Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 21: Which IUCD should be used for menorrhagia?

A. Copper-T
B. Copper-7
C. Levonorgestrel-releasing IUCD (Mirena) (Correct Answer)
D. Multiload

Explanation: **Explanation:** The correct answer is **Levonorgestrel-releasing IUCD (Mirena)**. **Why it is correct:** The Levonorgestrel-releasing intrauterine system (LNG-IUS) acts as a local hormonal delivery system. It releases 20 µg of levonorgestrel daily directly into the uterine cavity. This high local concentration of progestogen causes profound **endometrial atrophy** and downregulation of estrogen receptors. Clinically, this leads to a significant reduction in menstrual blood loss (up to 90% within 3–6 months), making it the first-line medical management for Idiopathic Menorrhagia and Heavy Menstrual Bleeding (HMB). **Why the other options are incorrect:** * **Copper-T, Copper-7, and Multiload:** These are non-hormonal, medicated copper-bearing IUCDs. Copper ions induce a sterile inflammatory response in the endometrium which is spermicidal. However, a well-known side effect of copper IUCDs is **increased menstrual blood loss** and dysmenorrhea. Therefore, they are contraindicated in patients already suffering from menorrhagia. **High-Yield Clinical Pearls for NEET-PG:** * **Life span:** Mirena is currently FDA-approved for up to 8 years (though traditionally taught as 5 years). * **Non-contraceptive uses:** Apart from menorrhagia, it is used in the management of endometriosis, adenomyosis, and endometrial hyperplasia. * **Mechanism of Contraception:** Primarily works by thickening cervical mucus (preventing sperm penetration) and causing endometrial atrophy (preventing implantation). * **Pearl:** LNG-IUS is often referred to as "medical hysterectomy" due to its efficacy in treating HMB without surgery.

Question 22: Copper-T with threads is visible in a case of early pregnancy. What is the treatment of choice?

A. Remove CuT only (Correct Answer)
B. Suction evacuation with Copper-T removal
C. Reassurance and continue pregnancy
D. Laparotomy

Explanation: **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.**

Question 23: What is the recommended injection interval for the use of Depot Medroxyprogesterone Acetate (DMPA) as a contraceptive?

A. Monthly
B. Every 3 months (Correct Answer)
C. Every 6 months
D. Yearly

Explanation: **Explanation:** **Depot Medroxyprogesterone Acetate (DMPA)**, commonly known by the brand name **Antara** in the Government of India’s family planning program, is a progestogen-only injectable contraceptive. **1. Why Option B is Correct:** The standard dosage of DMPA is **150 mg administered intramuscularly (IM)** every **3 months (12 to 13 weeks)**. It works primarily by suppressing ovulation through the inhibition of gonadotropin secretion (LH surge). Additionally, it increases cervical mucus viscosity and thins the endometrium, making it unfavorable for implantation. **2. Why Other Options are Incorrect:** * **Option A (Monthly):** This interval is characteristic of **Combined Injectable Contraceptives (CICs)** like Net-En + Estradiol valerate, or monthly progestogen injections like Norethisterone Enanthate (Net-En), which is actually given every 2 months (8 weeks). * **Options C & D (6 months/Yearly):** There are currently no FDA or WHO-approved injectable contraceptives that provide efficacy for 6 to 12 months. Long-acting reversible contraceptives (LARCs) for these durations are typically IUDs or subdermal implants. **3. High-Yield Clinical Pearls for NEET-PG:** * **Route:** 150 mg IM (gluteal/deltoid) or 104 mg Subcutaneous. * **Window Period:** A grace period of up to **4 weeks** (late injection) is generally permissible without requiring backup contraception, per WHO MEC criteria. * **Side Effects:** The most common side effect is **irregular menstrual bleeding** (amenorrhea is common after 1 year of use). * **Black Box Warning:** Long-term use may lead to a **decrease in Bone Mineral Density (BMD)**; however, this is usually reversible after discontinuation. * **Return to Fertility:** There is a characteristic **delay in return to fertility**, averaging **7–10 months** after the last injection.

Question 24: A woman with a history of deep vein thrombosis requires contraception. Which of the following methods is medically contraindicated for this patient?

A. Oral contraceptives (Correct Answer)
B. Intrauterine device (IUD)
C. Condoms
D. Laparoscopic tubal ligation

Explanation: **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.

Question 25: All of the following are long-acting reversible contraceptives except?

A. Oral contraceptive pills (Correct Answer)
B. Injectable progestins
C. Implants
D. Intrauterine devices

Explanation: **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.

Question 26: What is the Pearl Index of SAHELI?

A. 2/HWY (Correct Answer)
B. 14/HWY
C. 0.1/HWY
D. 9/HWY

Explanation: **Explanation:** The **Pearl Index** is the standard measure used to report the effectiveness of a contraceptive method, defined as the number of unintended pregnancies per 100 woman-years (HWY) of use. **1. Why Option A (2/HWY) is Correct:** **Saheli** (Centchroman/Ormeloxifene) is a unique, non-steroidal, non-hormonal Selective Estrogen Receptor Modulator (SERM) developed by CDRI, Lucknow. It works primarily by preventing implantation by altering the endometrium. Its Pearl Index is **1.83 to 2.83 per HWY**, which is generally rounded to **2/HWY** in standard textbooks and exams. This indicates high efficacy for a non-hormonal oral pill. **2. Why the Other Options are Incorrect:** * **Option B (14/HWY):** This represents the typical failure rate of barrier methods like the **Male Condom** (though its perfect use rate is lower). * **Option C (0.1/HWY):** This represents the Pearl Index of highly effective methods like **Vasectomy** or the **Levonorgestrel Intrauterine System (LNG-IUS/Mirena)**. * **Option D (9/HWY):** This is the typical failure rate associated with **Combined Oral Contraceptive Pills (COCPs)** under "typical use," though their "perfect use" rate is 0.3. **High-Yield Clinical Pearls for NEET-PG:** * **Dosage Schedule:** Saheli is taken **twice weekly** for the first 3 months, followed by **once weekly** (on the same day) thereafter. * **Composition:** It is non-steroidal; hence, it does not cause side effects like weight gain, nausea, or mood swings. * **Side Effects:** The most common side effect is **delayed menstruation** (prolonged cycles), which occurs in about 8% of users. * **Government Program:** It is included in the National Family Planning Program of India under the name **"Chhaya."**

Question 27: All of the following mechanisms might account for a reduced risk of upper genital tract infection in users of progestin-releasing IUDs, except:

A. Reduced retrograde menstruation
B. Decreased ovulation (Correct Answer)
C. Thickened cervical mucus
D. Decidual changes in the endometrium

Explanation: **Explanation:** The progestin-releasing IUD (e.g., LNG-IUD/Mirena) provides significant protection against Pelvic Inflammatory Disease (PID) and upper genital tract infections through local mechanical and hormonal changes. **Why "Decreased Ovulation" is the correct answer:** While the LNG-IUD does cause some systemic absorption of levonorgestrel, it is primarily a **local contraceptive**. In the majority of users (about 75–85%), **ovulation is maintained**. Since ovulation still occurs in most cycles, its suppression cannot be considered a consistent or primary mechanism for reducing the risk of infection. **Analysis of Incorrect Options (Mechanisms that DO reduce infection risk):** * **Thickened Cervical Mucus:** This is the primary contraceptive and protective mechanism. Progestin makes the cervical mucus thick and viscous, acting as a biological barrier that prevents the ascent of sperm and pathogenic bacteria into the uterine cavity. * **Reduced Retrograde Menstruation:** LNG-IUD causes profound endometrial atrophy, leading to lighter periods or amenorrhea. Less menstrual blood means less retrograde flow through the fallopian tubes, reducing the "seeding" of bacteria into the peritoneal cavity. * **Decidual Changes in the Endometrium:** Progestin induces decidualization followed by significant atrophy of the endometrial lining. This creates an unfavorable, "hostile" environment that is less susceptible to colonization by ascending pathogens. **Clinical Pearls for NEET-PG:** * **Primary Mechanism of LNG-IUD:** Thickening of cervical mucus and endometrial atrophy (prevents implantation). * **PID Risk:** The risk of PID with IUDs is highest only during the **first 20 days** post-insertion (due to the procedure itself). Long-term, the LNG-IUD is actually protective compared to the Copper-T. * **Non-contraceptive use:** LNG-IUD is the **Medical Management of Choice** for Heavy Menstrual Bleeding (HMB).

Question 28: What is the Yuzpe regimen for postcoital contraception?

A. 100 mg of ethinyl estradiol and 0.5 mg of levonorgestrel initially, followed by the same dose after 12 hours (Correct Answer)
B. 100 mg of ethinyl estradiol and 0.5 mg of levonorgestrel initially, followed by the same dose after 24 hours
C. Use of 150 mg of depot medroxyprogesterone acetate every 3 months
D. 200 mg of norethisterone enanthate every 60 days

Explanation: The **Yuzpe regimen** is a traditional method of emergency contraception (EC) that utilizes combined oral contraceptive (COC) pills. ### **Explanation of the Correct Answer** The regimen consists of two doses of a combination of **Ethinyl Estradiol (EE)** and **Levonorgestrel (LNG)**. The standard dosage is **100 mcg of EE and 0.5 mg (500 mcg) of LNG** taken as soon as possible after unprotected intercourse (ideally within 72 hours), followed by a **second identical dose 12 hours later**. It works primarily by inhibiting or delaying ovulation. Because it contains estrogen, it is associated with a high incidence of nausea (50%) and vomiting (20%). ### **Analysis of Incorrect Options** * **Option B:** The interval between doses in the Yuzpe regimen is strictly **12 hours**, not 24 hours. A 24-hour delay significantly reduces efficacy. * **Option C:** This describes **DMPA (Depot Medroxyprogesterone Acetate)**, which is an injectable progestogen-only contraceptive used for long-term birth control, not emergency contraception. * **Option D:** This describes **NET-EN (Norethisterone Enanthate)**, another long-acting injectable contraceptive administered every 2 months. ### **High-Yield NEET-PG Pearls** * **Gold Standard EC:** The most effective emergency contraceptive is the **Copper-T (Cu-T 380A)** IUD if inserted within 5 days. * **Drug of Choice (DOC):** The current hormonal DOC for EC is **Levonorgestrel (1.5 mg single dose)** due to better efficacy and fewer side effects than Yuzpe. * **Ulipristal Acetate:** A selective progesterone receptor modulator (30 mg dose) effective up to 120 hours (5 days). * **Failure Rate:** Yuzpe has a higher failure rate (~2-3%) compared to the LNG-only regimen (~1%).

Question 29: All of the following are contraindications for the use of progesterone-only pills except?

A. Pregnancy
B. Patient suffering from breast cancer
C. Peripheral vascular disease
D. Diabetes mellitus (Correct Answer)

Explanation: **Explanation:** The core concept behind this question lies in distinguishing the contraindications of **Progesterone-Only Pills (POPs)** from those of Combined Oral Contraceptive Pills (COCs). POPs do not contain estrogen, making them safer for patients with cardiovascular risks. **Why Diabetes Mellitus is the Correct Answer:** Diabetes mellitus is **not** a contraindication for POPs. According to the WHO Medical Eligibility Criteria (MEC), POPs are classified as **Category 1** (no restriction) for diabetic patients without vascular complications and **Category 2** (advantages outweigh risks) for those with complications. Unlike estrogen, progesterone has a minimal impact on carbohydrate metabolism and does not increase the risk of thromboembolism, making it a preferred hormonal choice for diabetic women. **Analysis of Incorrect Options (Contraindications):** * **Pregnancy (MEC 4):** Hormonal contraceptives are strictly contraindicated if pregnancy is confirmed, primarily to avoid unnecessary hormonal exposure to the fetus. * **Breast Cancer (MEC 4):** Current breast cancer is a baseline contraindication for all hormonal methods, as some breast tumors are progesterone-sensitive and may be stimulated by the pill. * **Peripheral Vascular Disease (PVD):** While the risk is significantly lower than with COCs, severe vascular diseases (including PVD with complications) are generally listed as contraindications or used with extreme caution (MEC 3/4) due to the potential for underlying thromboembolic risks. **High-Yield Clinical Pearls for NEET-PG:** * **POPs in Lactation:** POPs are the hormonal contraceptive of choice for breastfeeding mothers (started at 6 weeks postpartum) as they do not suppress milk production. * **The "3-Hour Rule":** Traditional POPs must be taken at the same time every day; a delay of >3 hours is considered a "missed pill." * **Most Common Side Effect:** Irregular menstrual bleeding (breakthrough bleeding) is the most frequent reason for discontinuation. * **Mechanism:** Primarily works by thickening cervical mucus and thinning the endometrium; ovulation is suppressed in only about 60-80% of cycles.

Question 30: Which of the following is a barrier method of contraception?

A. Male sterilization
B. Female sterilization
C. Spermicidal jelly (Correct Answer)
D. Natural family planning

Explanation: **Explanation:** The correct answer is **C. Spermicidal jelly**. **Why it is correct:** Barrier methods of contraception work by physically or chemically preventing sperm from entering the uterus and reaching the oocyte. These are broadly classified into **Physical barriers** (e.g., Male/Female condoms, Diaphragm, Cervical cap) and **Chemical barriers** (e.g., Spermicidal jellies, foams, creams, and suppositories). Spermicidal jellies contain surfactants, most commonly **Nonoxynol-9**, which disrupt the sperm cell membrane, effectively acting as a chemical barrier. **Why the other options are incorrect:** * **A & B (Male and Female Sterilization):** These are classified as **Permanent methods** (Terminal methods). They involve surgical intervention (Vasectomy or Tubectomy) to provide long-term, irreversible contraception rather than acting as a temporary barrier. * **D (Natural Family Planning):** These are **Behavioral methods** (e.g., Rhythm method, BBT, Cervical mucus method). They rely on periodic abstinence during the fertile window rather than using a mechanical or chemical device to block sperm. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal use:** Spermicides are rarely used alone due to a high failure rate (Pearl Index ~18-28); they are most effective when used in combination with physical barriers like a diaphragm. * **Dual Protection:** Only the **condom** (a physical barrier) provides significant protection against STIs and HIV. * **Nonoxynol-9 Warning:** Frequent use of spermicides can cause vaginal irritation, which may actually increase the risk of HIV transmission due to mucosal micro-abrasions. * **Vaginal Sponge (Today):** Acts as both a physical barrier, a chemical barrier (contains Nonoxynol-9), and an absorbent for semen.

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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