Contraception and Family Planning Practice Questions

Q: Which of the following is true regarding depot medroxy progesterone acetate?

It is known to diminish bone mineral density.. **Explanation:** **Depot Medroxyprogesterone Acetate (DMPA)**, commonly known by the brand name **Antara** (in the government supply) or **Depo-Provera**, is a long-acting injectable contraceptive. **Why Option C is correct:** DMPA works by suppressing the hypothalamic-pituitary-ovarian axis, which inhibits gonadotropin secretion (LH and FSH). This leads to the suppression of ovulation and a subsequent **hypoestrogenic state**. Since estrogen is essential for maintaining bone mass, prolonged use of DMPA leads to a **reduction in Bone Mineral Density (BMD)**. The FDA has issued a "Black Box Warning" stating that DMPA should generally not be used for more than 2 years unless other methods are inadequate, although BMD usually recovers after discontinuation. **Why other options are incorrect:** * **Option A:** DMPA is an **injectable** contraceptive, not a subdermal implant. (Example of a subdermal implant is *Nexplanon*). * **Option B:** The standard dose is **150 mg given Intramuscularly (IM)** every 3 months (90 days). There is also a subcutaneous version (DMPA-SC) at a dose of 104 mg. It is never given intravenously. * **Option D:** DMPA actually **decreases the risk of endometrial cancer** by approximately 80% due to the protective effect of progestin, which causes endometrial atrophy. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Primarily inhibits ovulation; also increases cervical mucus viscosity. * **Side Effects:** Amenorrhea (most common), weight gain, and delayed return to fertility (average 7–10 months). * **Beneficial Effects:** Reduces risk of PID, ectopic pregnancy, and iron deficiency anemia. * **Contraindication:** Current breast cancer and undiagnosed abnormal uterine bleeding.

Q: Which of the following conditions can be caused by Oral Contraceptive Pills (OCPs)?

All of the above. **Explanation:** Combined Oral Contraceptive Pills (OCPs) contain estrogen and progestogen, which exert systemic effects beyond contraception. The correct answer is **D (All of the above)** because OCPs are associated with specific hepatic and oncogenic risks. 1. **Hepatic Adenoma:** Estrogen in OCPs is a well-known risk factor for the development of benign liver tumors, specifically hepatic adenomas. These are highly vascular and carry a risk of spontaneous rupture and intraperitoneal hemorrhage. 2. **Cancer of the Cervix:** Long-term use of OCPs (typically >5 years) is associated with an increased risk of cervical cancer. While HPV is the primary cause, OCPs are thought to act as a co-factor by increasing the susceptibility of cervical cells to persistent HPV infection. 3. **Hepatic Vein Thrombosis (Budd-Chiari Syndrome):** Estrogen induces a hypercoagulable state by increasing clotting factors (II, VII, IX, X) and decreasing anticoagulants like Protein S and Antithrombin III. This significantly increases the risk of venous thromboembolism (VTE), including rare sites like the hepatic veins. **High-Yield Clinical Pearls for NEET-PG:** * **Protective Effects:** OCPs significantly **decrease** the risk of Ovarian cancer (by 50%), Endometrial cancer (by 50%), and Colorectal cancer. They also reduce the risk of Benign Breast Disease. * **Increased Risks:** OCPs **increase** the risk of Cervical cancer, Breast cancer (slight increase), and Hepatocellular adenoma. * **Absolute Contraindications:** History of VTE, known CAD/Stroke, Smokers >35 years (>15 cigarettes/day), Undiagnosed vaginal bleeding, and Active liver disease. * **Drug Interactions:** Enzyme inducers like Rifampicin and Phenytoin decrease OCP efficacy.

Q: The Billing method of contraception is synonymous with which of the following?

Cervical mucus method. **Explanation:** The **Billings Ovulation Method** is a natural family planning technique based on the observation of changes in **cervical mucus** throughout the menstrual cycle. **1. Why Cervical Mucus Method is Correct:** Under the influence of rising estrogen levels before ovulation, the cervical mucus undergoes predictable changes. It becomes **thin, clear, watery, and profuse** (often described as having the consistency of raw egg white). This is known as "fertile-type" mucus, which exhibits high **Spinnbarkeit** (stretchability). The Billings method requires the woman to identify these changes to determine her fertile window and avoid intercourse during this period. **2. Analysis of Incorrect Options:** * **A. Rhythm Method (Calendar Method):** This relies on calculating the fertile period based on the length of previous menstrual cycles (subtracting 18 days from the shortest and 11 days from the longest cycle). It does not involve physiological observations like mucus. * **B. Basal Body Temperature (BBT) Method:** This tracks the slight rise in body temperature (0.4–0.8°F) caused by **progesterone** after ovulation has already occurred. It is a retrospective indicator of ovulation. * **D. Abstinence:** This refers to refraining from all forms of sexual intercourse and is not a physiological monitoring method. **3. High-Yield Clinical Pearls for NEET-PG:** * **Spinnbarkeit Effect:** Refers to the elasticity of cervical mucus; maximum stretchability (up to 10-12 cm) occurs just before ovulation. * **Ferning Pattern:** On a slide, fertile mucus shows a "fern-like" pattern due to high sodium chloride content under estrogen influence. * **Symptothermal Method:** The most effective natural method, combining BBT, cervical mucus changes, and calendar calculations. * **Pearl Index:** Natural methods generally have a higher failure rate (approx. 20-25 per 100 woman-years) compared to hormonal or barrier methods.

Q: What is the approved duration of use for Mirena?

5 years. **Explanation:** **Mirena** is a Levonorgestrel-releasing Intrauterine System (LNG-IUS) that contains 52 mg of levonorgestrel. It releases the hormone at an initial rate of approximately 20 µg/day. * **Why Option C is Correct:** The FDA and standard clinical guidelines (including those followed in India) approve Mirena for a duration of **5 years**. Its primary mechanism involves thickening cervical mucus, inhibiting sperm capacitation, and causing endometrial atrophy. While recent studies suggest efficacy may extend beyond 5 years, for the purpose of NEET-PG and standard licensing exams, 5 years remains the gold-standard duration for contraception and the treatment of Heavy Menstrual Bleeding (HMB). * **Why Other Options are Incorrect:** * **Option A (3 years):** This is the duration for **Skyla**, another LNG-IUS which contains a lower dose (13.5 mg) of levonorgestrel. * **Option B (1 year):** No standard IUD is limited to only one year; Progestasert (an older progesterone IUD) required annual replacement but is no longer in common use. * **Option C (10 years):** This is the approved duration for the **Copper T 380A**, a non-hormonal intrauterine device. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Candidate:** Women with Idiopathic Menorrhagia (Mirena is the first-line medical management). * **Non-Contraceptive Benefits:** Reduces the risk of Pelvic Inflammatory Disease (PID) due to cervical mucus thickening and provides endometrial protection during Hormone Replacement Therapy (HRT). * **Common Side Effect:** Intermittent spotting or breakthrough bleeding is common in the first 3–6 months, often leading to amenorrhea thereafter.

Q: Which of the following is NOT a side effect of Depot Medroxyprogesterone Acetate (Depot MPA)?

Hepatitis. **Explanation:** **Depot Medroxyprogesterone Acetate (DMPA)**, commonly known as the "Antara" program injection in India, is a progestogen-only injectable contraceptive. **Why Hepatitis is the Correct Answer:** Hepatitis is not a side effect of DMPA. In fact, unlike oral contraceptive pills (OCPs) which undergo first-pass metabolism in the liver and can exacerbate cholestatic jaundice or liver adenomas, DMPA is administered parenterally. It does not adversely affect liver function and is not associated with hepatotoxicity. **Analysis of Incorrect Options:** * **Weight Gain (A):** This is a very common side effect. DMPA is the only contraceptive consistently linked to significant weight gain (average 1–2 kg/year), primarily due to its glucocorticoid-like activity and increased appetite. * **Irregular Bleeding (B):** During the first 3–6 months of use, breakthrough bleeding or spotting is the most common reason for discontinuation. * **Amenorrhea (C):** This is a hallmark of long-term DMPA use. Due to the profound suppression of the endometrium, approximately 50-70% of women become amenorrheic after one year of use. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Inhibits ovulation by suppressing the LH surge. * **Dose:** 150 mg IM every 3 months (12 weeks). * **Black Box Warning:** Long-term use is associated with **reversible loss of Bone Mineral Density (BMD)**. * **Return to Fertility:** There is a characteristic **delayed return to fertility** (average 7–10 months after the last injection). * **Non-contraceptive benefit:** Reduces the risk of endometrial cancer and helps in managing endometriosis and dysmenorrhea.

Q: Which of the following is NOT a side effect or complication of the Copper-T intrauterine device?

Ectopic pregnancy. ### Explanation The correct answer is **C. Ectopic pregnancy**. **Why Ectopic Pregnancy is NOT a side effect:** The Copper-T (Cu-T) is a highly effective contraceptive. While it does not provide 100% protection, it significantly reduces the **absolute risk** of both intrauterine and ectopic pregnancies compared to women using no contraception. If a woman becomes pregnant with a Cu-T in situ, the *relative* risk of that pregnancy being ectopic is higher, but the *overall* incidence of ectopic pregnancy is much lower than in the general population. Therefore, it is considered a protective factor rather than a side effect. **Analysis of Incorrect Options:** * **A. Menorrhagia:** This is the **most common side effect** and the most frequent reason for removal. The copper ions cause a local inflammatory response in the endometrium, leading to increased menstrual blood loss. * **B. Dysmenorrhea:** Increased uterine cramping and painful menstruation are common side effects, often occurring alongside menorrhagia due to increased prostaglandin synthesis. * **D. Perforation:** This is a serious but rare **iatrogenic complication**, usually occurring during insertion (incidence approx. 1 in 1000). It is most common in women with a retroverted uterus or those who are lactating (due to a soft, thinned uterine wall). **High-Yield Clinical Pearls for NEET-PG:** * **Most common side effect:** Bleeding (Menorrhagia). * **Most common cause for removal:** Bleeding and pain. * **Ideal time for insertion:** Within 10 days of the onset of menstruation (to ensure the patient is not pregnant and the cervix is slightly dilated). * **Mechanism of Action:** Primarily **spermicidal** (sterile inflammatory response is toxic to sperm); it also prevents fertilization and implantation. * **Emergency Contraception:** Cu-T is the most effective method of emergency contraception if inserted within 5 days of unprotected intercourse.

Q: Which of the following oral contraceptive pills contains the least amount of estrogen?

Femilon. **Explanation:** The concentration of estrogen (Ethinyl Estradiol) in Combined Oral Contraceptive Pills (COCPs) is a critical factor in determining their side-effect profile, particularly regarding thromboembolic risks and nausea. **1. Why Femilon is Correct:** **Femilon** is a "low-dose" third-generation COCP. It contains **20 mcg of Ethinyl Estradiol** (EE) combined with 150 mcg of Desogestrel. Currently, 20 mcg is among the lowest standard doses used in clinical practice to maintain contraceptive efficacy while minimizing estrogenic side effects. **2. Analysis of Incorrect Options:** * **Mala N:** This is a second-generation pill provided under the National Family Welfare Programme. It contains **30 mcg of EE** and 0.15 mg of Levonorgestrel. * **Novelon:** Also a third-generation pill containing Desogestrel (150 mcg), but it contains a higher dose of estrogen—**30 mcg of EE**. * **Triquilar:** This is a triphasic pill. The estrogen content varies throughout the cycle (30 mcg, 40 mcg, and 30 mcg), but the average and minimum doses are higher than those in Femilon. **3. High-Yield Clinical Pearls for NEET-PG:** * **Generation Classification:** COCPs are often classified by their progestogen component. Desogestrel (in Femilon/Novelon) is a **3rd generation** progestogen, which has less androgenic side effects (less acne/hirsutism) but a slightly higher risk of Venous Thromboembolism (VTE) compared to 2nd generation pills. * **Ultra-low dose:** Pills containing **<30 mcg** of EE are termed "low-dose" or "ultra-low dose." * **Centchroman (Saheli):** Remember that this is a Non-Steroidal, Selective Estrogen Receptor Modulator (SERM) and contains **zero** estrogen. It is the "Once-a-week" pill developed by CDRI, Lucknow. * **Mala D vs. Mala N:** Both contain 30 mcg EE; the difference is that Mala D is a paid brand, while Mala N is supplied free in government health centers.

Q: Progestin-only pills should not be taken by women with which of the following conditions?

Migraine headache without aura. **Explanation:** The question asks for the condition where Progestin-Only Pills (POPs) are **NOT** contraindicated. According to the WHO Medical Eligibility Criteria (MEC), **Migraine without aura** is classified as **MEC Category 2** (advantages generally outweigh risks) for POPs. Therefore, it is safe for these women to use them. **Why the correct answer is right:** Unlike combined oral contraceptives (COCs), which contain estrogen and are contraindicated in migraine patients due to an increased risk of ischemic stroke, POPs do not contain estrogen. They do not significantly alter coagulation factors or blood pressure, making them a safe alternative for women with migraines (without aura). **Why the other options are wrong:** * **Unexplained uterine bleeding (MEC 4):** This is a contraindication because the bleeding may be due to an undiagnosed malignancy (e.g., endometrial cancer) which must be ruled out before starting hormonal therapy. * **Breast Cancer (MEC 4):** Current breast cancer is a strict contraindication for all hormonal contraceptives, as progestins can stimulate the growth of hormone-sensitive tumor cells. * **Severe active liver disease (MEC 3/4):** Steroid hormones are metabolized in the liver. In cases of acute hepatitis, decompensated cirrhosis, or liver tumors (adenomas/hepatomas), POPs are contraindicated as they may worsen the condition or fail to be metabolized correctly. **High-Yield Clinical Pearls for NEET-PG:** * **MEC 4 (Absolute Contraindication):** Current Breast Cancer is the most high-yield MEC 4 for POPs. * **Migraine with Aura:** While COCs are MEC 4, POPs are generally considered MEC 2. * **Lactation:** POPs are the hormonal contraceptive of choice for breastfeeding mothers (MEC 1) as they do not suppress milk production, unlike COCs. * **Efficacy:** POPs must be taken at the same time every day; a delay of >3 hours is considered a "missed pill."

Question 1

Which of the following is true regarding depot medroxy progesterone acetate?

Accepted Answer

It is known to diminish bone mineral density.

Answer

It is a subdermal progestin implant.

Answer

It is a 150 mg dose given intravenously every 90 days.

Answer

It increases the risk of endometrial cancer.

Question 2

Which of the following conditions can be caused by Oral Contraceptive Pills (OCPs)?

Accepted Answer

All of the above

Answer

Hepatic adenoma

Answer

Cancer of the cervix

Answer

Hepatic vein thrombosis

Question 3

The Billing method of contraception is synonymous with which of the following?

Accepted Answer

Cervical mucus method

Answer

Rhythm method

Answer

Basal body temperature method

Answer

Abstinence

Question 4

A woman with an intrauterine contraceptive device (IUCD) develops pelvic inflammatory disease. What is the recommended initial management?

Accepted Answer

Maintain the IUCD, initiate antibiotic therapy, and assess the response before deciding on IUCD removal.

Answer

Start antibiotics and then remove the IUCD.

Answer

Remove the IUCD and then start antibiotics.

Answer

Delay intervention until the next menstrual cycle.

Question 5

What is the temporary contraceptive method of choice in a 37-year-old, well-educated, normal woman?

Accepted Answer

Diaphragm

Answer

IUCD

Answer

Mala-D

Answer

Mala-N

Question 6

What is the approved duration of use for Mirena?

Accepted Answer

5 years

Answer

3 years

Answer

1 year

Answer

10 years

Question 7

Which of the following is NOT a side effect of Depot Medroxyprogesterone Acetate (Depot MPA)?

Accepted Answer

Hepatitis

Answer

Weight gain

Answer

Irregular bleeding

Answer

Amenorrhea

Question 8

Which of the following is NOT a side effect or complication of the Copper-T intrauterine device?

Accepted Answer

Ectopic pregnancy

Answer

Menorrhagia

Answer

Dysmenorrhea

Answer

Perforation

Question 9

Which of the following oral contraceptive pills contains the least amount of estrogen?

Accepted Answer

Femilon

Answer

Mala N

Answer

Triquilar

Answer

Novelon

Question 10

Progestin-only pills should not be taken by women with which of the following conditions?

Accepted Answer

Migraine headache without aura

Answer

Unexplained uterine bleeding

Answer

Breast cancer

Answer

Severe active liver disease

Contraception and Family Planning — MCQs

Contraception and Family Planning — MCQs

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