Differential Diagnoses

1. Encounter for other general counseling and advice on contraception-This is a good differential diagnosis, if the patient only wants to discuss contraceptive management today and take time to decide which one she prefers. She may also want to talk to her partner prior to starting. I would highly suggest contraceptive management, since she has a cystocele and she does not want more children, but her partner does. Dietz, Shek, and Low’s study revealed that women with a cystocele are more likely to have a partial avulsion during pregnancy.

2. Cystocele-This is a secondary diagnosis because it was found on exam. She needs to be referred to pelvic floor therapy.

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3. Encounter for contraceptive management-This is a great differential diagnosis, because it covers a variety of contraceptive options and she wanted to start contraceptives. I would highly recommend the use of contraceptives to avoid pregnancy until the cystocele improves. Also, her partner may try to persuade her to have another baby when she is not ready for one right now. Since she has migraines and I do not know her migraine symptoms, I would recommend starting progesterone-only oral contraceptives, DEPO shot, or an IUD. Lodi and Advani state, “the association between hormonal contraception and stroke risk is estrogen dose-dependent and use of combined hormonal contraception increases the risk of stroke in women with any type of migraine”.

4. Counseling and instruction in natural family planning to avoid pregnancy-This would be a differential diagnosis if the patient does not want to use any type of contraceptive, but instead wants to do natural family planning. Hassoun states that this is the least effective method of preventing pregnancy and requires extensive education.

5. Malposition of uterus-This could be a differential diagnosis because her uterus is RV. She would benefit from pelvic floor therapy if she is experiencing any pain or discomfort.

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