RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01972
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080703

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Watercraft Operator) medically separated for chronic pelvic pain secondary to polycystic ovarian disease.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  A profile allowed for an alternate aerobic event to satisfy physical fitness standards.  She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic pelvic pain” and “polycystic ovarian disease” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated chronic pelvic pain secondary to polycystic ovarian disease as unfitting, rated 10%, with lapplication of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  “The applicant makes no specific contention in her application.  Her complete submission is at Exhibit A.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

 IPEB - Dated 20080501	VA* - (~6 Days. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pelvic Pain Secondary to Polycystic Ovarian Disease…	7615	10%	Polycystic Ovarian Syndrome (Also Claimed as Pelvic Pain)	7615	10%	20080627	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 12 (equals SC, NSC & deferred)	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20080828 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Pelvic Pain Condition.  The service treatment record (STR) documented polycystic ovary syndrome (PCOS) diagnosed by three laparoscopic exams.  Findings associated with PCOS are ovulatory dysfunction (infrequent ovulation [oligoovulation] and/or absent ovulation [anovulation]), clinical and/or biochemical signs of hyperandrogenism (excess male hormone), and polycystic ovaries (by diagnostic imaging or surgery).  Clinical hyperandrogenism manifests with hirsutism (excessive male-pattern hair growth) and treatment-resistant acne.  Polycystic ovaries are characterized by excessive ovarian size and follicle number.  Transabdominal and endovaginal ultrasounds of the pelvis were normal and showed unremarkable appearing ovaries.  A gynecology encounter documented a strong family history of endometriosis (uterine lining [endometrium] implanted outside of uterus).  The CI complained of severe pelvic pain, predominantly around her menses (menstrual cycles), concerning for endometriosis.  Based upon family history and clinical symptoms, the CI was treated with a medication (Danazol) that causes regression and atrophy (wasting or decrease in size) of ectopic (occurring at abnormal site) endometrial tissue.  A follow-up gynecology encounter noted “She is currently on Metformin [PCOS "off-label" treatment for oligomenorrhea, hirsutism, infertility, obesity, and prevention of type 2 diabetes mellitus] and has noted a marked improvement of her pain.  Her menses are regular and now not significantly painful.”  A diagnostic laparoscopy and examination under anesthesia showed minimal polycystic ovaries (decreased compared to previous exams) present bilaterally.  There were no endometriosis lesions, lesions, or scar tissue present.  The narrative summary recounted the history and interventions.  The CI complained of long-standing and significant daily pelvic pain.  Multiple diagnostic laparoscopes revealed polycystic ovaries and no other significant pathology.  Several suppressive medications provided variable relief.  The physical exam revealed lower abdominal tenderness.  The pelvic exam demonstrated cervical motion tenderness.  The uterus was normal size and tender.  Palpation of the adnexa (uterine appendages [ovaries, Fallopian tubes, and ligaments]) revealed tenderness bilaterally with no masses.  The diagnosis listed PCOS and chronic pelvic pain.  

The VA Compensation and Pension (C&P) exam recounted the history and interventions.  The CI reported a clinical diagnosis of endometriosis, but none had been visualized on three laparoscopic exams for pelvic pain.  The CI had had pelvic pain and she took an opioid (Vicodin) as needed.  She denied any functional impairment from this condition.  The CI reported PCOS diagnosed by laparoscope.  She complained of irregular menses (twice a month) which could not be controlled by treatment.  She reported no pelvic pain and denied any functional impairment from this condition.  The abdominal exam revealed no striae (stretch marks), distension of superficial veins, ostomy (surgically created opening), tenderness, splenomegaly (spleen enlargement), liver enlargement, ascites (abnormal fluid accumulation in the abdomen), or aortic aneurysm (enlargement/dilation of the aorta).  The examiner documented for the CI’s claimed conditions of endometriosis, PCOS, and pelvic pain, there were no diagnoses because there was no pathology to render diagnoses.

The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB rated the pelvic pain condition 10% (VA code 7615; ovary, disease, injury, or adhesions of; symptoms that require continuous treatment).  The PEB cited chronic pelvic pain secondary to polycystic ovarian disease, confirmed by laparoscopy, abdominal and pelvic tenderness by physical exam, opioids required for control of symptoms, and symptoms requiring continuous treatment.  The VARD, citing the C&P exam a week before separation, rated the pelvic pain condition 10% (7615).  The VARD cited pelvic pain, laparoscopy which showed polycystic ovaries, irregular bleeding, Metformin prescribed for PCOS, Toradol, Ultram, and opioids prescribed for pain, no abdominal tenderness by physical exam, pelvic exam declined, physician unable to provide a diagnosis because no pathology was present, and symptoms that required continuous treatment.  Board members agreed that symptoms in the proximate exams more closely approximated the 10% (require continuous treatment) than 30% (not controlled by continuous treatment) rating.  Her symptoms were intermittent as they were related to her irregular menses.  Symptoms were previously controlled with chronic medications and then treated, as needed, with opioids.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the pelvic pain condition.  

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of pelvic pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140502, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		
MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX AR20160004359 (PD201401972)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA