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M21-1, Part III, Subpart iv, Chapter 4, Section J – Disabilities of the Gynecological System and Breast

Overview


In This Section

This section contains the following topics:
Topic Topic Name

1

Female Sexual Arousal Disorder (FSAD)
2 Other Gynecological Disorders

3

Disorders of the Breast

 

1.  Female Sexual Arousal Disorder (FSAD)


Introduction

This topic contains information about evaluating FSAD, including


Change Date

May 14, 2018

III.iv.4.J.1.a.Definition:  FSAD

Female Sexual Arousal Disorder (FSAD) refers to the continual or recurrent physical inability of a woman to accomplish or maintain an ample lubrication-swelling reaction during sexual intercourse.  Decreased blood flow to the genital area is believed to contribute to FSAD similar to the role of vascular disease in male erectile dysfunction.  Other causes may include nerve and/or tissue damage.

Important:
  • FSAD is a physical disorder characterized by physiological findings/damage to the gynecological system.  It is not a psychiatric condition found in the Diagnostic and Statistical Manual, fifth version (DSM-5) for mental disorders.  DSM-5 does include a diagnosis of female sexual interest/arousal disorder, which is a different disorder and is not synonymous with FSAD.
  • A diagnosis of FSAD cannot be rendered or confirmed by a mental health examiner.  When a mental health examination or mental health treatment records suggest a diagnosis of FSAD, including FSAD secondary to medication for a psychiatric disorder, the diagnosis must be confirmed in other medical evidence by a qualified medical professional.

III.iv.4.J.1.b.Requesting Examinations for FSAD Claims

The Gynecological Conditions Disability Benefits Questionnaire (DBQ) is the appropriate DBQ to order when a Department of Veterans Affairs (VA) examination is necessary to assist in substantiating a claim of FSAD or other female sexual dysfunction.
Notes:
  • If the Veteran claims service connection (SC) for FSAD or other sexual dysfunction and the exam threshold described in 38 CFR 3.159(c)(4) is met, request the examination using the Gynecological ConditionsDisability Benefits Questionnaire.
  • The Gynecological Conditions Disability Benefits Questionnaire includes a specific section concerning FSAD that includes a request for the examiner to identify whether
    • the Veteran has FSAD, and
    • FSAD, if present, is at least as likely as not attributable to another condition.
  • In all cases, if an examiner diagnoses FSAD, the Gynecological Conditions Disability Benefits Questionnaire must be completed or sufficient alternative evidence (such as private medical evidence submitted in lieu of an examination) must be of record.
  • Some DBQs have not yet been updated to include language addressing the presence of FSAD when it is otherwise appropriate to address as a disability associated with another disability or disease.  When requesting the following DBQs for a female Veteran, add the language noted in italics below:
    • Diabetes Mellitus Disability Benefits Questionnaire
    • Parkinson’s Disease Disability Benefits Questionnaire
    • Amyotrophic Lateral Sclerosis (ALS—Lou Gehrig’s Disease) Disability Benefits Questionnaire
    • Central Nervous System and Neuromuscular Diseases Disability Benefits Questionnaire
    • Multiple Sclerosis (MS) Disability Benefits Questionnaire
Does the Veteran have female sexual arousal disorder (FSAD) that is at least as likely as not attributable to [claimed condition]?  If yes, please complete the Gynecological Conditions DBQ.

III.iv.4.J.1.c.  Within Scope Determinations for FSAD
If SC for FSAD is not expressly claimed, consider FSAD within scope of the claim in the circumstances described in the table below.
When …
Then consider FSAD within scope of the …
the gynecological conditions DBQ indicates that FSAD is attributable to the claimed gynecological disorder
claimed gynecological disorder.
Note:  When a gynecological disorder is claimed, the examiner must address whether FSAD is present and if it is related to the claimed gynecological disorder as noted in M21-1, Part III, Subpart iv, 4.J.1.b.
a mental health examination indicates a diagnosis of FSAD is present and provides possible nexus information linking it to medication or treatment for a mental health disorder
claimed mental health condition.
Note:  The diagnosis of FSAD must be confirmed by an appropriate non-mental health examiner.  Analyze the evidence of record to determine whether the criteria under 38 CFR 3.159(c)(4) are satisfied to request further examination of FSAD.
other evidence submitted with the claim leads to a within scope determination for FSAD as described at M21-1, Part III, Subpart iv, 6.B.2.c
claimed condition.

III.iv.4.J.1.d.Evaluating FSAD
When the requirements are met, SC for FSAD will be awarded as a stand-alone gynecological disability using 38 CFR 4.116, diagnostic code (DC) 7632 with a 0-percent evaluation.  This is the maximum evaluation available for FSAD.
Note:  The original clarification that FSAD is a disorder subject to SC was not a regulatory change.  Consequently, the provisions of 38 CFR 3.114 do not apply for assignment of the effective date.  Subsequent updates to 38 CFR 4.116, including the addition of DC 7632 for FSAD, effective May 13, 2018, are, similarly, not liberalizing.
Reference:  For more information on considering special monthly compensation (SMC) associated with FSAD, see M21-1, Part III, Subpart iv, 4.J.1.e.

III.iv.4.J.1.e.  Considering SMC Associated With FSAD

Entitlement to SMC (k) for loss of use of a creative organ will be inferred and awarded whenever SC for FSAD is granted.
Note:  If SC was previously established for FSAD but SMC was not awarded, place entitlement to SMC at issue and grant.  The effective date for the award of SMC will be the date SC for FSAD was established.

2.  Other Gynecological Disorders


Introduction

This topic contains information about evaluating other gynecological disorders, including


Change Date

May 14, 2018

III.iv.4.J.2.a.  SC for Disorders of Menstruation

A disease or injury resulting in ovarian dysfunction affecting the menstrual cycle, such as dysmenorrhea and secondary amenorrhea, can be service-connected (SC).  Evaluate using 38 CFR 4.116, DC 7615.
Note:  SC cannot be established for primary amenorrhea, which would not, by definition, be incurred or aggravated by service.

III.iv.4.J.2.b.  Evaluating Pelvic Organ Prolapse

Apply the principles below to evaluate pelvic organ prolapse.
  • Do not assign multiple evaluations under 38 CFR 4.116, DC 7621 for prolapse of multiple pelvic organs.
  • When prolapse is incomplete or complete, assign a 10-percent evaluation.  In addition, evaluate residual disabilities or symptoms under the corresponding DC and combine, as usual, under 38 CFR 4.25.
Example:  SC is warranted for pelvic organ prolapse.  Examination shows that, as a result of complete prolapse, the Veteran also experiences urinary incontinence requiring the wearing of absorbent materials that must be changed twice daily, impairment of sphincter control resulting in slight leakage, and localized dermatitis affecting less than five percent of body area that is treated with topical therapy.  The following evaluations will be established for the pelvic organ prolapse and residuals:
Note:  Prior to the changes to 38 CFR 4.116, effective May 13, 2018, these conditions were evaluated under 38 CFR 4.116, DC 7621 to 7623.
References:  For more information on

III.iv.4.J.2.c.  Malignant Neoplasms of the Gynecological System

Separate 100-percent evaluations will be assigned for both active gynecological cancer and active breast cancer.  Metastasis of a gynecological cancer or breast cancer to a different body system will also be evaluated separately.
Consider corresponding entitlement to SMC.
References:  For more information on

III.iv.4.J.2.d. Disfigurement Due to Benign or Malignant Neoplasms

Do not evaluate disfigurement due to benign or malignant neoplasms of the gynecological system analogous to 38 CFR 4.118, DC 7800.  DC 7800 is for evaluation of disfigurement of the head, face, or neck only.

III.iv.4.J.2.e.Cervical Dysplasia

Do not routinely award SC for cervical dysplasia, also referred to as cervical intraepithelial neoplasia (CIN).  Cervical dysplasia/CIN is not a disease or injury.  It is a cellular abnormality of the cervix revealed by Papanicolaou (Pap) smear testing that generally resolves without treatment or residuals.  In these cases, there is an abnormal laboratory finding but no disability, and SC is not warranted.
SC may be warranted if cervical dysplasia/CIN
  • requires treatment that leaves residuals, or
  • is linked to the subsequent development of cervical cancer.
Use the table below to determine the appropriate actions to take when SC is claimed following an in-service confirmed finding of cervical dysplasia/CIN.
If medical evidence shows the subsequent development of … Then award SC for …

Additional Information to Consider

  • chronic or severe dysplasia/CIN requiring treatment, and
  • chronic residuals of the required treatment
residuals of cervical dysplasia/CIN. Common procedures for treatment of chronic or severe dysplasia/CIN include

  • cauterization
  • laser surgery
  • cryosurgery, or
  • loop electrosurgical excision procedure (LEEP).
  • cervical cancer,and
  • a link between the in-service dysplasia/CIN and the cancer
cervical cancer and/or residuals. In-service cervical dysplasia that resolved without residuals is less likely to be related to later-developing cervical cancer.  However, these cases require a medical opinion to determine whether a relationship exists between the conditions.
Note:  Cervical dysplasia is often associated with human papillomavirus (HPV) infection.  There are over 60 types of HPV infection, and only certain types are associated with high-grade cervical dysplasia and cancer.
Reference:  For more information on considering claims for SC of HPV and/or genital warts, see M21-1, Part III, Subpart iv, 4.J.2.f.

III.iv.4.J.2.f.  HPV

Do not routinely award SC for HPV infection.  Usually, HPV infections are asymptomatic and identified only as a finding on a Pap smear.  Most resolve spontaneously without residuals requiring only periodic pap smears for follow-up.  In these cases, there is an abnormal laboratory finding but no disability, and SC is not warranted.
SC may be warranted if a disability develops as a result of an in-service HPV infection.  Two circumstances that may warrant SC are
  • genital warts that are shown in service or by nexus to be associated with the HPV infection, and
  • HPV resulting in persistent infection that progresses to cervical dysplasia and subsequently to cervical cancer.
Important:  A medical nexus is required to establish an association between genital warts and in-service HPV infection or between cervical cancer and in-service HPV infection.
Note:  There are multiple varieties of HPV infection which can cause common warts, plantar warts, and other findings.  HPV is not limited to sexual transmission.
References:  For more information on

3.  Disorders of the Breast


Introduction

This topic contains information about evaluating disorders of the breast, including


Change Date

May 14, 2018

III.iv.4.J.3.a.  Malignant Neoplasms of the Breast

Malignant neoplasms of male or female breast tissue (38 CFR 4.116, DC 7630) are evaluated at 100 percent for active cancer.
For female Veterans, consider corresponding entitlement to SMC.
Important:  Separate 100-percent evaluations will be assigned for both active gynecological cancer and active breast cancer.  Metastasis of a gynecological cancer or breast cancer to a different body system will also be evaluated separately.
References:  For more information on

III.iv.4.J.3.b. Disfigurement Due to Benign or Malignant Neoplasms

Do not evaluate disfigurement due to benign or malignant neoplasms of the breast analogous to 38 CFR 4.118, DC 7800 unless there is actual disfigurement of the head, face, or neck.  DC 7800 is for evaluation of disfigurement of the head, face, or neck only.

III.iv.4.J.3.c. Fibrocystic Breast Disease

Do not routinely award SC for fibrocystic breast disease.  Although this condition is termed a disease, it is actually a physiologic finding that is generally acute and transient.  In the absence of associated pathology, SC is not warranted.  Additionally, fibrocystic breasts are not associated with increased risk of breast cancer unless the changes are associated with atypical hyperplasia.
Examples of associated pathology that may warrant SC for fibrocystic breast disease are
  • persistent lumps or thickening requiring surgical excision, or
  • fibrocystic breast changes with associated atypical hyperplasia.
Use the table below to determine when SC for pathology associated with claimed fibrocystic breast disease is warranted as well as the proper DC to use in the evaluation.
If the service treatment records show … And medical evidence shows … Then award SC for …
fibrocystic breasts continuous symptoms and/or nexus to subsequent post-service excision of persistent lumps or thickening residuals of surgery under appropriate DCs including

fibrocystic breasts
  • the (in-service or post-service) development of atypical hyperplasia associated with the fibrocystic breasts
  • subsequent development of breast cancer, and
  • nexus between the fibrocystic breasts with associated atypical hyperplasia and the development of breast cancer
breast cancer and/or residuals under appropriate DCs including


III.iv.4.J.3.d.  Elective Breast Surgery

Breast surgeries that are not medically necessitated, such as reduction mammoplasty for cosmetic purposes and any expected residual effects thereof, arenot subject to SC. Such procedures are considered elective surgeries and therefore do not meet the provisions of a disease or injury incurred coincident with service.
Important:  If reduction mammoplasty is recommended to alleviate physical discomfort, such as back, shoulder, or neck pain, SC should be considered on the basis of aggravation only, and if so established, SMC (k) would be payable if the resultant tissue loss meets the requirements of the statute.
References:  For more information about

III.iv.4.J.3.e.  Gynecomastia
SC may be established for gynecomastia when the evidence shows that it was incurred in or caused by military service.  However, consideration must be given to whether there is clear evidence that the condition existed prior to service.
Evaluate gynecomastia depending on symptoms and/or pre- or post-surgical resection status under
Note:  Under 38 CFR 4.116, DC 7626, no more than a noncompensable evaluation can be assigned as there is no significant alteration in size or form since the removal of excess tissue results in a return to breast size within normal limits for a human male.
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