UTERUS DISEASE OF

LESLEY A. REIN · 2026 · Case ID: 26003654

MIXED

Summary

The veteran, who served from October 1985 to April 1986 and July 1987 to May 1997, appeals the denial of service connection for uterine fibroids and hysterectomy residuals, as well as remanded claims for a gynecological disability convalescence period, sinus disability, and obstructive sleep apnea (OSA) secondary to rhinitis or sinus disability. The Board granted service connection for uterine fibroids and hysterectomy, resolving reasonable doubt in the veteran's favor based on a December 2024 VA examiner's opinion. This opinion found the conditions at least as likely as not related to in-service pain and heavy bleeding, despite service treatment records being silent on fibroid complaints. The Board found the private medical opinion inadequate and a subsequent unfavorable VA opinion lacked probative weight as it failed to address the favorable opinion or the full scope of the veteran's reported symptoms and medical history. The Board found the evidence in approximate balance for these granted claims. The claim for a temporary total rating for gynecological disability following hysterectomy was remanded due to missing operative reports. The sinus disability claim was remanded because the VA examiner failed to address private treatment records for recurrent sinusitis and did not adequately explain why the veteran's sinusitis was unrelated to in-service diagnoses. The OSA claim was remanded because the VA examiner's opinion was inadequate, failing to address whether rhinitis or sinusitis aggravated the OSA, and the examiner's negative nexus opinion was based on general information rather than the veteran's specific history.

Rationale

Resolving reasonable doubt in Veteran's favor; Uterine fibroids related to in-service pain and heavy bleeding; Nexus established by VA examiner's opinion

Special Benefit

TEMPORARY TOTAL (§4.30)

Docket No.

13-33 585

Full Decision Text

Citation Nr: 26003654
Decision Date: 03/20/26 Archive Date: 03/20/26

DOCKET NO. 13-33 585
DATE: March 20, 2026

ORDER

Entitlement to service connection for status post hysterectomy with history of uterine fibroids is granted.

Entitlement to service connection for hysterectomy is granted.

REMANDED

Entitlement to a temporary total rating for a gynecological disability under the provisions of 38 C.F.R. § 4.30 for a period of convalescence following a July 2010 hysterectomy, is remanded.

Entitlement to service connection for a sinus disability, other than rhinitis, is remanded.

Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected allergic rhinitis and/or a claimed sinus disability, is remanded.

FINDINGS OF FACT

1. Resolving reasonable doubt in the Veteran's favor, her uterine fibroid disability is related to in-service pain and heavy bleeding experienced in-service.

2. Resolving reasonable doubt in the Veteran's favor, her hysterectomy is related to in-service pain and heavy bleeding experienced in-service.

CONCLUSIONS OF LAW

1. The criteria for service connection for residuals of uterine fibroids are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for residuals of hysterectomy are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from October 1985 to April 1986 and from July 1987 to May 1997.

These matters come before the Board of Veterans' Appeals (Board) on appeal from January 2011 (fibroids) and April 2012 rating decisions (sinus and OSA) issued by a Department of Veterans Affairs (VA) Regional Office (RO).

In July 2019, April 2021, October 2022, and June 2024, the Board remanded the issues to the Agency of Original Jurisdiction (AOJ) for further development. and most recently in November 2023. While in remand status, the AOJ issued a December 2024 rating decision which granted service connection for allergic rhinitis. As this action represent a full grant of the benefit sought as to the claim for service connection for allergic rhinitis, this issue is no longer on appeal before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The Board finds there has been substantial compliance with the recent remand directives as to the issues of entitlement to service connection for a uterine fibroids and a hysterectomy. See Stegall v. West, 11 Vet. App. 268, 271 (1998).

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995).

In addition, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38?C.F.R. §?3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38?C.F.R. §?3.310; Allen v. Brown, 7?Vet. App.?439 (1995).

When all the evidence is assembled, VA is responsible for determining whether the weight of the evidence is in approximate balance. If the positive and negative evidence is evenly or approximately balanced, the claimant receives the benefit of the doubt. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the
connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38?C.F.R. §?3.310; Allen v. Brown, 7?Vet. App.?439 (1995).

1. Entitlement to service connection for uterine fibroids is granted.

2. Entitlement to service connection for hysterectomy is granted.

The Veteran contends that she suffered from uterine fibroids and a subsequent hysterectomy as a result of her service and continues to suffer from residuals.

The Board has recharacterized the Veteran's claim (most recently characterized as service connection for a gynecological disability to include uterine fibroids and hysterectomy residuals).

The April 2023 VA gynecological conditions examiner diagnosed the Veteran with uterine fibroids, adenomyosis, and endometriosis, with a diagnosis date of 1998. The same noted the Veteran's July 2010 hysterectomy. The examiner noted that the conditions had improved but not resolved. The Veteran reported current symptoms of pelvic pain, fatigue, and urinary incontinence.

Thus, the first element of service connection, a current disability, is satisfied, and the question becomes whether the disability is related to service.

Regarding the Veteran's diagnosis of endometriosis, the Board notes that the Veteran is already service-connected for this diagnosis. As the April 2012 VA examiner opined that the Veteran's endometriosis with adenomyosis were at least as likely as not related heavy bleeding during service, which was noted in the September 2013 rating decision which granted service connection for endometriosis, the Board finds that the adenomyosis diagnosis is encompassed with the grant of endometriosis.

The Veteran underwent VA gynecological examinations in April 2012, July 2014, July 2021, and April 2023. As prior VA opinions have been found by the Board to be inadequate, the Board will focus on the opinions obtained pursuant to the most recent remand.

Pursuant to the recent remand, the Board founds that the prior remand did not comply with Stegall as the AOJ failed to obtain an opinion from independent medical expert (IME).

In December 2024, the AOJ obtained an etiology opinion from a VA general practice physicians assistant, K.R. K.R. determined that the Veteran's uterine fibroids and hysterectomy were at least as likely as not related to the pain and heavy bleeding the Veteran experienced during service. K.R. noted the Veteran's statement that she was diagnosed with an enlarged uterus while on active duty. She recalled feeling pressure in her lower abdomen, cramping, and heavy, painful, long-lasting periods, with occasional passage of blood clots. K.R. noted the Veteran's report that in 1998 she was diagnosed with a large uterus, which the Veteran reported was the same time she was diagnosed with endometriosis and adenomyosis. K.R. explained that uterine fibroids, or leiomyoma, are benign tumors that originate from uterine smooth muscle cells (myometrium). Common symptoms of fibroids may include abnormal uterine bleeding (heavy periods of periods, long lasting periods, more frequent periods), pelvic pain, disruption of surrounding pelvic structures (bowel and bladder), and back pain. Uterine fibroids may also be asymptomatic. K.R. acknowledged that the Veteran's service treatment records (STRs) are otherwise silent for subjective complaints, diagnosis, or treatment of uterine fibroids. Records, however do show evidence of anemia diagnosed on February 21, 1998, which may be secondary to heavy bleeding/menorrhagia as described by the Veteran in her statement in support of claim. STRs otherwise show history of infertility since January 1996 and diagnosis of elevated prolactin in January 1997 and prolactinoma in approximately May 1997. Medical records following release from active duty show diagnosis of fibroids in January 1988 and adenomyosis and endometriosis in February 1998.

Medical records following release from active duty additionally show evidence of chronic heavy menstrual bleeding and anemia. According to a June 16, 2009 private gynecology note with G.B., D.O., the
show evidence of anemia diagnosed on February 21, 1998, which may be secondary to heavy bleeding/menorrhagia as described by the Veteran in her statement in support of claim. STRs otherwise show history of infertility since January 1996 and diagnosis of elevated prolactin in January 1997 and prolactinoma in approximately May 1997. Medical records following release from active duty show diagnosis of fibroids in January 1988 and adenomyosis and endometriosis in February 1998.

Medical records following release from active duty additionally show evidence of chronic heavy menstrual bleeding and anemia. According to a June 16, 2009 private gynecology note with G.B., D.O., the Veteran was noted to have "heavy bleeding and some clots. Denied cramping. Had a blood transfusion 6/6/09." Diagnosis of menorrhagia, anemia secondary to blood loss, and uterine leiomyoma with recommendation for abdominal hysterectomy.

K.R. noted that the Veteran was noted to have underwent a hysterectomy on July 20, 2010. While the operative report is missing, K.R. noted that evidence of the Veteran's hysterectomy is well documented throughout her medical records.

Regarding the Veteran's symptoms in the absence of diagnosis during service, K.R. noted that the Veteran is competent to describe her current symptoms, in-service events, and ongoing symptoms. Therefore, the Veteran's statement in support of claim will be accepted as factual. In her statement in support of claim, the Veteran reported onset of cramping, heavy, painful, and long-lasting periods during active duty service consistent with uterine fibroids. The Veteran is noted to have undergone a hysterectomy in July 2010 for heavy menstrual periods secondary to uterine fibroids. Additionally, the Veteran is noted to be diagnosed with anemia in February 1988, which is consistent with heavy menstrual periods secondary to uterine fibroids.

Therefore, K.R. determined that the claimed uterine fibroid and hysterectomy, at least as likely as not onset during the Veteran's active service. K.R. noted that the Veteran's entrance examination is silent for pre-existing fibroids and that there is evidence of chronicity following release from active-duty service, which is supported by medical records. Therefore, a nexus is established.

As the opinion was not from an IME, the AOJ obtained a subsequent unfavorable opinion from obstetrician-gynecologist, Dr. T.D., in February 2025. However, as Dr. T.D. failed to address the favorable December 2024 VA etiology opinion, the Board finds this opinion is entitled no probative weight.

While the Board could remand the claim for yet another medical opinion, such a request could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304(c) ("The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination"); Andrews v. McDonough, 34 Vet. App. 216, 225 (2021) ("Remand is inappropriate where the predominant purpose is not to allow the Board to make a fully informed decision unencumbered by error but to allow VA to obtain more evidence so that it can properly deny the claim").

Based on a careful review of the evidence and resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence in approximate balance with regard to whether the Veteran's uterine fibroids and hysterectomy are related to her active service. In light of the foregoing, and resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for uterine fibroids and hysterectomy is warranted. As the criteria for service connection for uterine fibroids and hysterectomy have been met, the claims are granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102.

REASONS FOR REMAND

Regrettably, the remaining claims must be remanded for further development before the Board can make a fully informed decision on the claims.

Entitlement to a temporary total rating for a gynecological disability under the provisions of 38 C.F.R. § 4.30 for a period of convalescence following a July 2010 hysterectomy, is remanded.

The Veteran's treatment records make clear that the Veteran underwent a hysterectomy in July 2010. However, it is also consistently noted by VA examiners and the Veteran's attorney, that the operative report and other records concerning the Veteran's hysterectomy which was reportedly performed at Keesler Air Force Base Hospital, are not of record.

On review of the claims file, there is no indication
remaining claims must be remanded for further development before the Board can make a fully informed decision on the claims.

Entitlement to a temporary total rating for a gynecological disability under the provisions of 38 C.F.R. § 4.30 for a period of convalescence following a July 2010 hysterectomy, is remanded.

On review of the claims file, there is no indication that the AOJ has attempted to obtain these pertinent federal records. Remand is required to make necessary attempts to obtain the operative report and related records as these records could reasonably contain necessary information to adjudicate the Veteran's claim for a temporary total rating.

Entitlement to service connection for a sinus disability, other than rhinitis, is remanded.

Pursuant to the recent remand, the Board found the November 2022 VA opinion to be inadequate as the examiner did not address diagnoses of a sinus disability in the record including sinusitis, rhinitis, and sinobronchial syndrome.

In December 2024, the AOJ obtained a VA sinusitis/rhinitis examination and opinion. The examiner diagnosed the Veteran with allergic rhinitis and acute sinusitis, finding that sinusitis resolved in-service without residual or objective evidence of a chronic sinus infection. The examiner concluded that based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is a lack of substantiating evidence supporting a nexus between the current diagnosis of no diagnosis rendered and military service. Without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology.

In making this opinion, the examiner failed to address private treatment records reflecting a February 2023 diagnosis of recurrent sinusitis or June and November 2023 VA treatment records documenting chronic sinusitis with medication prescribed to treat symptoms. See February 2023 Private Treatment Note, June 2023 VA Treatment Note. Moreover, the examiner failed to opine as to why the Veteran's sinusitis was not related to her in-service treatment for diagnoses of sinusitis and sinobronchial syndrome.

Therefore, remand is required to obtain an adequate opinion that considers the pertinent medical evidence of record and substantially complies with the recent remand.

Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected allergic rhinitis and/or another claimed sinus disability, is remanded.

The Veteran seeks service connection for OSA which she relates to active service. Alternately, the Veteran asserts that her OSA is caused or aggravated by her service-connected rhinitis or other claimed sinus disability.

Pursuant to the recent remand, the AOJ obtained a VA sleep conditions examination and opinion. Based on review of the available evidence, the December 2024 VA examiner determined that it is less likely than not that the Veteran's OSA is due to service as there is a lack of substantiating evidence supporting a nexus between the current diagnosis and military service. Without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology. Addressing service connection as secondary to a sinus disability, the examiner concluded that the Veteran's OSA is less likely than not proximately due to or the result of sinusitis or rhinitis. In support of her negative opinion, the examiner wrote, "[t]hough having history of rhinitis and chronic sinusitis can worsen symptoms it is not a cause for her symptoms in this case after reviewing x rays." The December 2024 VA examiner failed to address whether the Veteran's rhinitis or sinusitis aggravated her OSA, which the examiner seems to have raised as a possibility.

The AOJ obtained an addendum opinion from the same examiner in February 2025 as it determined that the December 2024 opinion discussed the causes of sleep apnea in general cases but nothing specific to the Veteran's history. The examiner opined that the sinuses are not contributing to the Veterans' OSA. Though the rhinitis and sinusitis can cause inflammation in the nasal passages, the examiner explained that it is the collapse in the lower throat and the drop of the tongue in the airway that causes sleep apnea.

The Board finds that remand is required as the AOJ failed to obtain an adequate opinion that addressed all theories of entitlement and provided the required causation and aggravation opinions necessary for a secondary service connection opinion.

Accordingly, the matters are REM
the same examiner in February 2025 as it determined that the December 2024 opinion discussed the causes of sleep apnea in general cases but nothing specific to the Veteran's history. The examiner opined that the sinuses are not contributing to the Veterans' OSA. Though the rhinitis and sinusitis can cause inflammation in the nasal passages, the examiner explained that it is the collapse in the lower throat and the drop of the tongue in the airway that causes sleep apnea.

Accordingly, the matters are REMANDED for the following action:

1. Obtain all records concerning the Veteran's July 2010 hysterectomy at Keesler Air Force Base Hospital. Any negative response should be clearly documented in the claims file and the Veteran and her representative must be notified of the outcome.

2. Forward the Veteran's claims file to a VA examiner of appropriate expertise, to provide an addendum medical opinion addressing the nature and etiology of the Veteran's sinusitis. The examiner must review the claims file in its entirety and the review should be noted in the report. An examination should only be scheduled if deemed necessary by the examiner.

The examiner should:

(a) Address the Veteran's diagnosis of sinusitis during or approximate to the period on appeal.

The examiner must address the following pertinent evidence:

" February 2023 private treatment note reflecting a diagnosis of recurrent sinusitis. See February 6, 2023 Private Progress Note Assessment (uploaded as Medical Treatment Record-Non-Government Facility on July 18, 2024)

" VA treatment notes reflecting chronic sinusitis and the Veteran's approval for budesonide for chronic sinusitis causing midfacial pressure and pain, sinus headaches, nasal congestion, post-nasal drainage, and upper teeth pain. See June 23, November 6, 2023 VA Treatment Records (uploaded June 28, 2024)

(b) Then, if a diagnosis of recurrent/chronic sinusitis is confirmed, opine whether sinusitis had its onset during active service or is related to any incident of service.

The examiner must address the Veteran's in-service treatment for diagnoses of sinusitis and sinobronchial syndrome.

3. Then, forward the Veteran's claims file to a VA examiner of appropriate expertise, to provide an addendum medical opinion addressing the nature and etiology of the Veteran's OSA. The examiner must review the claims file in its entirety and the review should be noted in the report. An examination should only be scheduled if deemed necessary by the examiner.

The examiner should:

(a) Opine whether obstructive sleep apnea had its onset during active service or is related to any incident of service.

The examiner must address statement from the Veteran's husband that she has snored excessively since they were married in June 1995 and that this has been ongoing since. He has witnessed her stop breathing for short periods during her sleep and has had to shake her awake on several occasions to get her to start breathing again. See June 10, 2011 Buddy Statement

The examiner must address statement from the Veteran that she has a history of morning headaches and dry mouth and is unsure if her sinus episodes have anything to do with her sleep apnea but she is fatigued during the day and husband tells her she has snored and gasped for air at night since 1995. She has had excessive weight gain throughout her career starting in 1990 and has been told this may be due to underlying sleep apnea. See June 10, 2011 Statement in Support of Claim

(b) Opine whether the Veteran's sleep apnea was caused by her service-connected allergic rhinitis?

(d) Opine whether the Veteran's sleep apnea was caused by claimed sinusitis?

(e) Opine whether the Veteran's sleep apnea was aggravated by claimed sinusitis?

Both causation and aggravation must be addressed, and the clinician must offer separate opinions for both.

The examiner must address the December 2024 VA examiner's opinion that, "[t]hough having history of rhinitis and chronic sinusitis can worsen symptoms it is not a cause for her symptoms in this case after reviewing x-ray."

The examiner should note in the context of secondary service connection, aggravation means any increase in disability. Ward v. Wilkie, 31 Vet. App. 233, 239 (2019).

A complete rationale for all opinions expressed must be provided.

The Board emphasizes that it is not determining whether or not the Veteran's statements in
's sleep apnea was aggravated by claimed sinusitis?

Both causation and aggravation must be addressed, and the clinician must offer separate opinions for both.

The examiner should note in the context of secondary service connection, aggravation means any increase in disability. Ward v. Wilkie, 31 Vet. App. 233, 239 (2019).

A complete rationale for all opinions expressed must be provided.

The Board emphasizes that it is not determining whether or not the Veteran's statements in support of her claims are credible at this time, as the additional development set forth in the remand directives could impact that determination. Although the Board is requesting a medical opinion regarding the claims, this is for thoroughness and not based on a finding as to credibility.

LESLEY A. REIN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board C. Gates

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.

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