Citation Nr: 22019483 Decision Date: 04/01/22 Archive Date: 04/01/22 DOCKET NO. 16-00 800 DATE: April 1, 2022 REMANDED Entitlement to service connection for a gynecological condition is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1993 to May 1993, April 2002 to December 2002, February 2006 to September 2008, April 2010 to May 2010, and October 2011 to December 2011. Evidence affiliated with the claims file also indicates that the Veteran served in the Reserve from January 1993 to May 1993, April 2002 to December 2002, July 2003 to August 2003, June 2004, and February 2006 until her retirement in August 2013, including periods of active duty for training (ACDUTRA) from January 1993 to March 1993, October 2006 to September 2007, November 2011, and December 2011. This matter again comes before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Board previously remanded this matter in September 2018, December 2019, March 2021, and December 2021. Unfortunately, another remand is required in this case. The Board sincerely regrets the additional delay; however, further evidentiary development is necessary before the Veteran's claim can be adjudicated on the merits. As noted above, there is evidence of record indicating that the Veteran's military career consisted not only of periods of active duty service, but also service in the Reserve until her retirement in August 2013. See May 2021 Information Report (labeled Military Personnel Record). Although there are service treatment records and service personnel records associated with the claims file revealing the Veteran's education, performance, assignments, points, and awards, the precise dates of all periods of ACDUTRA and inactive duty for training (INACDUTRA) are not available. On remand, the RO should confirm the exact dates during which the Veteran served on ACDUTRA and INACDUTRA. As the Board is requesting these dates be verified, the Board also acknowledges the possibility and probability that the Veteran's treatment records during her Reserve service that have not already been obtained could reflect manifestations of symptomatology related to her gynecological condition(s). Thus, the Board also requests that any and all outstanding service treatment records related to the Veteran's Reserve service be obtained. After the Board issued the December 2021 remand, an addendum opinion was obtained regarding the nature and etiology of her diagnosed dysmenorrhea and menorrhagia. The examiner found that the Veteran's condition clearly and unmistakably existed prior to service but was not aggravated by her military service. However, the Board finds this opinion to be inadequate, because the examiner did not address the Veteran's in-service diagnoses of vaginitis candida albicans, atypical squamous cells of undetermined significance, epithelial cell abnormalities, and noted high risk human papillomavirus infection (HPV) DNA. See August 2006 Service Medical Records; September 2006 Service Medical Record with October 2006 Handwritten Note; April 2007 Service Medical Record; March 2008 Service Medical Record. The examiner also did not address that the Veteran underwent a colposcopy. See May 1997 Service Treatment Record. Furthermore, the Board notes that the Veteran reported in 2001 that her menstrual pattern had changed since taking depoprovera. See May 2001 Report of Medical History. However, the examiner did not address this report by the Veteran, even though she is competent to report her first-hand in-service experiences and the onset and continuity of her lay symptomatology. See Washington v. Nicholson, 19 Vet. App. 362 (2005); Layno v. Brown, 6 Vet. App. 465 (1994). Additionally, the examiner did not consider that the Veteran was prescribed a "metrogel" and reported a gynecological issue to her VA provider in March 2012 during her Reserve service and or that intermittent menorrhagia was diagnosed in December 2013, approximately four months after her retirement from the Reserve. See March 2012 VA History and Physical Examination; December 2013 VA OBGYN Consult. Therefore, the Board finds that an addendum opinion determining the nature and etiology of the Veteran's gynecological condition(s) be obtained on remand. The matters are REMANDED for the following action: 1. The RO should determine the specific dates of when the Veteran served on ACDUTRA and/or INACDUTRA. In this regards a report detailing the Veteran's award of Reserve retirement points will NOT represent compliance with this instruction. Rather, each and every date of active duty service, ACDUTRA, and INACDUTRA, must be verified. Then, issue a memorandum for inclusion in the claims file detailing each period of verified active military service, whether on active duty, ACDUTRA, or INADCUTRA. All outstanding medical treatment records associated with the Veteran's Reserve service should also be obtained. 2. Then, forward the claims file to an appropriate clinician who has not previously provided an opinion in this case to determine the nature and etiology of any and all gynecological condition(s) attributable to the Veteran throughout the period on appeal. If the clinician determines that a new examination (or telehealth interview, etc., if an in-person examination is not feasible) would be beneficial, one is to be provided. (a) The clinician should identify any and all gynecological condition(s) attributable to the Veteran throughout the period on appeal. (b) For each condition so identified, the clinician should opine as to whether it is at least as likely as not (probability of about 50 percent) that the Veteran's condition manifested during, or is the result of, her active duty service and/or ACDUTRA. (c) For each condition so identified, the clinician should opine as to whether there is clear and unmistakable (i.e., medically undebatable) evidence that the Veteran's condition existed prior to any periods of active duty service and/or ACDUTRA. (i) If the clinician answers in the affirmative, the clinician should opine as to whether there is clear and unmistakable (i.e., medically undebatable) evidence that (1) there was no increase in disability during active duty service and/or ACDUTRA or (2) any increase in disability was due to the natural progress of the pre-existing condition. In formulating his or her opinion(s) the clinician must consider and address the competent medical and lay evidence of record, including, but not limited to: (i) The Veteran's service treatment records, including but not limited to any and all gynecological examinations, her in-service diagnoses of secondary amenorrhea, vaginitis candida albicans, atypical squamous cells of undetermined significance, epithelial cell abnormalities, and noted high risk HPV DNA, and her May 2001 Report of Medical History indicating a change in her menstrual cycle while taking depoprovera; (ii) The Veteran's service personnel records indicating her exact periods of service on active duty and ACDUTRA; (iii) The Veteran's VA medical records, including but not limited to her March 2012 History and Physical Examination in which she reported gynecological issues and December 2013 OBGYN Consult diagnosing the Veteran with intermittent menorrhagia; and (iv) The Veteran's competent lay statements regarding her first-hand in-service experiences and the onset and continuity of her symptomatology. If the clinician determines that the Veteran's gynecological condition(s) is/are less likely than not caused and/or aggravated by her active duty service and/or ACDUTRA, the clinician should discuss what other factor(s) caused the disorder(s). In other words, the clinician should ascertain the most likely etiology of the Veteran's gynecological condition(s). (Continued on the next page) The clinician must provide a comprehensive report that includes a complete rationale for all opinions and conclusions reached. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Hoffman 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.