Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 181: What is the most suitable method for Medical Termination of Pregnancy (MTP) during the third month of gestation?

A. Dilatation and curettage
B. Extra-amniotic ethacridine
C. Hysterectomy
D. Suction and evacuation (Correct Answer)

Explanation: **Explanation:** The "third month" of gestation corresponds to **9–12 weeks** of pregnancy. According to standard obstetric guidelines and the MTP Act, **Suction and Evacuation (S&E)** is the gold standard and most suitable method for termination in the first trimester (up to 12 weeks). * **Why Suction and Evacuation is correct:** It is a safe, rapid, and highly effective surgical procedure. It involves dilating the cervix and using a vacuum source (electric or manual) to remove the products of conception. It has a lower risk of uterine perforation and hemorrhage compared to traditional curettage. **Analysis of Incorrect Options:** * **A. Dilatation and Curettage (D&C):** This is an older technique involving sharp metal curettes. It is no longer preferred because it carries a higher risk of uterine trauma, Asherman syndrome, and increased blood loss compared to suction. * **B. Extra-amniotic Ethacridine:** This is a method used for **second-trimester** abortions (usually 15–20 weeks). It is not indicated for the first trimester as surgical evacuation is much simpler and safer at 12 weeks. * **C. Hysterectomy:** This is a major surgery involving the removal of the uterus. It is never a primary method for MTP unless there is a concurrent life-threatening pathology (e.g., intractable hemorrhage or uterine malignancy). **High-Yield NEET-PG Pearls:** * **Up to 7 weeks (49 days):** Medical MTP (Mifepristone + Misoprostol) is the preferred choice. * **Up to 12 weeks:** Suction and Evacuation is the surgical method of choice. * **13–24 weeks:** Medical induction (Prostaglandins/Misoprostol) or Dilatation and Evacuation (D&E) are used. * **MTP Act Update:** Pregnancy can now be terminated up to **24 weeks** for specific categories of women (e.g., survivors of sexual assault, minors, fetal abnormalities) with the opinion of two doctors.

Question 182: What is the lifespan of an LNG-IUD?

A. 2 years
B. 5 years (Correct Answer)
C. 10 years
D. 12 years

Explanation: **Explanation:** The **Levonorgestrel-releasing Intrauterine Device (LNG-IUD)**, commonly known by the brand name **Mirena**, is a highly effective long-acting reversible contraceptive (LARC). It contains a reservoir of 52 mg of levonorgestrel which is released at an initial rate of 20 µg/day. 1. **Why 5 years is correct:** The reservoir is designed to maintain therapeutic hormone levels for a period of **5 years**. While recent studies suggest some models may remain effective for up to 7–8 years, the standard FDA-approved and textbook duration for the 52 mg LNG-IUD (Mirena) remains 5 years. It works primarily by thickening cervical mucus and causing endometrial atrophy. 2. **Why other options are incorrect:** * **2 years:** No standard IUD has a lifespan this short; however, some injectable contraceptives or older implants had shorter durations. * **10 years:** This is the standard lifespan for the **Copper T 380A** (non-hormonal IUD). * **12 years:** While some studies suggest Copper T 380A can last this long, it is not the standard recommendation for LNG systems. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Candidate:** LNG-IUD is the **treatment of choice for Menorrhagia** (DUB) as it reduces menstrual blood loss by up to 90%. * **Non-contraceptive benefits:** Used in the management of endometriosis, adenomyosis, and endometrial hyperplasia. * **Pearl:** Unlike Copper-T, the LNG-IUD often leads to **amenorrhea** or oligomenorrhea, which should be explained to the patient beforehand. * **Other variants:** *Kyleena* (19.5 mg LNG) is also approved for 5 years, while *Skyla* (13.5 mg LNG) is approved for 3 years.

Question 183: What is the composition of Nova-T?

A. Copper and silver (Correct Answer)
B. Copper and aluminium
C. Copper only
D. Copper and Selenium

Explanation: **Explanation:** The **Nova-T** is a second-generation Intrauterine Contraceptive Device (IUCD). Its core composition consists of a polyethylene frame wrapped with **copper wire** containing a **silver core**. 1. **Why Copper and Silver is correct:** The primary active component is copper (200 $mm^2$ surface area), which acts as a spermicide by causing a local inflammatory response in the endometrium. The addition of a **silver core** is the defining feature of Nova-T; it prevents the fragmentation of the copper wire, thereby increasing the device's lifespan and structural integrity. 2. **Why other options are incorrect:** * **Copper only:** This describes older devices like the Cu-T 200. Without the silver core, the copper wire is more prone to corrosion and fragmentation. * **Copper and Aluminium/Selenium:** These metals are not used in standard IUCD manufacturing. Aluminium lacks the necessary flexible properties, and Selenium has no established role in intrauterine contraception. **High-Yield Clinical Pearls for NEET-PG:** * **Lifespan:** Nova-T is approved for **5 years** of use. * **Surface Area:** It contains 200 $mm^2$ of copper (similar to Cu-T 200), but the silver core makes it more durable. * **Mechanism:** Copper ions inhibit sperm motility and acrosomal enzyme activity, preventing fertilization. * **Comparison:** Unlike the **Cu-T 380A** (the "Gold Standard" with a 10-year lifespan), Nova-T has a slightly lower efficacy but is often noted for easier insertion and removal due to its flexible side arms.

Question 184: Single pill of MALA-D contains which of the following components?

A. L-norgestrel 0.15 mg and Ethinylestradiol (EE) 0.03 mg (Correct Answer)
B. L-norgestrel 0.03 mg and Ethinylestradiol (EE) 0.15 mg
C. D-norgestrel 0.15 mg and Ethinylestradiol (EE) 0.03 mg
D. D-norgestrel 0.03 mg and Ethinylestradiol (EE) 0.15 mg

Explanation: **Explanation:** Mala-D and Mala-N are the standard Combined Oral Contraceptive Pills (COCPs) provided under the National Family Planning Programme in India. The correct composition of a single active pill is **0.15 mg of Levonorgestrel** (progestogen) and **0.03 mg (30 mcg) of Ethinylestradiol** (estrogen). 1. **Why Option A is correct:** This dosage represents a "low-dose" second-generation COCP. Levonorgestrel (L-norgestrel) is the active levorotatory isomer used in clinical practice. The 30 mcg dose of Ethinylestradiol is sufficient to inhibit ovulation by suppressing FSH/LH while minimizing estrogenic side effects like nausea and thromboembolism. 2. **Why Options B & D are incorrect:** These options swap the dosages. In COCPs, the progestogen component is always present in a higher numerical dose (milligrams) compared to the potent estrogen component (micrograms). 0.15 mg of EE would be a dangerously high dose. 3. **Why Option C is incorrect:** D-norgestrel (dextrorotatory) is pharmacologically inactive. Only the L-isomer (Levonorgestrel) binds to progesterone receptors to exert contraceptive effects. **High-Yield Clinical Pearls for NEET-PG:** * **Mala-D vs. Mala-N:** Both have the same hormonal composition. The only difference is that **Mala-D** (D = Desired) is a paid brand (nominal cost), while **Mala-N** (N = National/Nishulk) is distributed free of cost at government centers. * **Packet Composition:** Each cycle pack contains **28 pills**: 21 white hormonal pills and 7 brown non-hormonal pills (containing **60 mg Ferrous Fumarate**) to maintain the habit of daily pill-taking and prevent anemia. * **Mechanism of Action:** Primarily prevents ovulation by suppressing the LH surge; secondarily thickens cervical mucus and causes endometrial atrophy. * **Failure Rate:** 0.3 per 100 woman-years with perfect use (Pearl Index).

Question 185: Which of the following is a common side effect of DMPA (Depot Medroxyprogesterone Acetate)?

A. Delayed return of fertility
B. High failure rate
C. Irregular cycles (Correct Answer)
D. Weight gain

Explanation: **Explanation:** **DMPA (Depot Medroxyprogesterone Acetate)** is a progestogen-only injectable contraceptive administered intramuscularly every 3 months. **Why "Irregular Cycles" is the correct answer:** The most common side effect of DMPA, especially during the first year of use, is **menstrual irregularity**. Because DMPA provides a continuous high dose of progestogen, it causes the endometrial lining to become thin and atrophic. This leads to unpredictable spotting or breakthrough bleeding initially. With continued use, most women eventually develop **amenorrhea** (approx. 50-70% after one year), which is a hallmark of the drug. **Analysis of Incorrect Options:** * **A. Delayed return of fertility:** While this is a characteristic feature of DMPA (average delay of 7–9 months after the last injection), it is considered a **limitation or disadvantage** rather than the most common clinical side effect encountered during active use. * **B. High failure rate:** This is incorrect. DMPA is highly effective with a Pearl Index of approximately **0.2–0.3**, making it one of the most reliable reversible contraceptives. * **D. Weight gain:** While weight gain is a documented side effect of DMPA, menstrual irregularities occur more frequently and are the primary reason for discontinuation. **NEET-PG High-Yield Pearls:** * **Mechanism of Action:** Primarily inhibits ovulation by suppressing the LH surge. * **Dose:** 150 mg IM every 12 weeks (3 months). * **Black Box Warning:** Long-term use may lead to a decrease in **Bone Mineral Density (BMD)**; however, this is usually reversible after discontinuation. * **Antara Program:** Under the Government of India’s family planning initiative, DMPA is provided for free under the brand name **'Antara'**.

Question 186: All of the following statements regarding benefits of combined oral contraceptive pills are TRUE, EXCEPT:

A. It decreases the risk of ectopic pregnancy
B. It decreases the risk of cervical cancer (Correct Answer)
C. It improves dysmenorrhea from endometriosis
D. It decreases the incidence and severity of acute salpingitis

Explanation: **Explanation:** The correct answer is **B**, as Combined Oral Contraceptive Pills (COCPs) do **not** decrease the risk of cervical cancer; in fact, long-term use (typically >5 years) is associated with a slightly **increased risk** of cervical cancer. This is likely due to increased susceptibility to HPV infection or behavioral factors. **Analysis of Options:** * **Option A (Ectopic Pregnancy):** COCPs prevent ovulation. Since there is no ovum to fertilize, the absolute risk of both intrauterine and ectopic pregnancies is significantly reduced. * **Option C (Dysmenorrhea/Endometriosis):** COCPs suppress the menstrual cycle and induce a state of endometrial atrophy. This reduces prostaglandin production and prevents the cyclic growth of ectopic endometrial tissue, thereby alleviating pain. * **Option D (Acute Salpingitis):** COCPs decrease the risk of Pelvic Inflammatory Disease (PID). They thicken the cervical mucus, creating a barrier against ascending infections, and reduce menstrual flow, which limits the medium for bacterial growth. **High-Yield Clinical Pearls for NEET-PG:** * **Protective Effects (The "Big Three"):** COCPs significantly reduce the risk of **Ovarian cancer** (by 50%), **Endometrial cancer** (by 50%), and **Colorectal cancer**. * **Ovarian Cancer:** Protection is due to "ordered ovarian rest" (suppression of incessant ovulation). * **Endometrial Cancer:** Protection is due to the progestogen component preventing estrogen-induced hyperplasia. * **Increased Risks:** COCPs are associated with an increased risk of **Cervical cancer**, **Breast cancer**, and **Hepatic adenomas**. * **Non-Contraceptive Benefits:** They reduce the risk of functional ovarian cysts, benign breast disease, and iron-deficiency anemia.

Question 187: Which of the following is NOT a recommended treatment for a woman with an IUD in situ and a positive cervical cytology for Actinomyces infection?

A. No intervention needed
B. Hysterectomy (Correct Answer)
C. Extended course of antibiotics
D. Removal of IUD

Explanation: **Explanation:** The presence of *Actinomyces-like organisms* (ALO) on a routine cervical Pap smear in an asymptomatic IUD user is a common clinical scenario. *Actinomyces israelii* is a Gram-positive, anaerobic bacterium that is a normal commensal of the female genital tract but can proliferate in the presence of a foreign body like an IUD. **Why Hysterectomy is the Correct Answer:** Hysterectomy is a radical surgical procedure and is **never** indicated for the mere presence of *Actinomyces* on cytology. Management is conservative unless the patient is symptomatic. Performing a hysterectomy for an incidental finding on a Pap smear would be a gross over-treatment and is medically contraindicated. **Analysis of Other Options:** * **Option A (No intervention needed):** This is the **current standard of care** for asymptomatic women. If the patient has no symptoms (no pelvic pain, discharge, or fever), the IUD can be left in situ, and the patient is simply monitored. * **Option D (Removal of IUD):** This is a valid management option if the patient is concerned or symptomatic. However, it is not mandatory if she is asymptomatic. * **Option C (Extended course of antibiotics):** While not routinely recommended for asymptomatic colonization, a course of Penicillin (the drug of choice) may be prescribed if the IUD is removed or if there are mild symptoms of Pelvic Inflammatory Disease (PID). **NEET-PG High-Yield Pearls:** 1. **Asymptomatic + Actinomyces on Pap smear:** Do nothing (No treatment, no IUD removal). 2. **Symptomatic (Pelvic pain/PID) + Actinomyces:** Remove IUD and start high-dose **Penicillin G** (or Doxycycline if allergic). 3. **Pelvic Actinomycosis:** Classically presents with "woody" pelvic induration and "sulfur granules" in the discharge. 4. The risk of *Actinomyces* colonization increases with the **duration** of IUD use (especially >5 years).

Question 188: A 28-year-old P1L1 had a Copper-T inserted 2 years ago. On examination, Copper-T threads are not seen. Ultrasound shows the Copper-T partly in the abdominal cavity. What is the method of removal?

A. Hysteroscopy
B. No removal needed (wait and watch)
C. IUCD hook
D. Laparoscopy (Correct Answer)

Explanation: **Explanation:** The clinical scenario describes a **displaced or perforated IUCD**. When threads are not visible on examination (Missing IUCD), the first step is an ultrasound. In this case, the ultrasound confirms that the Copper-T is "partly in the abdominal cavity," indicating a **partial or complete uterine perforation.** **1. Why Laparoscopy is the Correct Answer:** Once an IUCD has perforated the uterine wall and entered the peritoneal cavity, it is considered an **extrauterine IUCD**. Even if the patient is asymptomatic, an extrauterine Copper-T must be removed because it can cause inflammatory adhesions, bowel perforation, or bladder injury. **Laparoscopy** is the gold standard and preferred surgical approach for retrieving a Copper-T from the abdominal cavity as it is minimally invasive and allows for direct visualization of the device and surrounding viscera. **2. Why Other Options are Incorrect:** * **Hysteroscopy:** This is used to remove an IUCD that is still within the uterine cavity (e.g., embedded in the myometrium or displaced upwards) but not for those that have migrated into the abdominal cavity. * **No removal needed:** This is incorrect. Copper is highly inflammatory; leaving it in the peritoneal cavity leads to significant adhesion formation and potential organ damage. * **IUCD hook:** This is a blind procedure used to retrieve an IUCD from the uterine cavity when threads are missing but the device is confirmed to be intrauterine. Using it for a perforated IUCD carries a high risk of uterine injury. **Clinical Pearls for NEET-PG:** * **Initial Investigation for Missing Threads:** Ultrasound (USG) is the first-line investigation. * **If USG is inconclusive:** Perform an X-ray of the Abdomen and Pelvis (Erect and Supine). * **Management Rule:** If the IUCD is **Intrauterine** → Hysteroscopy/IUCD Hook. If the IUCD is **Extrauterine** → Laparoscopy (preferred) or Laparotomy. * **Most common site of perforation:** Usually occurs at the time of insertion, often through the posterior wall or fundus.

Question 189: The active drug in Norplant, a subdermal implant hormonal contraceptive, is:

A. Norethisterone
B. Norethynodrel
C. Medroxyprogesterone
D. Levonorgestrel (Correct Answer)

Explanation: **Explanation:** **Norplant** is a first-generation subdermal contraceptive implant system. It consists of six flexible silastic capsules, each containing 36 mg of **Levonorgestrel (LNG)**, totaling 216 mg. The mechanism involves the slow, continuous release of the progestin into the systemic circulation, providing highly effective contraception for up to 5 years. **Why Levonorgestrel is correct:** Levonorgestrel is a potent second-generation synthetic progestin. In Norplant, it works primarily by thickening cervical mucus (preventing sperm penetration) and suppressing ovulation in approximately 50% of cycles. Its high bioavailability and long half-life make it the ideal candidate for long-acting reversible contraceptives (LARC). **Why other options are incorrect:** * **Norethisterone (A):** A first-generation progestin used primarily in oral contraceptive pills (OCPs) and as an injectable (NET-EN), but not used in subdermal implants. * **Norethynodrel (B):** One of the first progestins used in the original "pill" (Enovid); it is rarely used in modern long-acting delivery systems. * **Medroxyprogesterone (C):** This is the active ingredient in **DMPA** (Depo-Provera), which is an intramuscular or subcutaneous *injection*, not a subdermal implant. **High-Yield Clinical Pearls for NEET-PG:** * **Norplant vs. Implanon:** While Norplant has 6 rods (5 years), **Implanon/Nexplanon** is a single-rod implant containing **Etonogestrel** (3 years). * **Failure Rate:** The Pearl Index of Norplant is extremely low (~0.05), making it as effective as sterilization. * **Side Effects:** The most common reason for discontinuation is **irregular menstrual bleeding** (breakthrough bleeding). * **Insertion Site:** It is typically inserted sub-dermally in the inner aspect of the non-dominant upper arm.

Question 190: Which of the following is a health benefit of using combined oral contraceptives in pre-menopausal women?

A. Reduced risk of deep vein thrombosis
B. Reduced risk of migraine
C. Reduced risk of ovarian cancer (Correct Answer)
D. Reduced risk of ischemic stroke

Explanation: **Explanation:** **Why the correct answer is right:** Combined Oral Contraceptives (COCs) provide significant non-contraceptive health benefits, most notably a **reduced risk of ovarian cancer**. The underlying mechanism is the **suppression of ovulation**. By preventing the monthly "incessant ovulation" and the subsequent repeated trauma and repair of the ovarian epithelium, COCs decrease the risk of epithelial ovarian tumors. This protective effect is duration-dependent (increasing with longer use) and persists for up to 30 years after discontinuation. COCs also significantly reduce the risk of **endometrial cancer** (due to progestogen-induced endometrial atrophy) and **colorectal cancer**. **Why the incorrect options are wrong:** * **A & D (DVT and Ischemic Stroke):** COCs actually **increase** the risk of venous thromboembolism (VTE) and arterial strokes. The estrogen component (Ethinyl Estradiol) increases the hepatic synthesis of clotting factors (II, VII, IX, X) and decreases antithrombin III, creating a pro-coagulant state. * **B (Migraine):** COCs can exacerbate migraines, particularly during the hormone-free interval (estrogen withdrawal). Furthermore, COCs are **contraindicated** in women with migraine with aura due to a significantly elevated risk of ischemic stroke. **High-Yield Clinical Pearls for NEET-PG:** * **Cancer Protection:** 50% reduction in Ovarian and Endometrial cancer risk. * **Benign Conditions:** COCs reduce the risk of Benign Breast Disease (e.g., fibroadenoma), Pelvic Inflammatory Disease (PID), and ectopic pregnancy. * **Menstrual Benefits:** Used to treat dysmenorrhea, menorrhagia, and PCOS. * **Absolute Contraindications (WHO Category 4):** Smokers >35 years (>15 cigarettes/day), history of VTE/Stroke, Migraine with aura, and Breast Cancer.

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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