Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 331: Which of the following is true regarding depot medroxy progesterone acetate?

A. It is a subdermal progestin implant.
B. It is a 150 mg dose given intravenously every 90 days.
C. It is known to diminish bone mineral density. (Correct Answer)
D. It increases the risk of endometrial cancer.

Explanation: **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.

Question 332: Which of the following conditions can be caused by Oral Contraceptive Pills (OCPs)?

A. Hepatic adenoma
B. Cancer of the cervix
C. Hepatic vein thrombosis
D. All of the above (Correct Answer)

Explanation: **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.

Question 333: The Billing method of contraception is synonymous with which of the following?

A. Rhythm method
B. Basal body temperature method
C. Cervical mucus method (Correct Answer)
D. Abstinence

Explanation: **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.

Question 334: A woman with an intrauterine contraceptive device (IUCD) develops pelvic inflammatory disease. What is the recommended initial management?

A. Maintain the IUCD, initiate antibiotic therapy, and assess the response before deciding on IUCD removal. (Correct Answer)
B. Start antibiotics and then remove the IUCD.
C. Remove the IUCD and then start antibiotics.
D. Delay intervention until the next menstrual cycle.

Explanation: ### Explanation **1. Why Option A is Correct:** The current clinical consensus (supported by WHO Medical Eligibility Criteria and CDC guidelines) states that if a woman develops Pelvic Inflammatory Disease (PID) while using an IUCD, the device **does not need to be removed immediately**. The recommended approach is to initiate standard parenteral or oral antibiotic therapy while keeping the IUCD in situ. The patient should be closely monitored; if there is no clinical improvement within 48–72 hours of starting treatment, removal of the IUCD should then be considered. Research shows that clinical outcomes (cure rates) are similar whether the IUCD is removed or retained. **2. Why Other Options are Wrong:** * **Options B & C:** Routine removal of the IUCD at the start of treatment is no longer recommended. Early removal may lead to a loss of contraception and is not proven to speed up recovery. Furthermore, removing the IUCD before achieving therapeutic antibiotic levels (Option C) could theoretically risk transient bacteremia. * **Option D:** PID is an acute infection that requires prompt antibiotic intervention to prevent long-term sequelae like infertility, ectopic pregnancy, and chronic pelvic pain. Delaying treatment until the next cycle is clinically negligent. **3. Clinical Pearls for NEET-PG:** * **Risk Period:** The risk of PID is only increased during the first **20 days** following IUCD insertion (due to the introduction of vaginal flora into the uterus). After 20 days, the risk returns to the baseline of the general population. * **Actinomyces:** If *Actinomyces israelii* is found on a routine Pap smear in an asymptomatic IUCD user, the IUCD does **not** need to be removed. Treatment is only required if the patient is symptomatic. * **Contraindication:** A current, active pelvic infection (PID, purulent cervicitis) is a **Category 4** (absolute) contraindication for the *insertion* of an IUCD.

Question 335: What is the temporary contraceptive method of choice in a 37-year-old, well-educated, normal woman?

A. Diaphragm (Correct Answer)
B. IUCD
C. Mala-D
D. Mala-N

Explanation: The choice of contraception in this scenario is guided by the patient’s **age** and **socio-economic status (well-educated)**. ### **Why Diaphragm is the Correct Answer** In women over the age of 35, Combined Oral Contraceptive Pills (COCPs) like Mala-D/N are generally avoided due to the increased risk of cardiovascular complications and thromboembolism. While an IUCD is an option, the **Diaphragm** (a barrier method) is considered the method of choice for a "well-educated" woman in this age group because: 1. **Safety:** It has no systemic side effects or hormonal risks, making it ideal for women >35 years. 2. **Compliance:** A "well-educated" woman is statistically more likely to have the motivation and understanding required to use a barrier method correctly and consistently (proper insertion and use with spermicidal jelly). ### **Why Other Options are Incorrect** * **Mala-D & Mala-N (Options C & D):** These are COCPs. They are contraindicated/not preferred in women >35 years due to the risk of hypertension, myocardial infarction, and stroke. * **IUCD (Option B):** While highly effective, IUCDs are associated with side effects like menorrhagia (heavy menstrual bleeding) and Pelvic Inflammatory Disease (PID). In the hierarchy of "ideal" choices for a motivated, educated patient over 35, the non-invasive nature of the diaphragm is often prioritized in textbook recommendations. ### **NEET-PG High-Yield Pearls** * **Age Factor:** For women **<35 years**, the method of choice is typically **OCPs**. For women **>35 years**, the method of choice is the **Diaphragm** (if educated) or **IUCD**. * **Spacing:** The most common method used for spacing in India is the **IUCD**. * **Lactating Mothers:** The contraceptive of choice is the **Progestogen-Only Pill (POP)** or **Lactational Amenorrhea Method (LAM)** for the first 6 months. * **Newly Married Couple:** The best method is **OCPs** (specifically "Centchroman" or "Chhaya" is frequently tested).

Question 336: What is the approved duration of use for Mirena?

A. 3 years
B. 1 year
C. 5 years (Correct Answer)
D. 10 years

Explanation: **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.

Question 337: Which of the following is NOT a side effect of Depot Medroxyprogesterone Acetate (Depot MPA)?

A. Weight gain
B. Irregular bleeding
C. Amenorrhea
D. Hepatitis (Correct Answer)

Explanation: **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.

Question 338: Which of the following is NOT a side effect or complication of the Copper-T intrauterine device?

A. Menorrhagia
B. Dysmenorrhea
C. Ectopic pregnancy (Correct Answer)
D. Perforation

Explanation: ### 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.

Question 339: Which of the following oral contraceptive pills contains the least amount of estrogen?

A. Mala N
B. Triquilar
C. Femilon (Correct Answer)
D. Novelon

Explanation: **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.

Question 340: Progestin-only pills should not be taken by women with which of the following conditions?

A. Unexplained uterine bleeding
B. Breast cancer
C. Migraine headache without aura (Correct Answer)
D. Severe active liver disease

Explanation: **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."

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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