Review of VA claims file; Notice of disagreement with multiple statements from [REDACTED] VA outpatient treatment records from 1991- 2000; Reports of VA examinations December 8, 1999 and February 12, 2000; Medical evaluation by Dr. C. N. Bash October 3, 2000.
Service connection for polyc:ystic ovary syndrome is granted and is rated with the residuals of the cystic mass with left salpingo oophrectomy and a 30 percent evaluation is assigned effective April 17, 1998. The acne, hirsuitism and alopecia are rated separately and a 30 percent evaluation is assigned effective April 17, 1998.
REASONS AND BASES
[REDACTED] had active military service in the US Army from May 1988 to May 1990. Service connection has been in force for a ovarian mass with removal of the left ovary which has been evaluated 10 percent disabling since May 9, 1990 with entitlement to special monthly compensation due to anatomical loss of a creative organ. A decision by a decision review officer granted service connection for bilateral pes planus and other orthopedic conditions due to the pes planus which resolved a portion of her appeal but the issue of service connection for polycystic ovarian syndrome has not been resolved.
Service connection for polycystic ovary syndrome has been established as directly related to nilitary service. This condition is evaluated as 30 percent disabling from April 17, 1998. An evaluation of 30 percent is assigned whenever there is evidence of symptoms not controlled by continuous treatment.
A VA examination done in October 1998 noted that an exploratory laparotomy was done in the past with a left salpingo-oophorectomy due to a large ovarian cyst and reported that she has had irregular periods since the surgery and was told in I 995 that she might have polycystic ovary disease. An abdominal ultrasound revealed a complex right ovruian mass but a diagnostic laparoscopy was done which was negative. Since February 1998, she reported muscle spasms on the right side of the abdomen with continued irregular bleeding with facial acne treated with Doxycycline.. The physical examination showed her skin was clear and the pelvic examination found no obvious abnormalities. Assessment was normal gynecologic examination and the examiner stated that it was doubtful that her irregular menses are due to the surgery and . also doubted that the acne wa:, secondary to the menstrual difficulties.
VA outpatient treatment reports show complaints of irregular menses when seen on May 28, 1992 diagnosed as dysmenorrhea with con1inuing dysfunctional bleeding despite using birth control with recent pattern of heavy bleeding for a week and a half followed but no bleeding for two and one half weeks followed by bleeding for two and one half weeks. A report dated April 14, 1993 noted some skin changes due to electrolysis on inner thigh and facial areas. A report dated February 3, 1994 showed continued bleeding which occurred every day after the second Depo Provera injection with considerable dyspareunia. An ultrasonography-ofthe pelvis done on October 3, 1995 again suggested some changes in the right ovary but etiology was not determined but later thought to be a follicular cyst but a laparoscopy done in December 1995 was unremarkable. Treatment records in May 1998 confirmed increased menstrual bleeding for the past eight years with a trial of several types of birth control pills during recent months without relief of the symptoms. The physical examination showed diffuse abdominal tenderness. Diagnosis was polymenorrhea and further followup was recommended. A report dated December 18, 1998 confirmed ongoing menstrual bleeding with cycles occuning every 17-18 days with increased premenstrual symptoms, bloating, cramping and mood swings. Diagnrn;is was again polymenorrhea. A report dated January 12, 1999 noted that a diagnosis of polycystic ovarian disease was being considered and a subsequent report dated March 18, 1999 diagnosed polycystic ovarian disease with hypermenorrhea. A report dated May 20, 1999 noted acne on her face and back present for the past year with some patches of post inflammatory lesions on her forehead and cheeks but no active lesiorn;. A report dated June 17, 1999 diagnoses polycystic ovary disease and notes continuing heavy menstrual bleeding for the past five to seven years usually lasting 17 days and has tried Depo Prov era and several types of birth control pills without success but some recent moderation of the bleeding but no change in the duration of her cycles. A report dated October 15, 1999 noted the history of polycystic ovary disease with dysmenorrhea with abnormal hair growth on her face including sideburns and upper lip and on her breasts which she has been treating with electrolysis with some thinning of her hair on the crown of her head and facial and chest acne as well treated with topical antibiotics. The examiner related the alopecia to the polycystic ovary disease on a more likely than not basis.
AV A examination was requested for the purpose of determine if the polycystic ovary s:yndrome began in service. The report of the VA examination done on March 31, 2000 confirms that the examiner considered the issue and reviewed medical literature which she stated are "prospective" studies and stated that she was unable to link the condition to the ovary disease for which she was treated in service and was only able to state that there is a possibiliyy of onset in service relative to the removal of the left ovary.
An independent medical opinion was submitted completed by Dr. C. N. Bash. The report dated October 3, 2000 confirmed that Dr. Bash reviewed the record including the service medical records, post service medical records and pertinent medical literature. Dr. Bash opined that [REDACTED] in service symptoms of irregular menses and cystic left ovary represent the first signs and symp oms o polycystic ovary disease syndrome. Dr. Bash reviewed the records including her service medical records citing records in 1989 and into 1990 and post service records through August 1990 to support his conclusions and also stated his belief that the examiner who completed the VA examination in March 1990 misconstrued the facts since she was treated in service for irregular and heavy menses which pre dated the removal of the left ovary with subsequent laboratory resuUs consistent with ovarian polycystic syndrome.
In accessing the evidence [REDACTED] currently has polycystic ovary syndrome. The record shows that she did develop irregular menses in service with removal of the left ovary in September 1989 and post service records show continuing problems with heavy and irregular menses following her separation from service in May 1990. A VA examination done in October 1998 found no link between service and the polycystic ovary syndrome. Another VA examination was done in March 2000 to determine if there is a link between the symptoms noted in military service and the polycystic ovary syndrome but the examiner stated that there is only a possibility that the disease began in service but was not able to reach any clear conclusion. Dr. Bash reviewed the same evidence and has provided a persuasive argument that the polycystic ovary syndrome did have its origins in military service. There are three medical opinions of record for consideration wllich include the initial report which finds no linkage, the second report in March 2000 in which the examiner could reach no conclusion and the report by Dr. Bash which establishes a clear relationship between military service and onset of the polycystic ovary s dro there is at least a balancing of the evidence for and against, reasonable doubt is resolved in [REDACTED] favor in granting service connection for this disability effective the date of the claim filed on April 17, 1998. As to the evaluation warranted for this condition, the polycystic ovary syndrome is rated with the residuals of the removal of the left ovary and the evaluation is increased to 30 percent since the symptoms including the heavy, prolonged and irregular menses are not controlled by the various medications which have been tried over the years. She also has increased hair growth on her face, chest, and thigh with some alopecia on the crown of her head. There is .:llso evidence ofpigmentary changes in the facial areas which is a residual of the electrolysis to remove the unwanted hair. The records show some acne as well which is also part of the polycystic ovary syndrome affecting the facial area and torso treated with topical antibiotics. For want of a closer condition listed in the Schedule For Rating Disabilities, the acne is rated as eczema under 38 CFR 4.118, diagnostic code 7806. This particular diagnostic code also provides VA compensation for cosmetic deformity due to dermatitis which is also pertinent in this case because of the hirsuitism and alopecia. The record shows some thinning of the hair at the crown and hair growth on the facial areas including the sideburns and upper lip and aho of the chest and inner thigh which she has treated with electrolysis which left some pigmentary changes. Considering all these elements including the acne, abnormal hair grown and the thinning of the hair, a 30 p,ercent evaluation is assigned since there is probably a marked cosmetic deformity or degree of disfigw-ement due to this manifestation of the polycystic ovary syndrome. The higher evaluation of 50 percent is not assigned since the evidence does not show extensive acne with systemic or nervous manifestations or an exceptional degree of cosmetic deformity.
Since the decision by the decision review officer grants service connection for the polycystic ovary syndrome [REDACTED] notice of disagreement is now resolved.