Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 211: Which of the following is an active component of emergency contraceptive pills?

A. Estradiol
B. Levonorgestrel (Correct Answer)
C. Estrone
D. Prostaglandin E2

Explanation: **Explanation:** **Levonorgestrel (Option B)** is the correct answer. It is a second-generation synthetic progestogen and the most widely used active component in emergency contraceptive pills (ECPs). The standard regimen involves a single dose of **1.5 mg** (or two doses of 0.75 mg taken 12 hours apart) administered as soon as possible, ideally within **72 hours** of unprotected intercourse. Its primary mechanism of action is the **delay or inhibition of ovulation** by suppressing the LH surge. It does not disrupt an established pregnancy and is not an abortifacient. **Analysis of Incorrect Options:** * **Estradiol (Option A) & Estrone (Option C):** These are estrogens. While the older "Yuzpe Regimen" used a combination of Ethinyl Estradiol and Levonorgestrel, pure estrogens are not used as emergency contraceptives due to lower efficacy and significant side effects like severe nausea and vomiting. * **Prostaglandin E2 (Option D):** PGE2 (Dinoprostone) is used for cervical ripening and induction of labor or mid-trimester abortion. It has no role in preventing pregnancy post-coitus. **High-Yield Clinical Pearls for NEET-PG:** * **Window of Efficacy:** Levonorgestrel is effective up to 72 hours, whereas **Ulipristal Acetate** (a selective progesterone receptor modulator) is effective up to **120 hours (5 days)** and is currently considered the most effective oral ECP. * **Gold Standard:** The **Copper-T IUD** is the most effective method of emergency contraception if inserted within 5 days of unprotected intercourse. * **Failure Rate:** The failure rate of the LNG regimen is approximately 1.1%–3%. It is less effective in women with a BMI >30 kg/m².

Question 212: What is true about Implanon?

A. Releases > 67 ug/day of drug
B. Prevents STDs
C. Has a lifespan of 3 years (Correct Answer)
D. Contains levonorgestrel

Explanation: **Explanation:** **Implanon** is a long-acting reversible contraceptive (LARC) consisting of a single-rod subdermal implant. **Why Option C is correct:** Implanon is designed to provide highly effective contraception for a duration of **3 years**. It works primarily by suppressing ovulation through the continuous release of progestogen and thickening the cervical mucus to prevent sperm penetration. **Analysis of Incorrect Options:** * **Option A:** Implanon releases approximately **60–70 µg/day** of the hormone initially, which gradually declines to about **25–30 µg/day** by the end of the third year. It does not maintain a release rate >67 µg/day throughout its lifespan. * **Option B:** Like all hormonal contraceptives, Implanon **does not protect against Sexually Transmitted Diseases (STDs)** or HIV. Barrier methods (condoms) are required for STD protection. * **Option D:** Implanon contains **Etonogestrel** (68 mg), which is the active metabolite of desogestrel. Levonorgestrel is found in other systems like the LNG-IUD (Mirena) or Jadelle (a two-rod implant). **High-Yield Clinical Pearls for NEET-PG:** * **Nexplanon:** The newer version of Implanon is called Nexplanon; it is **radio-opaque** (visible on X-ray) and has an improved applicator to prevent deep insertion. * **Failure Rate:** It is the most effective reversible contraceptive method, with a Pearl Index of approximately **0.05**. * **Side Effects:** The most common reason for discontinuation is **irregular menstrual bleeding** (amenorrhea or spotting). * **Insertion Site:** It is inserted subdermally in the non-dominant upper arm, specifically in the groove between the biceps and triceps.

Question 213: Non-contraceptive benefits of oral contraceptive agents are against the development of all of the following except?

A. Ectopic pregnancy
B. Endometrial carcinoma
C. Ovarian carcinoma
D. Cervical carcinoma (Correct Answer)

Explanation: Combined Oral Contraceptive Pills (COCPs) provide significant non-contraceptive health benefits by suppressing ovulation and regulating hormonal fluctuations. However, they do not protect against **Cervical Carcinoma**; in fact, long-term use (typically >5 years) is associated with a slightly increased risk of cervical cancer, likely due to increased susceptibility to HPV infection and lifestyle factors. ### Why the other options are incorrect: * **Ectopic Pregnancy:** COCPs prevent ectopic pregnancy by the primary mechanism of inhibiting ovulation. If there is no ovum, fertilization cannot occur, virtually eliminating the risk of any pregnancy. * **Endometrial Carcinoma:** The progestogen component in COCPs opposes the proliferative effect of estrogen on the endometrium, leading to atrophy. This reduces the risk of endometrial cancer by approximately 50%, a benefit that persists for years after discontinuation. * **Ovarian Carcinoma:** By suppressing ovulation, COCPs reduce "incessant ovulation" and the repeated trauma to the ovarian epithelium. This reduces the risk of epithelial ovarian cancer by about 40-50%. ### High-Yield Clinical Pearls for NEET-PG: * **Protective Effect:** COCPs are protective against **Endometrial, Ovarian, and Colorectal cancers**, as well as Benign Breast Disease and Pelvic Inflammatory Disease (PID). * **Increased Risk:** COCPs are associated with an increased risk of **Cervical cancer, Breast cancer, and Hepatic adenoma**. * **Therapeutic Uses:** They are first-line treatments for Dysmenorrhea, Menorrhagia (DUB), and Polycystic Ovary Syndrome (PCOS). * **Duration:** The protective effect against ovarian and endometrial cancer increases with the duration of use and lasts for up to 15–20 years after stopping the pill.

Question 214: Saheli or Centchroman contains which of the following active pharmaceutical ingredients?

A. Estrogen + progesterone
B. Raloxifene
C. Ormeloxifene (Correct Answer)
D. Steroid

Explanation: **Explanation:** **Correct Option: C. Ormeloxifene** Saheli (Centchroman) is a unique, non-steroidal oral contraceptive pill developed by the Central Drug Research Institute (CDRI), Lucknow. Its active ingredient is **Ormeloxifene**, which belongs to the class of **Selective Estrogen Receptor Modulators (SERMs)**. The mechanism of action is based on its competitive antagonism of estrogen receptors in the uterus. By blocking these receptors, it prevents the normal proliferative changes in the endometrium, making it asynchronous and unsuitable for implantation. It also alters cervical mucus and increases tubal motility. Because it is non-steroidal, it does not suppress ovulation, meaning the hypothalamic-pituitary-ovarian axis remains intact. **Incorrect Options:** * **A & D (Estrogen + Progesterone / Steroids):** Traditional Combined Oral Contraceptive Pills (COCPs) contain steroids (Ethinylestradiol and Progestogens). Saheli is specifically marketed as a **non-steroidal** alternative, avoiding side effects like weight gain, nausea, and increased risk of thromboembolism. * **B (Raloxifene):** While Raloxifene is also a SERM, it is primarily used for the prevention and treatment of osteoporosis in postmenopausal women and to reduce the risk of invasive breast cancer, not as a contraceptive. **High-Yield Clinical Pearls for NEET-PG:** * **Dosage Schedule:** It is taken **twice weekly** for the first 3 months (e.g., Sunday and Wednesday), followed by **once weekly** thereafter. * **Failure Rate:** The Pearl Index is approximately **1.83 to 1.96**. * **Side Effects:** The most common side effect is **delayed menstrual cycles** (prolonged cycles), which occurs in about 8% of users. * **Contraindications:** Polycystic Ovarian Syndrome (PCOS), cervical dysplasia, and recent history of jaundice or liver disease. * **Government Program:** It is included in the National Family Planning Program of India under the brand name **'Chhaya'**.

Question 215: Unsuccessfulness of Depot Medroxyprogesterone Acetate (DMPA) has been primarily because of which of the following?

A. Breakthrough bleeding (Correct Answer)
B. Effect on lactation
C. Delay in return of fertility
D. Failure rate

Explanation: **Explanation:** The primary reason for the "unsuccessfulness" of DMPA (marketed as Antara in India) refers to its **high discontinuation rate** rather than its contraceptive efficacy. 1. **Why Breakthrough Bleeding (BTB) is correct:** DMPA is a progestogen-only injectable. The lack of estrogen leads to an unstable endometrium, causing irregular spotting or breakthrough bleeding, especially in the first 3–6 months. This side effect is the most common reason women stop using the method, leading to its perceived "unsuccessfulness" in long-term family planning programs. Over time, this usually progresses to amenorrhea, which can also be a cause for discontinuation due to cultural myths or fear of pregnancy. 2. **Analysis of Incorrect Options:** * **Effect on lactation:** DMPA is actually the **contraceptive of choice in lactating mothers** (after 6 weeks postpartum) as it does not affect the quality or quantity of breast milk. * **Delay in return of fertility:** While DMPA causes a significant delay (average 7–10 months after the last dose), it is a known pharmacological profile of the drug. While it may deter some users, it is not the leading cause of mid-treatment discontinuation compared to bleeding. * **Failure rate:** DMPA is highly effective. Its Pearl Index is **0.2–0.3**, making it one of the most reliable reversible contraceptives. **High-Yield Clinical Pearls for NEET-PG:** * **Dosage:** 150 mg intramuscularly every 3 months (12 weeks). * **Mechanism:** Primarily inhibits ovulation by suppressing the LH surge. * **Side Effects:** Weight gain (most common metabolic side effect) and a reversible decrease in **Bone Mineral Density (BMD)**. * **Amenorrhea:** By the end of 1 year, approximately 50–60% of users develop amenorrhea.

Question 216: For the postcoital douche method of contraception, select the most appropriate rate of use effectiveness (failure rate or percentage of pregnancies per year of actual patient use).

A. 80% (Correct Answer)
B. 40%
C. 15 to 25%
D. 5 to 15%

Explanation: **Explanation:** The **postcoital douche** is one of the least effective methods of contraception. The correct answer is **80%** because this method relies on flushing the vagina with water or medicated solutions immediately after intercourse. **Why 80% is correct:** Physiologically, spermatozoa are highly motile and can reach the cervical canal within **90 seconds** of ejaculation. By the time a woman performs a douche, a significant number of sperm have already ascended beyond the reach of the douche solution into the uterus and fallopian tubes. Furthermore, the pressure of the douching fluid may actually propel sperm further into the cervical os, inadvertently facilitating fertilization rather than preventing it. Consequently, the failure rate (use-effectiveness) is extremely high, approximately 80 pregnancies per 100 woman-years. **Analysis of Incorrect Options:** * **40% (Option B):** While still a high failure rate, this underestimates the inefficiency of douching. * **15 to 25% (Option C):** This range typically represents the failure rates of **barrier methods** (like the female condom or diaphragm) or **behavioral methods** (like withdrawal/coitus interruptus) during typical use. * **5 to 15% (Option D):** This represents the typical use failure rate of **Combined Oral Contraceptive Pills (COCPs)** or Injectables. **High-Yield Clinical Pearls for NEET-PG:** * **Pearl 1:** The most effective reversible contraceptives (LARC) like the Copper-T or Mirena have failure rates of **<1%**. * **Pearl 2:** Postcoital douching is not only ineffective but also increases the risk of **Pelvic Inflammatory Disease (PID)** and **Ectopic Pregnancy** by altering vaginal flora and forcing pathogens upward. * **Pearl 3:** For NEET-PG, always distinguish between **Theoretical Effectiveness** (perfect use) and **Use Effectiveness** (typical use). Douching fails miserably in both.

Question 217: For effective protection after unprotected intercourse, one single tablet of levonorgestrel 0.75mg has already been taken. When should the next dose be taken?

A. 1 tablet after 24 hours
B. 1 tablet after 12 hours (Correct Answer)
C. 2 tablets after 12 hours
D. 2 tablets after 24 hours

Explanation: **Explanation:** The question refers to the **Yuzpe regimen** or the traditional two-dose Levonorgestrel (LNG) emergency contraceptive protocol. **1. Why Option B is Correct:** The standard emergency contraceptive dose for Levonorgestrel is **1.5 mg**. When using the 0.75 mg formulation, the protocol requires two doses to reach the therapeutic threshold. The second 0.75 mg tablet must be taken exactly **12 hours** after the first dose. This timing ensures sustained hormonal levels to effectively delay or inhibit ovulation, which is the primary mechanism of action. **2. Why Other Options are Incorrect:** * **Options A & D:** Waiting 24 hours is incorrect because the plasma half-life and pharmacokinetics of LNG in this regimen are optimized for a 12-hour interval. Delaying the second dose reduces efficacy. * **Option C:** Taking two tablets (1.5 mg) 12 hours after an initial 0.75 mg dose would result in a total dose of 2.25 mg, which is unnecessary and increases the risk of side effects like nausea and vomiting without providing additional contraceptive benefit. **3. NEET-PG High-Yield Clinical Pearls:** * **The "Gold Standard" Change:** While the 12-hour split dose is the traditional method, the WHO now recommends a **single dose of 1.5 mg (e.g., i-Pill, 72-HOURS)** as it is equally effective and improves patient compliance. * **Time Window:** LNG is effective if taken within **72 hours** of unprotected intercourse, though efficacy is highest within the first 24 hours. * **Mechanism:** It primarily works by preventing the LH surge; it does **not** work if implantation has already occurred (it is not an abortifacient). * **Most Effective EC:** The **Copper-T (IUCD)** remains the most effective emergency contraceptive if inserted within 5 days. * **Ulipristal Acetate:** A selective progesterone receptor modulator (30 mg) is now preferred over LNG for use up to 120 hours (5 days).

Question 218: Oral contraceptive pills are contraindicated in all of the following conditions except:

A. Smoking in a patient 35 years or older
B. Coronary occlusion
C. Polycystic ovarian disease (Correct Answer)
D. Cerebrovascular disease

Explanation: **Explanation:** The correct answer is **Polycystic Ovarian Disease (PCOD/PCOS)**. In fact, Combined Oral Contraceptive Pills (COCPs) are considered the **first-line management** for PCOS. They help regulate menstrual cycles, provide endometrial protection against hyperplasia (by counteracting unopposed estrogen), and treat hyperandrogenism (hirsutism and acne) by increasing Sex Hormone Binding Globulin (SHBG), which lowers free testosterone levels. **Analysis of Contraindications (WHO Medical Eligibility Criteria - Category 4):** The other options represent absolute contraindications to COCPs due to the increased risk of thromboembolism and cardiovascular events associated with the estrogen component: * **Smoking in a patient ≥35 years:** Smoking significantly synergizes with estrogen to increase the risk of myocardial infarction and stroke. It is an absolute contraindication if the patient smokes ≥15 cigarettes/day and is over 35. * **Coronary Occlusion (Ischemic Heart Disease):** Estrogen increases the synthesis of clotting factors and promotes a pro-thrombotic state, which can exacerbate or trigger further coronary events. * **Cerebrovascular Disease:** A history of stroke or TIA is a Category 4 contraindication because COCPs increase the risk of ischemic stroke. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications (Mnemonic: ACHES):** **A**bdominal pain (Gallbladder disease/Tumors), **C**hest pain (IHD), **H**eadaches (Migraine with aura), **E**ye problems (Vascular disease), **S**evere leg pain (DVT). * **Breast Cancer:** COCPs are absolutely contraindicated in current breast cancer. * **Liver Disease:** Active viral hepatitis or decompensated cirrhosis are contraindications. * **PCOS Benefit:** COCPs containing **Cyproterone acetate** or **Drospirenone** are preferred in PCOS for their superior anti-androgenic properties.

Question 219: Use of combined oral contraceptives accounts for an increase in risk of which of the following?

A. Breast cancer
B. Ovarian cancer
C. Endometrial cancer
D. None of the above (Correct Answer)

Explanation: ### Explanation The correct answer is **D. None of the above**, based on the most recent clinical guidelines and epidemiological data regarding Combined Oral Contraceptive (COC) use. **1. Why "None of the above" is correct:** While historical studies suggested a slight increase in breast cancer risk, modern low-dose COCs are generally considered to have a **neutral effect** on the overall lifetime risk of breast cancer in the general population. More importantly, COCs are well-documented to have a **protective effect** against several cancers. Therefore, they do not "account for an increase in risk" in a statistically significant or clinically definitive way for the options provided. **2. Analysis of Incorrect Options:** * **Ovarian Cancer (Option B):** COCs significantly **decrease** the risk of ovarian cancer (by ~40-50%). This protection is due to the suppression of ovulation ("incessant ovulation" theory) and persists for up to 15–20 years after discontinuation. * **Endometrial Cancer (Option C):** COCs **decrease** the risk of endometrial cancer (by ~50%). The progestogen component antagonizes the proliferative effect of estrogen on the endometrium, preventing hyperplasia. * **Breast Cancer (Option A):** While a controversial topic, the *Collaborative Group on Hormonal Factors in Breast Cancer* noted a very small relative risk (1.24) during use, which returns to baseline 10 years after stopping. However, for NEET-PG purposes, COCs are not primarily associated with an *increased* risk compared to their protective benefits elsewhere. **3. High-Yield Clinical Pearls for NEET-PG:** * **Protective Effects:** COCs reduce the risk of Ovarian, Endometrial, and Colorectal cancers. * **Increased Risk:** COCs are associated with an increased risk of **Cervical Cancer** (especially with >5 years of use) and **Hepatocellular Adenoma**. * **Non-Contraceptive Benefits:** Reduction in Ectopic pregnancy, PID, Benign Breast Disease, and Dysmenorrhea. * **Absolute Contraindications:** Undiagnosed vaginal bleeding, history of Thromboembolism (VTE), Smokers >35 years (>15 cigarettes/day), and Migraine with aura.

Question 220: All Intrauterine Contraceptive Devices (IUCDs) are changed every 4-5 years except:

A. Cu-280
B. Cu-320
C. Multiload devices
D. Progestasert (Correct Answer)

Explanation: **Explanation:** The lifespan of an Intrauterine Contraceptive Device (IUCD) is determined by the rate of release of its active component (copper or hormone) and the surface area of the device. **Why Progestasert is the correct answer:** Progestasert is a first-generation **hormone-releasing IUCD** that contains 38 mg of Progesterone. It releases the hormone at a rate of 65 µg/day. Due to the relatively rapid depletion of its hormone reservoir, it has the shortest lifespan among all IUCDs and must be **replaced every year (12 months)**. This makes it the exception to the 4–10 year lifespan of most copper-bearing devices. **Analysis of incorrect options:** * **Cu-280 and Cu-320:** These are older copper-T variants. While the modern Cu-T 380A lasts for 10 years, earlier models like the Cu-200 and Cu-250 typically lasted **3–5 years**. * **Multiload devices (e.g., ML Cu-250 and ML Cu-375):** These devices are designed with flexible "fins" to reduce expulsion. The ML Cu-250 is effective for **3 years**, while the ML Cu-375 is effective for **5 years**. **High-Yield Clinical Pearls for NEET-PG:** * **Cu-T 380A (Mala):** Currently the most widely used; lifespan is **10 years**. * **LNG-20 (Mirena):** Releases Levonorgestrel; lifespan is **5 years** (recently extended to 8 years in some guidelines, but 5 remains the standard exam answer). * **Mechanism of Action:** Copper IUCDs cause a sterile inflammatory response that is spermicidal. Hormone IUCDs (like Progestasert/Mirena) primarily act by thickening cervical mucus and thinning the endometrium. * **Ideal Candidate:** Multiparous women in a stable monogamous relationship.

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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