Contraception and Family Planning Practice Questions

Q: A 28-year-old female presents with irregular slight bleeding after taking combined oral contraceptive pills for three months to manage heavy menstrual bleeding. What is your advice?

Reassure the patient as this is breakthrough bleeding.. **Explanation:** **1. Why Option C is Correct:** The patient is experiencing **breakthrough bleeding (BTB)**, which is the most common side effect of Combined Oral Contraceptive Pills (COCPs), especially during the first **3–6 months** of use. This occurs because the exogenous hormones cause the endometrium to become thin and fragile, leading to asynchronous breakdown and spotting. Since the patient has only been on the pills for three months, the initial management is **reassurance and observation**, as this side effect usually resolves spontaneously once the endometrium stabilizes. **2. Why Other Options are Incorrect:** * **Option A:** Endometrial sampling is generally reserved for women >35 years or those with persistent abnormal uterine bleeding (AUB) despite medical therapy. In a 28-year-old with a clear pharmacological cause (COCP initiation), neoplasia is highly unlikely. * **Option B:** Progestin-only preparations (POPs) are actually *more* likely to cause irregular spotting and breakthrough bleeding compared to COCPs due to the lack of estrogen-induced endometrial stabilization. * **Option D:** Discontinuing the pills is unnecessary and would lead to the return of her original complaint (heavy menstrual bleeding) and loss of contraceptive protection. **Clinical Pearls for NEET-PG:** * **Breakthrough Bleeding (BTB):** Most common in the first 3 cycles. * **Management of persistent BTB:** If bleeding persists beyond 3 months, the dose of estrogen can be increased or the type of progestin changed. * **Early vs. Late Cycle Bleeding:** * Bleeding in the **early/follicular phase** suggests estrogen deficiency (increase estrogen). * Bleeding in the **late/luteal phase** suggests progestin deficiency (increase progestin). * **Most common cause of BTB:** Missing a pill (non-compliance). Always rule this out first in clinical practice.

Q: Which of the following is NOT used as emergency contraception?

Saheli. **Explanation:** The correct answer is **Saheli (Centchroman)**. **1. Why Saheli is the correct answer:** Saheli is a **Selective Estrogen Receptor Modulator (SERM)**. It is used as a **non-steroidal, weekly oral contraceptive pill** for routine birth control, not for emergency use. Its mechanism involves altering the uterine endometrium to prevent implantation and speeding up ovum transport. Because it requires a steady-state buildup (taken twice weekly for the first 3 months, then once weekly), it is ineffective as a post-coital emergency measure. **2. Why the other options are incorrect (Emergency Contraceptive Methods):** * **Combined Oral Contraceptive Pills (COCs):** Used in the **Yuzpe Regimen**. It involves taking two doses (each containing 100 mcg Ethinyl Estradiol + 0.5 mg Levonorgestrel) 12 hours apart within 72 hours of intercourse. * **Intrauterine Device (IUD):** The **Copper T-380A** is the **most effective** emergency contraceptive. It can be inserted up to 5 days (120 hours) after unprotected intercourse and prevents pregnancy by interfering with fertilization and implantation. * **High-dose Estrogen:** Historically used (e.g., Ethinyl Estradiol 5mg daily for 5 days), this method is now largely obsolete due to severe side effects like nausea and vomiting, but it remains a recognized pharmacological method for emergency contraception. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC):** Levonorgestrel (LNG) 1.5 mg single dose (within 72 hours) is the current standard. * **Most Effective Method:** Copper IUD (failure rate <0.1%). * **Ulipristal Acetate:** A Selective Progesterone Receptor Modulator (SPRM) effective up to 120 hours (5 days); it is more effective than LNG in obese women. * **Mifepristone:** Can be used as an emergency contraceptive in low doses (10–25 mg).

Q: What is true about Mirena?

A progestogen-containing intrauterine device. **Mirena** is a Levonorgestrel-releasing Intrauterine System (LNG-IUS). It is a T-shaped plastic device that serves as a highly effective, long-acting reversible contraceptive (LARC). ### **Explanation of Options:** * **A is Correct:** Mirena contains **Levonorgestrel (LNG)**, which is a second-generation synthetic **progestogen**. It releases approximately 20 µg of LNG directly into the uterine cavity every 24 hours. * **B is Incorrect:** It contains **Levonorgestrel**, not desogestrel. Desogestrel is commonly found in third-generation combined oral contraceptive pills (COCPs) or progestogen-only pills (Cerazette). * **C is Incorrect:** Progestogens cause **endometrial atrophy**, not hyperplasia. By suppressing the proliferative effect of estrogen, Mirena thins the endometrial lining, which is why it is used as a first-line treatment for Heavy Menstrual Bleeding (HMB). * **D is Incorrect:** Mirena significantly affects menses. Initially, it may cause irregular spotting, but it eventually leads to **amenorrhea** in approximately 20-40% of users after one year due to profound endometrial suppression. ### **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** Primarily works by thickening cervical mucus (preventing sperm penetration) and causing endometrial atrophy (preventing implantation). It does not consistently inhibit ovulation. * **Duration:** Approved for use for up to **8 years** (recently updated from 5 years). * **Non-Contraceptive Uses:** First-line management for **Idiopathic Menorrhagia**, management of endometriosis, and as the progestogen component of Hormone Replacement Therapy (HRT) to protect the endometrium. * **Pearl:** Unlike Copper-T, Mirena **decreases** the risk of Pelvic Inflammatory Disease (PID) by thickening the cervical mucus plug.

Q: Which contraceptive method should be avoided in patients with epilepsy?

Oral contraceptives. **Explanation:** The primary concern in managing contraception for patients with epilepsy is the **pharmacokinetic interaction** between antiepileptic drugs (AEDs) and hormonal contraceptives. **1. Why Oral Contraceptives (OCPs) are avoided:** Most traditional AEDs (e.g., Phenytoin, Carbamazepine, Phenobarbital, Primidone) are **potent hepatic enzyme inducers** (Cytochrome P450 system). These enzymes accelerate the metabolism of estrogen and progesterone in OCPs, significantly reducing their serum concentrations. This leads to a high risk of **contraceptive failure** and unintended pregnancy. Conversely, OCPs can lower the serum levels of certain AEDs like **Lamotrigine**, potentially triggering breakthrough seizures. **2. Analysis of Incorrect Options:** * **Condoms (Barrier Methods):** These do not involve systemic hormones or hepatic metabolism; therefore, there is no drug interaction. * **Intrauterine Contraceptive Devices (IUCDs):** Copper T or Levonorgestrel-releasing IUS (Mirena) act locally. They are considered the **gold standard** for women on enzyme-inducing AEDs because their efficacy is not affected by liver enzymes. * **Post-coital pills:** While emergency contraception (EC) can be used, it is not "avoided" in the same sense as maintenance OCPs. However, a double dose (3mg Levonorgestrel) is often recommended if the patient is on enzyme-inducers. **Clinical Pearls for NEET-PG:** * **Drug of Choice:** The Copper IUCD or LNG-IUS are the most reliable methods for epileptic patients. * **DMPA (Injectable):** Can be used, but the injection interval is sometimes shortened to 10 weeks instead of 12. * **Non-inducing AEDs:** Valproate, Levetiracetam, and Gabapentin do not significantly interact with OCPs, but OCPs are still generally avoided as a first-line precaution in epilepsy management.

Q: What is the most ideal site for sterilization by tubectomy?

Isthmus. The **isthmus** is the most ideal site for tubal sterilization (tubectomy) because it is the narrowest and least vascular part of the Fallopian tube. ### Why Isthmus is the Correct Answer: 1. **Anatomical Advantage:** The isthmus has a thick muscular wall and a narrow lumen. This makes it technically easier to ligate and excise (as in the Pomeroy technique) or to apply mechanical devices like clips or rings. 2. **Vascularity:** It is relatively less vascular compared to the ampulla, minimizing the risk of intraoperative bleeding and hematoma formation. 3. **Reversibility:** Because the isthmus is narrow, a tubectomy here destroys the least amount of tubal tissue. If a patient requests tubal re-anastomosis (reversal) later, the isthmic-isthmic repair offers the highest success rates due to the matching luminal diameters. ### Why Other Options are Incorrect: * **Ampulla:** This is the widest and most vascular part of the tube. Sterilization here carries a higher risk of bleeding and requires destroying a larger segment of the tube, making future reversal difficult. * **Fimbriated extremity:** Removing the fimbria (fimbriectomy) is highly effective but makes the procedure virtually irreversible. * **Interstitial portion:** This is the segment that traverses the uterine wall. Surgery here is technically difficult, carries a high risk of uterine bleeding, and increases the risk of cornual pregnancy if failure occurs. ### Clinical Pearls for NEET-PG: * **Pomeroy’s Method:** The most common technique used worldwide; it involves ligating a loop of the isthmus with absorbable suture. * **Failure Rate:** The Pearl Index for tubectomy is approximately **0.5 per 100 woman-years**. * **Madlener Technique:** Avoided today due to high failure rates (re-canalization). * **Irving and Uchida Techniques:** Have the lowest failure rates but are surgically more complex.

Question 1

With contraceptive failure, which method has a relatively increased risk of ectopic pregnancy?

Accepted Answer

Tubal sterilization

Answer

Condoms

Answer

Vasectomy

Answer

Vaginal ring

Question 2

A 28-year-old female presents with irregular slight bleeding after taking combined oral contraceptive pills for three months to manage heavy menstrual bleeding. What is your advice?

Accepted Answer

Reassure the patient as this is breakthrough bleeding.

Answer

Endometrial sampling to rule out neoplasia.

Answer

Change over to progestin-only preparations.

Answer

Discontinue oral contraceptive pills.

Question 3

Which of the following is NOT used as emergency contraception?

Accepted Answer

Saheli

Answer

Combined oral contraceptive pills

Answer

Intrauterine device (IUD)

Answer

High-dose estrogen for 5 days

Question 4

Depot medroxyprogesterone acetate is sparingly used as a contraceptive because it causes:

Accepted Answer

Irregular menstrual bleeding

Answer

Cardiovascular complications

Answer

Lactational failure

Answer

Breast cancer

Question 5

What is true about Mirena?

Accepted Answer

A progestogen-containing intrauterine device

Answer

Contains desogestrel

Answer

Causes endometrial hyperplasia

Answer

Has no effect on menses

Question 6

Intermenstrual bleeding is a frequent side effect seen with which of the following?

Accepted Answer

Combined OCPs during early months of use.

Answer

Progestin-only pills during early months of use.

Answer

Combined OCPs throughout use.

Answer

Progestin-only pills where AUB never occurs.

Question 7

What is the drug of choice for medical termination of pregnancy in a patient who is second gravida with asthma at 16 weeks gestation?

Accepted Answer

Hypertonic saline

Answer

Prostaglandin

Answer

Ethacridine lactate

Answer

Intra-amniotic dexamethasone

Question 8

Progestogen-only pills (POPs) carry a risk of:

Accepted Answer

Ectopic pregnancy

Answer

Hypertension

Answer

Embolism

Answer

Irregular bleeding

Question 9

Which contraceptive method should be avoided in patients with epilepsy?

Accepted Answer

Oral contraceptives

Answer

Condoms

Answer

Intrauterine contraceptive devices

Answer

Post-coital pills

Question 10

What is the most ideal site for sterilization by tubectomy?

Accepted Answer

Isthmus

Answer

Ampulla

Answer

Fimbriated extremity

Answer

Interstitial portion

Contraception and Family Planning — MCQs

Contraception and Family Planning — MCQs

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