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C&P Exam Prep: Benign Uterine Neoplasm (Fibroid)

DC 7631 gynecological 38 CFR 4.116

DBQ Overview

Interview + Physical
Form Name
Gynecological_Conditions
Form Code
Gynecological_Conditions
Page Count
10
Examiner Type
Gynecologist, Gynecologic Oncologist, or appropriate clinician
Estimated Duration
30-45 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To evaluate the current severity of a service-connected or potentially service-connected benign uterine neoplasm (fibroid) under Diagnostic Code 7631, assessing symptoms, functional impairment, treatment history, and impact on daily activities and employment.

What the examiner evaluates:

  • Current diagnosis and confirmation of benign uterine fibroid(s)
  • Severity and frequency of pelvic pain (mild, moderate, or severe)
  • Menstrual disturbances including heavy bleeding, irregular menstruation, and dysmenorrhea
  • Pelvic pressure or fullness symptoms
  • Presence of anemia secondary to heavy menstrual bleeding
  • Urinary symptoms (frequency, urgency, incomplete emptying) due to uterine pressure
  • Bowel symptoms related to fibroid compression
  • Treatment history including surgery, hormone therapy, interventional procedures (e.g., uterine fibroid embolization), and medications
  • Residuals or complications from treatment (e.g., post-hysterectomy changes, adhesions)
  • Functional impact on work, daily activities, and quality of life
  • Need for absorbent materials due to menorrhagia or incontinence
  • Laboratory values including hemoglobin and hematocrit if anemia is present
  • Any additional gynecological diagnoses identified during examination
  • Nexus to military service or relationship to other service-connected conditions

The exam will include both a clinical interview and a physical examination, typically including a pelvic exam. You have the right to have a chaperone present. If you are uncomfortable with any part of the exam, you may request a same-sex examiner. In most states, you have the right to record the examination on your own device - notify the examiner at the start of the appointment.

Typical duration: 30-45 minutes

Hemoglobin (HGB) and Hematocrit (HCT)

Blood values that indicate the presence and severity of anemia, which can result from chronic heavy menstrual bleeding caused by uterine fibroids.

What to expect:

A blood draw may be ordered or recent lab results reviewed. The examiner will document HGB and HCT values on the DBQ. Normal HGB for women is approximately 12.0-16.0 g/dL; below 12.0 g/dL indicates anemia.

Key thresholds:

  • HGB below 12.0 g/dL — Supports documentation of anemia secondary to fibroid-related menorrhagia, which can influence overall disability rating and may warrant a separate evaluation under DC 7700 (anemia).
  • HGB below 10.0 g/dL — Moderate to severe anemia; strengthens the case for higher disability rating and demonstrates significant functional impairment from blood loss.

Tips:

  • Bring copies of any recent CBC (complete blood count) lab results to the exam.
  • If you have experienced fatigue, lightheadedness, or shortness of breath, mention these symptoms explicitly as they may be anemia-related.
  • Ask your treating provider to document any history of iron deficiency anemia in your medical records before the exam.

Pain considerations: Anemia-related fatigue can compound pain-related functional limitations. Be sure to describe how fatigue from blood loss affects your ability to work, exercise, or complete daily tasks.

Absorbent Material Usage Assessment

The DBQ specifically quantifies how frequently absorbent materials (pads, tampons, adult incontinence products) must be changed due to menorrhagia or urinary leakage caused by fibroid pressure. This measurement directly maps to rating criteria.

What to expect:

The examiner will ask how many times per day or week you change absorbent materials. The DBQ has specific checkboxes: does not require absorbent material; changed less than 2 times per day; changed 2-4 times per day; changed more than 4 times per day.

Key thresholds:

  • Does not require absorbent material — Suggests minimal bleeding or incontinence impact; may support lower rating levels.
  • Changed less than 2 times per day — Moderate menorrhagia; supports mid-range rating considerations.
  • Changed 2-4 times per day — Significant menorrhagia; supports higher functional impairment rating.
  • Changed more than 4 times per day — Severe menorrhagia with major functional limitation; supports maximum rating considerations and documents severe impact on daily functioning.

Tips:

  • Track your actual daily usage of absorbent materials for at least two to four weeks before the exam using a calendar or notes app.
  • Report your usage on your worst or most representative days, not your best days.
  • Include both menstrual pads and any incontinence pads if you use them due to urinary leakage from fibroid pressure on the bladder.
  • If your bleeding varies, describe the full range - your lightest days AND your heaviest days - so the examiner understands the complete picture.

Pain considerations: Heavy bleeding episodes are often accompanied by severe cramping and pelvic pain. Describe how pain during these episodes prevents you from working, exercising, or leaving home.

Urinary Symptom Frequency Assessment

How frequently urinary symptoms (urgency, frequency, incomplete emptying) occur due to fibroid compression of the bladder. The DBQ captures incontinence frequency: less than once a week, 1-3 times per week, 4 or more times per week, or daily/more often.

What to expect:

The examiner will ask about urinary leakage, urgency, and frequency. Be prepared to describe how often episodes occur and what triggers them (sneezing, lifting, prolonged standing, etc.).

Key thresholds:

  • Urinary symptoms less than once per week — Minimal urinary impact from fibroids.
  • Urinary symptoms 1-3 times per week — Moderate urinary impact; supports documentation of functional limitation.
  • Urinary symptoms 4 or more times per week or daily — Significant urinary impairment; may support separate evaluation for urinary incontinence or urgency as a secondary condition.

Tips:

  • Keep a bladder diary for 1-2 weeks before the exam logging episodes of urgency, leakage, and nighttime waking.
  • Note whether you have modified your activities (avoiding long car trips, staying near restrooms, limiting fluid intake) due to urinary symptoms.
  • Describe any appliances or protective garments you use specifically for urinary leakage.

Pain considerations: Bladder pressure from large fibroids can cause a constant sensation of pelvic fullness and discomfort. Describe this pressure as a separate symptom from episodic pain.

Estimate

Rating Criteria Breakdown

100% Active malignant neoplasm or during active treatment with an ...

Active malignant neoplasm or during active treatment with antineoplastic therapy (chemotherapy, radiation). Note: DC 7631 applies to benign neoplasms, but if a fibroid transforms or a separate malignant neoplasm is identified, a 100% rating applies during active treatment. Also applies during the active treatment period following surgical intervention for the neoplasm, per 38 CFR 4.116 general rating principles and Note following DC ratings for neoplasms.

Key Symptoms

  • Active antineoplastic chemotherapy
  • Active radiation therapy
  • Post-surgical recovery period following treatment of neoplasm
  • Confirmed malignant transformation requiring active oncologic treatment

CFR: A 100% evaluation shall be assigned from the date of onset of primary malignancy, or date of hospital admission for treatment, and shall continue for six months following the completion of therapy. After six months, the appropriate disability rating shall be determined by mandatory VA examination.

30% Symptoms are NOT controlled by continuous treatment. Under 3 ...

Symptoms are NOT controlled by continuous treatment. Under 38 CFR 4.116, DC 7631, a 30% rating applies when symptoms persist despite ongoing medical management, indicating that treatment is insufficient to adequately control the condition and functional impairment continues.

Key Symptoms

  • Persistent pelvic pain despite ongoing treatment (hormonal therapy, pain management)
  • Heavy or irregular bleeding not adequately controlled by medication
  • Persistent pelvic pressure causing functional limitation despite treatment
  • Menstrual disturbances continuing despite continuous therapeutic intervention
  • Anemia from ongoing blood loss not fully corrected
  • Persistent dysmenorrhea causing work absences or significant activity restriction despite treatment

CFR: Symptoms are not controlled by continuous treatment for the following: moderate to severe pain, heavy or irregular bleeding, pelvic pressure, frequent or continuous menstrual disturbances, or other signs and/or symptoms.

10% Symptoms require continuous treatment. Under 38 CFR 4.116, D ...

Symptoms require continuous treatment. Under 38 CFR 4.116, DC 7631, a 10% rating applies when the benign uterine neoplasm causes symptoms that require continuous treatment to control, such as ongoing pelvic pain, menstrual irregularities, or pelvic pressure requiring regular medication or medical management.

Key Symptoms

  • Pelvic pain requiring regular use of pain medication (NSAIDs, hormonal therapy)
  • Irregular menstruation requiring hormonal management
  • Dysmenorrhea requiring ongoing treatment
  • Frequent or continuous menstrual disturbances requiring medication
  • Pelvic pressure managed with ongoing treatment
  • Heavy menstrual bleeding controlled with medication (hormonal IUD, tranexamic acid, etc.)

CFR: Symptoms require continuous treatment for the following: mild to moderate pain, irregular menstruation, dysmenorrhea associated with ovarian dysfunction, secondary amenorrhea associated with ovarian dysfunction, frequent or continuous menstrual disturbances, pelvic pressure, or other signs and/or symptoms.

0% Symptoms do not require continuous treatment OR symptoms are ...

Symptoms do not require continuous treatment OR symptoms are well-controlled with continuous treatment. Under 38 CFR 4.116, DC 7631, a 0% rating applies when the neoplasm is present but causes no significant symptomatic impairment or symptoms are fully managed without functional limitation.

Key Symptoms

  • Fibroid diagnosed but asymptomatic or minimally symptomatic
  • No pelvic pain or only very occasional mild pelvic pressure
  • No menstrual disturbances or very minor irregularities fully controlled with treatment
  • No anemia
  • No functional impairment in work or daily activities

CFR: Symptoms do not require continuous treatment for the following: mild pain, irregular menstruation, dysmenorrhea associated with ovarian dysfunction, secondary amenorrhea associated with ovarian dysfunction, frequent or continuous menstrual disturbances, pelvic pressure, or other signs and/or symptoms.

How to Describe Your Symptoms

Pelvic Pain

How to describe:

Describe the location (lower abdomen, pelvis, lower back), character (cramping, pressure, aching, stabbing), intensity on a 0-10 scale, duration of each episode, and frequency per week or month. Explain what activities trigger or worsen pain (standing, walking, intercourse, bowel movements) and what, if anything, provides relief. Distinguish between baseline daily pain and acute flare-ups.

Worst-day example:

“On my worst days, which happen about 8 to 10 days per month, I have a constant 7 out of 10 cramping pressure in my lower pelvis that prevents me from sitting at my desk for more than 30 minutes at a time. I have missed work approximately 2 days per month because the pain is unresponsive to ibuprofen and I cannot concentrate or function normally. I need to lie down with a heating pad for several hours.”

What the examiner listens for:

Specific pain severity levels (mild, moderate, severe), frequency of pain episodes, functional limitation caused by pain, whether pain is controlled or uncontrolled by treatment, and impact on employment and daily activities.

Understatements to avoid:

Do not say 'it's manageable' or 'I just deal with it' - these phrases suggest your symptoms are controlled. Instead, accurately describe how much effort, medication, and lifestyle modification it takes to manage the pain, and note that it still limits your functioning even with treatment.

Menstrual Disturbances and Heavy Bleeding

How to describe:

Quantify bleeding using specific metrics: how many pads or tampons per day on heavy days, how many days per cycle are heavy, how often you pass clots and what size, cycle length and regularity, and number of cycles per year that are abnormal. Describe the impact on your daily life - missed work, inability to leave home, accidents or leakage through clothing.

Worst-day example:

“During my heaviest days, which last 4 to 5 days each cycle, I soak through a super-plus tampon and a maxi pad every 1 to 2 hours. I have had accidents at work where blood soaked through my clothing. I carry a change of clothes and extra supplies everywhere I go. During these days I cannot be away from a restroom for more than 90 minutes and I have left work early or called in sick 3 to 4 times in the past 6 months because of this.”

What the examiner listens for:

Frequency of absorbent material changes per day (less than 2, 2-4, or more than 4 times daily), presence of clots, cycle irregularity, impact on work attendance, social withdrawal, and whether bleeding is controlled or uncontrolled by current treatment.

Understatements to avoid:

Do not simply say 'my periods are heavy.' Give the examiner quantifiable information. Avoid minimizing by saying 'it's normal for me' - what you experience may be significantly above medical norms and directly relevant to your disability rating level.

Pelvic Pressure and Bulk Symptoms

How to describe:

Describe the sensation of pelvic fullness, heaviness, or pressure as distinct from pain. Note whether it is constant or intermittent, what makes it worse (prolonged standing, end of day, physical exertion), and how it limits your ability to walk, stand, sit, or exercise. If fibroids are large, describe any visible abdominal distension.

Worst-day example:

“I feel a constant heaviness and fullness in my lower pelvis, like something is pressing down inside me. By the end of a workday after standing for several hours, the pressure becomes a 6 out of 10 and forces me to sit or lie down. I have stopped exercising because physical activity worsens the pressure significantly. This has been constant for the past year and my current hormonal treatment has not reduced this sensation.”

What the examiner listens for:

Constant versus intermittent pressure, aggravating factors, impact on mobility and physical activity, and whether pelvic pressure is an uncontrolled symptom despite treatment.

Understatements to avoid:

Do not overlook pelvic pressure as a minor symptom. It is a specifically listed criterion under DC 7631 and directly maps to DBQ checkboxes. Ensure you mention it explicitly if you experience it.

Urinary Symptoms from Fibroid Compression

How to describe:

Describe urinary frequency (number of times per day and night), urgency episodes, any leakage, sensation of incomplete emptying, or hesitancy. Note how often these symptoms occur per week and whether you use absorbent materials specifically for urinary leakage. Explain how urinary symptoms affect your daily routine, travel, work, and social activities.

Worst-day example:

“My large fibroid presses on my bladder and I urinate 12 to 15 times per day and 3 to 4 times at night. I have urgency leakage approximately 4 to 5 days per week where I cannot make it to the restroom in time. I wear an incontinence pad daily. I have declined job opportunities that require travel or fieldwork because I need constant access to a restroom.”

What the examiner listens for:

Frequency and severity of urinary symptoms, use of absorbent materials for incontinence, impact on employment and social activities, and whether symptoms are attributed to fibroid compression versus another condition.

Understatements to avoid:

Do not attribute urinary symptoms only to other causes without mentioning the fibroid connection. If your gynecologist has noted that fibroid size contributes to bladder pressure, make sure to state this explicitly during the exam.

Functional Impact on Work and Daily Life

How to describe:

Describe specific ways your fibroid symptoms limit your ability to work, including missed days, reduced hours, inability to perform physical job tasks, need for frequent restroom breaks, and difficulty concentrating due to pain or fatigue. Also describe how symptoms affect household tasks, childcare, social activities, exercise, sleep, and relationships.

Worst-day example:

“In the past 12 months I have missed approximately 18 days of work due to fibroid-related pain, heavy bleeding, and fatigue from anemia. On days I do work, I need to take 4 to 6 ibuprofen and change absorbent materials every 1 to 2 hours. I have been passed over for a promotion because my supervisor noted my attendance issues. At home, I am unable to cook, clean, or care for my children on my worst days. I sleep poorly 10 to 12 nights per month due to pelvic pain and nighttime bleeding.”

What the examiner listens for:

Concrete examples of functional limitation, impact on employment (missed days, reduced productivity, job modifications), and how the condition affects activities of daily living.

Understatements to avoid:

Do not give vague answers like 'it affects my life sometimes.' Provide specific numbers - missed work days, frequency of symptoms, hours of limitation per day - so the examiner can accurately document functional impairment.

Treatment History and Treatment Adequacy

How to describe:

List all treatments you have received in chronological order: medications (NSAIDs, hormonal therapy, iron supplements), procedures (uterine fibroid embolization, endometrial ablation, myomectomy, hysterectomy), and any other therapeutic interventions. For each, describe whether it helped, how much it helped, and whether symptoms persist despite treatment.

Worst-day example:

“I have been on combined oral contraceptives for 2 years to manage bleeding and pain. Despite this, I still have 4 to 5 days of heavy bleeding per cycle requiring pad changes more than 4 times per day. My pain is somewhat reduced from an 8 to a 6 out of 10 on heavy days, but it remains severe enough to prevent me from working. My gynecologist has recommended a hysterectomy because conservative treatments have failed to adequately control my symptoms.”

What the examiner listens for:

Whether current treatment is controlling symptoms (critical to determining 10% versus 30% rating), duration of treatment, types of interventions attempted, and documentation of treatment failure.

Understatements to avoid:

Do not say treatment is 'working fine' if you still have significant symptoms. Treatment may reduce severity without achieving full control. Accurately describe the residual symptoms that persist even with your current regimen.

Common Mistakes to Avoid

Prep Checklist

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Before Your Exam

Day Of

During the Exam

After the Exam

Your Rights During a C&P Exam

  • You have the right to request a same-sex examiner for any gynecological C&P examination. Make this request in advance by contacting the VA or exam vendor.
  • You have the right to have a chaperone present during your gynecological examination. The exam facility is required to provide one upon request.
  • In most states, you have the right to record your C&P examination on your own device. Notify the examiner at the start of the appointment. Verify your state's recording consent laws before the exam.
  • You have the right to receive a copy of the completed DBQ and all examination results. Request this from the exam vendor or VAMC following your appointment.
  • You have the right to submit your own medical evidence, including private medical records, imaging reports, laboratory results, and nexus letters from your treating physicians, and to have this evidence considered in your claim.
  • You have the right to request a new examination if you believe the original C&P exam was inadequate, incomplete, or conducted by an unqualified examiner. This request can be made during the appeals process.
  • You have the right to have a Veterans Service Officer (VSO), accredited claims agent, or VA-accredited attorney assist you in preparing for and submitting your claim at no charge.
  • You have the right to submit buddy statements (lay statements) from family members, friends, coworkers, or supervisors who can corroborate how your condition affects your daily life and functioning.
  • Under 38 CFR 4.1 and 4.2, your disability rating must reflect the full range of your condition over the entire rating period - not just how you feel on the day of the examination. You have the right to insist that the examiner document your worst typical days.
  • You have the right to appeal a C&P exam finding or rating decision through the Supplemental Claim lane, Higher-Level Review lane, or Board of Veterans' Appeals if you believe the rating does not accurately reflect your disability level.
  • You have the right to request a VA examination for any secondary conditions (such as anemia, urinary incontinence, or bowel dysfunction) that you believe are caused or aggravated by your service-connected uterine fibroid condition.

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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.