Contraception and Family Planning — MCQs

An intrauterine pregnancy of approximately 10 weeks gestation is confirmed in a 30-year-old gravida 5, para 4 woman with an IUD in place. The patient expresses a strong desire for the pregnancy to be continued. On examination, the string of the IUD is noted to be protruding from the cervical os. What is the most appropriate course of action?

Q40Easy

At the Primary Health Centre (PHC) level, a woman who complains of spotting following Intrauterine Contraceptive Device (IUCD) insertion should be advised:

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 31: For emergency contraception, when must an IUD be inserted?

A. Immediately
B. Within 5 days of coitus (Correct Answer)
C. Within 7 days of coitus
D. An IUD is not used as emergency contraception

Explanation: The Cu-T 380A Intrauterine Device (IUD) is the most effective method of emergency contraception (EC), with a failure rate of less than 0.1%. ### **Explanation of the Correct Answer** **Option B (Within 5 days of coitus)** is correct because the primary mechanism of the IUD as EC is to prevent implantation by causing a sterile inflammatory reaction in the endometrium that is toxic to the blastocyst. Since implantation typically occurs 6 to 12 days after fertilization, inserting the IUD within **120 hours (5 days)** of unprotected intercourse ensures the uterine environment is altered before the blastocyst can implant. ### **Analysis of Incorrect Options** * **Option A:** While "the sooner, the better" applies to hormonal EC (like Levonorgestrel), an IUD does not *have* to be inserted immediately to be effective; it remains highly effective up to the 5-day window. * **Option C:** Seven days exceeds the standard window for guaranteed efficacy, as implantation may have already commenced. (Note: Some guidelines suggest it can be inserted up to 5 days after the *earliest estimated day of ovulation*, but for NEET-PG, the standard "5 days after coitus" rule applies). * **Option D:** This is incorrect; the Cu-IUD is actually the "Gold Standard" for EC due to its superior efficacy compared to oral pills. ### **High-Yield Clinical Pearls for NEET-PG** * **Efficacy:** Cu-IUD is >99% effective, making it more effective than Ulipristal acetate or Levonorgestrel. * **Dual Benefit:** It provides immediate EC and continues to provide long-term contraception for up to 10 years. * **Contraindication:** It should not be used if the patient has a current Pelvic Inflammatory Disease (PID) or is already pregnant. * **Mechanism:** Primarily prevents implantation (post-fertilization) and is also spermicidal.

Question 32: Which of the following is NOT a mechanism of action of an oral contraceptive containing a combination of oestrogen-progestin?

A. Inhibition of ovulation
B. A change in the cervical mucus
C. Inhibition of motility of the uterine tubes (Correct Answer)
D. All of the above

Explanation: The Combined Oral Contraceptive Pill (COCP) works primarily through a multi-pronged approach involving the hypothalamic-pituitary-ovarian axis and local changes in the reproductive tract. ### **Explanation of the Correct Answer** **Option C (Inhibition of motility of the uterine tubes)** is the correct answer because it is **not** a primary or established mechanism of action for COCPs. While Progestogen-Only Pills (POPs) and certain hormonal states can subtly influence tubal cilia and peristalsis, this is not the defined pharmacological mechanism by which combined estrogen-progestin pills prevent pregnancy. ### **Analysis of Other Options** * **Option A (Inhibition of Ovulation):** This is the **primary mechanism**. The estrogen component suppresses Follicle Stimulating Hormone (FSH), preventing follicular development. The progestin component suppresses Luteinizing Hormone (LH), preventing the LH surge and subsequent ovulation. * **Option B (Change in cervical mucus):** This is a crucial secondary mechanism mediated by the progestin. It makes the cervical mucus thick, viscid, and scanty, creating a "hostile" environment that acts as a barrier to sperm penetration. * **Endometrial Changes (Implicit):** Though not listed, COCPs also cause endometrial atrophy, making the lining unreceptive to implantation. ### **NEET-PG High-Yield Pearls** * **Most Potent Component:** The progestin is primarily responsible for the contraceptive effect (LH suppression and mucus changes). * **Pearl on Tubal Motility:** If a question asks about the mechanism of **Progesterone-only pills (POPs)** or **Levonorgestrel IUDs**, tubal motility changes are sometimes cited, but for **COCPs**, focus on the "Triple Effect": Ovulation inhibition, Cervical mucus thickening, and Endometrial thinning. * **Failure Rate:** The Pearl Index for COCPs with perfect use is **0.3**, but with typical use, it is approximately **9**.

Question 33: Which of the following is NOT a non-contraceptive advantage of oral contraceptive pills?

A. Reduced risk of pelvic inflammatory disease
B. Reduced risk of hepatic adenoma (Correct Answer)
C. Reduced risk of benign breast disease
D. Reduced risk of anemia

Explanation: **Explanation:** Combined Oral Contraceptive Pills (COCPs) offer several health benefits beyond pregnancy prevention. However, **Hepatic Adenoma** is a known, albeit rare, **complication** of long-term COCP use, not a benefit. Estrogen in the pills can stimulate the growth of these benign liver tumors, which carry a risk of rupture and intraperitoneal hemorrhage. **Analysis of Options:** * **A. Reduced risk of Pelvic Inflammatory Disease (PID):** COCPs increase the viscosity of cervical mucus, creating a barrier that prevents the upward migration of pathogenic bacteria into the upper genital tract. * **C. Reduced risk of Benign Breast Disease:** COCPs are protective against fibroadenomas and fibrocystic breast disease (though they do not significantly reduce the risk of breast cancer). * **D. Reduced risk of Anemia:** By inhibiting ovulation and thinning the endometrial lining, COCPs reduce the volume and duration of menstrual bleeding (menorrhagia), thereby preventing iron-deficiency anemia. **High-Yield Clinical Pearls for NEET-PG:** * **Cancer Protection:** COCPs significantly reduce the risk of **Ovarian cancer** (by 50%) and **Endometrial cancer** (by 50%). This protection persists for 15–20 years after discontinuation. They also reduce the risk of **Colorectal cancer**. * **Cancer Risks:** COCPs are associated with a slight increase in the risk of **Cervical cancer** (especially with >5 years of use) and **Breast cancer**. * **Other Benefits:** Reduced risk of ectopic pregnancy, functional ovarian cysts, and improvement in acne and dysmenorrhea.

Question 34: Cryosurgery is effective in all of the following conditions EXCEPT:

A. Chronic cervicitis
B. Squamous intraepithelial lesion
C. Condyloma acuminata
D. Severe dysplasia or carcinoma in situ (CIS) lesions (Correct Answer)

Explanation: **Explanation:** Cryosurgery (cryotherapy) is an ablative procedure that uses extreme cold (usually via nitrous oxide or carbon dioxide) to cause tissue necrosis. Its primary limitation is the lack of a tissue specimen for histopathology and its limited depth of penetration. **Why Option D is the Correct Answer:** Cryosurgery is contraindicated in **Severe Dysplasia (CIN 3) or Carcinoma in Situ (CIS)**. These high-grade lesions carry a significant risk of occult invasive cancer. Because cryosurgery destroys tissue without providing a biopsy sample, an underlying invasive malignancy could be missed. Furthermore, cryosurgery may not reach the required depth to eliminate deep-seated dysplastic cells in severe cases, leading to high recurrence rates. These conditions are better managed with excisional procedures like **LEEP (Loop Electrosurgical Excision Procedure)** or **Cold Knife Conization**. **Analysis of Incorrect Options:** * **A. Chronic Cervicitis:** Cryosurgery is a standard treatment for symptomatic chronic cervicitis and cervical erosions (ectopy) to promote the growth of healthy squamous epithelium. * **B. Squamous Intraepithelial Lesion (SIL):** Cryosurgery is effective for **Low-grade SIL (CIN 1)**, provided the lesion is small, entirely visible on the ectocervix, and the endocervical curettage (ECC) is negative. * **C. Condyloma Acuminata:** Cryotherapy is a first-line modality for treating external genital warts caused by HPV, as it effectively destroys the superficial viral lesions. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisite for Cryosurgery:** The transformation zone must be fully visible (Satisfactory Colposcopy). * **The "Ice Ball" Technique:** A freeze-thaw-freeze cycle is used; the ice ball should extend 3-5 mm beyond the edge of the probe. * **Side Effect:** Patients often experience a profuse, watery vaginal discharge for 2–4 weeks post-procedure. * **Absolute Contraindications:** Suspected invasive cancer, pregnancy, and lesions extending into the endocervical canal.

Question 35: What is the best gestational age to perform a single ultrasound scan during pregnancy?

A. 6-8 weeks
B. 10-12 weeks
C. 18-22 weeks (Correct Answer)
D. 34-36 weeks

Explanation: **Explanation:** The **18–22 week scan**, commonly known as the **Anomaly Scan** or **Level II Ultrasound**, is considered the most critical single scan in pregnancy. At this gestational age, fetal anatomy is sufficiently developed to be visualized in detail, yet the fetus is small enough and the amniotic fluid volume is optimal to allow for clear imaging. This window is the "gold standard" for detecting major structural congenital anomalies (e.g., neural tube defects, cardiac malformations). **Analysis of Options:** * **A & B (6–12 weeks):** While early scans are excellent for confirming viability, dating (via Crown-Rump Length), and screening for chromosomal markers (like Nuchal Translucency at 11–13.6 weeks), the organs are not yet fully developed for a comprehensive structural survey. * **D (34–36 weeks):** Late third-trimester scans are primarily used for assessing fetal growth, placental position, and liquor volume. However, increased fetal size and bone mineralization at this stage make a detailed anatomical survey difficult. **High-Yield NEET-PG Pearls:** * **Best time for Dating:** 7–12 weeks (CRL is the most accurate parameter for gestational age). * **Best time for NT Scan:** 11 weeks to 13 weeks 6 days. * **Legal Limit for MTP (India):** The Medical Termination of Pregnancy (Amendment) Act 2021 allows termination up to **24 weeks** for specific categories (including fetal anomalies), making the 18–22 week scan legally crucial for decision-making. * **Cervical Length:** Also measured during the 18–22 week scan to screen for risk of preterm labor.

Question 36: Combined OCPs can be used in all conditions except which of the following?

A. Fibroadenoma
B. Breast cancer (Correct Answer)
C. Ectopic pregnancy
D. Iron deficiency anemia

Explanation: **Explanation:** The correct answer is **Breast cancer**. Combined Oral Contraceptive Pills (COCPs) are contraindicated in breast cancer because it is a **hormone-sensitive malignancy**. Estrogen and progesterone can stimulate the proliferation of breast cancer cells, potentially worsening the prognosis or causing recurrence. According to the WHO Medical Eligibility Criteria (MEC), current breast cancer is classified as **Category 4** (unacceptable health risk). **Analysis of Options:** * **Fibroadenoma:** This is a benign breast condition. COCPs are not contraindicated and, in some cases, may even reduce the risk of benign breast disease. * **Ectopic Pregnancy:** COCPs are highly effective at preventing pregnancy. By preventing ovulation, they significantly reduce the absolute risk of both intrauterine and ectopic pregnancies. A history of ectopic pregnancy is not a contraindication. * **Iron Deficiency Anemia:** COCPs are actually **beneficial** here. They reduce menstrual blood loss (menorrhagia) and induce withdrawal bleeds that are lighter and shorter, thereby helping to improve hemoglobin levels. **High-Yield Clinical Pearls for NEET-PG:** * **WHO MEC Category 4 (Absolute Contraindications):** Undiagnosed vaginal bleeding, smokers >35 years (>15 cigarettes/day), history of DVT/PE, ischemic heart disease, stroke, complicated valvular heart disease, and active liver disease (cirrhosis/tumors). * **Cancer Risks:** COCPs **increase** the risk of breast and cervical cancer but are **protective** against ovarian, endometrial, and colorectal cancers. * **Non-contraceptive benefits:** Reduced risk of PID, ectopic pregnancy, and functional ovarian cysts.

Question 37: Which of the following is a constituent of the minipill?

A. Only progesterone (Correct Answer)
B. Only estrogen
C. Estrogen and progesterone
D. Norethisterone and estradiol

Explanation: **Explanation:** The **Minipill**, also known as the **Progestogen-Only Pill (POP)**, contains only a low dose of a progestogen and lacks an estrogen component. It is primarily indicated for women in whom estrogen is contraindicated, such as those who are breastfeeding (as it does not suppress lactation) or those with a history of thromboembolism. **Why the options are correct/incorrect:** * **Option A (Correct):** The minipill consists of **only progesterone** (e.g., Levonorgestrel 0.03 mg, Norethisterone 0.35 mg, or Desogestrel 0.075 mg). Its primary mechanism of action is increasing the viscosity of cervical mucus to prevent sperm penetration and causing endometrial thinning. * **Option B:** There is no contraceptive pill that contains only estrogen, as unopposed estrogen increases the risk of endometrial hyperplasia and carries a high risk of thromboembolism. * **Option C:** This describes the **Combined Oral Contraceptive Pill (COCP)**, which contains both estrogen (usually Ethinyl Estradiol) and a progestogen. * **Option D:** This is a specific combination of a progestogen and an estrogen, typical of a COCP or hormone replacement therapy, not a minipill. **High-Yield Clinical Pearls for NEET-PG:** 1. **Mechanism:** Unlike the COCP, the minipill does not consistently inhibit ovulation (except for the Desogestrel pill). Its efficacy depends on **cervical mucus thickening**. 2. **Strict Timing:** The minipill must be taken at the **same time every day**. A delay of more than **3 hours** (12 hours for Desogestrel) is considered a "missed pill." 3. **Drug of Choice:** It is the preferred oral contraceptive for **lactating mothers** because it does not affect the quantity or quality of breast milk. 4. **Side Effect:** The most common side effect is **irregular menstrual bleeding** or spotting.

Question 38: Which of the following statements about Mifepristone is FALSE?

A. It is used for induction of abortion.
B. It is a selective progesterone receptor modulator.
C. It is a glucocorticoid receptor agonist. (Correct Answer)
D. It is a progesterone receptor antagonist in the endometrium.

Explanation: **Explanation:** Mifepristone (RU-486) is a synthetic steroid compound with a high affinity for progesterone and glucocorticoid receptors. The correct answer is **Option C** because Mifepristone acts as a **glucocorticoid receptor antagonist**, not an agonist. At high doses, it blocks the action of cortisol, which is why it is also FDA-approved for managing hyperglycemia in patients with Cushing’s syndrome. **Analysis of Options:** * **Option A (True):** Mifepristone is primarily used for the medical termination of pregnancy (MTP). It sensitizes the myometrium to prostaglandins and causes decidual breakdown, leading to abortion. * **Option B (True):** It is classified as a Selective Progesterone Receptor Modulator (SPRM). It exhibits tissue-specific effects, primarily acting as an antagonist in the presence of progesterone. * **Option D (True):** In the endometrium, it acts as a competitive antagonist at the progesterone receptor level. This leads to the shedding of the decidua and prevents the maintenance of early pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **MTP Protocol:** The standard regimen is **200 mg Mifepristone (oral)** followed by **800 mcg Misoprostol (vaginal/oral/sublingual)** 24–48 hours later for pregnancies up to 63–70 days. * **Emergency Contraception:** A single dose of 10 mg Mifepristone is highly effective if taken within 120 hours of unprotected intercourse. * **Other Uses:** Management of uterine fibroids (reduces size), endometriosis, and induction of labor in intrauterine fetal death (IUFD). * **Contraindication:** Chronic ectopic pregnancy and patients on long-term corticosteroid therapy (due to its antiglucocorticoid action).

Question 39: An intrauterine pregnancy of approximately 10 weeks gestation is confirmed in a 30-year-old gravida 5, para 4 woman with an IUD in place. The patient expresses a strong desire for the pregnancy to be continued. On examination, the string of the IUD is noted to be protruding from the cervical os. What is the most appropriate course of action?

A. Leave the IUD in place without any other treatment
B. Leave the IUD in place and continue prophylactic antibiotics throughout pregnancy
C. Remove the IUD immediately (Correct Answer)
D. Terminate the pregnancy because of the high risk of infection

Explanation: **Explanation:** The management of a pregnancy with an Intrauterine Device (IUD) in situ depends on the visibility of the strings and the gestational age. **1. Why Option C is Correct:** When a woman becomes pregnant with an IUD and the **strings are visible**, the most appropriate action is to **remove the IUD immediately** (ideally before 12 weeks). Leaving the IUD in place significantly increases the risk of: * **Spontaneous Abortion:** Risk increases by up to 50%. * **Septic Abortion:** A life-threatening infection. * **Preterm Labor and Delivery:** Risk increases fourfold. Removal of the IUD reduces these risks, although the risk of miscarriage remains slightly higher than in a normal pregnancy. **2. Why Incorrect Options are Wrong:** * **Options A & B:** Leaving the IUD in place (with or without antibiotics) exposes the patient to a high risk of chorioamnionitis and septic abortion. Prophylactic antibiotics do not mitigate the mechanical and infectious risks posed by the foreign body. * **Option D:** Pregnancy termination is not mandatory. If the patient desires to continue the pregnancy, removal of the IUD is the standard of care. The risk of congenital malformations is not increased by the presence of an IUD. **High-Yield Clinical Pearls for NEET-PG:** * **Strings NOT visible:** If strings are not seen, perform an ultrasound. If the IUD is intrauterine, it should be **left alone** to avoid disrupting the pregnancy. * **Ectopic Risk:** While IUDs are highly effective, if a pregnancy *does* occur, the **probability** of it being an ectopic pregnancy is higher (approx. 1 in 20) compared to the general population. * **Teratogenicity:** There is no evidence that IUDs cause birth defects. * **Actinomyces:** If *Actinomyces* is found on a PAP smear in an asymptomatic IUD user, the IUD does **not** need to be removed.

Question 40: At the Primary Health Centre (PHC) level, a woman who complains of spotting following Intrauterine Contraceptive Device (IUCD) insertion should be advised:

A. Analgesics and observation
B. Antibiotics and observation
C. Iron supplements and observation (Correct Answer)
D. Removal of IUCD

Explanation: **Explanation:** The most common side effect of Intrauterine Contraceptive Devices (IUCDs) like Cu-T 380A is **increased menstrual blood loss and intermenstrual spotting**. This typically occurs during the first 3–6 months following insertion as the endometrium adjusts to the foreign body. **Why Iron Supplements and Observation?** At the PHC level, the primary goal is to manage side effects without discontinuing a highly effective method of contraception. Since chronic spotting or heavy bleeding can lead to a depletion of iron stores and subsequent anemia, the standard protocol is to provide **Iron and Folic Acid (IFA) supplements**. Reassurance and observation are key, as spotting usually subsides spontaneously after a few cycles. **Analysis of Incorrect Options:** * **Analgesics (A):** While NSAIDs (like Mefenamic acid) are effective for managing IUCD-induced *cramping* or heavy bleeding by reducing prostaglandin levels, they are not the primary management for isolated spotting at the PHC level. * **Antibiotics (B):** Spotting is a mechanical/hormonal side effect, not an infectious one. Antibiotics are only indicated if there are signs of Pelvic Inflammatory Disease (PID). * **Removal of IUCD (D):** This is a last resort. Removal is only indicated if the bleeding is persistent, severe, or if the patient is unwilling to continue despite counseling. **NEET-PG High-Yield Pearls:** * **Most common side effect of IUCD:** Bleeding (spotting or menorrhagia). * **Most common reason for removal:** Bleeding and pain. * **Ideal time for insertion:** Within 10 days of the start of the menstrual cycle (to ensure the patient is not pregnant). * **Mechanism of Cu-T:** Primarily spermicidal; causes a sterile inflammatory response in the endometrium.

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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