Contraception and Family Planning Practice Questions

Q: Which of the following liver disorders is a complication associated with oral contraceptives?

Intrahepatic cholestasis. ### Explanation **Correct Answer: D. Intrahepatic cholestasis** **Why it is correct:** Combined Oral Contraceptive Pills (COCPs) contain estrogen and progesterone, which can interfere with the transport of bile acids across the canalicular membrane. Estrogen, in particular, decreases the activity of the bile salt export pump (BSEP), leading to **intrahepatic cholestasis**. This condition mimics "Intrahepatic Cholestasis of Pregnancy" (ICP). Patients typically present with pruritus (often involving palms and soles) and mild jaundice, which resolves upon discontinuation of the pill. **Analysis of Incorrect Options:** * **A. Drug-induced hepatitis with fatty change:** While some drugs cause steatosis, COCPs are more typically associated with cholestasis or specific benign tumors rather than generalized fatty hepatitis. * **B. Cholangiocarcinoma:** There is no established causal link between COCP use and bile duct cancer (cholangiocarcinoma). In fact, some studies suggest COCPs may have a protective effect against certain hepatobiliary cancers. * **C. Cavernous hemangiomas:** These are the most common benign liver tumors but are generally congenital. While they may enlarge during pregnancy due to hormonal sensitivity, they are **not** primarily caused by COCPs. Note: COCPs are strongly associated with **Hepatic Adenomas**, not hemangiomas. **High-Yield Clinical Pearls for NEET-PG:** * **Hepatic Adenoma:** This is the most classic liver tumor associated with long-term COCP use. It carries a risk of rupture and intraperitoneal hemorrhage. * **Contraindications:** According to WHO Medical Eligibility Criteria (MEC), COCPs are **Category 4 (Absolute Contraindication)** in patients with active viral hepatitis, decompensated cirrhosis, or hepatocellular carcinoma. * **Gallstones:** Estrogen increases cholesterol saturation in bile, increasing the risk of cholelithiasis (gallstones) in COCP users.

Q: Which oral contraceptive pill has the least failure rate?

Combined pill. **Explanation:** The **Combined Oral Contraceptive Pill (COCP)** is the most effective oral contraceptive method because it utilizes a dual mechanism of action. It contains both estrogen and progestogen, which work synergistically to **suppress ovulation** by inhibiting the release of FSH and LH from the pituitary gland. When used perfectly, the failure rate is as low as **0.1 per 100 woman-years** (Pearl Index), making it superior to other oral formulations. **Analysis of Options:** * **Combined Pill (Correct):** By consistently inhibiting ovulation and thickening cervical mucus, it provides the highest level of protection among oral options. * **Mini Pill (Progestogen-Only Pill):** These primarily work by thickening cervical mucus and altering the endometrium. Since they do not consistently suppress ovulation in all cycles and have a very narrow "missed pill" window (3 hours for traditional formulations), they have a higher failure rate (approx. 0.3–9.0). * **Sequential Pill:** These were designed to mimic the natural cycle (estrogen followed by estrogen+progesterone). They were found to be less effective than COCPs and carried a higher risk of endometrial cancer; they are largely obsolete in modern practice. **High-Yield Clinical Pearls for NEET-PG:** * **Pearl Index:** The standard measure for contraceptive failure (number of pregnancies per 100 woman-years). * **Most common side effect of COCP:** Breakthrough bleeding (especially in the first 3 months). * **Most serious side effect:** Venous Thromboembolism (VTE), primarily due to the estrogen component. * **Non-contraceptive benefits:** Reduced risk of ovarian and endometrial cancers (protective effect lasts years after discontinuation). * **Drug Interactions:** Enzyme inducers like Rifampicin and Phenytoin decrease the efficacy of OCPs.

Q: A patient gives a history of missing a single dose of her combined oral contraceptive pill. What advice should be given?

Take 2 pills the next day and continue with the course.. **Explanation:** The management of missed Combined Oral Contraceptive Pills (COCPs) is a high-yield topic based on the WHO Medical Eligibility Criteria. **1. Why Option B is Correct:** When a **single pill** is missed (less than 24 hours late) or if 24 to 48 hours have passed since the last pill was taken, the risk of ovulation is minimal. The standard protocol is to **take the missed pill as soon as remembered**, even if it means taking two pills on the same day (the missed one + the scheduled one). The patient should then continue the rest of the pack as usual. In this scenario, back-up contraception (like condoms) is generally not required. **2. Why Incorrect Options are Wrong:** * **Option A:** Ignoring the missed dose increases the risk of "escape ovulation" due to a drop in hormone levels, potentially leading to contraceptive failure. * **Option C:** Taking two pills every day for the remainder of the cycle is unnecessary and would cause significant hormonal side effects (nausea, breast tenderness) without providing additional protection. * **Option D:** Discontinuing the course is only recommended if multiple pills are missed in certain weeks or if the patient prefers to switch methods. For a single missed pill, the cycle can be safely salvaged. **3. Clinical Pearls for NEET-PG:** * **The "7-Day Rule":** If **2 or more pills** are missed (more than 48 hours since the last pill), the patient should take the most recent missed pill, discard other missed pills, and use **back-up contraception for the next 7 days**. * **Emergency Contraception (EC):** If 2+ pills are missed in the **first week** of the pack and unprotected intercourse occurred, EC should be considered. * **Vomiting/Diarrhea:** If severe vomiting occurs within 2 hours of pill intake, it should be treated as a missed dose.

Q: Pelvic Inflammatory Disease occurs least commonly with which contraceptive method?

Condom. **Explanation:** The correct answer is **Condom (Option B)**. Pelvic Inflammatory Disease (PID) is primarily caused by the ascending spread of sexually transmitted infections (STIs), most commonly *Chlamydia trachomatis* and *Neisseria gonorrhoeae*. Condoms act as a **mechanical barrier** that prevents the transmission of these pathogens from the male urethra to the female genital tract. By preventing the initial infection, condoms provide the highest level of protection against PID compared to all other contraceptive methods. **Analysis of Incorrect Options:** * **Oral Contraceptive Pills (OCPs):** While OCPs provide a degree of protection against PID by thickening cervical mucus (making it harder for bacteria to ascend) and reducing menstrual flow (less medium for bacterial growth), they do not prevent the acquisition of STIs. * **Intrauterine Contraceptive Device (IUCD):** Historically, IUCDs were associated with an increased risk of PID, particularly during the first 20 days post-insertion due to the introduction of vaginal flora into the uterus. They offer no protection against STIs. * **Diaphragm:** While it provides some barrier protection to the cervix, its efficacy in preventing STIs and subsequent PID is significantly lower than that of male condoms. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis for PID:** Laparoscopy (shows tubal edema and exudates). * **Most Common Cause:** *Chlamydia trachomatis* (often subclinical/silent). * **Fitz-Hugh-Curtis Syndrome:** A complication of PID involving perihepatitis ("violin-string" adhesions). * **OCP Benefit:** OCPs reduce the *severity* of PID but not the *incidence* of lower genital tract infections.

Q: Copper-T with threads is visible in a case of early pregnancy. What is the treatment of choice?

Remove CuT only. **Explanation:** The management of a pregnancy with an intrauterine contraceptive device (IUCD) in situ depends primarily on whether the **threads are visible** and the **gestational age**. **Why Option A is Correct:** When a woman becomes pregnant with a Copper-T (CuT) in situ and the strings are visible, the treatment of choice is **immediate removal of the CuT**. Leaving the device in place significantly increases the risk of **septic abortion** (by 50%), mid-trimester miscarriage, and preterm labor. Removing the device early reduces these risks, although there is a small (approx. 25-30%) risk of spontaneous abortion triggered by the removal itself. Since the patient is in "early pregnancy" and strings are visible, removal is the safest priority. **Why Other Options are Incorrect:** * **Option B:** Suction evacuation is only indicated if the patient **desires medical termination of pregnancy (MTP)**. The question implies management of the CuT to continue the pregnancy safely. * **Option C:** Reassurance alone is dangerous. Leaving the CuT increases the risk of maternal sepsis and chorioamnionitis. * **Option D:** Laparotomy is reserved for ectopic pregnancies or if the CuT has perforated the uterus and is located intra-abdominally (translocated IUCD), which is not indicated here. **High-Yield Clinical Pearls for NEET-PG:** * **Threads NOT visible:** Perform an ultrasound. If the IUCD is intrauterine, **do not** attempt removal as it may rupture the sac. * **Ectopic Risk:** While IUCDs prevent all pregnancies, if a failure occurs, the *proportion* of pregnancies that are ectopic is higher (approx. 1 in 20). * **Teratogenicity:** Copper-T is **not** known to be teratogenic to the fetus. * **Gold Standard:** If the patient wants to continue the pregnancy and strings are visible, **pull them out.**

Q: A woman with a history of deep vein thrombosis requires contraception. Which of the following methods is medically contraindicated for this patient?

Oral contraceptives. **Explanation:** The correct answer is **Oral Contraceptives (Combined Oral Contraceptive Pills - COCPs)**. **1. Why Oral Contraceptives are Contraindicated:** Combined oral contraceptives contain **estrogen**, which is known to increase the hepatic synthesis of clotting factors (II, VII, IX, and X) and decrease natural anticoagulants like Antithrombin III. This induces a pro-thrombotic state. According to the **WHO Medical Eligibility Criteria (MEC)**, a history of Deep Vein Thrombosis (DVT) or current DVT is classified as **MEC Category 4** (unacceptable health risk) for estrogen-containing methods, as they significantly increase the risk of recurrent thromboembolism. **2. Why Incorrect Options are Wrong:** * **Intrauterine Device (IUD):** Both the Copper-T and Levonorgestrel-releasing IUS are safe (MEC 1). They do not contain estrogen and do not affect the systemic coagulation cascade. * **Condoms:** These are barrier methods with no systemic hormonal effects, making them safe for patients with any medical comorbidity. * **Laparoscopic Tubal Ligation:** This is a permanent surgical method. While surgery itself carries a transient risk of DVT, the method does not involve long-term hormonal exposure and is not contraindicated once the patient is stable. **High-Yield Clinical Pearls for NEET-PG:** * **Progestogen-Only Pills (POPs):** These are generally safe (MEC 2) for women with a history of DVT and are the hormonal "method of choice" if estrogen must be avoided. * **MEC Category 4 for COCPs:** Includes history of DVT/PE, Migraine with aura, Smokers >35 years (>15 cigarettes/day), and Breast Cancer. * **DMPA (Injectable):** Use caution in active DVT (MEC 3), but history of DVT is MEC 2.

Q: All of the following are long-acting reversible contraceptives except?

Oral contraceptive pills. **Explanation:** The core concept of **Long-Acting Reversible Contraception (LARC)** refers to methods that provide highly effective pregnancy prevention for an extended period (typically 3 months to 10 years) without requiring daily or frequent action by the user. **Why Oral Contraceptive Pills (OCPs) are the correct answer:** OCPs are classified as **Short-Acting Reversible Contraceptives (SARC)**. Their efficacy is highly user-dependent, requiring strict daily adherence. If a user forgets a pill, the failure rate increases significantly. Because they do not provide long-term protection from a single administration, they do not fit the LARC criteria. **Analysis of Incorrect Options:** * **Intrauterine Devices (IUDs):** Both Copper-T (non-hormonal) and LNG-IUS (Mirena) are classic LARCs. They provide protection for 3 to 10 years after a single insertion. * **Implants:** Subdermal implants (e.g., Norplant, Nexplanon) are LARCs that provide continuous contraception for 3 to 5 years. * **Injectable Progestins:** While sometimes debated in strict definitions due to their 3-month duration, the WHO and standard textbooks (like Williams) often group **DMPA (Depot Medroxyprogesterone Acetate)** under long-acting methods because they remove the "daily" compliance burden. **NEET-PG High-Yield Pearls:** * **Most Effective:** LARCs (Implants and IUDs) have "typical use" failure rates nearly identical to "perfect use" failure rates (<1%), making them more effective than sterilization. * **Tier 1 Contraceptives:** Implants and IUDs. * **Tier 2 Contraceptives:** Injectables, OCPs, Patches, and Vaginal rings. * **Quick Start:** LARCs can be inserted at any time during the menstrual cycle if pregnancy is reasonably excluded. * **Lactational Amenorrhea Method (LAM):** Only effective for the first 6 months postpartum if the mother is exclusively breastfeeding and remains amenorrheic.

Q: For emergency contraception, when must an IUD be inserted?

Within 5 days of coitus. The Cu-T 380A Intrauterine Device (IUD) is the most effective method of emergency contraception (EC), with a failure rate of less than 0.1%. ### **Explanation of the Correct Answer** **Option B (Within 5 days of coitus)** is correct because the primary mechanism of the IUD as EC is to prevent implantation by causing a sterile inflammatory reaction in the endometrium that is toxic to the blastocyst. Since implantation typically occurs 6 to 12 days after fertilization, inserting the IUD within **120 hours (5 days)** of unprotected intercourse ensures the uterine environment is altered before the blastocyst can implant. ### **Analysis of Incorrect Options** * **Option A:** While "the sooner, the better" applies to hormonal EC (like Levonorgestrel), an IUD does not *have* to be inserted immediately to be effective; it remains highly effective up to the 5-day window. * **Option C:** Seven days exceeds the standard window for guaranteed efficacy, as implantation may have already commenced. (Note: Some guidelines suggest it can be inserted up to 5 days after the *earliest estimated day of ovulation*, but for NEET-PG, the standard "5 days after coitus" rule applies). * **Option D:** This is incorrect; the Cu-IUD is actually the "Gold Standard" for EC due to its superior efficacy compared to oral pills. ### **High-Yield Clinical Pearls for NEET-PG** * **Efficacy:** Cu-IUD is >99% effective, making it more effective than Ulipristal acetate or Levonorgestrel. * **Dual Benefit:** It provides immediate EC and continues to provide long-term contraception for up to 10 years. * **Contraindication:** It should not be used if the patient has a current Pelvic Inflammatory Disease (PID) or is already pregnant. * **Mechanism:** Primarily prevents implantation (post-fertilization) and is also spermicidal.

Question 1

Which of the following liver disorders is a complication associated with oral contraceptives?

Accepted Answer

Intrahepatic cholestasis

Answer

Drug-induced hepatitis with fatty change

Answer

Cholangiocarcinoma

Answer

Cavernous hemangiomas

Question 2

Which oral contraceptive pill has the least failure rate?

Accepted Answer

Combined pill

Answer

Sequential pill

Answer

Mini pill

Answer

None of the above

Question 3

Which method of sterilization is least effective?

Accepted Answer

Hysteroscopic tubal occlusion

Answer

Pomeroy's technique

Answer

Laparoscopy

Answer

Vaginal fimbriectomy

Question 4

A patient gives a history of missing a single dose of her combined oral contraceptive pill. What advice should be given?

Accepted Answer

Take 2 pills the next day and continue with the course.

Answer

Continue with the course without regard to the missed dose.

Answer

Take 2 pills every day for the remaining part of the course.

Answer

Discontinue the course and use an alternative method of contraception.

Question 5

Pelvic Inflammatory Disease occurs least commonly with which contraceptive method?

Accepted Answer

Condom

Answer

Oral Contraceptive Pills (OCPs)

Answer

Intrauterine Contraceptive Device (IUCD)

Answer

Diaphragm

Question 6

Copper-T with threads is visible in a case of early pregnancy. What is the treatment of choice?

Accepted Answer

Remove CuT only

Answer

Suction evacuation with Copper-T removal

Answer

Reassurance and continue pregnancy

Answer

Laparotomy

Question 7

A woman with a history of deep vein thrombosis requires contraception. Which of the following methods is medically contraindicated for this patient?

Accepted Answer

Oral contraceptives

Answer

Intrauterine device (IUD)

Answer

Condoms

Answer

Laparoscopic tubal ligation

Question 8

All of the following are long-acting reversible contraceptives except?

Accepted Answer

Oral contraceptive pills

Answer

Injectable progestins

Answer

Implants

Answer

Intrauterine devices

Question 9

All of the following are contraindications for the use of progesterone-only pills except?

Accepted Answer

Diabetes mellitus

Answer

Pregnancy

Answer

Patient suffering from breast cancer

Answer

Peripheral vascular disease

Question 10

For emergency contraception, when must an IUD be inserted?

Accepted Answer

Within 5 days of coitus

Answer

Immediately

Answer

Within 7 days of coitus

Answer

An IUD is not used as emergency contraception

Contraception and Family Planning — MCQs

Contraception and Family Planning — MCQs

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