BVA9504217 DOCKET NO. 92-24 778 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Fargo, North Dakota THE ISSUE Entitlement to service connection for a disability manifested by amenorrhea, to include a pituitary gland disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD P. A. Dowdell, Associate Counsel INTRODUCTION The veteran served on active duty from May 1984 to July 1988. This matter came before the Board of Veterans' Appeals (hereinafter the Board) on appeal from a June 1992 rating decision from the Fargo, North Dakota, Regional Office (RO). The RO denied service connection for a pituitary gland disorder on the basis that this disorder existed prior to service and was not "aggravated" by service. The veteran timely completed an appeal as to that issue. In October 1994, the Board of Veterans' Appeals requested an opinion from an independent medical expert. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in essence, that the RO committed error in denying a claim of entitlement to service connection for a pituitary gland disorder. The veteran asserts that she should be service connected for polycystic ovary syndrome because despite the presence of irregular menses prior to service, she was unaware the disability at issue existed until diagnosed in service. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claim for service connection for a disability manifested by amenorrhea, to include a pituitary gland disorder. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the agency of original jurisdiction. 2. A disability manifested by amenorrhea existed prior to service. 3. The preexisting disability manifested by amenorrhea did not undergo a pathological increase during the veteran's period of active service. CONCLUSION OF LAW A preexisting disability manifested by amenorrhea was not aggravated by active service. 38 U.S.C.A. §§ 1131, 1153, 5107 (West 1991); 38 C.F.R. § 3.306(a), (b) and (c) (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board notes that the veteran's claim is "well-grounded" within the meaning of 38 U.S.C.A. § 5107. That is, the Board finds that she has presented a claim which is plausible. The Board is also satisfied that all relevant facts have been properly developed. No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107. The veteran has appealed the denial of service connection for polycystic ovary syndrome. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury or disease in line of duty. 38 U.S.C.A. § 1131. A preexisting injury or disease will be considered to have been aggravated by active 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 that disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b). The specific finding requirement that an increase in disability is due to the natural progress of the condition will be met when the available evidence of a nature generally acceptable as competent shows that the increase in severity of a disease or injury or acceleration in progress was that normally to be expected by reason of inherent character of the condition, aside from an extraneous or contributing cause or influence peculiar to military service. Consideration will be given to the circumstances, conditions, and hardships of service. 38 C.F.R. § 3.306(c). 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 examination, acceptance, and enrollment, or if clear and unmistakable evidence demonstrates that the injury or the disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1111, 1137 (West 1991). In determining whether service connection is warranted for a disability, the VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet.App. 49 (1990). The service medical records reveal that at the time of examination for entrance into service in November 1983, the veteran denied a medical history of having been treated for a female disorder. However, she reported pertinent medical history of a change in menstrual pattern. She indicated that her last menstrual period began February 1, 1983 and lasted approximately five days with some blood. She reported that since February 1983 to the present, she had had menstrual cramping without blood on approximately two occasions. She expected her next menstrual period with blood at any time from December 1983 to February 1984. On the report of medical examination, the examiner noted that he was unable to perform the pelvic examination. The clinical evaluation of the pelvic was noted as "most probably okay." At an examination in November 1984, the veteran gave a medical history of irregular periods since menarche, and indicated that she usually had intervening periods of absent menses for 2 to 3 months. She had a normal pelvic examination at that time, and when examined in January 1986. A pap smear was negative in April 1986. In August 1987, the veteran was evaluated for amenorrhea. She reported complaints of having no menses yet. The veteran desired to start birth control pills to regulate her menses. The examiner's assessment was secondary amenorrhea and oligomenorrhea. Serum prolactin was prescribed, and she was to start birth control pills with her next menses. In September 1987, it was noted that she had achieved a normal prolactin value. An October 1987 treatment record noted that the veteran had an elevated prolactin level approximately in the 70's. It was also indicated that the veteran needed a CT scan of the sella turcica to rule out pituitary microadenoma. Medical records dated later that same month reported a finding of amenorrhea and that the CT scan was normal. There was no evidence of pituitary microadenoma. A February 1988 treatment record noted that the veteran's prolactin level was elevated with amenorrhea. The diagnostic impression was pituitary microadenoma. At the separation examination conducted in March 1988, the veteran reported no pertinent history of being treated for a female disorder or having had a change in menstrual pattern. However, she indicated she had been on medication to regulate her menstrual flow since January 1988. Physical examination produced no pertinent abnormal clinical findings, and a relevant diagnosis was not provided. The report of the Medical Board examination performed in March 1988 noted that in November 1987 the veteran's pap smear had been normal. A treatment record dated in March 1988 after the separation examination demonstrated that the veteran was evaluated due to complaints of irregular menses. The CT scan was noted as normal and the prolactin level was elevated. The diagnosis was amenorrhea for two months. A subsequent treatment record dated later that same month reveals a diagnosis of microadenoma of the pituitary. A June 1988 treatment record showed a diagnosis of prolactinemia. At the initial post service VA examination conducted in September 1988, the veteran reported to the examiner a medical history of irregular periods since menarche. She also stated that she was started on medication in October 1987 because of elevated prolactin levels. The examiner was unable to do a pelvic examination due to the lack of a speculum. The examiner's diagnostic impression was history of amenorrhea with elevated prolactin levels. A VA outpatient treatment record dated in October 1988 demonstrates the veteran was seen for evaluation of Bromocriptine therapy of approximately one year's duration. The veteran denied symptoms of galactorrhea, pregnancy, lethargy, temperature intolerance, muscular aches, peripheral vision loss, or renal or liver disease. The examiner's diagnostic impression was amenorrhea. A VA outpatient treatment record dated in December 1988 reveals the veteran was seen for complaints of dizziness, lightheadedness and fainting spells. She reported that she had had her last period in November 1988. The diagnosis was dizziness secondary to Bromocriptine. A VA outpatient treatment record dated in June 1989 notes the veteran was on Bromocriptine for about one year but stopped due to fainting spells. The veteran indicated that her last menstruation was in November 1988 and that since that time she had had a slight amount of spotting approximately every two months. The diagnosis was hyperprolactinemia. A treatment record dated in November 1989 reveals the veteran denied symptomatology of galactorrhea, menses, headaches, and blurred vision. The diagnosis was amenorrhea. A VA outpatient treatment record dated in May 1990 showed the veteran reported a history of having had three periods during the months dated from November 1989 to April 1990. She denied symptoms of galactorrhea, headaches or blurred vision. The examiner's assessment was prolactinoma. It was noted that menses were irregular, but improved. A VA outpatient treatment record dated in November 1990 notes the veteran reported that she had no period since her last evaluation in May 1990. The veteran was currently on no medication. The last prolactin level was less than two in November 1989 and May 1990. The examiner's diagnostic impression was stable prolactinoma and hirsutism with amenorrhea. A VA outpatient treatment record dated in October 1991 notes that the veteran was generally doing well. The veteran reported that her periods had been regular for the past one year. A VA outpatient treatment record dated in December 1991 notes that the veteran had regular monthly menstrual periods. Her last period was dated December 11 to December 15, 1991. Currently, the veteran was taking Spironolactone. She reported that she was not experiencing headaches, visual problems or nausea. Her last prolactin level was noted to be good. The examiner's diagnostic impression was that the veteran was doing well. The veteran was provided a VA examination in May 1992 for evaluation of hyperprolactinemia with amenorrhea. She reported a medical history of experiencing menarche at age 17 with subsequent irregular menses without moliminol symptoms. She indicated that she consulted an Air Force physician for evaluation of irregular menses in August 1987. She reported that, during that evaluation, a prolactin count was found to be 71, substantially above the normal limit of 20. A CAT scan obtained in October 1987 was reportedly normal. The veteran stated that she was placed on a low dose of Parlodel, but that she experienced severe dizzy spells associated with the use of that medication and discontinued it after a few weeks. She indicated that the prolactin was normalized on that medication. The veteran reported that after taking the Parlodel (despite normalization of the prolactin) her periods did not become normal. She reported that she was seen at the Fargo VA Medical Center with complaints of dizziness in October 1988. The veteran reported that the prolactin at that evaluation was normal. She indicated that subsequent to discontinuation of the Parlodel that all prolactins have been normal. At the time of this evaluation, the veteran denied hirsutism or other physical complaints. Because of the irregular menses, the veteran reported that she was placed on Spironolactone which had regularized her menses and all these menses were reported to be currently associated with moliminol symptoms. The veteran denied irregular menses or galactorrhea and was characterized as asymptomatic regarding prolactin excess. It was noted that the veteran had never taken drugs associated with prolactin elevation. The examiner found no objective finding referable to hyperprolactinemia. In addition, it was noted that the CAT scan repeat approximately one year after the initial one remained negative. The examiner commented that continuous medication would be required to regularize menses and should the veteran prove infertile once the veteran desires fertility, it may be necessary to use fertility drugs to induce ovulation. The recent prolactin and thyroid function tests were noted to have been normal. Assays of the androgen levels were noted to be normal. The examiner stated that the veteran had a history of substantial hyperprolactinemia associated with irregular menses. However, given the entire clinical picture, the examiner felt that the diagnosis was more compatible with polycystic ovarian syndrome rather than idiopathic hyperprolactinemia. The examiner commented that the evidence supporting polycystic ovarian syndrome would be the fact that the hyperprolactinemia had not recurred with discontinuance of the Parlodel and that the veteran's menses had regularized on an androgen blocker. Sworn testimony provided by the veteran at her personal hearing in November 1992 was essentially an elaboration of previously mentioned contentions. The veteran testified that she was unaware of any disease process at the time of her enlistment in May 1984. She referred to having irregular periods prior to enlistment, but thought that this was normal. She stated that she first learned of her condition after having a CT scan in service. This case was referred to an independent medical expert in October 1994. The following questions were posed: 1) Is the reported history of irregular menses prior to service pathognomonic of any disability, to include polycystic ovary syndrome, currently diagnosed? 2) Were the reported symptoms and clinical findings demonstrated in service pathognomonic of polycystic ovary syndrome? 3) Did any preexisting disability manifested by irregular menses undergo an increase in severity during service? In response, the Board received the following opinion dated in December 1994. After a careful review of the enclosed records, it is my opinion that the veteran has secondary amenorrhea with anovulation. Because the patient does not ovulate, she has [a] build-up of the endometrium from the estrogen that is produced by the ovary, and has bleeding every 2-3 months. There is no evidence that this patient has enlargement of the ovaries, or hirsutism that would be associated with polycystic ovary disease. Although not all patients demonstrate hirsutism, most of them do. Spironolactone has several actions; it is a derivative of progesterone and has progestin-like effects. It also blocks mineralocorticoid as well as androgen action. These are relatively weak effects of this medication. It is my opinion that the reason this patient has menstrual function with spironolactone is because of its progestin effect, not because it is blocking androgens. The patient does not have high levels of androgen. In answer to the three questions posed: 1) Is the reported history of irregular menses prior to service pathomnemonic [sic] of any disability, to include polycystic ovary syndrome, currently diagnosed? The answer is no. Irregular menses and amenorrhea occur with many disorders and is not pathomnemonic [sic] of polycystic ovary disease. 2) Were the reported symptoms and clinical findings demonstrated in service pathognomonic of polycystic ovary syndrome? Again the answer is no. The patient had amenorrhea prior to entering the service. This continued during her tour of duty. 3) Did any preexisting disability manifested by irregular menses undergo an increase in severity during service? Review of the records indicates that there was no worsening of her amenorrhea during service. While taking birth control pills she had one prolactin elevation. This was not repeated and subsequent prolactin levels on or off bromocriptine which would suppress prolactin, were normal. This makes it very unlikely that the patient had an underlying disorder or abnormality of secretion of prolactin. I find no evidence to confirm that this patient has polycystic ovary syndrome. In a response signed on February 6, 1995, the veteran indicated she had no further evidence or argument to submit. The Board finds that the medical evidence does not demonstrate that the veteran's preservice disability manifested by amenorrhea increased in severity during her period of active service. The record establishes that, at the time of the veteran's enlistment examination, she reported a pertinent medical history of irregular menses. In addition, the veteran reported at examination in November 1984 that she had had irregular menses since menarche. Further, the most recent VA endocrinology examination stated that the veteran's hyperprolactinemia was associated with irregular menses. The independent medical expert expressed in his opinion dated in December 1994 that there was no worsening of the veteran's amenorrhea during service. He also reported that he found no evidence to confirm that the veteran had polycystic ovary syndrome. The evidence clearly shows that the veteran's preservice disability manifested by amenorrhea did not undergo a pathological increase during service. Although the service medical records reveal that the veteran received treatment for the purposes of attempting to regulate her menses, this was essentially the same level of impairment which existed prior to the veteran's period of active service, and a continuation of her earlier problems. Clearly, the opinion by the independent medical expert is more credible as that opinion was based on a review of the entire record and contains reasons for the conclusions reached. In summary, the evidence of record fails to indicate that the veteran's preservice disability manifested by amenorrhea was aggravated beyond normal and expected progression. Based upon these findings and following a full review of the record, the Board concludes that the veteran's amenorrhea preexisted service and was not aggravated by active service. The preponderance of the evidence is against the claim, and service connection for a disability manifested by amenorrhea, to include a pituitary gland disorder, is not warranted. 38 U.S.C.A. § 5107. ORDER Service connection for a disability manifested by amenorrhea, to include a pituitary gland disorder, is denied. U. R. POWELL The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.