uterine fibroids is remanded. 6. Entitlement to service connection for a total hysterectomy due to uterine fibroids is remanded. The Veteran contends that she developed fibroids in service, but that they were not discovered until after her separation. During her Board hearing, she stated that a private gynecologist, Dr. Sills, in 1989. She was taken off of her in-service birth control, and she developed increased problems with her cycle. Dr. S. did an ultrasound and found her fibroids. She testified that while she was pregnant with her son in 1992 that her fibroids continued to be an issue. She stated she had surgery to remove her fibroids. Although she had her fibroids removed, she eventually had to have a hysterectomy due to the fibroids. The Veteran discussed her ongoing symptoms of pain and cramping while participating in physical training. It is unclear from the testimony whether these symptoms were present during her period of active duty service, or if these symptoms occurred during periods of ACDUTRA or INACDUTRA. Service treatment records included a March 1984 form that the Veteran completed related to her periods. The form is undated, but the Veteran listed her age as 18. Her period usually lasted 4 days, and occurred once per month. She did not spot between periods. She endorsed swelling of her abdomen during her periods, but denied severe cramps, breast swelling, and feet swelling with periods. On April 23, 1984, the Veteran sought treatment for menstrual cramps for the past 24 hours. Her cramps occurred "infrequently," and she had no vaginal discharge, no fever, and no dizziness. She was assessed with dysmenorrhea. She was given motrin. A handwritten note by a physician includes something about "menstrual cramps," but the handwriting is too difficult to read. An April 17, 1986, record for a routine PAP smear included the Veteran's report that her last menses was "kind of rough." She had been off of birth control pills for more than one month. She stopped taking them because she felt she no longer needed them. She was "taking something given by mother to ease cramps." Her abdomen was soft without pathology noted. On examination, her corpus (main body of the uterus) was "mobile NSSCno tenderness on palpation." There were no masses noted and no tenderness of the adnexa. Her pelvic examination was within normal limits. A May 1986 family practice clinic included that her last period in April only lasted 3 days. On the question of if she had "significant pain with [her] periods," she responded: "stomach cramps." She did not have vaginal bleeding or spotting between periods, she did not have bleeding or pain with sexual intercourse. An October 1988 Mayport Family Practice noted that the Veteran's pelvic exam, including cervix, uterus, and adnexa were all within normal limits. As noted above, a March 1993 record showed that the Veteran had pain and cramping during a physical training run. She was 7 months post C-section with a history of uterine fibroids. VA treatment records from July 2008 included a report that she had fibroids removed 3 to 4 years ago (2004), which relieved symptoms, but they have progressively returned. She also had a C-section 16 years ago. She reported a history of fibroids since 1993. She was previously seeing Dr. M. at WK South. She had heavy bleeding beginning July 19, 2008, and sharp abdominal pains intermittently. She also reported intermittent problems with fibroids for years. She had a history of a D & C at age 15-16. She had anemia which required a transfusion. Her care was transferred to LSU. An August 14, 2008, LSU record included that her menstrual cycles generally occurred once a month and lasted 5 to 7 days; however, recently she was beginning to have more than one menstrual cycle per month. She was noted to have a history of open myomectomy. An August 22, 2008, LSU record noted that the Veteran was status-post abdominal hysterectomy, right salpingo-oophorectomy. The Veteran participated in a VA examination in June 2017. She was diagnosed with uterine leiomyoma and ovarian cyst. She had a total abdominal hysterectomy, with right salpingo-oophorectomy, for uterine fibroids. She reported that the date of the onset of symptoms was 1984, and the condition worsened to the point that surgery was required. She had a hysterectomy in "around 2007." The condition resolved after hysterectomy. Following examination and a review of the treatment records the examiner provided a negative nexus opinion. She had a well-documented history of Leiomyoma resulting in hysterectomy. She hypothesizes that the menstrual cramps and pelvic pain that occurred during her military service, were related to her later diagnosed leiomyomas. "While symptoms of Leiomyoma can consist of menstrual cramping, pelvic pain, these symptoms can be associated with a number of gynecological conditions. Any association with more than one gynecologic condition decreases the chance of probability to less than 50 percent making this hypothesis less likely than not." The examiner noted that the Veteran's menstrual cramping and pelvic pain in service were not of a level that was "alerting" to an in-service provider as imaging was not provided. There was "no testing of that nature can be located in the STRs. No nexus can be established." The examiner opined that the Veteran's Leiomyoma status post hysterectomy is less likely than not related to her in-service menstrual cramps and pelvic pain. On remand, an addendum opinion must be sought which addresses the Veteran's contention that fibroids that were discovered prior to 1992 would have been present or "in development" in 1989 when she was in service. The examiner also needs to address the 1993 treatment for abdominal cramps when running during her menses. 7. Entitlement to service connection for depression, secondary to pain and fibroids/hysterectomy, is remanded. The Veteran argues that she has developed depression as a result of her medical symptoms, including her fibroids and her hysterectomy. She felt that her depression was due to her feeling that she had been "medically neglected." Her VA treatment records included diagnosis of adjustment disorder due to hysterectomy and major depressive disorder. The Veteran's depression claim is intertwined with the claims on appeal. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). The matters are REMANDED for the following action: 1. Determine the Veteran's periods of ACDUTRA and INACDUTRA service. 2. Obtain any additional service treatment records from the Veteran's period of National Guard/Reserve service. 3. Obtain any VA treatment records prior to 2008 (the Veteran has indicated service as early as 1992). Any negative responses must be added to the electronic record. 4. Request that the Veteran provide a release for private treatment records from Dr. Montgomery at WK South regarding her gynecological treatment. 5. Request that the Veteran provide a release for private treatment records from Dr. Sills regarding her gynecological treatment. 6. Request that the Veteran provide information and a release for any private treatment records associated with her complaints of joint pain, to include her left ankle injury. 7. Request that the Veteran provide information and releases for treatment for her fibroids in the 1990s. A 1993 record indicated her fibroids were noted at the time of her son's birth in 1992. However, the record does not contain treatment records from this period. 8. Schedule the Veteran for a VA sleep disorder examination. Following a review of the record and examination of the Veteran, the following opinions must be provided: (a.) Is it at least as likely as not (50/50 probability or greater) that the Veteran's sleep apnea is due to or began during her military service? i. The examiner must address the Veteran's contention that her sleep apnea is due to her in-service shift work. ii. The examiner must address the Veteran's contention that her roommates in service complained of her snoring and witnessed apneic events. (b.) Is it at least as likely as not (50/50 probability or greater) that the Veteran's has a sleep disorder other than sleep apnea that is due to or began during her military service? A complete rationale must accompany each opinion expressed. 9. Schedule the Veteran for a VA arthritis examination. Following a review of the record and examination of the Veteran, the examiner must provide the following: (a.) Does the Veteran have a current diagnosis or diagnoses associated with her complaints of bilateral hand pain/swollen joints and bilateral feet symptoms? (b.) Is it at least as likely as not (50/50 probability or greater) that the Veteran's bilateral hand pain/symptoms/diagnosis is due to or began during service? The examiner should address the Veteran's belief that her joint symptoms are due to physical trainings in service. The examiner should address whether her hand symptoms are due to her in-service military occupational specialty. (c.) Is it at least as likely as not (50/50 probability or greater) that the Veteran's bilateral foot pain/symptoms/diagnosis is due to or began during service? The examiner should address the Veteran's belief that her joint symptoms are due to physical trainings in service. The examiner should question the Veteran about the time period when she injured her left ankle. (d.) Is it at least as likely as not (50/50 probability or greater) that the Veteran's joint pain/symptoms/diagnosis are due to her depression? A complete explanation must accompany each opinion expressed. 10. Schedule the Veteran for a VA spine examination. Following a review of the record and interview and examination of the Veteran, the examiner should provide the following opinions: Is it at least as likely as not (50/50 probability or greater) that the Veteran has a current low back disability that is due to her military service? The examiner must address her 1993 treatment for back pain following a physical therapy run, and her complaints of low back pain during push-ups, sit-ups, and during physical training while on her period. A complete explanation must accompany each opinion expressed. 11. Schedule the Veteran for a VA sinus examination to determine if she has a sinus or allergic rhinitis condition related to service. Following a review of her record, and interview and examination of the Veteran, the examiner should provide the following opinions: (a.) During the period on appeal (from a year prior to the claim date) has the Veteran been diagnosed with a sinus or allergic rhinitis condition? (b.) Is it at least as likely as not (50/50 probability or greater) that the Veteran's sinus/rhinitis symptoms are related to her military service? i. The examiner must address the Veteran's contentions that her sinus symptoms were due to working with an incinerator in service. ii. The examiner must address the Veteran's contentions that her symptoms began during service. A complete explanation must accompany each opinion expressed. 12. Return the 2017 examination to the examiner for an addendum opinion. Following a review of the record, the examiner should provide the following: (a.) Is it at least as likely as not (50/50 probability or greater) that her fibroids began in service? The examiner must address the following contentions: i. addresses the Veteran's contention that her fibroids that were discovered post-service (as early as 1992 according to available records) would have been present or "in development" in 1989 when she was in service. ii. address the 1993 treatment for abdominal cramps when running during her menses during ACDUTRA service. (Continued on the next page) A complete explanation must accompany each opinion expressed. 13. After completing the development requested above, readjudicate the Veteran's claims. If any of the benefits sought are not granted in full, the Veteran and his representative should be furnished a Supplemental Statement of the Case and given the opportunity to respond thereto. The case should then be returned to the Board, if otherwise in order. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. H. Stubbs, 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.