UTERUS DISEASE OF

THOMAS L. ENGLISH · 2026 · Case ID: 26004669

MIXED

Summary

The Veteran served in the Army from July 1975 to August 1981, with subsequent service in the Army National Guard. The Veteran appealed the denial of service connection for residuals of a hysterectomy, urinary incontinence, a heart disorder, and COPD. The Board granted service connection for residuals of a hysterectomy, finding it was at least as likely as not that the condition manifested during service with continuity of symptoms, supported by post-service treatment records and the Veteran's lay testimony. Service connection for urinary incontinence was also granted, found to be secondary to the hysterectomy residuals, based on a December 2021 DBQ. The claims for a heart disorder and COPD were remanded due to inadequate nexus opinions. The October 2024 VA opinions were found contradictory and conclusory, failing to adequately address TERA exposure, secondary causation, or aggravation. The remand directs new opinions on the etiology of the heart condition and COPD, considering TERA exposure, medical history, and potential secondary links to service-connected conditions or medications, requiring separate rationales for causation and aggravation.

Rationale

Resolving all reasonable doubt in the Veteran's favor; At least as likely as not (approximate balance of evidence); Continuity of symptoms since active service; Supported by post-service treatment records and lay evidence

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

15-31 492

Full Decision Text

Citation Nr: 26004669
Decision Date: 04/17/26 Archive Date: 04/17/26

DOCKET NO. 15-31 492
DATE: April 17, 2026

ORDER

Service connection for residuals associated with a hysterectomy is granted.

Service connection for urinary incontinence (claimed as a kidney disorder and overactive bladder) is granted.

REMANDED

Service connection for a heart disorder, to include as secondary to a service-connected disability and/or exposure to toxic chemicals, is remanded.

Service connection for chronic obstructive pulmonary disease (COPD), to include as secondary to a service-connected disability and/or exposure to toxic chemicals, is remanded.

FINDINGS OF FACT

1. Resolving all reasonable doubt in the Veteran's favor, it is at least as likely as not her gynecological condition manifested during active-duty service with a continuity of symptomology since active service.

2. The Veteran's urinary incontinence is secondary to her now service-connected residuals associated with a hysterectomy.

CONCLUSIONS OF LAW

1. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for residuals associated with a hysterectomy have been met. 38 U.S.C. §§ 1110, 1111; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309.

2. The criteria for service connection for urinary incontinence as secondary to the Veteran's now service-connected residuals associated with a hysterectomy have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from July 1975 to August 1981 and served in the Army National Guard from June 1996 to August 2004, with periods of active and inactive duty for training.

These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO).

In her August 2015 substantive appeal, the Veteran requested a Travel Board hearing. However, in November 2017, the Veteran's attorney withdrew this hearing request. 38 C.F.R. § 20.704 (e).

This appeal was previously before the Board in February 2019, February 2021, October 2022, April 2023, and August 2024.

Service Connection

Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a).

In some cases, service connection may be established by showing evidence of a chronic disease in service, which requires a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303 (b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. The provisions of 38 C.F.R. § 3.303 (b) pertaining to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized under 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Service connection may also be granted for any disease diagnosed after discharge, when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d).

In order to establish service connection for a claimed disorder on a direct basis, there must be competent evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

A claim for secondary service connection requires medical evidence that connects the asserted secondary disability to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998). To establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v
between the current disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

The United States Court of Appeals for Veterans Claims (Court) held in the case of Ward v. Wilkie, 31 Vet. App. 233 (2019), that aggravation pursuant to 38 C.F.R. § 3.310 does not require a permanent worsening of the condition. Rather, the Court explained, "aggravation" is any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase, regardless of its permanence. Id.

A claim will be denied if the evidence persuasively weighs against the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 3.102.

1. Service connection for residuals associated with a hysterectomy is granted.

The Veteran contends service connection is warranted for residuals associated with a hysterectomy. See July 2013 Notice of Disagreement. For the reasons detailed below, the Board finds service connection is warranted as it is approximately at least as likely as not (an approximate balance of positive and negative evidence) that the record indicates a continuity of symptoms since separation from active service.

As to a current diagnosis, a December 2021 Gynecological Conditions Disability Benefits Questionnaire indicates a diagnosis of a hysterectomy with residual scarring and urinary incontinence.

Regarding an in-service event, the Veteran's available service medical records confirm she was treated for several gynecological-related issues, including heavy bleeding and treatment.

Post-service treatment records show continued gynecological problems shortly after service. Specifically, July 1982 VA treatment records show the Veteran reported experiencing abdominal pain over several months and reflect an assessment of an ovarian cyst. Subsequent VA treatment records dated in October 1982 and February 1985 show continued treatment for ovarian cysts until the Veteran ultimately underwent a total hysterectomy in June 1988 due to recurrent dysfunctional uterine bleeding.

As to a nexus, VA received a negative etiological opinion for direct service connection in October 2024. For their rationale, the examiner finds no evidence of in-service chronic and continuous treatment or care or a diagnosis rendered within twelve months of separation from active duty. They also note the Veteran's separation examination is negative or silent for "the claimed condition." The examiner goes on to note the "referenced treatment" occurred during post-discharge.

The Board does not find the October 2024 negative nexus opinion to be probative because the examiner's opinion does not appear to address the post-service medical evidence or the lay evidence of record from the Veteran indicating a continuity of symptoms since active service.

In this case, the Veteran is competent to describe in-service events and observable symptomology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). As such, given the documentation within the Veteran's post-service records, the Board, resolving all reasonable doubt in the Veteran's favor, finds it is at least as likely as not her gynecological condition manifested during active-duty service with continuity of symptomology since active-duty service.

Thus, the Board finds it is approximately at least as likely as not the Veteran's gynecological condition manifested during active-duty service with continuity of symptomology since discharge. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker, 708 F.3d at 1338-39. As such, entitlement to service connection for residuals associated with a hysterectomy is granted.

2. Service connection
such, given the documentation within the Veteran's post-service records, the Board, resolving all reasonable doubt in the Veteran's favor, finds it is at least as likely as not her gynecological condition manifested during active-duty service with continuity of symptomology since active-duty service.

2. Service connection for urinary incontinence (claimed as a kidney disorder and overactive bladder) is granted.

The Veteran contends service connection is warranted for "urinary frequency." See July 2013 Notice of Disagreement. For the reasons detailed below, the Board finds service connection is warranted.

Regarding this, the Board observes the December 2021 Gynecological Conditions Disability Benefits Questionnaire reflects the examiner indicates the Veteran has urinary incontinence or leakage in addition to a diagnosis with a total hysterectomy with an overactive bladder.

Accordingly, in this case, the medical evidence indicates the Veteran's urinary condition is secondary to her now service-connected residuals associated with a hysterectomy, and thus, entitlement to service connection for a urinary condition as secondary to the now service-connected residuals associated with a hysterectomy is warranted. 38 C.F.R. 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

REASONS FOR REMAND

1. Service connection for a heart disorder, to include as secondary to a service-connected disability and/or exposure to toxic chemicals, is remanded.

The Veteran contends service connection is warranted for a heart condition. See July 2013 Notice of Disagreement.

As to this, the Board received a negative nexus opinion for direct service connection in October 2024. The examiner notes the Veteran has been diagnosed with valvular heart disease and bradycardia with a first-degree heart block. They note valvular heart disease can be caused by cardiac conditions, hyperlipidemia, smoking, congenital factors, and age, and bradycardia is a heart rate less than 60 beats per minute, which can be caused by age, heart conditions, and other medications. The examiner finds the Veteran's heart-related conditions are consistent with age-related changes and current co-morbidities of hypertension, hyperlipidemia, and age. They find no medical or scientific evidence available that provides any indication of a relationship between the development of the Veteran's heart-related conditions and her presumed TERA exposure. Instead, the examiner finds the risk factors outside of active service far outweigh the factors identified in the TERA such as hypertension, hyperlipidemia, age, and genetics. The examiner concludes by stating, "The claimed heart disorder condition was less likely than not (likelihood is less than approximately balanced or nearly equal) that there is a nexus between the Veteran's chronic obstructive pulmonary disease and the TERA."

For several reasons, the Board finds the October 2024 negative nexus opinion to be inadequate. First, the examiner finds no medical or scientific evidence available that provides any indication of a relationship between the development of the Veteran's heart-related conditions and the Veteran's presumed TERA exposure. However, the examiner then finds the risk factors outside of active service far outweigh the factors identified in the TERA. In one sentence the examiner finds no "medical or scientific evidence" as to a relationship between the Veteran's hear-related conditions and her presumed TERA exposure but then indicates factors outside of active service "outweigh the factors identified in the TERA." As a result, the examiner makes contradictory findings. Secondly, the examiner states, "The claimed heart disorder condition was less likely than not (likelihood is less than approximately balanced or nearly equal) that there is a nexus between the Veteran's chronic obstructive pulmonary disease and the TERA." Thus, the examiner inaccurately states their conclusion.

VA received another negative nexus opinion as to direct service connection in October 2024. The examiner notes the reports of symptoms occurred post-discharge from active duty, and they state the most recent VA treatment records deny chest pain. The Board also finds the October 2024 to be inadequate because while the examiner finds the Veteran's reports of symptoms occurred post-service, they provide no rationale as to why the reports could be or could not be related to the Veteran's active service to include their presumed TERA exposure. Further, the denial of chest pain on its own is not dispositive as to whether service connection is warranted.

As to secondary service connection and
disease and the TERA." Thus, the examiner inaccurately states their conclusion.

As to secondary service connection and causation, VA received a negative nexus opinion in October 2024. The examiner finds the medical literature does not support the Veteran's valvular heart disease or bradycardia are caused by her service-connected psychiatric condition. However, the Board does not find nexus opinion to be probative because the examiner did not provide separate opinions and rationales for secondary causation and secondary aggravation. The Court has held causation and aggravation are independent concepts and should have separate findings and rationales. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018). Further, in their October 2024 opinion as to direct service connection, the examiner notes valvular heart disease can be caused by medications; however, they provide no discussion as to whether the Veteran's medications she takes for her service-connected conditions caused or aggravates her heart condition.

In October 2024, VA received another nexus opinion as to secondary service connection and aggravation. The examiner finds the medical literature does not support that valvular heart disease or bradycardia are aggravated by the Veteran's service-connected psychiatric condition.

The Board finds the October 2024 nexus opinion to be inadequate because the examiner's findings are mostly conclusory. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (holding an examiner may not merely list facts and conclusions with no reasoned explanation connecting the two). Further, the examiner notes, the Veteran "has been treated conservatively for cardiac conditions without invasive procedures." However, the examiner offers no explanation as to how the finding is related to the Board's prior remand directives as it seems to be unrelated to the issue.

Accordingly, a remand is warranted for new opinions consistent with the remand directives below.

2. Service connection for COPD, to include as secondary to a service-connected disability and/or exposure to toxic chemicals, is remanded.

The Veteran contends service connection is warranted for COPD. See July 2013 Notice of Disagreement.

As to direct service connection, VA received a nexus opinion in October 2024. For their rationale, the examiner finds there is no evidence of in-service chronic and continuous treatment and care or a diagnosis rendered within 12 months of separation from active service. The examiner notes the report of symptoms occurred post-discharge from active duty. They further note the main cause of COPD is tobacco smoking, for which the Veteran has a history of smoking.

The Board also finds the October 2024 to be inadequate because while the examiner finds the Veteran's reports of symptoms occurred post-service, they provide no rationale as to why the reports could be or could not be related to the Veteran's active service to include their presumed TERA exposure.

VA received another nexus opinion in October 2024. The examiner finds there is no medical or scientific evidence available that provides any indication of a relationship between COPD and the Veteran's presumed TERA exposure. The examiner placed more weight on risk factors, such as smoking and family history, outside of the military service than Veteran's presumed TERA exposure.

The Board finds the probative value of the October 2024 opinion is reduced because the examiner does not adequately address the Veteran's presumed TERA exposure. Regarding this, in their October 2024 opinion for secondary service connection, they note COPD is caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke for which the Veteran has a history. The Board notes the Veteran's presumed TERA exposure was found to consist of lead, fumes, combustion byproducts, and explosive substances. However, it's unclear why the examiner notes COPD is caused by irritating gases or particulate matter but instead only addresses it in the opinion for secondary service connection.

As to secondary service connection, VA received a negative nexus opinion in October 2024. The examiner notes the main cause of COPD is tobacco smoking, and the medical literature does not support that COPD is caused by PTSD. Therefore, it is less likely than not
they note COPD is caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke for which the Veteran has a history. The Board notes the Veteran's presumed TERA exposure was found to consist of lead, fumes, combustion byproducts, and explosive substances. However, it's unclear why the examiner notes COPD is caused by irritating gases or particulate matter but instead only addresses it in the opinion for secondary service connection.

The Board finds the probative value of the October 2024 opinion is reduced because the examiner did not provide separate opinions and rationales for secondary causation and secondary aggravation. The Court has held causation and aggravation are independent concepts and should have separate findings and rationales. See Atencio, supra.

VA received another nexus opinion as to secondary service connection in October 2024. The examiner provides a similar opinion as to the prior secondary service connection opinion. They note COPD is caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke for which the Veteran has a history. The examiner concludes by stating it is less likely than not the Veteran's COPD has been aggravated by the Veteran's service-connected PTSD. However, the Board finds the probative value of this opinion is reduced because while the examiner concludes the Veteran's COPD is not aggravated by the Veteran's service-connected PTSD, the rationale in the opinion signals as if the examiner addresses causation.

Accordingly, a remand is warranted for new opinions consistent with the remand directives below.

The matters are REMANDED for the following action:

1. Obtain any outstanding VA treatment records and any outstanding private medical records identified by the Veteran as relevant to her claim.

2. Obtain an addendum medical opinion (from an examiner different than who provided the previous opinions) to determine the nature and etiology of the Veteran's claims for service connection for a heart condition and COPD. The Board will leave it to the examiner as to whether additional examinations are warranted.

The Veteran's entire record should be made available to and reviewed by the examiner.

If the examiner finds another examination is warranted, all indicated tests should be conducted if necessary, and all findings reported in detail. The appropriate DBQ should be completed. Further, the examiner should elicit from the Veteran a complete history of her symptomatology, including any in-service symptomatology and treatment, as well as her complete post-service history of symptoms and treatment. The examiner should document this information within the DBQ.

Following a review of the record, to include the Veteran's lay statements as well as any other evidence that may be added to the record concerning onset and recurrence of symptomatology, the examiner should provide an opinion as to the following:

(a.) Whether it is approximately at least as likely as not (an approximate balance of positive and negative evidence) any heart condition or COPD had its clinical onset during active service or is related to any in service disease, event, or injury to include the Veteran's presumed TERA exposure or exposure to lead, fumes, combustion byproducts, explosive substances during service?

In rendering this opinion, the clinician is asked to consider and discuss the Veteran's total potential exposure through all applicable military deployments and the synergistic, combined effect of all toxic exposure risk activities, and their opinions must reflect consideration or discussion of the following:

i. VA treatment records showing respiratory complaints as early as February 1988;

ii. Complaints of chest pain as early as September 1988;

iii. A November 1990 VA treatment record showing an assessment of pleurisy;

iv. A March 1995 treatment record showing complaints of chest pain, thought to be related to either a possible panic attack or coronary artery disease;

v. A December 2023 memorandum showing that, in addition to lead, the Veteran is presumed to have been exposed to fumes, combustion byproducts, and explosive substances during her service; and

vi. The VA examiner's October 2024 noting COPD is caused by long-term exposure to irritating gases or particulate matter in addition to cigarette smoke.

(b.) If the answer to (a.) is in the negative, is it approximately at least as likely as not (an approximate balance of positive and negative evidence) the Veteran's heart condition or COPD was caused by a service-connected condition to include medications?

NOTE: The examiner is advised all that is needed is a "but for" causation.

In other words, would the
v. A December 2023 memorandum showing that, in addition to lead, the Veteran is presumed to have been exposed to fumes, combustion byproducts, and explosive substances during her service; and

vi. The VA examiner's October 2024 noting COPD is caused by long-term exposure to irritating gases or particulate matter in addition to cigarette smoke.

NOTE: The examiner is advised all that is needed is a "but for" causation.

In other words, would the Veteran have developed a heart condition or COPD "but for" her service-connected condition either because of an etiological link or the service-connected disability resulted in an inability to effectively treat the Veteran's heart condition or COPD?

(c.) If the answer to (b.) is in the negative, is it approximately at least as likely as not (an approximate balance of positive and negative evidence) the Veteran's heart condition or COPD is aggravated (any incremental increase in disability or any additional impairment of earning capacity regardless of its permanence) by a service-connected condition to include medications?

NOTE: The examiner is advised all that is needed is a "but for" aggravation.

In other words, would the Veteran's heart condition or COPD be less severe "but for" her service-connected condition either because there is an etiological link or the service-connected disability resulted in an inability to effectively treat the heart condition or COPD?

The examiner must provide separate opinions and rationales for secondary causation and secondary aggravation.

The clinician's opinion must reflect consideration or discussion of the following:

i. An April 1995 VA treatment record suggesting the Veteran's chest pain could be related to a psychiatric disability and

ii. The VA October 2024 examiner's opinion noting valvular heart disease can be caused by medications.

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In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements as to her in-service symptoms. The opinion must reflect consideration of the Veteran's reports as to her history and symptomatology.

The examiner must provide a comprehensive report that includes a complete rationale for all opinions and conclusions reached.

Thomas L. English

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Buck Denton

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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