Contraception and Family Planning Practice Questions

Q: Use of oral contraceptives decreases the incidence of all of the following except?

Hepatic adenoma. **Explanation:** The correct answer is **C. Hepatic adenoma**. Combined Oral Contraceptive Pills (COCPs) are associated with several non-contraceptive benefits, but they also carry specific metabolic and neoplastic risks. **Hepatic adenoma** is a rare, benign liver tumor that is actually **increased** by the use of COCPs. The risk is dose-dependent and duration-dependent, linked primarily to the estrogen component which can stimulate hepatocyte proliferation. **Why other options are incorrect:** * **Ectopic pregnancy:** COCPs decrease the overall risk of ectopic pregnancy because they are highly effective at preventing ovulation and conception. If there is no pregnancy, there is no risk of an ectopic one. * **Epithelial ovarian malignancy:** COCPs provide a significant protective effect against ovarian cancer (approx. 40-50% reduction). This is due to the suppression of "incessant ovulation," which reduces trauma to the ovarian epithelium. This protection persists for years after discontinuation. * **Pelvic Inflammatory Disease (PID):** Progestogens in COCPs thicken the cervical mucus, creating a physical barrier that prevents the upward migration of pathogens (like *N. gonorrhoeae*) into the upper reproductive tract. **High-Yield NEET-PG Pearls:** * **Protective Effects of COCPs:** Decreased risk of Endometrial cancer, Ovarian cancer (Epithelial), Benign breast disease, PID, and Iron deficiency anemia (due to reduced menstrual flow). * **Increased Risks of COCPs:** Hepatic adenoma, Venous Thromboembolism (VTE), Hypertension, and a slight increase in the risk of Cervical cancer (linked to HPV persistence) and Breast cancer. * **Absolute Contraindications:** Undiagnosed vaginal bleeding, history of VTE, smokers >35 years (>15 cigarettes/day), and estrogen-dependent tumors.

Q: What is the minimum effective dose of estrogen in oral contraceptive pills (OCPs)?

20 mcg. **Explanation:** The correct answer is **20 mcg**. The evolution of Combined Oral Contraceptive Pills (COCPs) has been characterized by a steady reduction in the dose of estrogen (Ethinyl Estradiol) to minimize side effects while maintaining contraceptive efficacy. 1. **Why 20 mcg is correct:** Modern "low-dose" OCPs typically contain 20–35 mcg of Ethinyl Estradiol. Clinical studies have established that **20 mcg** is the minimum effective dose required to consistently suppress follicle-stimulating hormone (FSH) and prevent ovulation. While ultra-low-dose pills (15 mcg) exist, 20 mcg remains the standard minimum threshold for reliable efficacy in conventional practice. 2. **Why other options are incorrect:** * **30 mcg:** This is a common dosage in "low-dose" pills (e.g., Mala-N and Mala-D contain 30 mcg), but it is not the *minimum* effective dose. * **50 mcg:** Pills containing ≥50 mcg are termed "high-dose" pills. These are rarely used today due to a significantly higher risk of venous thromboembolism (VTE) and cardiovascular complications. * **40 mcg:** This is an intermediate dose used in older formulations but does not represent the minimum threshold. **High-Yield Clinical Pearls for NEET-PG:** * **Mala-N & Mala-D:** Contain 30 mcg Ethinyl Estradiol + 0.15 mg Levonorgestrel. * **Centchroman (Saheli):** A Non-steroidal, Selective Estrogen Receptor Modulator (SERM). Dosage: 30 mg twice weekly for 3 months, then once weekly. * **Mechanism of Action:** Estrogen primarily inhibits **FSH** (preventing follicular development), while Progesterone inhibits **LH surge** (preventing ovulation) and thickens cervical mucus. * **VTE Risk:** The risk of thromboembolism is directly proportional to the dose of estrogen. This is why the shift toward 20 mcg is clinically significant.

Q: Which of the following intrauterine devices has the minimum failure rate?

Levonorgestrel IUD. The efficacy of an Intrauterine Device (IUD) is primarily determined by its mechanism of action and the surface area of the active component. ### **Explanation of the Correct Answer** **C. Levonorgestrel IUD (LNG-20) / Mirena:** This is the most effective reversible contraceptive method available. It has a failure rate of approximately **0.2 per 100 woman-years**, which is comparable to surgical sterilization. Its superior efficacy is due to a dual mechanism: it acts as a local foreign body and releases 20 µg of levonorgestrel daily. This thickens cervical mucus (preventing sperm penetration), causes endometrial atrophy (preventing implantation), and occasionally inhibits ovulation. ### **Analysis of Incorrect Options** * **A. Progestasert:** This was a first-generation hormonal IUD that released natural progesterone. It had a higher failure rate (approx. 2.0%) and a short lifespan (1 year), making it less effective than modern LNG-IUDs. * **B. Cu T-380 A:** This is the most effective copper IUD with a failure rate of **0.6–0.8 per 100 woman-years**. While highly effective and the "gold standard" for non-hormonal IUDs, its failure rate is slightly higher than the LNG-IUD. * **D. T Cu-200:** This is an older generation copper IUD with a smaller surface area (200 $mm^2$). Lower copper surface area correlates with higher failure rates (approx. 2.0–3.0%). ### **NEET-PG High-Yield Pearls** * **Most effective overall contraceptive:** Implant (Nexplanon) > LNG-IUD > Vasectomy. * **Life span of IUDs:** Cu T-380A (10 years), LNG-20/Mirena (5–7 years), Cu T-200 (3 years). * **Ideal Candidate for LNG-IUD:** Women with Menorrhagia (DUB) or Endometriosis, as it significantly reduces menstrual blood loss. * **Commonest side effect:** For Copper T, it is **bleeding**; for LNG-IUD, it is **amenorrhea/spotting**.

Q: A couple requires emergency contraception four days after unprotected intercourse. What is the recommended contraceptive method?

Copper T 380 IUD. ### Explanation **Correct Option: B. Copper T 380 IUD** The key to this question lies in the **timing of emergency contraception (EC)**. The patient is presenting **four days (96 hours)** after unprotected intercourse. * **Copper T 380 IUD:** This is the most effective method of emergency contraception. It can be inserted up to **5 days (120 hours)** after unprotected intercourse or up to 5 days after the earliest expected date of ovulation. It works primarily by preventing fertilization and interfering with implantation. It has a failure rate of less than 0.1%. **Why other options are incorrect:** * **A. Oral contraceptive pills (OCPs):** Standard OCPs are not used as EC unless taken in specific high doses (Yuzpe regimen). Even then, they are less effective than the IUD and generally recommended within 72 hours. * **C. Yuzpe method:** This involves combined estrogen-progestogen pills. It must be initiated within **72 hours** for optimal efficacy and is associated with significant side effects like nausea and vomiting. * **D. Low dose progestogen-only pills:** While Levonorgestrel (LNG) 1.5mg is a common EC, it is most effective within 72 hours. While it can be used up to 120 hours, its efficacy decreases significantly after 72 hours compared to the Copper IUD. **High-Yield NEET-PG Pearls:** 1. **Gold Standard:** The Copper IUD is the most effective EC and provides ongoing long-term contraception. 2. **Ulipristal Acetate (30mg):** This is the most effective *oral* EC and can be used up to **120 hours** (5 days). However, if the Copper IUD is an option, it remains superior. 3. **Levonorgestrel (LNG):** Recommended dose is 1.5 mg (single dose) or 0.75 mg (two doses 12 hours apart). 4. **Mechanism:** EC methods primarily work by delaying ovulation; however, the Copper IUD also prevents implantation. EC **cannot** disrupt an already established pregnancy (it is not an abortifacient).

Q: A woman was taking progestin-only pills for contraception. Which side-effect is not likely to occur?

Dysmenorrhea. **Explanation:** Progestin-only pills (POPs), often called the "minipill," primarily work by thickening cervical mucus and thinning the endometrial lining. In many women, they also inhibit ovulation. **Why Dysmenorrhea is the correct answer:** Dysmenorrhea (painful menstruation) is primarily caused by high levels of **prostaglandins** released during the shedding of a secretory endometrium. Progestins cause endometrial atrophy and often lead to anovulation. By thinning the uterine lining and reducing menstrual flow (or causing amenorrhea), POPs actually **improve or treat dysmenorrhea** rather than causing it. Therefore, it is the "least likely" side effect. **Analysis of Incorrect Options:** * **Acne:** Progestins (especially older generations like Levonorgestrel) have varying degrees of **androgenic activity**. This can stimulate sebaceous glands, leading to acne and oily skin. * **Amenorrhea:** Due to the continuous administration of progestin without an estrogen-induced proliferative phase, the endometrium becomes thin and atrophic. This frequently results in irregular spotting or complete cessation of menses (amenorrhea). * **Obesity:** Weight gain is a commonly reported side effect of hormonal contraceptives, including POPs, often attributed to increased appetite or fluid retention associated with progestogenic effects. **High-Yield NEET-PG Pearls:** * **Mechanism of Action:** The primary mechanism of POPs is **cervical mucus thickening**. Inhibition of ovulation occurs in only about 60-80% of cycles. * **The "3-Hour Rule":** Traditional POPs must be taken at the same time every day; a delay of more than 3 hours requires backup contraception for 48 hours. * **Ideal Candidate:** POPs are the contraceptive of choice for **lactating mothers** (as they don't suppress milk production) and women with contraindications to estrogen (e.g., history of DVT or smokers >35 years).

Q: Which of the following is true regarding depot medroxy progesterone acetate?

It is known to diminish bone mineral density.. **Explanation:** **Depot Medroxyprogesterone Acetate (DMPA)**, commonly known by the brand name **Antara** (in the government supply) or **Depo-Provera**, is a long-acting injectable contraceptive. **Why Option C is correct:** DMPA works by suppressing the hypothalamic-pituitary-ovarian axis, which inhibits gonadotropin secretion (LH and FSH). This leads to the suppression of ovulation and a subsequent **hypoestrogenic state**. Since estrogen is essential for maintaining bone mass, prolonged use of DMPA leads to a **reduction in Bone Mineral Density (BMD)**. The FDA has issued a "Black Box Warning" stating that DMPA should generally not be used for more than 2 years unless other methods are inadequate, although BMD usually recovers after discontinuation. **Why other options are incorrect:** * **Option A:** DMPA is an **injectable** contraceptive, not a subdermal implant. (Example of a subdermal implant is *Nexplanon*). * **Option B:** The standard dose is **150 mg given Intramuscularly (IM)** every 3 months (90 days). There is also a subcutaneous version (DMPA-SC) at a dose of 104 mg. It is never given intravenously. * **Option D:** DMPA actually **decreases the risk of endometrial cancer** by approximately 80% due to the protective effect of progestin, which causes endometrial atrophy. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Primarily inhibits ovulation; also increases cervical mucus viscosity. * **Side Effects:** Amenorrhea (most common), weight gain, and delayed return to fertility (average 7–10 months). * **Beneficial Effects:** Reduces risk of PID, ectopic pregnancy, and iron deficiency anemia. * **Contraindication:** Current breast cancer and undiagnosed abnormal uterine bleeding.

Q: Which of the following is NOT a side effect of Depot Medroxyprogesterone Acetate (Depot MPA)?

Hepatitis. **Explanation:** **Depot Medroxyprogesterone Acetate (DMPA)**, commonly known as the "Antara" program injection in India, is a progestogen-only injectable contraceptive. **Why Hepatitis is the Correct Answer:** Hepatitis is not a side effect of DMPA. In fact, unlike oral contraceptive pills (OCPs) which undergo first-pass metabolism in the liver and can exacerbate cholestatic jaundice or liver adenomas, DMPA is administered parenterally. It does not adversely affect liver function and is not associated with hepatotoxicity. **Analysis of Incorrect Options:** * **Weight Gain (A):** This is a very common side effect. DMPA is the only contraceptive consistently linked to significant weight gain (average 1–2 kg/year), primarily due to its glucocorticoid-like activity and increased appetite. * **Irregular Bleeding (B):** During the first 3–6 months of use, breakthrough bleeding or spotting is the most common reason for discontinuation. * **Amenorrhea (C):** This is a hallmark of long-term DMPA use. Due to the profound suppression of the endometrium, approximately 50-70% of women become amenorrheic after one year of use. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Inhibits ovulation by suppressing the LH surge. * **Dose:** 150 mg IM every 3 months (12 weeks). * **Black Box Warning:** Long-term use is associated with **reversible loss of Bone Mineral Density (BMD)**. * **Return to Fertility:** There is a characteristic **delayed return to fertility** (average 7–10 months after the last injection). * **Non-contraceptive benefit:** Reduces the risk of endometrial cancer and helps in managing endometriosis and dysmenorrhea.

Q: Which of the following is NOT a side effect or complication of the Copper-T intrauterine device?

Ectopic pregnancy. ### Explanation The correct answer is **C. Ectopic pregnancy**. **Why Ectopic Pregnancy is NOT a side effect:** The Copper-T (Cu-T) is a highly effective contraceptive. While it does not provide 100% protection, it significantly reduces the **absolute risk** of both intrauterine and ectopic pregnancies compared to women using no contraception. If a woman becomes pregnant with a Cu-T in situ, the *relative* risk of that pregnancy being ectopic is higher, but the *overall* incidence of ectopic pregnancy is much lower than in the general population. Therefore, it is considered a protective factor rather than a side effect. **Analysis of Incorrect Options:** * **A. Menorrhagia:** This is the **most common side effect** and the most frequent reason for removal. The copper ions cause a local inflammatory response in the endometrium, leading to increased menstrual blood loss. * **B. Dysmenorrhea:** Increased uterine cramping and painful menstruation are common side effects, often occurring alongside menorrhagia due to increased prostaglandin synthesis. * **D. Perforation:** This is a serious but rare **iatrogenic complication**, usually occurring during insertion (incidence approx. 1 in 1000). It is most common in women with a retroverted uterus or those who are lactating (due to a soft, thinned uterine wall). **High-Yield Clinical Pearls for NEET-PG:** * **Most common side effect:** Bleeding (Menorrhagia). * **Most common cause for removal:** Bleeding and pain. * **Ideal time for insertion:** Within 10 days of the onset of menstruation (to ensure the patient is not pregnant and the cervix is slightly dilated). * **Mechanism of Action:** Primarily **spermicidal** (sterile inflammatory response is toxic to sperm); it also prevents fertilization and implantation. * **Emergency Contraception:** Cu-T is the most effective method of emergency contraception if inserted within 5 days of unprotected intercourse.

Q: Which of the following oral contraceptive pills contains the least amount of estrogen?

Femilon. **Explanation:** The concentration of estrogen (Ethinyl Estradiol) in Combined Oral Contraceptive Pills (COCPs) is a critical factor in determining their side-effect profile, particularly regarding thromboembolic risks and nausea. **1. Why Femilon is Correct:** **Femilon** is a "low-dose" third-generation COCP. It contains **20 mcg of Ethinyl Estradiol** (EE) combined with 150 mcg of Desogestrel. Currently, 20 mcg is among the lowest standard doses used in clinical practice to maintain contraceptive efficacy while minimizing estrogenic side effects. **2. Analysis of Incorrect Options:** * **Mala N:** This is a second-generation pill provided under the National Family Welfare Programme. It contains **30 mcg of EE** and 0.15 mg of Levonorgestrel. * **Novelon:** Also a third-generation pill containing Desogestrel (150 mcg), but it contains a higher dose of estrogen—**30 mcg of EE**. * **Triquilar:** This is a triphasic pill. The estrogen content varies throughout the cycle (30 mcg, 40 mcg, and 30 mcg), but the average and minimum doses are higher than those in Femilon. **3. High-Yield Clinical Pearls for NEET-PG:** * **Generation Classification:** COCPs are often classified by their progestogen component. Desogestrel (in Femilon/Novelon) is a **3rd generation** progestogen, which has less androgenic side effects (less acne/hirsutism) but a slightly higher risk of Venous Thromboembolism (VTE) compared to 2nd generation pills. * **Ultra-low dose:** Pills containing **<30 mcg** of EE are termed "low-dose" or "ultra-low dose." * **Centchroman (Saheli):** Remember that this is a Non-Steroidal, Selective Estrogen Receptor Modulator (SERM) and contains **zero** estrogen. It is the "Once-a-week" pill developed by CDRI, Lucknow. * **Mala D vs. Mala N:** Both contain 30 mcg EE; the difference is that Mala D is a paid brand, while Mala N is supplied free in government health centers.

Question 1

Use of oral contraceptives decreases the incidence of all of the following except?

Accepted Answer

Hepatic adenoma

Answer

Ectopic pregnancy

Answer

Epithelial ovarian malignancy

Answer

Pelvic inflammatory disease

Question 2

What is the minimum effective dose of estrogen in oral contraceptive pills (OCPs)?

Accepted Answer

20 mcg

Answer

30 mcg

Answer

40 mcg

Answer

50 mcg

Question 3

Which of the following intrauterine devices has the minimum failure rate?

Accepted Answer

Levonorgestrel IUD

Answer

Progestase

Answer

Cu T-380 A

Answer

T Cu -200

Question 4

A couple requires emergency contraception four days after unprotected intercourse. What is the recommended contraceptive method?

Accepted Answer

Copper T 380 IUD

Answer

Oral contraceptive pills

Answer

Yuzpe method

Answer

Low dose progestogen-only pills

Question 5

A woman was taking progestin-only pills for contraception. Which side-effect is not likely to occur?

Accepted Answer

Dysmenorrhea

Answer

Acne

Answer

Amenorrhea

Answer

Obesity

Question 6

Which of the following is true regarding depot medroxy progesterone acetate?

Accepted Answer

It is known to diminish bone mineral density.

Answer

It is a subdermal progestin implant.

Answer

It is a 150 mg dose given intravenously every 90 days.

Answer

It increases the risk of endometrial cancer.

Question 7

A woman with an intrauterine contraceptive device (IUCD) develops pelvic inflammatory disease. What is the recommended initial management?

Accepted Answer

Maintain the IUCD, initiate antibiotic therapy, and assess the response before deciding on IUCD removal.

Answer

Start antibiotics and then remove the IUCD.

Answer

Remove the IUCD and then start antibiotics.

Answer

Delay intervention until the next menstrual cycle.

Question 8

Which of the following is NOT a side effect of Depot Medroxyprogesterone Acetate (Depot MPA)?

Accepted Answer

Hepatitis

Answer

Weight gain

Answer

Irregular bleeding

Answer

Amenorrhea

Question 9

Which of the following is NOT a side effect or complication of the Copper-T intrauterine device?

Accepted Answer

Ectopic pregnancy

Answer

Menorrhagia

Answer

Dysmenorrhea

Answer

Perforation

Question 10

Which of the following oral contraceptive pills contains the least amount of estrogen?

Accepted Answer

Femilon

Answer

Mala N

Answer

Triquilar

Answer

Novelon

Contraception and Family Planning — MCQs

Contraception and Family Planning — MCQs

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