Citation Nr: 0005659 Decision Date: 03/02/00 Archive Date: 03/14/00 DOCKET NO. 96-09 873 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to an increased rating for scars of the head and face, currently rated as 10 percent disabling. 2. Entitlement to a compensable rating for scars of the left lateral chest and low back. 3. Entitlement to a compensable rating for ptosis of the right eye. 4. Entitlement to service connection for amenorrhea. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESSES AT HEARING ON APPEAL Appellant and her spouse. ATTORNEY FOR THE BOARD A. Shawkey, Counsel INTRODUCTION The veteran served on active duty from August 1983 to August 1987. This matter comes to the Board of Veterans' Appeals (Board) on appeal from July 1994 and January 1996 rating decisions of the Department of Veterans Affairs (VA) regional office (RO) in Manchester, New Hampshire. In the July 1994 rating decision, which followed a routine VA physical examination, the RO continued the veteran's 10 percent rating for scars of the head and face and continued a 60 percent rating for status post head injury with left hemiparesis and left foot drop. In a July 1994 Notice of Disagreement, the veteran disagreed with the 10 percent rating for scars of the head and face. In conjunction with the appeal of the July 1994 rating decision, the veteran attended a December 1994 RO hearing where she continued to disagree with the 10 percent rating assigned for scars of the head and face while raising additional issues of a compensable rating for ptosis, an increased rating for organic affective disorder due to head injury, service connection for scars of the abdomen, service connection for scars of the chest and back, service connection for incontinence, and service connection for amenorrhea. In a September 1995 rating decision, the RO increased the veteran's rating for organic affective disorder due to head injury from 10 to 30 percent disabling, and continued her other ratings. In the January 1996 rating decision, the RO denied service connection for a back disability, left knee sprain, right hallux valgus, urinary incontinence, amenorrhea and scars of the abdomen. Also in this decision the RO granted service connection for scars of the left lateral chest and low back and assigned a noncompensable rating, continued a 10 percent evaluation for scars of the head and face and continued a noncompensable evaluation for ptosis. In the veteran's February 1996 Notice of Disagreement, she specifically disagreed with the denial of her claim for an increased rating for scars of the head and face, a noncompensable rating for scars of the left lateral chest and low back, a noncompensable rating for ptosis of the right eye and the denial of service connection for urinary incontinence and amenorrhea. In regard to urinary incontinence, this disability (characterized as a neurogenic bladder) was granted by the RO in May 1998 and represents a full grant of benefits. Thus, it will not be further addressed in this decision. In a July 1998 statement, the veteran's representative said that the veteran had withdrawn the issue of an increased rating for ptosis. Later, in March 1999, the veteran's representative informed the RO that the veteran had requested that all current issues on appeal be withdrawn. The RO responded to this letter by contacting the veteran in March 1999 and informing her that she had to sign a request that the appeal be withdrawn. She responded by stating that she wanted to think about it. The RO then sent the veteran a letter of clarification regarding her intent to withdraw the appeal. The RO did not thereafter receive any correspondence from the veteran regarding a withdrawal of the appeal. In view of the absence of the express written consent of the veteran to withdraw the appeal, it remains in appellate status. 38 C.F.R. § 20.204 (1999). It is noted that the representative has advanced contentions concerning the propriety of reduction of facial scars from 30 percent to 10 percent; however, that reduction in 1993 was never appealed and is not before the Board. FINDINGS OF FACT 1. The veteran's facial and head scars are no more than moderately disfiguring. 2. The veteran has a scar on her scalp which is tender and painful at times. 3. The veteran's left lateral chest scar and low back scar are well healed and are not tender or painful; nor do they present limitation of function. 4. Amenorrhea is not attributable to service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for disfiguring scars of the head and scalp have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.118, Diagnostic Code 7800 (1999). 2. The criteria for a separate 10 percent rating for a tender and painful scalp scar have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.118, Diagnostic Code 7804 (1999). 3. The criteria for a compensable rating for scars of the left lateral chest and low back have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.118, Diagnostic Codes 7803, 7804, 7805 (1999). 4. The criteria for a compensable rating for ptosis of the right eye have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.84a (Diagnostic Code 6019), 4.118 (Diagnostic Code 7800) (1999). 5. Amenorrhea was not incurred in or aggravated by service. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran's enlistment examination report in December 1982 shows normal genitourinary and pelvic examinations. On a December 1983 Report of Medical History, the veteran denied having a female disorder or change in menstrual pattern. She reported that her last menses was in November 1982. In February 1984 the veteran underwent a gynecological examination which was minimal in all respects. The veteran reported that her last menses was in December 1983 and requested birth control pills. An August 1986 service medical record shows that the veteran had recently married and wanted to start on birth control pills. It also shows that she had had unprotected intercourse for four years without getting pregnant. It further shows that she was worried about infertility, but didn't want to become pregnant at that time. She was assessed as having a normal examination and history of infertility. In regard to infertility, the examiner recommended that this issue be deferred until after a one year attempt by the veteran and her husband to conceive. The record contains a Traffic Accident Report showing that the veteran was involved in an automobile accident on February 28, 1987. On March 1, 1987, the veteran was transferred from the Womack Army Community Hospital to the Cape Fear Valley Medical Center. She was subsequently transferred to the Walter Reed Army Community Hospital on March 18, 1987, and was given final diagnoses of multiple trauma with severe head injury secondary to automobile accident, acute right-sided subdural hematoma, rupture of left hemidiaphragm, acute left subdural hygroma, fracture of the left fifth, sixth and seventh ribs, multiple abrasions and contusions, resolved, and anemia secondary to blood loss, resolved. In July 1987 a medical board found that the veteran was physically unfit for active duty due to injuries stemming from the February 1987 motor vehicle accident. She was discharged from active duty in August 1987. In January 1988 the veteran was admitted to a VA medical facility for 17 days where she underwent a cranioplasty. Findings on examination revealed an obvious deformity over the right frontoparietal region and a depressed right eyebrow with minimal function of the frontalis muscle on that side. Other abnormalities included a left lateral chest scar. A VA examiner who performed a January 1988 examination noted that the veteran had no complaints pertaining to the pelvic region and that a pelvic examination had not been performed. A VA discharge summary in February 1988 shows that the veteran was being discharged with birth control pills that she had requested. Results of a VA examination performed in January 1989 show that the veteran had a normal genitourinary evaluation and a normal evaluation of her eyes. In regard to scarring, the veteran had a 5 inch scar beginning at the hairline, running sagitally and caudally. A 3 inch shunt scar was identified transversely in the middle of the right lower quadrant. A 3 inch right upper quadrant scar represented an old repair of a pyloric stenosis. A 1 inch scar was identified at the lumbosacral joint in the sagittal plane representing the incision through which a shunt had been established. There was a 1 inch scar transversely at the level of the left 9th rib in the mid axillary line representing an incision through which drainage of the left hemithorax had been performed. Findings from a VA examination in January 1990 show that in regard to the veteran's eyes, she had normal fundi, extraocular muscle that was okay, and pupils that reacted. She was also found to have a drooping right upper eyelid. Also noted was a "Y" shaped forehead scar measuring 12 centimeters in length and a curvilinear craniotomy scar on the right fronto-parietal measuring about 16 centimeters in length. There was no strabismus, no mystogmus, no extraocular muscle paralysis and no papillary change. In October 1980 the veteran underwent a mental status examination where she was found to have stigmata of her injury including facial scars that were reasonably done cosmetically, but were still noticeable. There was also drooping of the left side of her face. Results of a VA neurological examination performed in October 1990 show that the right side of the veteran's skull over the bone flap of the skull was tender to touch. The examiner noted that the veteran had undergone cosmetic surgery for right eye ptosis and multiple cosmetic surgeries for more normal appearing right-sided scar as a result of the bone flap operation. A December 1990 VA treatment record notes that the veteran was post pill amenorrhea for six months. It also notes that she had been on birth control pills for three years with no risk of pregnancy. Test results revealed a low "FSH" and low "LH". An impression was given in January 1991 of hyperestrogenism secondary to "Pit cause". The physician stated that it was possibly post traumatic or constitutionally low gonvarotrophus with an ovulation. A June 1991 VA treatment record shows that the veteran had problem oligomenorrhea. The veteran was advised to resume Ortho-Novum 777. At a VA dermatology examination in April 1992, the veteran complained of itchiness of her scalp scar frontally. On examination there was a 12 centimeter in length curvilinear scar on the forehead. A plate was felt in the skull measuring 12.5x9x.5 centimeters. There was a 16 centimeter craniotomy scar on the right frontoparietal region which was itchy. The examiner noted that the scars were primarily on the scalp. There were some small scars in the right lower quadrant left posterior thorax region. These scars were not itchy. The veteran was diagnosed as having scarring with pruritus of scalp scars. Photographs were taken revealing a whitish hairline scar and whitish forehead scar. At a VA gynecological examination in June 1994, the veteran reported having only a vary scanty menstrual flow regardless of whether she was taking the pill. She also reported that had been on the pill for the last seven years and that her last menses was earlier that month. Her only complaint was her scanty periods and concern over the possibility of future pregnancies. The veteran was diagnosed as having oligomenorrhea, perhaps related to ingestion of birth control pills. Results of a VA brain examination in June 1994 revealed multiple scars on the veteran's face, back and right abdomen. In a July 1994 rating decision the RO continued the veteran's 10 percent rating for scars of the head and face and continued a 60 percent rating for status post head injury with left hemiparesis and left foot drop. In a July 1994 Notice of Disagreement, the veteran disagreed with the 10 percent rating for scars of the head and face, and also disagreed with a 10 percent rating for a neuropsychiatric disability (rated as organic affective disorder due to head injury) and a noncompensable rating for left upper extremity weakness due to head injury. At a RO hearing in December 1994, the veteran testified as to having a long scar on her head extending from her nose to around the back of her ear, a scar on the left side of her body, and one on her lower back. She said that the scar on her head was particularly bothersome in that she felt intense pain to touch, such as when combing her hair or bumping her head when getting into her car. She also complained of occasional itchiness regarding the scars on her back and scalp. She said that her right eye kind of drooped down and that she didn't have as much distinct peripheral vision on her right as she did on her left because of the drooping. In regard to amenorrhea, the veteran said that her periods were normal prior to the accident in March 1987, but that if she didn't take medication, she wouldn't have a period. She said that she wanted to have children one day and having a normal menstrual cycle played an integral part in a normal pregnancy. She said that the medication she took was Novum 777 which VA administered. According to a January 1995 VA gynecological report, the veteran's last menstrual period was in December 1994. The report also notes that the veteran had had amenorrhea since an automobile accident in 1987 with a withdrawal bleed after taking Ortho-Novum 777. She had no other subjective complaints. She was given an impression of amenorrhea. Results of a VA eye examination performed in January 1995 revealed uncorrected distance eye vision was 20/25 and corrected was 20/20 in each eye. Near eye uncorrected vision for each eye was 20/25 and corrected to 20/20. There was no diplopia and no visual field deficit. Dilated fundus examination revealed completely normal findings to the ora serrata in each eye. The veteran was diagnosed as having completely normal eye exam with a slight increase in myopia as evidence in the refraction. New glasses were recommended. The veteran's prognosis was excellent in terms of vision. At a VA dermatology examination in August 1995, the veteran complained of some numbness of her cranial scar. Examination of her cranium revealed a right parietal flap well-healed scar which measured 12 inches in length and extended from the right forehead to the retroauricular area involving the entire right parietal cranium. The scar on the veteran's forehead was well healed and thin lined and was not a cosmetic problem. The scar on her left lateral lower chest measured 1 inch in length and was well healed. In addition, there was a 1 inch scar in the veteran's L5 midline back which was well-healed without deformity. The veteran's diagnoses included multiple scars from multi-trauma problems resulting from an auto accident in 1987, a well healed right parietal flap scar with no cosmetic deformity where there was an extension into the veteran's right forehead, and minor scars involving the left lateral chest and lower back. In the January 1996 rating decision, the RO denied service connection for a back disability, left knee sprain, right hallux valgus, urinary incontinence, amenorrhea and scars of the abdomen. Also in this decision the RO granted service connection for scars of the left lateral chest and low back and assigned a noncompensable rating, continued a 10 percent evaluation for scars of the head and face and continued a noncompensable evaluation for ptosis. At a VA examination in December 1997, a photograph was taken of the veteran's face showing a bulge in the right temporal area. Multiple scars were identified including a 1-1/2 inch long oblique scar on the right lateral side of the forehead, a transverse 2-inch linear scar on the upper mid forehead, a 9 inch curved linear scar, which ran front to the back of the scalp and behind the right ear - which was somewhat depressed and itched from time to time, a 1 inch linear scar (post shunt) in the lower back which itched at times and a 1 inch in length and 1/4 to 1/2 inch wide scar which was slightly elevated and present on the left lateral side of the chest. The examiner described the scars as pinkish-white in color. They had no adhesion, inflammation, edema or keloid formation. There was no tenderness present. The left lateral side of the scalp showed a small depressed area, which measured 1-1/2 x 1 inch in maximum dimension. The veteran's bulge was described as being firm and nontender measuring 1-1/2 x 1 x 1/2 inches overall maximum dimension. In regard to the veteran's eye, the examiner stated that the right eye was slightly smaller than the left with slight drooping of the eyelid, which did not cover any portion of the pupil. The veteran was diagnosed as having bulge in the right temporal region of the face causing some disfigurement, slight ptosis of the right eyelid and multiple scars secondary to an automobile accident. A women's VA health clinic progress note dated in January 1998 shows that the veteran was being seen due to a concern over her ability to get pregnant. The note indicates that she had been on birth control pills for one and a half years to help regulate menses which had been sparse since her head injury. In May 1998 the veteran was seen at the VA women's health clinic at which time she announced that she was 3 months pregnant. In August 1998 the veteran underwent a VA examination to evaluate her scars and to address question as to whether she had hypothalamic dysfunction. The examiner stated that he had reviewed the veteran's claims folder in addition to photographs that were taken. In regard to hypothalamic dysfunction, the examiner said that this was difficult to ascertain. He said that endocrinology studies had not been performed recently, but that the veteran did state that she had lack of menstrual periods and that she felt cold all of the time. He said that this could be a manifestation of a hypothalamic dysfunction. He also said that etiology could be her severe head injury, her internal hydrocephalus and her subdural hematoma and her shunt. In regard to scarring, the examiner said that the 9 inch scar running from the front to the back of the veteran's scalp was slightly depressed with a slight loss of tissue. The linear post shunt scar on the lower back and 3 inch linear scar on the right lower quadrant of the abdomen were well healed. The examiner said that there was no functional impairment of the parts affected by the scars other than the left foot. In June 1999 the veteran underwent a VA general examination for purposes of determining whether she had hypothalamic dysfunction. The examiner indicated that he had reviewed the veteran's claims file, including medical records from the Department of Obstetrics and Gynecology, Hitchcock Clinic, where she underwent a fertility work-up in June 1998. He reported her history of having taken Ortho-Novum 777 for several years because of abnormal menses since her head injury in 1987 and of experiencing light withdrawal bleeding at appropriate times in her cycle while on Ortho-Novum 777. He reported that the veteran kept a diary of her menstrual activity since stopping Ortho-Novum in 1996 and found that her periods were more or less regular, with an interval approximately one a month. He also reported that the amount of bleeding was quite minimal, at times only one day or more often two days. He further reported that the veteran had given birth vaginally to a normal, healthy female baby five weeks earlier. He stated that "[t]he veteran's observation that she has light menstrual bleeding on a fairly regular basis, in conjunction with her successful pregnancy, normal delivery, and normal lactation, speak for the basic integrity of her hypothalamic pituitary ovarian axis at this time." "Essentially, she would not have been able to conceive, have full-term pregnancy, and to lactate normally were she suffering from a major hypothalamic or pituitary dysfunction at this time." "The fact that her menses are often light and of short duration does not indicate a significant malfunction of this hormonal system." The examiner concluded that there was no clinical evidence of significant impairment of the hypothalamic pituitary ovarian axis in the veteran at that time. II. Legal Analysis A. Increased Rating Claims The veteran's claims for increased ratings for scars of the head and face, scars of the left lateral chest and low back, and for ptosis of the right eye, are well grounded meaning plausible. The file shows that the RO has properly developed the evidence, and there is no further VA duty to assist the veteran with her claim. 38 U.S.C.A. § 5107(a) (West 1991). Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Scars of the Head and Face The criteria for rating disfiguring scars of the head, face and neck are found under 38 C.F.R. § 4.118, Diagnostic Code 7800. Under this code, a 10 percent rating is warranted for moderately disfiguring scars and a 30 percent rating is warranted for severe scars, especially if producing a marked unsightly deformity of eyelids, lips or auricles. A 50 percent rating is warranted for complete or exceptionally repugnant deformities of one side of face or marked or repugnant bilateral disfigurement. A Note following Code 7800 states that when in addition to tissue loss and cicatrization there is marked discoloration, color contrast, or the like, the 50 percent rating may be increased to 80 percent, the 30 percent to 50 percent, and the 10 percent to 30 percent. For superficial scars that are poorly nourished with repeated ulceration a 10 percent rating is warranted. 38 C.F.R. § 4.118, Diagnostic Code 7803. For superficial scars that are tender and painful on objective demonstration, a 10 percent rating is warranted. 38 C.F.R. § 4.118, Diagnostic Code 7804. For scars that affect limitation of function, such scars are to be rated on limitation of function of part affected. 38 C.F.R. § 4.118, Diagnostic Code 7805. In assessing the degree of disfigurement caused by the veteran's facial and head scars, the evidence supports the current 10 percent rating for moderate disfigurement. The evidence is fairly consistent in showing two primary scars. One which is described as a curvilinear scar on the veteran's forehead measuring approximately 12 centimeters long, and the other is approximately 16 centimeters long located on the right parietal flap extending from the front of the veteran's scalp to the back. As far as disfigurement, this latter scar was noted by a VA examiner in August 1995 as not being a cosmetic problem. This examiner went on to diagnose the veteran as having a right parietal flap scar with no cosmetic deformity. An earlier VA examiner in 1990 stated that the veteran had undergone multiple cosmetic surgeries for a more normal appearing right-sided scar as a result of the bone flap operation. In view of this evidence as well as a photograph of the scar on file, it cannot be said that this scar is more than moderately disfiguring. As far as the veteran's forehead scar, the evidence likewise does not support a finding of greater than moderate disfigurement. A VA examiner in 1980 said that the veteran's facial scars were reasonably done cosmetically, but were still noticeable. A photograph taken of this scar in August 1998 shows a whitish thin scar line on the veteran's right forehead which is noticeable, but does not rise to the level of severe disfigurement to the veteran's face. In regard to an increased rating (to 30 percent) for tissue loss, cicatrization and marked discoloration, color contrast or the like, the evidence pertaining to these scars does not meet this criteria. See Note to Diagnostic Code 7800. More specifically, while a VA examiner in August 1998 said that there was a slight loss of tissue with respect to the scalp scar, both scars were described as being pinkish-white in appearance. This was indeed shown by a photograph of the scars taken in August 1998 in which they both appeared to be white. Since there is no marked discoloration, color contrast or the like, the criteria for an increased rating (to 30 percent) for the forehead and scalp scars have not been met. Id. Consideration must also be given to the bulge in the temporal region of the veteran's face. Although not a scar, this bulge is rated by analogy to Diagnostic Code 7800 because of its disfiguring nature on the veteran's face. In this regard, a VA examiner in December 1997 diagnosed the veteran as having a bulge in the right temporal region of the face causing "some disfigurement". Measurements of the bulge taken at this examination revealed that it was 1-1/2x1x1/2 inches overall maximum dimension and was not tender. Taking into consideration the size of the bulge as well as the diagnosis given in 1987, in addition to a photograph of the bulge taken in December 1997, it cannot be said that it approximates a severe or unsightly deformity. In addition to the moderate level of disfigurement caused by the veteran's facial and head scars, these scars must also be considered in view of their symptomatology, i.e., whether the scars are poorly nourished subject to ulcerations, or whether they are tender and painful on objective demonstration. Diagnostic Codes 7803, 7804. Esteban v. Brown, 6 Vet. App. 259, 261-262 (1994). The scar on the veteran's forehead has not been shown to be tender and painful on objective demonstration, nor has the veteran contended as much. In fact, a VA examiner in December 1997 said that none of the veteran's scars showed adhesion, inflammation, edema, keloid formation or tenderness. The scars have never been shown to be other than well healed nor have they ever been shown to involve ulcerations. As far as the veteran's scalp scar, the evidence weighs both in favor of and against pain and tenderness. Evidence against this symptomatology includes the VA examiner's opinion in December 1997 as noted above. In addition, the VA examiner in August 1995 described this scar as being well- healed. In contrast, a VA neurologist in October 1990 stated that the right side of the veteran's skull over the bone flap of the skull was tender to touch. This is consistent with the veteran's testimony of experiencing intense pain when touching this scar such as when combing her hair or bumping her head when getting into her car. In sum, the evidence is in relative equipoise in regard to tenderness and pain on objective demonstration with respect to the veteran's scalp scar. Consequently, the benefit of the doubt will rest with the veteran, thus warranting a separate 10 percent rating under Diagnostic Code 7804 for the veteran's scalp scar. 38 C.F.R. § 4.3; 38 U.S.C.A. § 5107(b). Consideration has also been given to a separate rating for limitation of function due to these scars, but there is no evidence showing such limitation. In fact, the VA examiner who conducted the August 1998 examination stated that there was no functional impairment of the parts affected by the veteran's scars other than a foot scar, a scar which is not currently the subject of this appeal. 38 C.F.R. § 4.118, Diagnostic Code 7805. Esteban v. Brown, 6 Vet. App. 259, 261-262 (1994). For the reasons given above, the veteran's facial scar, scalp scar and right temporal bulge most approximate the criteria for moderate disfigurement of the face and head warranting a 10 percent rating. Moreover, since the disfiguring nature of the veteran's scalp scar is separate and distinct from the pain and tenderness that it elicits, the assignment of a separate 10 percent rating under Code 7804 for pain and tenderness is warranted and does not violate the rule against pyramiding. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262-162 (1994). Scars of the Left Lateral Chest and Low Back These scars must again be considered under the provisions of Diagnostic Codes 7803, 7804, and 7805. The veteran's left lateral chest scar was described by a VA examiner in December 1997 as measuring 1 inch in length and 1/4 to 1/2 inch wide and slightly elevated. The veteran's low back scar was described by the examiner as being a 1 inch linear scar (post shunt) which itched at times. Like the veteran's facial and head scars, the examiner said that these scars were pinkish-white in color with no adhesion, inflammation, edema or keloid formation. At a later VA examination in August 1998, the examiner described the veteran's back scar as being well healed with no defect or tissue loss. Notwithstanding occasional itchiness from the veteran's low back scar, the evidence does not show that these scars meet the criteria under Code 7803 for poorly nourished scars with repeated ulceration, nor under Code 7804 for painful and tender scars, nor does it meet the criteria for limitation of function under Code 7805. In regard to limitation of function, the examiner who conducted the August 1998 examination stated that there was no functional impairment of the parts affected by the veteran's scars other than a scar of the left foot, a scar which is not the subject of this appeal. Since the preponderance of the evidence is against the veteran's claim for a compensable rating for scars of the left lateral chest and back, the benefit of the doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Ptosis of the Right Eye The veteran contends that she is entitled to a compensable rating for ptosis because she does not have as much distinct peripheral vision on her right side as she does on her left side due to right eye drooping. Ptosis, unilateral or bilateral, with the pupil wholly obscured is rated equivalent to visual acuity of 5/200 (1.5/60). Ptosis, unilateral or bilateral, with the pupil one-half or more obscured is rated equivalent to visual acuity of 20/100 (6/30). Ptosis, unilateral or bilateral, with less interference of vision is rated as disfigurement. 38 C.F.R. § 4.84a, Diagnostic Code 6019 (1999). Disfiguring scars of the head, face or neck warrant a noncompensable evaluation if the disfigurement is slight. Moderate disfigurement warrants a 10 percent evaluation. A 30 percent evaluation is warranted for severe disfigurement, especially if producing a marked and unsightly deformity of the eyelids, lips or auricles. 38 C.F.R. § 4.118, Diagnostic Code 7800 (1999). The medical evidence in this case does not show that the veteran's ptosis interferes with her vision. She was found at a VA eye examination in January 1995 to have no visual field defect and was diagnosed as having a completely normal eye exam with a slight increase in myopia. The slight increase in myopia was due to refraction, not ptosis. In addition, a VA examiner in December 1997 stated that the veteran's right eye was slightly smaller than the left with slight drooping of the eyelid, but that the drooping did not cover any portion of the pupil. In regard to disfigurement, the examiner in December 1997 diagnosed the veteran as having slight ptosis. This diagnosis is consistent with a photograph taken of the veteran's face in December 1997 showing that the ptosis was not that noticeable and certainly no more than slightly disfiguring. In short, the preponderance of the evidence is against a showing that the veteran's right ptosis interferes with her vision, or results in more than slight disfigurement. Consequently, entitlement to a compensable rating for ptosis of the right eye is not warranted. 38 C.F.R. §§ 4.84a (Diagnostic Code 6019), 4.118 (Diagnostic Code 7800). Since the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Service Connection for Amenorrhea The veteran's claim of service connection for amenorrhea (absence or abnormal stoppage of the menses, Dorland's Illustrated Medical Dictionary 55 (28th ed. 1994)) is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, the veteran is found to have presented a claim which is not inherently implausible. Furthermore, after examining the record, the Board is satisfied that all relevant facts have been properly developed and no further assistance is required to comply with the duty to assist as mandated by 38 U.S.C.A. § 5107(a). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection may be granted under the provisions of 38 C.F.R. § 3.303(b), when the evidence, regardless of its date, shows that a veteran had a chronic condition in service or during the applicable presumptive period. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. In this regard, the Court of Appeals for Veterans Claims (formerly known as the Court of Veterans Appeals) has repeatedly cautioned that the regulatory requirement is for a showing of continuity of symptomatology, not treatment. Savage v. Gober, 10 Vet. App. 488, 496-497 (1997); Wilson v. Derwinski, 2 Vet. App. 16, 19 (1992). The veteran testified in December 1994 that her periods were regular prior to the 1987 automobile accident and that since then she has had to take birth control pills to maintain regular menses. She said that she wanted to have children one day and that a normal menses was integral to a normal pregnancy. Service medical records show that prior to her 1987 automobile accident, in August 1986, the veteran was seen at a medical facility where she reported that she had had unprotected intercourse for four years without getting pregnant. She further reported that she had recently gotten married and wanted to start taking birth control pills. She said that she was worried about infertility, but did not want to get pregnant at that time. She was given an assessment of normal examination and history of infertility. Postservice medical records show that the veteran again began taking birth control pills, Ortho-Novum 777, in 1988. They also show that she was found to be post pill amenorrhea for six months in December 1990 and had problems with oligomenorrhea (infrequent menstrual flow, Dorland's Illustrated Medical Dictionary, 1174 (28th ed. 1994)) in June 1991 and June 1994. She was subsequently given an impression of amenorrhea by a VA gynecologist in January 1995. Notwithstanding the above-noted evidence reflecting irregular menses as well as stoppage, the veteran reported to a VA women's health clinic in January 1998 announcing that she was three months pregnant. Additionally, while a VA examiner in August 1998 said that the veteran's complaint of a lack of menstrual periods and of always being cold could be a manifestation of hypothalamic dysfunction and that such a dysfunction would be etiology related to her severe head injury, internal hydrocephalus and subdural hematoma, he did not actually diagnose the veteran as having this dysfunction. Thus, his opinion is speculative and of limited probative weight. In contrast, a subsequent VA examiner in June 1999 rendered a nonspeculative opinion that the veteran did not have hypothalamic dysfunction. This examiner had the benefit of reviewing results of infertility tests that had been performed at a private clinic in June 1998. He had also been informed that the veteran had delivered a normal, health baby girl five weeks earlier. He stated that since the veteran stopped taking birth control pills in 1996, she kept a diary of her menstrual activity and found that her periods were more or less regular, with an interval of approximately one a month - though the interval of bleeding was minimal, lasting sometimes only a day or two. He also stated that "[t]he veteran's observation that she has light menstrual bleeding on a fairly regular basis, in conjunction with her successful pregnancy, normal delivery, and normal lactation, speak for the basic integrity of her hypothalamic pituitary ovarian axis at this time". As far as the short duration of the veteran's menses, the examiner stated that "The fact that [the veteran's] menses are often light and of short duration does not indicate a significant malfunction of this hormonal system." The examiner concluded by stating that there was no clinical evidence of significant impairment of the hypothalamic pituitary ovarian axis in the veteran at that time. In view of this most recent medical evidence showing that the veteran has had a fairly consistent menses since 1996 and has just recently delivered a baby, the weight of evidence goes against her claim of service connection for amenorrhea. 38 C.F.R. § 3.303. As the weight of evidence goes against this claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107(b). ORDER A rating in excess of 10 percent for disfiguring scars of the head and face is denied. A separate 10 percent rating for a tender and painful scalp scar is granted, subject to the law and regulations governing the payment of monetary benefits. A compensable rating for scars of the left lateral chest and low back is denied. A compensable rating for ptosis of the right eye is denied. The claim of service connection for amenorrhea is denied. C.W. Symanski Member, Board of Veterans' Appeals