BVA9504248 DOCKET NO. 92-52 991 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for a retroverted uterus and menstrual irregularities. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Christopher P. Kissel, Associate Counsel INTRODUCTION The appellant served on active duty in the United States Army from April 18, 1990, to August 1, 1990. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 1991 rating decision of the Columbia, South Carolina, Department of Veterans Affairs Regional Office (VARO). The procedural history of this case has been thoroughly set forth in the Board's remand decision of September 25, 1992. In accordance with the Board's September 1992 remand, the requested development was accomplished, to the extent possible, and the case has been returned to the Board for further appellate review. With respect to the development of the record on appeal, it is the Board's opinion that VARO fulfilled its statutory duty to assist the appellant in developing the pertinent facts in this case; it appears that all VA and private medical records which are available have been associated with the claims file. See Dusek v. Derwinski, 2 Vet.App. 519 (1992). Accordingly, the Board will proceed to a disposition of the claim which is presently certified for appellate consideration. See Certification of Appeal, VA Form 1-8 (confirmed on May 12, 1994). CONTENTIONS OF APPELLANT ON APPEAL The appellant contends, in substance, that she was told for the first time in service by a physician that she had a retroverted uterus. She maintains that a menstrual disorder was incurred in service, manifested by pain and excessive uterine bleeding occurring at regular cycles, or in the alternative, that such disorder was aggravated 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(s). 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 a fair preponderance of the evidence is against the appellant's claim for entitlement to service connection for a retroverted uterus and menstrual irregularities. FINDINGS OF FACT 1. The appellant served on active duty in the U. S. Army from April to August 1990, at which time she received an uncharacterized separation from military service for failure to meet procurement medical fitness standards. 2. Service clinical records reflect treatment in June and July 1990 for complaints of menstrual cramps. The report dated in July 1990 reflects the appellant complained of menstrual problems and reported that this was not a new problem of recent onset. 3. In July 1990, the evaluating physician on a U. S. Army EPSBD concluded that the appellant had a history of recurrent episodes of amenorrhea, oligomenorrhea, menometrorrhagia and dysmenorrhea existing prior to service. Objective clinical findings on examination revealed a retroverted uterus. Diagnoses established by the EPSBD were amenorrhea, oligomenorrhea and dysmenorrhea, medically determined not to have been service aggravated. 4. On VA gynecological examination in November 1993, the appellant reported a history of dysmenorrhea and dyspareunia with her periods and occasional severe pain the two days preceding her periods, as well as pain during her periods with heavy bleeding; the medical impression included lower quadrant pain, dyspareunia, dysmenorrhea and menorrhagia with heavy periods; the diagnoses were endometriosis, or persistent ovarian cyst. 5. In December 1994, pursuant to the Board's request for a medical opinion from VHA, a physician who is an Assistant Professor of Obstetrics/Gynecology at the Medical College of Georgia, concluded that it was without a doubt and clearly documented that the appellant's menstrual irregularities and excessive menstrual bleeding existed prior to her military service and did not manifest any pathologic change during service. 6. The VHA medical opinion of December 1994 further reflects the physician's opinion that the appellant's retroverted uterus is not a pathological condition, disease, or gynecological abnormality. 7. The greater weight of the relevant and probative evidence of record does not establish a pathologic increase in the appellant's pre-existing menstrual irregularities during her brief period of military service. CONCLUSIONS OF LAW 1. A retroverted uterus is not a disease or injury within the meaning of applicable legislation providing VA disability compensation benefits. 38 C.F.R. §§ 3.303(c), 4.116 (1993). 2. Menstrual irregularities clearly and unmistakably pre-existed service, thereby rebutting the presumption of soundness, and were not aggravated by military service. 38 U.S.C.A. §§ 1101, 1131, 1137, 1153, 5107(b) (West 1991); 38 C.F.R. §§ 3.304, 3.306 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, the Board finds that the appellant has submitted evidence which is sufficient to justify a belief that her claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991) and Murphy v. Derwinski, 1 Vet.App. 78 (1990). Furthermore, the undersigned believes that this case has been adequately developed for appellate review purposes by the VA, and that a disposition on the merits is now in order. I. Factual Background The appellant served in the U. S. Army from April to August 1990. She received an uncharacterized separation from military service for failure to meet procurement medical fitness standards. In July 1990, an Entrance Physical Standards Board (EPSBD) offered a professional medical conclusion that the appellant had a history of recurrent menstrual irregularities existing prior to service, and based upon review of her medical records, the EPSBD found no evidence of in-service aggravation of those disorders. Objective clinical findings on EPSBD examination were significant for a retroverted uterus. She was diagnosed with three menstrual cycle bleeding disorders: amenorrhea, oligomenorrhea, and dysmenorrhea. Based on the EPSBD's findings, the appellant was recommended medically for uncharacterized separation from service. Her term of enlistment was only three months and fourteen days. Service entrance physical examination conducted in January 1990 was negative for a history of complaints, treatment, manifestations or diagnosis of a gynecological disorder or a history of a change in the appellant's menstrual pattern. Service clinical records reflects outpatient treatment on June 12, 1990, for the appellant's complaints of non-incapacitating menstrual cramps. She was diagnosed at that time with normal menstrual cramping and prescribed Motrin for her complaints. On June 14, 1990, she was issued a three months supply of birth control pills. Exactly one month later, on July 12, 1990, the appellant was seen as an outpatient complaining of menstrual cramps. Significantly, the treatment report notes a negative response to the query "[i]s this a new problem of recent onset." She was then referred to the OB/GYN clinic on July 13, 1990, for further evaluation of her condition. The report of that visit indicates that procedures were initiated to separate her from service for failure to meet medical procurement standards, as more fully described above and reflected in the findings of the EPSBD report of July 16, 1990. Evidence documenting medical treatment prior to the appellant's enlistment in the U. S. Army in April 1990 consisted of a hospital report from the Beaufort Memorial Hospital, Beaufort, SC, reflecting a period of hospitalization from July 5-6, 1987. That report details treatment primarily for a right pelvis fracture sustained by the appellant in a car accident. Additional clinical findings during her hospitalization revealed that she was three and one half months pregnant. Regarding her pregnancy, the discharge report indicates that she elected to abort the fetus. It was also noted that she had some microscopic hematuria with spontaneous urine voiding; however, following catheterization, her urine showed no gross blood. Discharge diagnoses were the same as those noted upon her admission: Fracture of the right superior and inferior pubic areas; microscopic hematuria; and, intra-uterine pregnancy. Additional medical records, obtained as a result of the Board's September 1992 remand, include private outpatient reports from E. Washington, M.D., dating from January through April 1992, which reflect treatment for skin rash, severe stomach pains and leg numbness. "Known Medical Problems" of anemia and a retroverted uterus were noted on a report dated January 28, 1992. The appellant's contentions of record, including her testimony elicited at a hearing held at VARO in September 1991, generally reflect her belief that her menstrual bleeding disorders became manifest following vigorous physical activity during basic and advanced infantry training during her military service in 1990. She testified at her hearing in September 1991 that she had no medical problems whatsoever related to her displaced uterus or any menstrual disorders prior to her military service. In connection with her claim for benefits, the appellant was examined on VA gynecological examination (VAX) in November 1993. The diagnoses established on the basis of the appellant's reported medical history and the results of examination were (1) endometriosis, scar tissue from pelvic inflammatory disease or, (2) persistent ovarian cyst. Medical history reported by the appellant was significant for regular, but occasionally irregular, menses every month lasting six to seven days with heavy flow. She reported dysmenorrhea and dyspareunia with her periods and occasional severe pain the two days preceding her periods, as well as pain during her periods with heavy bleeding. She reported no bleeding between periods. Clinical findings on physical examination of the external genitalia, vagina and cervix was normal except for a tender right ovary. The examiner noted the following impression: The patient is an otherwise healthy 23 year old black female with bilateral lower quadrant pain, dyspurnia [sic], dysmenorrhea and menorrhagia with heavy periods. There was no evidence of fibroids or other abnormalities on exam, however the patient does have marked uterine and right adnexal tenderness. In addition to the above, and pursuant to 38 C.F.R. § 20.901, the Board requested a medical opinion from the Chief Medical Director, Veterans Health Administration (VHA), to address the following question: The dispositive issue on appeal concerns the etiology of the appellant's gynecological abnormalities and menstrual irregularities relative to her brief period of military service. It is requested that his case be referred to an appropriate medical specialist for review of the entire claims file and an opinion addressing the true diagnosis and etiology of the veteran's retroverted uterus and menstrual irregularities. Please provide a formal opinion as to whether or not the veteran currently has any of the gynecological abnormalities as noted in service, and, if so, their approximate date of onset. The question of permanent worsening of those conditions in service must be also addressed, together with whether or not any of the gynecological abnormalities noted during and after service represent a developmental defect or a congenital malformation. Accordingly, in December 1994, the opinion of a physician associated with the VA Medical Center, Augusta, Georgia, who is presently an Assistant Professor of Obstetrics/Gynecology at the Medical College of Georgia, was made part of the record on appeal, and in January 1995 was made available to the appellant's representative for review and response prior to the preparation of this decision in accordance with the Board's notice and comment procedures. 38 C.F.R. § 20.903 (1993); see also Thurber v. Brown, 5 Vet.App. 119 (1993) and Chairman's Memorandum No. 01- 93-12 (May 28, 1993). After reviewing all of the evidence of record and thoroughly discussing the appellant's medical history relative to her retroverted uterus and associated menstrual bleeding disorders, the aforementioned physician stated, in pertinent part, the following opinion: In my opinion, the subject has no pathologic condition that first became apparent while on active military service. With respect to the nature and etiology of the appellant's condition, the physician offered the following commentary based on his review of the record in this case: Clearly, retroversion or retroflexion of the uterus within itself is not a pathological condition, disease, or gynecological abnormality. The uterus is not a fixed organ nor does it have a fixed 'normal' position. The position is variable within the general population and within the same individual at different times. Approximately 25% of the population has a retroverted uterus. In the records provided me I find statements concerning the patient's claim that she had a 'retroverted' uterus documented prior to military service. The first recorded exam documenting uterine position was on July 2, 1990. Exam at VAMC in Charleston, SC on November 4, 199[3] described the uterus as being retroflexed. It is without doubt and clearly documented, that the subject had menstrual irregularities and excessive menstrual bleeding prior to her military service. History obtained at VAMC in Charleston on November 4, 199[3] revealed that the subject's menstrual periods were regular for the most part, but heavy with menstrual cramping. II. Analysis The appellant is seeking service connection for a retroverted uterus and menstrual irregularities which she attributes to her military service experience. 38 U.S.C.A. § 1131 (West 1991). Service connection connotes many factors, but basically it means that the facts shown by the evidence establish that a particular injury or disease resulting in disability was incurred in service, or if pre-existing such service, was aggravated therein. 38 U.S.C.A. §§ 1101, 1131, 1153 (West 1991); 38 C.F.R. §§ 3.303, 3.306 (1993). A pre-existing disease or injury will be considered to have been aggravated by military service when there has been an increase in the disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 C.F.R. § 3.306(a) (1993). The "presumption of sound condition" upon entrance to military service is rebutted only by clear and unmistakable (obvious and manifest) evidence demonstrating that an injury or disease existed prior to service. 38 U.S.C.A. §§ 1111, 1137 (West 1991). Initially, with respect to the appellant's retroverted uterus, the Board notes that congenital or developmental defects or conditions are not considered to be diseases or injuries within the meaning of applicable legislation providing VA disability compensation benefits. 38 C.F.R. § 3.303(c), (1993). Congenital malformations involving natural menopause, amenorrhea (when based upon developmental defect or abnormality), and pregnancy and childbirth and their incidents, except surgical complications under certain circumstances, e.g., childbirth during active military service, are not ratable conditions. See 38 C.F.R. § 4.116 (1993). As clearly indicated by the December 1994 VHA medical opinion, the appellant's retroverted uterus is "... not a pathological condition, disease, or gynecological abnormality." The physician who authored that opinion further noted that the "... uterus is not a fixed organ nor does it have a fixed 'normal' position. The position is variable within the general population and within the same individual at different times. Approximately 25% of the population has a retroverted uterus." Taken as a whole, the medical evidence of record establishes that the appellant's menstrual bleeding irregularities, variously diagnosed in service as amenorrhea, oligomenorrhea, and dysmenorrhea, and diagnosed after service as dyspareunia, dysmenorrhea and menorrhagia, existed prior to service, and therefore, did not originate in service. As indicated above in the Factual Background, service clinical records reflect that in July 1990, the appellant reported a history of a menstrual bleeding problem that was not of recent onset. Although no specific dates of onset were provided by the appellant at that time, given her brief period of military service (three months in 1990), the Board believes that the evidence in this case clearly and unmistakably establishes that her menstrual bleeding irregularities predated her entrance to military service. The medical findings of the EPSBD made during service reflect a pre- existing condition. Moreover, the December 1994 medical opinion obtained by the Board from VHA supports this assessment as well. Following his review of the evidence of record, the physician who authored the aforementioned medical opinion specifically indicated that "[i]t is without doubt and clearly documented, that the subject had menstrual irregularities and excessive menstrual bleeding prior to her military service." There is no other competent evidence of record to show otherwise. Accordingly, entitlement to service connection for this condition on a direct incurrence basis is not warranted in this case. 38 C.F.R. § 3.303(c) (1993). The Board has carefully reviewed the evidence in order to determine whether service connection may be granted on the basis of aggravation of the pre-existing menstrual irregularities. As indicated above, service connection based on aggravation requires evidence of an increase in the underlying pathology of the disability during service. Notwithstanding the appellant's contentions to the contrary, the undersigned concludes that the weight of the evidence of record does not establish a reasonable probability of in-service aggravation. Although the appellant was treated on two (2) occasions in service for complaints referable to a menstrual cramping/bleeding problem, there is no evidence whatsoever of pathologic increase in severity of that condition during her brief period of military service. Indeed, the VHA's physician specifically noted that "[i]n my opinion, the subject has no pathologic condition that first became apparent while on active military service." (Emphasis added by the VHA physician). The appellant's contentions of record are of insufficient probative value so as to be dispositive of the issue presented on appeal. See Espiritu v. Derwinski, 2 Vet.App. 492 (1992) (holding that the Board is not required to entertain unsupported lay speculation on medical issues). Moreover, the Board notes that the usual effects of medical treatment provided in service, which includes pain relief medication therapy, in this case, Motrin, will not establish a basis for service connection unless the underlying disease or injury was otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1) (1993). Based on the foregoing, the Board believes that service connection for the claimed disability should be denied. The fair preponderance of the evidence found probative to the issue weighs clearly and convincingly against a grant of the benefits sought; the benefit of the doubt is for application only where the evidence of record is found to be relatively evenly balanced. 38 U.S.C.A. § 5107(b) (West 1991). ORDER The appeal is denied. C. P. RUSSELL Member, Board of Veterans' Appeals 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.