Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 391: Which of the following medications is used as a post-coital pill?

A. 25 mg Mifepristone
B. Misoprostol
C. 0.75 mg Levonorgestrel (Correct Answer)
D. 10 mg Ethinylestradiol

Explanation: **Explanation:** **1. Why Levonorgestrel (LNG) is correct:** Levonorgestrel is a synthetic progestogen and is the most widely used emergency contraceptive (EC) pill. The standard regimen involves either a single dose of **1.5 mg** or two doses of **0.75 mg** taken 12 hours apart. To be effective, it must be administered within **72 hours** of unprotected intercourse. Its primary mechanism of action is the **inhibition or delay of ovulation** by suppressing the LH surge; it does not disrupt an established pregnancy. **2. Analysis of Incorrect Options:** * **A. 25 mg Mifepristone:** While Mifepristone (an anti-progestin) is highly effective as an EC, the standard low-dose used for this purpose is **10 mg**. A 25 mg dose is not the conventional EC strength; higher doses (200 mg) are used for medical abortion in combination with Misoprostol. * **B. Misoprostol:** This is a Prostaglandin E1 analogue used for cervical ripening, induction of labor, and medical abortion. It has no role as a primary post-coital contraceptive. * **C. 10 mg Ethinylestradiol:** High-dose estrogens alone are no longer used due to severe side effects like nausea and vomiting. In the older **Yuzpe Regimen**, 100 mcg of Ethinylestradiol was combined with 0.5 mg of LNG. **3. High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** The most effective emergency contraceptive is the **Copper-T (IUCD)**, which can be inserted up to 5 days after intercourse. * **Ulipristal Acetate (30 mg):** A selective progesterone receptor modulator (SPRM) that is effective up to **120 hours (5 days)** and is superior to LNG in efficacy. * **Failure Rate:** LNG has a failure rate of approximately 1–3%. It is less effective in women with a BMI >30 kg/m². * **Centchroman (Saheli):** A non-steroidal SERM used as a weekly oral contraceptive, not as a standard post-coital pill.

Question 392: What is the effect of progesterone-only pills?

A. Completely suppresses ovulation
B. Thins the lining of the uterus
C. Thickens cervical mucus
D. All of the above (Correct Answer)

Explanation: Progesterone-only pills (POPs), also known as "mini-pills," exert their contraceptive effect through a multi-modal mechanism of action. Unlike combined oral contraceptives, they do not contain estrogen, making them suitable for breastfeeding mothers and women with contraindications to estrogen. **Explanation of the Correct Answer:** The correct answer is **D (All of the above)** because POPs act on three primary levels: 1. **Thickening of Cervical Mucus:** This is the **primary and most consistent mechanism**. Progesterone makes the mucus thick, sticky, and scanty, creating a "hostile" environment that prevents sperm penetration into the upper reproductive tract. 2. **Endometrial Alteration:** Progesterone leads to endometrial atrophy (thinning of the lining). This makes the uterus unreceptive to the implantation of a fertilized ovum. 3. **Suppression of Ovulation:** While POPs do not suppress ovulation in every cycle (unlike combined pills), they do inhibit the mid-cycle LH surge in approximately 40–60% of users, thereby preventing follicular rupture. **Why individual options are part of the whole:** * **Option A:** While not 100% consistent, ovulation suppression is a significant component of its efficacy, especially with newer desogestrel-containing POPs. * **Option B & C:** These represent the peripheral mechanisms that provide backup protection even if ovulation occurs. **High-Yield Clinical Pearls for NEET-PG:** * **The "3-Hour Rule":** Traditional POPs (Levonorgestrel) must be taken at the same time every day. A delay of more than **3 hours** is considered a missed dose. * **Drug of Choice:** POPs are the contraceptive of choice for **lactating mothers** as they do not suppress milk production. * **Side Effects:** The most common side effect is **irregular menstrual bleeding** (breakthrough bleeding). * **Ectopic Pregnancy:** While the absolute risk is low, if a woman becomes pregnant while on POPs, there is a higher *proportionate* risk that the pregnancy will be ectopic.

Question 393: While using the "safe period" method for contraception, what is considered the unsafe period?

A. Days 3-7 of the menstrual cycle
B. Days 12-18 of the menstrual cycle (Correct Answer)
C. Days 7-21 of the menstrual cycle
D. Days 21-28 of the menstrual cycle

Explanation: **Explanation:** The "Safe Period" or **Rhythm Method** is based on the physiological timing of ovulation and the lifespan of gametes. To determine the unsafe period, we consider two key factors: the **ovum survives for about 24 hours** after ovulation, and **sperm can survive for up to 48–72 hours** in the female reproductive tract. In a standard 28-day cycle, ovulation typically occurs on Day 14. To account for the viability of sperm deposited before ovulation and the survival of the egg after, a "buffer" is created. The **unsafe period** (fertile window) is generally calculated as **3 days before and 3 days after ovulation** (Day 11 to Day 17). Option B (Days 12–18) most closely aligns with this high-risk window for conception. **Analysis of Incorrect Options:** * **Option A (Days 3–7):** This is the early follicular phase/menstrual phase. Estrogen levels are low, and the follicle is not yet mature, making conception highly unlikely. * **Option C (Days 7–21):** While this range includes the unsafe period, it is overly broad. In a regular cycle, the first week and the third week are generally considered safe. * **Option D (Days 21–28):** This is the late luteal phase. After the ovum degenerates (24 hours post-ovulation), fertilization is impossible. This is the "absolute safe period." **NEET-PG High-Yield Pearls:** * **Ogino-Knaus Formula:** For irregular cycles, the fertile period is calculated as: (Shortest cycle minus 18 days) to (Longest cycle minus 11 days). * **Pearl Index:** The failure rate of the rhythm method is high (approx. 20–25 per 100 woman-years). * **Standard Days Method:** Uses "CycleBeads" to identify Days 8–19 as unsafe for women with cycles between 26–32 days.

Question 394: DMPA is administered every:

A. 3 months (Correct Answer)
B. 6 months
C. 9 months
D. 45 days

Explanation: **Explanation:** **DMPA (Depot Medroxyprogesterone Acetate)**, commonly known by the brand name **Antara** in the Government of India’s family planning program, is an injectable progestogen-only contraceptive. 1. **Why 3 months is correct:** The standard dose of DMPA is **150 mg**, administered via **deep intramuscular (IM)** injection into the gluteus maximus or deltoid. It works primarily by suppressing ovulation through the inhibition of gonadotropin secretion. The pharmacological half-life and duration of action of a 150 mg dose provide effective contraception for **13 weeks (3 months)**. A grace period of up to 2–4 weeks is usually permitted if a dose is delayed. 2. **Analysis of Incorrect Options:** * **6 months & 9 months:** These intervals are too long; the hormone levels would fall below the therapeutic threshold, leading to a failure of ovulation suppression. * **45 days:** This is the interval for **NET-EN (Norethisterone Enanthate)**, another injectable contraceptive (brand name Chhaya/Nari) which is given as 200 mg IM every **2 months (8 weeks)**. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Primarily prevents ovulation; secondarily thickens cervical mucus and thins the endometrium. * **Side Effects:** The most common side effect is **irregular menstrual bleeding** (spotting), eventually leading to **amenorrhea** in 50% of users after one year. * **Weight Gain:** DMPA is significantly associated with weight gain. * **Bone Mineral Density (BMD):** Long-term use may cause a reversible decrease in BMD (FDA Black Box Warning). * **Return to Fertility:** There is a characteristic **delay in the return to fertility**, averaging 7–10 months after the last injection.

Question 395: Emergency contraception prevents pregnancy by all of the following mechanisms, except?

A. Delaying or inhibiting ovulation
B. Inhibiting fertilization
C. Preventing implantation of the fertilized egg
D. Interrupting an early pregnancy (Correct Answer)

Explanation: **Explanation:** The core concept to understand is that **Emergency Contraception (EC)** is a preventive measure, not an abortifacient. According to the WHO and medical guidelines, pregnancy is defined as beginning at the point of implantation. **Why Option D is the correct answer:** Emergency contraception works strictly **before** a pregnancy is established. It cannot terminate or interrupt an existing clinical pregnancy. If a woman is already pregnant, taking EC (like Levonorgestrel or Ulipristal) will not cause an abortion or harm the developing fetus. Medications that interrupt early pregnancy are classified as **Mifepristone and Misoprostol** (Medical Abortion), not emergency contraception. **Why other options are incorrect:** * **A. Delaying or inhibiting ovulation:** This is the **primary mechanism** of hormonal ECs. Levonorgestrel (LNG) suppresses the LH surge, thereby preventing the release of an egg. * **B. Inhibiting fertilization:** ECs can alter cervical mucus or affect sperm migration and function, making it difficult for sperm to reach and fertilize the egg. * **C. Preventing implantation:** While controversial in some studies, it is traditionally accepted that ECs (especially the Copper-T IUD) can cause endometrial changes that make the uterus inhospitable for a fertilized egg to implant. **High-Yield NEET-PG Pearls:** * **Most effective EC:** Copper-T 380A (can be used up to 5 days after unprotected intercourse). * **Drug of Choice (Hormonal):** Levonorgestrel (1.5 mg single dose) is preferred over the older Yuzpe regimen (combined pills) due to fewer side effects. * **Ulipristal Acetate:** A selective progesterone receptor modulator (SPRM) effective up to 120 hours (5 days) and is more effective than LNG in obese women. * **Timeframe:** For maximum efficacy, hormonal EC should be taken as soon as possible, ideally within 72 hours.

Question 396: What is the fertile period in a woman with a menstrual cycle length varying between 26 to 31 days?

A. Days 8 to 21 of the cycle (Correct Answer)
B. Days 15 to 25 of the cycle
C. Days 5 to 15 of the cycle
D. The first 5 days of the cycle

Explanation: This question tests the application of the **Calendar Method (Ogino-Knaus Method)**, a rhythm-based contraceptive technique used to identify the fertile window based on cycle variability. ### **1. Calculation of the Fertile Period** To determine the fertile window, we apply two standard formulas to the woman's cycle history (usually tracked over 6–12 months): * **First Fertile Day:** Shortest cycle minus 18 days. * **Last Fertile Day:** Longest cycle minus 11 days. **Applying the data:** * Shortest cycle = 26 days → $26 - 18 = \mathbf{8^{th}\ day}$ * Longest cycle = 31 days → $31 - 11 = \mathbf{20^{th}\ day}$ (The window extends through the end of day 20, effectively covering **days 8 to 21**). The logic accounts for the fact that sperm can survive for up to 5 days in the female reproductive tract and the ovum survives for about 24 hours. ### **2. Analysis of Incorrect Options** * **Option B (15–25 days):** This starts too late. In a 26-day cycle, ovulation occurs around day 12; waiting until day 15 would miss the most fertile period. * **Option C (5–15 days):** This assumes a very short cycle. While it covers the start of the window for a 26-day cycle, it fails to account for the 31-day cycle where ovulation occurs much later (around day 17). * **Option D (First 5 days):** This is generally considered the "safe period" (menstruation), as follicular development is insufficient for ovulation this early. ### **3. NEET-PG High-Yield Pearls** * **Standard Days Method:** Only applicable for women with cycles between 26–32 days; the fertile window is fixed at **days 8–19**. * **Luteal Phase:** Always constant at **14 days**. Variability in cycle length is due to the fluctuating length of the **follicular phase**. * **Pearl:** The Calendar Method is the least reliable natural method due to cycle irregularity; the **Symptothermal Method** (combining cervical mucus and basal body temperature) is more effective.

Question 397: After withdrawal of DMPA, most women conceive within what timeframe?

A. Immediately
B. 2-4 weeks
C. 1 year (Correct Answer)
D. 6 months

Explanation: **Explanation:** The correct answer is **1 year (Option C)**. **1. Understanding the Concept:** Depot Medroxyprogesterone Acetate (DMPA) is a long-acting injectable progestogen that inhibits ovulation by suppressing the hypothalamic-pituitary-ovarian axis. Unlike oral contraceptives, DMPA has a **delayed return to fertility**. This is because the drug is highly lipophilic and is released slowly from the muscle/fat depot. Even after the 3-month contraceptive effect wears off, sub-therapeutic levels may persist in the body, delaying the resumption of regular ovulation. On average, it takes about **7 to 10 months** for fertility to return, with approximately **60-70% of women conceiving by 12 months** and over 90% by 24 months. **2. Analysis of Incorrect Options:** * **Option A & B (Immediately / 2-4 weeks):** These are incorrect because the suppression of the pituitary axis by DMPA is profound and long-lasting. Unlike Barrier methods or Copper-T, where fertility returns immediately upon removal, DMPA requires time for the drug to be completely metabolized. * **Option D (6 months):** While some women may ovulate by 6 months, the majority of the population requires a longer duration (closer to 10-12 months) to achieve pregnancy. **3. High-Yield Facts for NEET-PG:** * **Dose:** 150 mg intramuscularly (IM) every 3 months (12 weeks). * **Mechanism:** Primarily inhibits ovulation; also thickens cervical mucus and thins the endometrium. * **Side Effects:** Menstrual irregularities (most common), weight gain, and a **reversible decrease in Bone Mineral Density (BMD)**. * **Amenorrhea:** Approximately 50% of users develop amenorrhea after 1 year of use. * **Clinical Pearl:** Always counsel patients that DMPA does *not* cause permanent infertility, but they must be prepared for a significant delay (up to 12-18 months) before conception.

Question 398: A woman is taking very low-dose combined oral contraceptive pills. After missing to take pills for how many consecutive days is there a failure of the contraceptive method?

A. One missed pill
B. Two missed pills (Correct Answer)
C. Three missed pills
D. Four missed pills

Explanation: ### Explanation **Correct Answer: B. Two missed pills** The primary mechanism of action for Combined Oral Contraceptive Pills (COCPs) is the suppression of ovulation via the inhibition of the hypothalamic-pituitary-ovarian axis. In **very low-dose COCPs** (typically containing 20 mcg of ethinyl estradiol), the margin for error is significantly smaller compared to standard-dose pills. 1. **Why Two Missed Pills is the Threshold:** Missing **two or more** consecutive pills (a gap of 48 hours or more since the last pill should have been taken) allows Follicle Stimulating Hormone (FSH) levels to rise sufficiently to trigger follicular development. This "escape ovulation" significantly increases the risk of contraceptive failure. At this point, backup contraception (like condoms) is required for the next 7 days. 2. **Why Option A is Incorrect:** Missing **one pill** (less than 48 hours since the last dose) does not typically result in the loss of contraceptive efficacy, even with low-dose pills. The recommendation is to take the missed pill as soon as remembered and continue the pack; no backup method is needed. 3. **Why Options C and D are Incorrect:** While missing three or four pills certainly results in failure, the **earliest** point at which the method is clinically considered to have failed (requiring emergency intervention or backup) is after the second missed pill. --- ### High-Yield Clinical Pearls for NEET-PG: * **The "7-Day Rule":** If 2 or more pills are missed, backup contraception is needed for 7 consecutive days of active pill-taking. * **Critical Period:** The most dangerous time to miss pills is at the **beginning or end of a cycle**, as this extends the hormone-free interval (PFI), allowing for follicular escape. * **Vomiting/Diarrhea:** Severe vomiting or diarrhea within 2 hours of pill intake is treated as a "missed pill." * **Emergency Contraception (EC):** If 2 or more pills are missed in the **first week** of the pack and unprotected intercourse occurred during the hormone-free interval or Week 1, EC should be considered.

Question 399: Which of the following is NOT a benefit of using a levonorgestrel intrauterine system (IUS) for the treatment of abnormal uterine bleeding?

A. Provides contraceptive cover
B. Effective for associated dysmenorrhea
C. No breakthrough bleeding (Correct Answer)
D. Women become amenorrheic within one year after insertion

Explanation: The Levonorgestrel Intrauterine System (LNG-IUS), such as Mirena, is a highly effective treatment for heavy menstrual bleeding (HMB). However, it is notorious for causing **breakthrough bleeding (spotting)** during the initial 3 to 6 months of use. ### Explanation of Options: * **Correct Answer (C):** The statement "No breakthrough bleeding" is incorrect. Irregular spotting or breakthrough bleeding is the **most common side effect** and the primary reason for early discontinuation. This occurs due to the local effect of progestogen causing endometrial atrophy and vascular fragility before the lining stabilizes. * **Option A:** LNG-IUS provides highly effective, long-term reversible contraception (LARC) with a Pearl Index comparable to sterilization, making it ideal for women needing both therapy and birth control. * **Option B:** By suppressing endometrial proliferation and reducing prostaglandin synthesis, the LNG-IUS significantly improves associated spasmodic dysmenorrhea. * **Option D:** Approximately 20–50% of women become amenorrheic within one year of insertion due to profound endometrial atrophy. This is considered a therapeutic benefit in the context of abnormal uterine bleeding. ### High-Yield Clinical Pearls for NEET-PG: * **Mechanism:** Releases 20 µg of Levonorgestrel daily; primarily acts by thickening cervical mucus and causing endometrial atrophy. * **First-line Treatment:** LNG-IUS is the **medical treatment of choice** for HMB (NICE guidelines) and is also used in endometriosis and endometrial hyperplasia without atypia. * **Life Span:** Currently approved for **8 years** for contraception (Mirena) but usually replaced every 5 years for HMB management. * **Non-Contraceptive Benefit:** It reduces the risk of Pelvic Inflammatory Disease (PID) by thickening cervical mucus, preventing sperm and bacteria from entering the upper genital tract.

Question 400: Use of progestin-only pills as a mode of contraception is contraindicated in all of the following conditions, EXCEPT:

A. Lactation (Correct Answer)
B. Liver tumors
C. Acute liver disease
D. Known breast cancer

Explanation: **Explanation:** Progestin-only pills (POPs), also known as the "mini-pill," are a preferred method of contraception in specific clinical scenarios where estrogen is contraindicated. **Why Lactation is the Correct Answer:** Lactation is an **indication**, not a contraindication, for POPs. Unlike combined oral contraceptives (COCs), POPs do not contain estrogen. Estrogen is known to suppress milk production (hypogalactia). Therefore, POPs are the hormonal contraceptive of choice for breastfeeding mothers as they do not affect the quantity or quality of breast milk and have no adverse effects on the infant. **Why the Other Options are Wrong (Contraindications):** According to the WHO Medical Eligibility Criteria (MEC Category 4): * **Liver Tumors (Benign or Malignant) and Acute Liver Disease:** Progestins are metabolized in the liver. In the presence of active liver disease (e.g., acute viral hepatitis, cirrhosis, or hepatoma), the metabolism of these hormones is impaired, potentially exacerbating the condition. * **Known Breast Cancer:** Breast cancer is often a hormone-sensitive tumor. Progestins may stimulate the growth of breast cancer cells; thus, any current breast malignancy is an absolute contraindication for all hormonal contraceptives. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** The primary mechanism of POPs is **thickening of the cervical mucus**, which prevents sperm penetration. They also cause endometrial thinning. Unlike COCs, they do not consistently inhibit ovulation (ovulation is inhibited in only ~60-80% of cycles). * **The "3-Hour Rule":** POPs must be taken at the same time every day. A delay of more than 3 hours is considered a "missed pill." * **MEC Category 4 (Absolute Contraindication):** Current Breast Cancer is the most significant absolute contraindication for POPs.

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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