Hormonal contraceptives US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Hormonal contraceptives. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Hormonal contraceptives US Medical PG Question 1: A 22-year-old woman comes to the physician for a follow-up examination. She had a spontaneous abortion 3 months ago. Her last menstrual period was 3 weeks ago. She reports feeling sad occasionally but has continued working and attending social events. She does not have any suicidal ideation or tendencies. She does not smoke. Vital signs are within normal limits. Physical examination including pelvic examination show no abnormalities. A urine pregnancy test is negative. She wants to avoid becoming pregnant for the foreseeable future and is started on combined oral contraceptive pills. Which of the following is the patient at risk of developing?
- A. Endometriosis
- B. Functional ovarian cysts
- C. Acne
- D. Hypertension (Correct Answer)
- E. Premenstrual syndrome
Hormonal contraceptives Explanation: **Hypertension**
- **Combined oral contraceptives (COCs)** can cause a small but significant increase in blood pressure, leading to **hypertension** in some women.
- This risk is dose-dependent and is generally higher with older formulations containing higher estrogen doses.
*Endometriosis*
- **Combined oral contraceptives** are often used as a treatment for **endometriosis** to suppress ovarian activity and reduce endometrial lesions.
- Therefore, COCs typically reduce the risk or symptoms of endometriosis rather than causing it.
*Functional ovarian cysts*
- **Combined oral contraceptives** work by suppressing ovulation, which is the process that leads to the formation of **functional ovarian cysts**.
- As such, COCs actually decrease the incidence of functional ovarian cysts.
*Acne*
- The estrogen component in **combined oral contraceptives** has an anti-androgenic effect, which can reduce sebum production and improve **acne**.
- Many COCs are specifically approved for the treatment of acne, making it an unlikely risk.
*Premenstrual syndrome*
- **Combined oral contraceptives** can help stabilize hormonal fluctuations throughout the menstrual cycle, often leading to an improvement in symptoms of **premenstrual syndrome (PMS)**.
- They are commonly prescribed to manage moderate to severe PMS symptoms.
Hormonal contraceptives US Medical PG Question 2: A 36-year-old woman comes to the physician to discuss contraceptive options. She is currently sexually active with one male partner, and they have not been using any contraception. She has no significant past medical history and takes no medications. She has smoked one pack of cigarettes daily for 15 years. She is allergic to latex and copper. A urine pregnancy test is negative. Which of the following contraceptive methods is contraindicated in this patient?
- A. Diaphragm with spermicide
- B. Condoms
- C. Progestin-only pill
- D. Combined oral contraceptive pill (Correct Answer)
- E. Intrauterine device
Hormonal contraceptives Explanation: ***Combined oral contraceptive pill***
- This patient, a 36-year-old woman, smokes one pack of cigarettes daily, which puts her at increased risk for **cardiovascular events** if she uses combined oral contraceptives.
- The risk of **thrombosis**, **myocardial infarction**, and **stroke** associated with combined hormonal contraceptives is significantly elevated in women over 35 who smoke.
*Diaphragm with spermicide*
- A diaphragm with spermicide is a **barrier method** that can be used by women of any age and smoking status.
- It does not contain hormones and therefore does not increase the risk of **cardiovascular events** in smokers.
*Condoms*
- The patient has a **latex allergy**, which would contraindicate the use of standard latex condoms.
- However, there are non-latex condom alternatives (e.g., polyurethane, polyisoprene) that would be safe and effective for this patient.
*Progestin-only pill*
- The **progestin-only pill** does not carry the same cardiovascular risks as combined oral contraceptives for smokers.
- It works by thickening cervical mucus and thinning the endometrium, and is often a safe option for women with contraindications to estrogen.
*Intrauterine device*
- The patient has a **copper allergy**, which would contraindicate the use of a copper IUD.
- However, a **hormonal IUD** (e.g., levonorgestrel-releasing IUD) would be a safe and effective option as it does not contain copper or estrogen.
Hormonal contraceptives US Medical PG Question 3: A 19-year-old woman comes to the physician because of recent weight gain. She started a combined oral contraceptive for dysmenorrhea and acne six months ago. She has been taking the medication consistently and experiences withdrawal bleeding on the 4th week of each pill pack. Her acne and dysmenorrhea have improved significantly. The patient increased her daily exercise regimen to 60 minutes of running and weight training three months ago. She started college six months ago. She has not had any changes in her sleep or energy levels. Her height is 162 cm and she weighs 62 kg; six months ago she weighed 55 kg. Examination shows clear skin and no other abnormalities. A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?
- A. Measure serum testosterone concentration
- B. Perform a low-dose dexamethasone suppression test
- C. Measure serum TSH level
- D. Switch contraceptive to a non-hormonal contraceptive method
- E. Reassure the patient (Correct Answer)
Hormonal contraceptives Explanation: ***Reassure the patient***
- The patient's **weight gain of 7 kg (BMI 23.6 kg/m²) over six months is within the normal range** and is likely due to the combination of starting college (lifestyle changes) and increased muscle mass from her intensified exercise regimen.
- Her improved acne and dysmenorrhea, consistent withdrawal bleeding, and lack of other concerning symptoms (e.g., changes in sleep, energy, or examination abnormalities) suggest the oral contraceptive is well-tolerated and effective for its intended purposes.
*Measure serum testosterone concentration*
- Although **PCOS** can cause weight gain and acne, the patient's acne has significantly improved with combined oral contraceptives, and her menstrual cycles are regular (withdrawal bleeding).
- There are no other signs of hyperandrogenism (e.g., hirsutism, clitoromegaly) to warrant testosterone measurement.
*Perform a low-dose dexamethasone suppression test*
- This test is used to diagnose **Cushing syndrome**, which can cause weight gain and acne.
- However, the patient does not exhibit other classic features of Cushing syndrome such as central obesity, moon facies, striae, or proximal muscle weakness, and her skin is described as clear.
*Measure serum TSH level*
- **Hypothyroidism** can lead to weight gain, but the patient reports no changes in her sleep or energy levels, and increased exercise suggests she is not experiencing fatigue.
- Other common symptoms of hypothyroidism, such as cold intolerance or constipation, are not mentioned.
*Switch contraceptive to a non-hormonal contraceptive method*
- While some women experience weight gain with hormonal contraceptives, the **evidence for significant weight gain directly attributable to oral contraceptives is mixed and often minimal**.
- Given that her primary concerns (dysmenorrhea and acne) have significantly improved without other adverse effects, and her weight gain can be otherwise explained, switching contraception is not the most appropriate first step.
Hormonal contraceptives US Medical PG Question 4: A 22-year-old female presents to her PCP after having unprotected sex with her boyfriend 2 days ago. She has been monogamous with her boyfriend but is very concerned about pregnancy. The patient requests emergency contraception to decrease her likelihood of getting pregnant. A blood hCG test returns negative. The PCP prescribes the patient ethinyl estradiol 100 mcg and levonorgestrel 0.5 mg to be taken 12 hours apart. What is the most likely mechanism of action for this combined prescription?
- A. Inhibition or delayed ovulation (Correct Answer)
- B. Interference of corpus luteum function
- C. Thickening of cervical mucus with sperm trapping
- D. Tubal constriction inhibiting sperm transportation
- E. Alteration of the endometrium impairing implantation of the fertilized egg
Hormonal contraceptives Explanation: ***Inhibition or delayed ovulation***
- The high doses of **estrogen** and **progestin** in the combined emergency contraception pill primarily act by suppressing the **luteinizing hormone (LH) surge**, which is essential for ovulation.
- By inhibiting or delaying ovulation, the pill prevents the release of an egg, thus preventing fertilization since sperm cannot meet an egg.
*Interference of corpus luteum function*
- While hormonal contraceptives can affect the **corpus luteum**, high-dose emergency contraception primarily acts *before* the formation of a mature corpus luteum by preventing ovulation itself.
- Once the corpus luteum is formed, its function is usually maintained if pregnancy occurs, and emergency contraception given *after* implantation is generally ineffective at terminating a pregnancy.
*Thickening of cervical mucus with sperm trapping*
- This is a well-known mechanism of action for *continuous* hormonal contraception (e.g., daily birth control pills), where lower, consistent doses of progestin make cervical mucus impenetrable to sperm.
- While it might play a *minor* role, it is not the primary mechanism of action for high-dose emergency contraception administered acutely, which mainly targets ovulation.
*Tubal constriction inhibiting sperm transportation*
- There is no strong evidence to suggest that combined emergency contraception pills cause **tubal constriction** to significantly impair sperm or egg transport.
- The main sites of action are the **hypothalamic-pituitary-ovarian axis** (for ovulation) and possibly the endometrium (for implantation), not direct tubal motility.
*Alteration of the endometrium impairing implantation of the fertilized egg*
- While hormonal contraceptives can alter the **endometrium** making it less receptive to implantation, this is considered a *secondary* or less significant mechanism for combined emergency contraception.
- The primary goal and most effective action of these pills is to prevent fertilization by inhibiting ovulation, especially when taken shortly after unprotected intercourse and before implantation.
Hormonal contraceptives US Medical PG Question 5: An otherwise healthy 18-year-old girl comes to the physician because of a 1-year history of severe acne vulgaris over her face, upper back, and arms. Treatment with oral antibiotics and topical combination therapy with benzoyl peroxide and retinoid has not completely resolved her symptoms. Examination shows oily skin with numerous comedones, pustules, and scarring over the face and upper back. Long-term therapy is started with combined oral contraceptives. This medication significantly reduces the risk of developing which of the following conditions?
- A. Endometrial cancer (Correct Answer)
- B. Hepatic adenoma
- C. Hypertension
- D. Malignant melanoma
- E. Deep vein thrombosis
Hormonal contraceptives Explanation: ***Endometrial cancer***
- Combined oral contraceptives (COCs) reduce the risk of **endometrial cancer** by suppressing chronic **estrogen-induced endometrial proliferation** through progesterone's anti-proliferative effects.
- The protective effect increases with the **duration of COC use** and persists for several years after discontinuation.
*Hepatic adenoma*
- **Hepatic adenomas** are a recognized, though rare, complication of combined oral contraceptive use.
- The risk increases with **higher estrogen doses** and **longer duration of use**.
*Hypertension*
- COCs can cause a **slight increase in blood pressure** in some women, particularly due to the estrogen component, and are therefore a risk factor for hypertension, not protective against it.
- This effect is generally mild, but blood pressure monitoring is recommended for women on COCs.
*Malignant melanoma*
- There is **no clear evidence** that combined oral contraceptives significantly reduce the risk of malignant melanoma.
- Some studies have suggested a possible *increased risk* or no association, but protective effects are not established.
*Deep vein thrombosis*
- COCs, especially those containing higher estrogen doses, are associated with an **increased risk of deep vein thrombosis (DVT)** due to their effects on coagulation factors.
- This is a well-known adverse effect, not a condition prevented by COC use.
Hormonal contraceptives US Medical PG Question 6: A 21-year-old G2P1 woman presents to the clinic and is curious about contraception immediately after her baby is born. She is anxious about taking care of one child and does not believe that she can handle the responsibility of caring for another. She has no other questions or complaints today. Her past medical history consists of generalized anxiety disorder, antithrombin deficiency, and chronic deep vein thrombosis. She has been hospitalized for acute on chronic deep vein thrombosis. Her only medication is buspirone. Her blood pressure is 119/78 mm Hg and the heart rate is 78/min. BMI of the patient is 32 kg/m2. On physical examination, her fundal height is 21 cm from pubic symphysis. No ovarian masses are palpated during the bimanual examination. Ultrasound exhibits a monoamniotic, monochorionic fetus. Which of the following forms of contraception would be the most detrimental given her risk factors?
- A. Copper IUD
- B. Transdermal contraceptive patch (Correct Answer)
- C. Norethindrone
- D. Depot medroxyprogesterone acetate
- E. Levonorgestrel IUD
Hormonal contraceptives Explanation: ***Transdermal contraceptive patch***
- The transdermal contraceptive patch contains **estrogen**, which significantly increases the risk of **thromboembolism**. With a history of **antithrombin deficiency** and **recurrent deep vein thrombosis (DVT)**, estrogen-containing contraception is absolutely contraindicated due to the high risk of fatal clotting events.
- The patient's underlying **antithrombin deficiency** makes her particularly susceptible to prothrombotic effects, and combined hormonal contraceptives like the patch further exacerbate this risk.
*Copper IUD*
- The **copper IUD** is a **non-hormonal** contraceptive option, making it safe for individuals with a history of thromboembolism.
- Its mechanism of action involves creating a local inflammatory reaction in the uterus to prevent fertilization and implantation, thus posing no systemic clotting risk.
*Norethindrone*
- **Norethindrone** is a **progestin-only pill**, which does not contain estrogen and is generally considered safe for individuals with a history of thromboembolism.
- Progestin-only contraceptives avoid the estrogen-induced increase in clotting factors, making them a suitable option in this high-risk patient.
*Depot medroxyprogesterone acetate*
- **Depot medroxyprogesterone acetate (DMPA)** is an injectable **progestin-only contraceptive** that is safe for patients with a history of **thromboembolism**.
- It works by suppressing ovulation and thickening cervical mucus and does not carry the same clotting risks as estrogen-containing methods.
*Levonorgestrel IUD*
- The **levonorgestrel IUD** is a **progestin-only** contraceptive that releases hormones locally within the uterus, with minimal systemic absorption.
- It is a safe and highly effective option for patients with a history of thromboembolism due to the absence of estrogen and limited systemic hormonal effects.
Hormonal contraceptives US Medical PG Question 7: A 44-year-old woman comes to the physician because of a 6-month history of fatigue, constipation, and a 7-kg (15.4-lb) weight gain. Menses occur irregularly in intervals of 40–50 days. Her pulse is 51/min, and blood pressure is 145/86 mm Hg. Examination shows conjunctival pallor and cool, dry skin. There is mild, nonpitting periorbital edema. Serum thyroid-stimulating hormone concentration is 8.1 μU/mL. Treatment with the appropriate pharmacotherapy is initiated. After several weeks of therapy with this drug, which of the following hormonal changes is expected?
- A. Increased TRH
- B. Increased T3
- C. Decreased T4
- D. Increased T4
- E. Decreased TSH (Correct Answer)
Hormonal contraceptives Explanation: ***Decreased TSH***
- The patient has **primary hypothyroidism** (elevated TSH 8.1 μU/mL, symptoms of fatigue, constipation, bradycardia, weight gain, cool dry skin) and is treated with **levothyroxine (synthetic T4)**.
- The phrase **"after several weeks of therapy"** is key: while T4 levels rise within days of starting levothyroxine, **TSH takes 6-8 weeks to normalize** due to the negative feedback loop.
- As circulating thyroid hormone levels are restored, the **hypothalamic-pituitary-thyroid axis** re-establishes negative feedback, leading to **decreased TSH secretion** from the pituitary.
- **Decreased TSH is the primary clinical marker** used to assess adequacy of thyroid hormone replacement after several weeks of therapy.
*Increased T4*
- While T4 levels do increase with levothyroxine therapy, this occurs **rapidly (within days)**, not over "several weeks."
- The question's timeframe of "several weeks" directs attention to the **delayed TSH response**, which is what clinicians monitor at 6-8 weeks to adjust dosing.
- T4 elevation is immediate; TSH normalization takes weeks and is the endpoint being tested.
*Increased T3*
- T3 levels will increase as **T4 is peripherally converted to the active form T3**, but this is not the primary hormonal change being monitored after several weeks.
- The question asks about expected hormonal changes in the context of treatment monitoring, where **TSH is the gold standard**.
*Increased TRH*
- **Thyrotropin-releasing hormone (TRH)** from the hypothalamus stimulates TSH release. In primary hypothyroidism, both TRH and TSH are elevated.
- With thyroid hormone replacement, negative feedback would lead to **decreased TRH**, not increased.
*Decreased T4*
- This is the opposite of what occurs with levothyroxine therapy.
- The goal of treatment is to **increase** deficient T4 levels to the physiological range.
Hormonal contraceptives US Medical PG Question 8: A 56-year-old homeless male presents to a free clinic for a health evaluation. He states that he has not seen a physician in over 25 years but finally decided to seek medical attention after he noticed recent chronic fatigue and weight gain. Upon questioning, he endorses drinking 2 handles of whiskey per day. On exam, the physician observes the findings shown in Figures A-D. Which of the following findings would also be expected to be observed in this patient?
- A. Microcytic anemia
- B. 4-hertz hand tremor
- C. Direct hyperbilirubinemia
- D. Nystagmus
- E. Testicular atrophy (Correct Answer)
Hormonal contraceptives Explanation: ***Testicular atrophy***
- The image shows **caput medusae**, a sign of severe **portal hypertension** due to **cirrhosis**, likely from chronic alcohol abuse. Testicular atrophy is a common finding in alcoholic cirrhosis due to **impaired liver metabolism of estrogens**, leading to hyperestrogenism and hypogonadism.
- **Malnutrition** and **direct toxic effects of alcohol** on the testes also contribute to atrophy.
*Microcytic anemia*
- **Chronic alcohol abuse** typically causes **macrocytic anemia** (due to folate deficiency) or occasionally normocytic anemia, not microcytic anemia.
- Microcytic anemia is usually associated with **iron deficiency**, **thalassemia**, or **sideroblastic anemia**.
*4-hertz hand tremor*
- A **4-6 Hz "action" tremor** is characteristic of **essential tremor**, while **alcohol withdrawal** can cause a coarse, rapid tremor.
- Tremors associated with chronic liver disease are typically **asterixis** (flapping tremor), which is an irregular, high-amplitude tremor, not a 4-hertz hand tremor.
*Direct hyperbilirubinemia*
- **Cirrhosis** can lead to hyperbilirubinemia, but it's typically **mixed hyperbilirubinemia** (both direct and indirect) or predominantly indirect in early stages.
- Predominant **direct hyperbilirubinemia** is usually seen in **biliary obstruction** or **cholestatic liver diseases**, which are not directly implied by the presentation of alcoholic cirrhosis.
*Nystagmus*
- **Nystagmus** is often associated with **Wernicke encephalopathy**, a complication of severe **thiamine deficiency** often seen in chronic alcoholics.
- While possible, it is a specific neurological finding, whereas **testicular atrophy** is a more systemic and direct consequence of hormonal imbalances in advanced liver disease.
Hormonal contraceptives US Medical PG Question 9: A 58-year-old woman presents to the office after receiving a bone mineral density screening test result with a T score of -4.1 and a Z score of -3.8. She is diagnosed with osteoporosis. A review of her medical history reveals that she has taken estrogen-containing oral contraceptive pills from the age of 20 to 30. She suffered from heartburn from the age of 45 and took lansoprazole and ranitidine often for her symptoms. She also was on lithium for 2 years after being diagnosed with bipolar disorder at the age of 54. Last year she was diagnosed with congestive heart failure and was started on low dose hydrochlorothiazide. Which of her medications most likely contributed to the development of her osteoporosis?
- A. Ranitidine
- B. Lansoprazole (Correct Answer)
- C. Hydrochlorothiazide
- D. Lithium
- E. Estrogen
Hormonal contraceptives Explanation: ***Lansoprazole***
- **Proton pump inhibitors (PPIs)** like lansoprazole reduce gastric acid production, which can impair the absorption of **calcium** and **magnesium**, leading to a negative impact on bone mineral density with long-term use.
- Chronic use of PPIs has been associated with an increased risk of **osteoporosis** and **fractures**, especially in older adults.
*Ranitidine*
- Ranitidine is a **H2-receptor blocker**, which also reduces stomach acid but acts via a different mechanism than PPIs. It is generally not as strongly linked to osteoporosis as PPIs.
- While decreased gastric acid can affect nutrient absorption, the evidence for ranitidine directly causing osteoporosis is significantly weaker compared to PPIs.
*Hydrochlorothiazide*
- **Thiazide diuretics** like hydrochlorothiazide are known to **decrease urinary calcium excretion**, which can actually have a protective effect on bone mineral density, or at least be neutral.
- Therefore, hydrochlorothiazide is unlikely to contribute to or worsen osteoporosis; it may even be beneficial for bone health.
*Lithium*
- Lithium typically does not have a direct adverse effect on bone mineral density; its primary effects are on the **central nervous system**.
- Some studies have suggested potential complex effects on bone metabolism, but it is not a recognized direct cause of osteoporosis.
*Estrogen*
- **Estrogen** generally has a **protective effect on bone health** by inhibiting bone resorption.
- The past use of estrogen-containing oral contraceptive pills would have been protective during that period and does not contribute to current osteoporosis; rather, post-menopausal estrogen deficiency is a major risk factor for osteoporosis.
Hormonal contraceptives US Medical PG Question 10: A 50-year-old woman comes to the physician for the evaluation of excessive hair growth on her chin over the past 2 weeks. She also reports progressive enlargement of her gums. Three months ago, she underwent a liver transplantation due to Wilson disease. Following the procedure, the patient was started on transplant rejection prophylaxis. She has a history of poorly-controlled type 2 diabetes mellitus. Temperature is 37°C (98.6°F), pulse is 80/min, respirations are 22/min, and blood pressure is 150/80 mm Hg. Physical examination shows dark-pigmented, coarse hair on the chin, upper lip, and chest. The gingiva and the labial mucosa are swollen. There is a well-healed scar on her right lower abdomen. Which of the following drugs is the most likely cause of this patient's findings?
- A. Daclizumab
- B. Cyclosporine (Correct Answer)
- C. Sirolimus
- D. Methotrexate
- E. Tacrolimus
Hormonal contraceptives Explanation: **Cyclosporine**
* This patient's **combination of hirsutism** (excessive hair growth) **and gingival hyperplasia** (gum enlargement) is the classic presentation of cyclosporine toxicity, an immunosuppressant commonly used for transplant rejection prophylaxis.
* Cyclosporine is a **calcineurin inhibitor** that prevents T-cell activation and is highly effective in preventing graft rejection.
* The **simultaneous presence of both hirsutism and prominent gingival hyperplasia** is particularly characteristic of cyclosporine.
*Daclizumab*
* **Daclizumab** is a **monoclonal antibody** targeting the IL-2 receptor, which was previously used for transplant prophylaxis but has been discontinued for this indication.
* It is not associated with hirsutism or gingival hyperplasia.
*Sirolimus*
* **Sirolimus** is an **mTOR inhibitor** used as an immunosuppressant, known for side effects like hyperlipidemia, myelosuppression, and delayed wound healing.
* It does **not** typically cause hirsutism or gingival hyperplasia.
*Methotrexate*
* **Methotrexate** is an **antimetabolite** and immunosuppressant commonly used in autoimmune diseases and cancer, with side effects including bone marrow suppression, mucositis, and liver toxicity.
* Hirsutism and gingival hyperplasia are **not** characteristic side effects of methotrexate.
*Tacrolimus*
* **Tacrolimus** is another **calcineurin inhibitor**, similar to cyclosporine, but with a different side effect profile. While tacrolimus can cause hirsutism, **gingival hyperplasia is significantly less common** with tacrolimus compared to cyclosporine.
* The **presence of prominent gingival hyperplasia alongside hirsutism strongly favors cyclosporine** over tacrolimus.
* Tacrolimus is more commonly associated with **neurotoxicity** (e.g., tremor) and **nephrotoxicity**.
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