Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 91: All of the following agents are used for emergency contraception, EXCEPT?

A. Combined Pill
B. Levonorgestrel
C. Misoprostol (Correct Answer)
D. Mifepristone

Explanation: **Explanation:** The correct answer is **Misoprostol**. Emergency contraception (EC) is intended to prevent pregnancy after unprotected intercourse by inhibiting or delaying ovulation or preventing fertilization. **Why Misoprostol is the correct answer:** Misoprostol is a **Prostaglandin E1 (PGE1) analogue**. Its primary roles in obstetrics include medical abortion (in combination with Mifepristone), induction of labor, and management of postpartum hemorrhage (PPH) due to its potent uterine-contracting properties. It does **not** prevent conception or inhibit ovulation, making it ineffective as an emergency contraceptive. **Analysis of other options:** * **Combined Oral Contraceptive Pills (COCs):** Used in the **Yuzpe Regimen** (two doses of 100 mcg Ethinylestradiol + 0.5 mg Levonorgestrel, 12 hours apart). While effective, it is less preferred now due to high rates of nausea and vomiting. * **Levonorgestrel (LNG):** The current "Gold Standard" for hormonal EC (e.g., i-Pill, 72-H). It is taken as a single dose of **1.5 mg** within 72 hours. It works primarily by delaying the LH surge and inhibiting ovulation. * **Mifepristone:** An anti-progestin that can be used for EC in low doses (**10–25 mg**). It is highly effective with fewer side effects than the Yuzpe regimen. **High-Yield Clinical Pearls for NEET-PG:** * **Most Effective EC:** The **Copper-T (IUCD)** is the most effective method of emergency contraception if inserted within 5 days (120 hours) of unprotected intercourse. * **Ulipristal Acetate:** A selective progesterone receptor modulator (SPRM) used as a single 30 mg dose; it is effective up to 120 hours and is superior to LNG in efficacy. * **Time Frame:** Most hormonal ECs are licensed for use within 72 hours, but Ulipristal and Copper-T are effective up to 120 hours.

Question 92: The best contraceptive method in a patient with heart disease is:

A. Double barrier (Correct Answer)
B. IUCD
C. Tubectomy
D. Oral pills

Explanation: **Explanation:** In patients with heart disease, the primary goal of contraception is to avoid methods that increase hemodynamic stress, risk of thromboembolism, or infective endocarditis. **Why Double Barrier is the Correct Answer:** The **Double Barrier method** (e.g., condom plus diaphragm/spermicide) is considered the safest because it is **non-hormonal and non-invasive**. It carries zero risk of thromboembolism, does not alter blood pressure, and poses no risk of pelvic infection or vasovagal syncope. While it has a higher failure rate than hormonal methods, in the context of cardiac safety, it is the preferred choice to avoid systemic complications. **Why Other Options are Incorrect:** * **IUCD (Intrauterine Contraceptive Device):** It is generally avoided in cardiac patients due to the risk of **vasovagal shock** during insertion. Furthermore, there is a theoretical risk of pelvic infections leading to **Infective Endocarditis**, particularly in patients with valvular heart disease. * **Tubectomy:** This is a surgical procedure requiring anesthesia and often involves creating a pneumoperitoneum (in laparoscopy), which can severely compromise cardiac output and venous return. It is considered too high-risk for many cardiac patients. * **Oral Pills (Combined Oral Contraceptives):** These are strictly **contraindicated** in most heart diseases because the estrogen component increases the risk of **thromboembolism**, hypertension, and fluid retention, which can precipitate heart failure. **High-Yield Clinical Pearls for NEET-PG:** * **Progesterone-only pills (POPs)** or implants are safer than COCs if a hormonal method is needed, as they lack estrogen. * If a cardiac patient requires sterilization, **Vasectomy** (of the partner) is the safest permanent method. * For IUCD insertion in cardiac patients (if absolutely necessary), **prophylactic antibiotics** are recommended to prevent endocarditis.

Question 93: All of the following are side effects of Oral Contraceptive Pills except?

A. Thromboembolism
B. Liver disease
C. Ovarian tumor (Correct Answer)
D. Breast Carcinoma

Explanation: **Explanation:** The correct answer is **Ovarian tumor** because Combined Oral Contraceptive Pills (COCPs) are actually **protective** against ovarian cancer, rather than being a causative factor. **1. Why Ovarian Tumor is the correct answer (Protective Effect):** COCPs suppress ovulation by inhibiting the release of FSH and LH. According to the "Incessant Ovulation Theory," reducing the number of ovulatory cycles decreases repetitive trauma to the ovarian epithelium. Using COCPs for 5 years reduces the risk of epithelial ovarian cancer by approximately 50%, and this protection persists for up to 15–20 years after discontinuation. **2. Analysis of Incorrect Options (Known Side Effects/Risks):** * **Thromboembolism (A):** The estrogen component (Ethinyl Estradiol) increases the synthesis of clotting factors (II, VII, IX, X) and decreases Antithrombin III, significantly raising the risk of Venous Thromboembolism (VTE). * **Liver Disease (B):** COCPs are contraindicated in active liver disease (e.g., viral hepatitis, cirrhosis) as they are metabolized in the liver. They are also associated with an increased risk of benign **Hepatic Adenomas**. * **Breast Carcinoma (D):** There is a slight, transient increase in the relative risk of breast cancer diagnosis among current and recent users, though the risk returns to baseline 10 years after stopping. **High-Yield Clinical Pearls for NEET-PG:** * **Cancer Protection:** COCPs reduce the risk of **Ovarian, Endometrial, and Colorectal cancers**. * **Cancer Risk:** COCPs slightly increase the risk of **Breast and Cervical cancers**. * **Absolute Contraindications:** History of VTE, smokers >35 years (≥15 cigarettes/day), migraine with aura, and undiagnosed abnormal uterine bleeding.

Question 94: All of the following are advantages of depot progestogen contraception EXCEPT:

A. It can be given to lactating mothers.
B. A 150mg dose is effective for a period of 12 weeks.
C. It provides good cycle control. (Correct Answer)
D. It prevents ectopic pregnancy.

Explanation: **Explanation:** The correct answer is **C (It provides good cycle control)** because depot progestogen (DMPA) is notorious for causing **menstrual irregularities**. Since it contains only progestogen and no estrogen, the endometrium becomes thin and unstable. This leads to breakthrough bleeding, spotting, or most commonly, **amenorrhea** (seen in 50-70% of users after one year). Therefore, it does not provide "good cycle control." **Analysis of other options:** * **Option A:** Progestogen-only contraceptives do not interfere with the quantity or quality of breast milk. In fact, they may slightly increase milk production, making them the preferred choice for **lactating mothers** (can be started 6 weeks postpartum). * **Option B:** The standard dose of **DMPA (Depot Medroxyprogesterone Acetate)** is **150 mg intramuscularly every 3 months (12 weeks)**. It works primarily by suppressing ovulation via the HPO axis. * **Option C:** By effectively suppressing ovulation, DMPA significantly reduces the absolute risk of both intrauterine and **ectopic pregnancies**. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Primarily inhibits ovulation (suppresses LH surge) and increases cervical mucus viscosity. * **Return of Fertility:** There is a **delayed return to fertility** (average 7–10 months after the last injection). * **Side Effects:** Weight gain (most common reason for discontinuation) and a reversible decrease in **Bone Mineral Density (BMD)**. * **Antara Program:** Under India’s public health program, DMPA is marketed as the **"Antara"** injection.

Question 95: Centchroman, a non-hormonal contraceptive pill, is taken orally:

A. Daily for the first three months, then once a week.
B. Twice a week for the first three months, then once a week. (Correct Answer)
C. Thrice a week for the first three months, then once a week.
D. Twice a week for the first five months, then once a week.

Explanation: **Explanation:** **Centchroman (Ormeloxifene)** is a unique Selective Estrogen Receptor Modulator (SERM) developed by CDRI, Lucknow. It is the world’s first non-steroidal, non-hormonal oral contraceptive pill. **1. Why Option B is Correct:** The standard dosage schedule for Centchroman (marketed as **Saheli** or **Chhaya**) is **30 mg twice a week for the first 3 months**, followed by **once a week** thereafter. The twice-weekly loading dose is necessary to achieve steady-state plasma concentrations and ensure immediate contraceptive efficacy. It is ideally started on the first day of the menstrual cycle. **2. Why Other Options are Incorrect:** * **Option A:** Daily dosing is characteristic of Combined Oral Contraceptive Pills (COCPs) or Progesterone-Only Pills (POPs). Centchroman has a long half-life (approx. 170 hours), making daily administration unnecessary and potentially toxic. * **Option C & D:** Thrice-weekly or five-month loading periods do not align with the pharmacokinetics of the drug. Clinical trials established that a 3-month twice-weekly regimen provides the optimal balance between efficacy (Pearl Index ~1.3–1.8) and safety. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** It acts as an estrogen antagonist in the uterus (preventing implantation by altering the endometrium) and as a weak agonist in other tissues. It does not suppress ovulation in most cycles. * **Side Effects:** The most common side effect is **delayed menstruation** (prolonged cycles), which occurs in about 8% of users. It does not cause nausea, weight gain, or mood swings typical of hormonal pills. * **Contraindications:** Polycystic Ovarian Syndrome (PCOS), cervical dysplasia, and recent history of jaundice or liver disease. * **Government Initiative:** Under the National Family Planning Programme (Antara program), it is distributed free of cost as **'Chhaya'**.

Question 96: What menstrual abnormality is typically seen in a woman using a subdermal progesterone implant for contraception?

A. Menorrhagia
B. Metrorrhagia (Correct Answer)
C. Polymenorrhea
D. Amenorrhea

Explanation: **Explanation:** Subdermal progesterone implants (e.g., Nexplanon/Implanon) primarily work by suppressing ovulation and thickening cervical mucus. However, their effect on the endometrium is the primary cause of menstrual changes. **Why Metrorrhagia is correct:** The continuous, low-dose release of progestogen leads to **endometrial atrophy** and an unstable endometrial lining. This results in **irregular, unpredictable spotting or breakthrough bleeding (metrorrhagia)**. This is the most common reason for discontinuation of the method. While some women eventually develop amenorrhea, irregular bleeding remains the hallmark side effect during the initial months of use. **Analysis of Incorrect Options:** * **A. Menorrhagia:** Heavy menstrual bleeding is rare with progestogen-only methods. In fact, these implants typically reduce total menstrual blood loss. * **C. Polymenorrhea:** While cycles may become frequent, the bleeding pattern is usually too irregular to be classified as regular frequent cycles (polymenorrhea); it is better described as unscheduled spotting. * **D. Amenorrhea:** While approximately 20% of users may develop amenorrhea after one year, it is less "typical" or characteristic in the early phase compared to the high incidence of irregular spotting. **High-Yield Clinical Pearls for NEET-PG:** * **Composition:** Nexplanon contains **Etonogestrel** (68 mg). * **Duration:** Effective for **3 years**. * **Mechanism:** Primarily inhibits ovulation (suppresses LH surge). * **Failure Rate:** It is the **most effective** reversible contraceptive method (Pearl Index ~0.05). * **Contraindication:** Active breast cancer or unexplained vaginal bleeding.

Question 97: What are the contraindications for the medical method (mifepristone + misoprostol) of first-trimester medical termination of pregnancy?

A. Patient with a hemoglobin level of 7 gm%
B. Suspected ectopic pregnancy
C. Glaucoma
D. All of the above (Correct Answer)

Explanation: The medical method of termination of pregnancy (MTP) using the combination of **Mifepristone** (Progesterone antagonist) and **Misoprostol** (Prostaglandin E1 analogue) is highly effective but requires careful patient selection to avoid life-threatening complications. ### **Explanation of Options:** * **A. Hemoglobin (Hb) level of 7 gm%:** Severe anemia is a contraindication because medical MTP is associated with heavier and more prolonged bleeding compared to surgical evacuation. A patient with an initial Hb of 7 gm% has no physiological reserve to tolerate further blood loss, risking hemorrhagic shock. * **B. Suspected Ectopic Pregnancy:** Mifepristone and Misoprostol act on the intrauterine decidua and myometrium. They are **ineffective** for tubal pregnancies. Using them in a suspected ectopic case delays definitive surgical or medical (Methotrexate) management, risking tubal rupture and internal hemorrhage. * **C. Glaucoma:** While Misoprostol is a PGE1 analogue, prostaglandins can theoretically increase intraocular pressure or cause vasodilation that exacerbates certain types of glaucoma. In the context of NEET-PG, active glaucoma is a standard contraindication listed for prostaglandin use in MTP. ### **High-Yield Clinical Pearls for NEET-PG:** 1. **Absolute Contraindications:** Confirmed/suspected ectopic pregnancy, chronic adrenal failure, long-term corticosteroid therapy, bleeding disorders, concurrent anticoagulant use, and known allergy to prostaglandins. 2. **The "IUD" Rule:** If an intrauterine device is present, it must be removed before administering the drugs. 3. **Dosage (WHO/ROGS):** 200 mg Mifepristone orally followed by 400–800 mcg Misoprostol (vaginal/sublingual/buccal) 24–48 hours later. 4. **Legal Limit:** In India, medical MTP is generally recommended up to **9 weeks (63 days)** of gestation. 5. **Asthma:** Note that while **PGF2α (Carboprost)** is contraindicated in asthma, **PGE1 (Misoprostol)** is a bronchodilator and is generally safe.

Question 98: Which of the following is NOT a reversible method of contraception?

A. Oral Contraceptive Pill (OCP)
B. Vasectomy (Correct Answer)
C. Intrauterine Contraceptive Device (IUCD)
D. Depot injection

Explanation: **Explanation:** The core concept tested here is the classification of contraceptive methods into **reversible (temporary)** and **irreversible (permanent)** categories. **Why Vasectomy is the Correct Answer:** Vasectomy is a surgical procedure involving the ligation and excision of a segment of the *vas deferens*. It is classified as a **permanent/terminal method** of sterilization. While surgical reversal (vasovasostomy) is theoretically possible, it is technically difficult, expensive, and does not guarantee the restoration of fertility due to the development of anti-sperm antibodies. Therefore, for clinical and counseling purposes, it is considered irreversible. **Why the other options are incorrect:** * **Oral Contraceptive Pills (OCPs):** These are hormonal methods that suppress ovulation. Fertility typically returns within 1–3 months of discontinuation. * **Intrauterine Contraceptive Device (IUCD):** These are Long-Acting Reversible Contraceptives (LARC). Fertility is restored immediately upon the removal of the device (e.g., Cu-T 380A or LNG-IUS). * **Depot Injection (DMPA):** This is a progestogen-only injectable. While it may cause a "delayed return to fertility" (averaging 7–9 months after the last dose), it remains a reversible method. **High-Yield Clinical Pearls for NEET-PG:** * **Failure Rate:** Vasectomy is more effective than Tubectomy (Pearl Index ~0.1 vs 0.5). * **Non-Scalpel Vasectomy (NSV):** The preferred technique today; it involves no skin incision, only a puncture. * **Post-procedure advice:** Vasectomy is **not** immediately effective. A backup method must be used for **3 months or 20 ejaculations** until azoospermia is confirmed by semen analysis. * **LARC:** IUCDs and Implants are the most effective reversible methods.

Question 99: All of the following are spermicidal agents, EXCEPT?

A. Nonoxynol-9
B. Octoxynol-9
C. Menfegol
D. Foscarnet (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Foscarnet**. **1. Why Foscarnet is the correct answer:** Foscarnet is an **antiviral medication** used primarily to treat cytomegalovirus (CMV) retinitis and acyclovir-resistant herpes simplex virus (HSV) infections. It acts as a pyrophosphate analogue that inhibits viral DNA polymerase. It has no spermicidal properties and is not used in contraception. **2. Analysis of Spermicidal Agents (Incorrect Options):** Spermicides are chemical barriers that immobilize or kill sperm by disrupting the cell membrane (surfactant action). * **Nonoxynol-9 (Option A):** This is the most widely used spermicide globally. It is a non-ionic surfactant that disrupts the lipid membrane of the spermatozoa. * **Octoxynol-9 (Option B):** Similar to Nonoxynol-9, this is a surfactant used in various contraceptive jellies and creams. * **Menfegol (Option C):** A foaming tablet spermicide commonly used in several countries. Like the others, it acts by destroying the sperm cell membrane. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** Most spermicides act as **surfactants** that disrupt the sperm surface membrane, leading to loss of motility and decreased oxygen uptake. * **Failure Rate:** When used alone, spermicides have a high failure rate (Pearl Index of ~18–28 per 100 woman-years). They are most effective when used with mechanical barriers like condoms or diaphragms. * **STI Risk:** Nonoxynol-9 does **not** protect against HIV/STIs. In fact, frequent use can cause vaginal/rectal irritation and mucosal friability, potentially *increasing* the risk of HIV transmission. * **Other Spermicides to Remember:** Benzalkonium chloride and Chlorhexidine.

Question 100: What is the preferred investigation to confirm the presence of an intrauterine device (IUD) when its strings are not visible?

A. Pelvic X-ray
B. Ultrasound (USG) (Correct Answer)
C. CT Abdomen
D. MRI Pelvis

Explanation: **Explanation:** When the strings of an Intrauterine Device (IUD) are not visible during a speculum examination (a condition known as "Missing Strings"), the primary clinical concern is to differentiate between **expulsion**, **malposition**, or **uterine perforation**. **1. Why Ultrasound (USG) is the Correct Answer:** Ultrasound is the **first-line investigation** of choice because it is non-invasive, cost-effective, and lacks ionizing radiation. It is highly sensitive in confirming the intrauterine location of the device. A properly placed IUD will appear as a highly echogenic (bright) linear structure with posterior acoustic shadowing within the endometrial cavity. **2. Why Other Options are Incorrect:** * **Pelvic X-ray:** This is the second-line investigation. It is only performed if the USG fails to locate the IUD in the uterus. An X-ray (including the abdomen and pelvis) helps identify an extrauterine IUD (perforation) or confirm expulsion if the device is absent from the film. * **CT Abdomen:** While CT can locate a perforated IUD, it is not the initial investigation due to high radiation doses and unnecessary cost. * **MRI Pelvis:** MRI is rarely indicated for IUD localization. While safe, it is expensive and provides no significant diagnostic advantage over USG or X-ray in this context. **Clinical Pearls for NEET-PG:** * **Initial Step:** If strings are missing, the first step is to rule out pregnancy and then perform a USG. * **Uterine Perforation:** If USG shows an empty uterus and the patient did not notice the IUD falling out, an **X-ray Abdomen/Pelvis (Erect and Supine)** is mandatory to locate the device in the peritoneal cavity. * **Management of Perforation:** A perforated IUD (especially Copper-T) must be removed via **Laparoscopy** due to the risk of adhesion formation.

Practice by Chapter

Natural Family Planning Methods

Practice Questions

Barrier Methods

Practice Questions

Hormonal Contraceptives

Practice Questions

Intrauterine Devices

Practice Questions

Emergency Contraception

Practice Questions

Permanent Contraception Methods

Practice Questions

Contraception in Special Populations

Practice Questions

Contraceptive Counseling

Practice Questions

Side Effects and Complications of Contraceptives

Practice Questions

Future Contraceptive Technologies

Practice Questions

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