Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 451: Depot medroxyprogesterone acetate is sparingly used as a contraceptive because it causes:

A. Cardiovascular complications
B. Lactational failure
C. Breast cancer
D. Irregular menstrual bleeding (Correct Answer)

Explanation: ### Explanation **Correct Option: D. Irregular menstrual bleeding** Depot medroxyprogesterone acetate (DMPA) is a progestogen-only injectable contraceptive. Its primary mechanism of action is the suppression of ovulation via the inhibition of gonadotropin secretion. The most common reason for its low acceptability and high discontinuation rate is **menstrual irregularity**. Because DMPA contains no estrogen to stabilize the endometrium, users frequently experience breakthrough bleeding, spotting, or prolonged bleeding in the first few months. With long-term use (after 1 year), approximately 50-70% of women develop secondary amenorrhea due to endometrial atrophy. **Analysis of Incorrect Options:** * **A. Cardiovascular complications:** Unlike combined oral contraceptives (COCs), DMPA does not contain estrogen and is not associated with a significant increase in the risk of thromboembolism, stroke, or myocardial infarction. It is often a preferred choice for women with cardiovascular contraindications to estrogen. * **B. Lactational failure:** Progestogen-only methods like DMPA do not suppress lactation. In fact, they are the contraceptives of choice for breastfeeding mothers (usually started 6 weeks postpartum) as they have no adverse effect on milk volume or quality. * **C. Breast cancer:** There is no definitive evidence linking DMPA use to a significant increase in the long-term risk of breast cancer. It actually provides a protective effect against endometrial cancer. **High-Yield Clinical Pearls for NEET-PG:** * **Dose:** 150 mg intramuscularly (IM) every 3 months (12 weeks). * **Return to Fertility:** There is a characteristic **delayed return to fertility** (average 7–10 months after the last injection) due to the slow release of the drug from the injection site. * **Bone Mineral Density (BMD):** Long-term use is associated with a reversible decrease in BMD (FDA Black Box Warning). * **Weight Gain:** DMPA is one of the few contraceptives consistently associated with significant weight gain.

Question 452: Which of the following is an absolute contraindication of oral contraceptive pills?

A. Pulmonary hypertension
B. H. mole (Correct Answer)
C. Breast carcinoma
D. Uterine bleeding

Explanation: **Explanation:** The correct answer is **H. mole (Hydatidiform Mole)**. In the context of the WHO Medical Eligibility Criteria (MEC) for contraceptive use, a molar pregnancy with persistently elevated or rising β-hCG levels is an **absolute contraindication (MEC Category 4)** for Combined Oral Contraceptive (COC) pills. **Why H. Mole?** The primary concern is the potential for COCs to interfere with the monitoring of post-molar gestational trophoblastic neoplasia (GTN). Elevated estrogen levels were historically thought to increase the risk of malignant transformation (choriocarcinoma), though modern studies suggest the main issue is the diagnostic confusion caused by hormonal influence on hCG levels. COCs should only be initiated once hCG levels have normalized. **Analysis of Other Options:** * **A. Pulmonary Hypertension:** While a serious condition, it is generally classified as MEC Category 3 or 4 depending on severity and underlying cause (e.g., risk of thromboembolism). However, in standard Indian health guidelines and NEET-PG patterns, H. mole is prioritized as the classic absolute contraindication due to its oncogenic monitoring implications. * **C. Breast Carcinoma:** Current breast cancer is an absolute contraindication (MEC 4). However, in many MCQ formats, H. mole is the "more" specific answer related to trophoblastic follow-up. * **D. Uterine Bleeding:** Undiagnosed vaginal bleeding is a **relative contraindication (MEC 2/3)** until a diagnosis is established to rule out malignancy. **High-Yield NEET-PG Pearls:** * **MEC Category 4 (Absolute Contraindications):** Smokers >35 years (>15 cigarettes/day), History of DVT/PE, Ischemic heart disease, Migraine with aura, Breast cancer, and Liver tumors. * **H. Mole Protocol:** Use barrier methods until hCG is undetectable; COCs are the preferred method *after* hCG normalization to prevent pregnancy during the follow-up period. * **Protective Effects of COCs:** Reduced risk of Ovarian and Endometrial cancers (persists for 15+ years after discontinuation).

Question 453: What is the Pearl index?

A. Failure rate per 1 woman-year
B. Failure rate per 10 women-years
C. Failure rate per 100 women-years (Correct Answer)
D. Failure rate per 1000 women-years

Explanation: The **Pearl Index** is the most common method used in clinical trials and epidemiological studies to report the effectiveness of a contraceptive method. ### **Explanation of the Correct Answer** The Pearl Index is defined as the number of unintended pregnancies per **100 woman-years** of exposure. It represents the failure rate of a contraceptive method when used by 100 women over one year (or 1,200 months of use). The formula is: **Pearl Index = (Total number of pregnancies × 1200) / (Total number of months of exposure)** A lower Pearl Index indicates a more effective contraceptive method. For example, the Pearl Index of an IUD is typically <1, whereas for male condoms with typical use, it is approximately 13-18. ### **Analysis of Incorrect Options** * **Option A, B, and D:** These are incorrect because the standard denominator for the Pearl Index is internationally defined as **100 woman-years**. Using 1, 10, or 1000 would not align with the standardized statistical reporting required for comparing different contraceptive methods. ### **High-Yield Clinical Pearls for NEET-PG** * **Perfect Use vs. Typical Use:** The Pearl Index can be calculated for "perfect use" (theoretical efficacy) and "typical use" (real-world efficacy). * **Most Effective:** Implants (Nexplanon) have the lowest Pearl Index (~0.05), making them the most effective reversible contraceptive. * **Limitation:** The Pearl Index assumes a constant failure rate over time, but in reality, failure rates usually decrease as users become more experienced with the method. * **Life Table Analysis:** This is an alternative method to the Pearl Index that calculates failure rates for specific time intervals (e.g., at 6 months, 12 months).

Question 454: What is true about Mirena?

A. A progestogen-containing intrauterine device (Correct Answer)
B. Contains desogestrel
C. Causes endometrial hyperplasia
D. Has no effect on menses

Explanation: **Mirena** is a Levonorgestrel-releasing Intrauterine System (LNG-IUS). It is a T-shaped plastic device that serves as a highly effective, long-acting reversible contraceptive (LARC). ### **Explanation of Options:** * **A is Correct:** Mirena contains **Levonorgestrel (LNG)**, which is a second-generation synthetic **progestogen**. It releases approximately 20 µg of LNG directly into the uterine cavity every 24 hours. * **B is Incorrect:** It contains **Levonorgestrel**, not desogestrel. Desogestrel is commonly found in third-generation combined oral contraceptive pills (COCPs) or progestogen-only pills (Cerazette). * **C is Incorrect:** Progestogens cause **endometrial atrophy**, not hyperplasia. By suppressing the proliferative effect of estrogen, Mirena thins the endometrial lining, which is why it is used as a first-line treatment for Heavy Menstrual Bleeding (HMB). * **D is Incorrect:** Mirena significantly affects menses. Initially, it may cause irregular spotting, but it eventually leads to **amenorrhea** in approximately 20-40% of users after one year due to profound endometrial suppression. ### **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** Primarily works by thickening cervical mucus (preventing sperm penetration) and causing endometrial atrophy (preventing implantation). It does not consistently inhibit ovulation. * **Duration:** Approved for use for up to **8 years** (recently updated from 5 years). * **Non-Contraceptive Uses:** First-line management for **Idiopathic Menorrhagia**, management of endometriosis, and as the progestogen component of Hormone Replacement Therapy (HRT) to protect the endometrium. * **Pearl:** Unlike Copper-T, Mirena **decreases** the risk of Pelvic Inflammatory Disease (PID) by thickening the cervical mucus plug.

Question 455: Which of the following is NOT a common side effect of oral contraceptive pills?

A. Weight gain
B. Breast discomfort
C. Ovarian malignancy (Correct Answer)
D. Deep vein thrombosis (DVT)

Explanation: **Explanation:** The correct answer is **C. Ovarian malignancy**. This is because Combined Oral Contraceptive Pills (COCPs) are actually **protective** against ovarian cancer. By suppressing ovulation (the "incessant ovulation" theory), COCPs reduce the repetitive trauma to the ovarian epithelium, thereby decreasing the risk of epithelial ovarian cancer by approximately 40-50%. This protective effect increases with the duration of use and persists for years after discontinuation. **Analysis of other options:** * **Weight Gain (A):** Estrogen can cause fluid retention, and progestogens may have an anabolic effect or increase appetite, making weight gain a frequently reported (though often subjective) side effect. * **Breast Discomfort (B):** Mastalgia or breast tenderness is a common estrogenic side effect due to ductal proliferation and fluid retention. * **Deep Vein Thrombosis (DVT) (D):** Estrogen increases the hepatic synthesis of clotting factors (II, VII, IX, X) and decreases Antithrombin III. This creates a hypercoagulable state, significantly increasing the risk of venous thromboembolism (VTE). **NEET-PG High-Yield Pearls:** * **Cancer Risks:** COCPs **decrease** the risk of Ovarian and Endometrial cancer (the "Protective Effect"). However, they may slightly **increase** the risk of Cervical and Breast cancer. * **Benign Conditions:** COCPs also reduce the risk of Benign Breast Disease, Pelvic Inflammatory Disease (PID), and Ectopic pregnancy. * **Absolute Contraindications:** History of Thromboembolism, Undiagnosed vaginal bleeding, Smokers >35 years, and Estrogen-dependent tumors (Breast CA).

Question 456: Regarding coitus interruptus, which of the following is a false statement?

A. Discharge of semen outside the female genitalia at the end of intercourse.
B. Inexpensive.
C. Can be used by men with a history of premature ejaculation. (Correct Answer)
D. Very high failure rate.

Explanation: **Explanation:** Coitus interruptus, also known as the "withdrawal method," is a traditional behavioral method of contraception. **Why Option C is the Correct Answer (False Statement):** Coitus interruptus requires significant self-control and precise timing by the male partner to withdraw the penis from the vagina before ejaculation occurs. Men with **premature ejaculation** lack this voluntary control over the timing of climax. Therefore, they are unable to ensure withdrawal happens before semen enters the female genital tract, making this method highly unreliable and contraindicated for them. **Analysis of Other Options:** * **Option A (True):** By definition, the method involves the male withdrawing the penis and discharging semen completely away from the female's external genitalia to prevent sperm from entering the reproductive tract. * **Option B (True):** It is entirely free of cost as it requires no devices, hormonal prescriptions, or clinical procedures. * **Option C (True):** It has a **very high failure rate** (Typical use failure rate is approximately 20-22%). This is due to the presence of pre-ejaculatory fluid (which may contain sperm) and the high risk of human error/lack of timing. **High-Yield Clinical Pearls for NEET-PG:** * **Pearl 1:** Coitus interruptus offers **zero protection** against Sexually Transmitted Infections (STIs) and HIV. * **Pearl 2:** The primary cause of failure (besides late withdrawal) is the **pre-ejaculatory fluid** from Cowper’s glands, which can contain viable sperm from previous ejaculations. * **Pearl 3:** It is categorized under "Natural/Behavioral Methods" along with the Rhythm method (Safe period), Lactational Amenorrhea Method (LAM), and Basal Body Temperature method.

Question 457: Which intrauterine device (IUD) has the least failure rate?

A. Copper T 200 (CUT-200)
B. Lippes Loop
C. Levonorgestrel-releasing intrauterine device (LNG-IUD) (Correct Answer)
D. Nova-T

Explanation: **Explanation:** The efficacy of an intrauterine device (IUD) is measured by its failure rate, typically expressed as the **Pearl Index** (number of pregnancies per 100 woman-years). **Why LNG-IUD is the Correct Answer:** The **Levonorgestrel-releasing intrauterine device (LNG-IUD)**, commonly known by the brand name Mirena, has the lowest failure rate among all IUDs, at approximately **0.1% to 0.2%**. Its superior efficacy is due to a dual mechanism: it acts as a local foreign body (like traditional IUDs) and releases 20 µg of levonorgestrel daily. This thickens cervical mucus (preventing sperm penetration), thins the endometrium (preventing implantation), and may inhibit ovulation in some cycles. **Analysis of Incorrect Options:** * **Lippes Loop:** A first-generation, non-medicated (inert) IUD. It has the highest failure rate (approx. 3% or more) and is largely obsolete in modern practice. * **Copper T 200 (CuT-200):** A second-generation medicated IUD. With a smaller surface area of copper (200 $mm^2$), its failure rate is higher (approx. 2%) compared to the CuT-380A. * **Nova-T:** A second-generation IUD containing copper with a silver core. While more effective than CuT-200, its failure rate (approx. 0.8%–1.2%) is still higher than the LNG-IUD. **High-Yield Clinical Pearls for NEET-PG:** * **Most effective overall contraceptive:** Implants (Etonogestrel), followed closely by LNG-IUD and Vasectomy. * **Ideal Candidate for LNG-IUD:** Women with Menorrhagia (it is the medical treatment of choice for DUB/AUB-E). * **CuT-380A:** The most common IUD used in the National Family Planning Program of India; it is effective for **10 years**, whereas LNG-IUD is effective for **5–8 years** (depending on the model).

Question 458: What is the highest failure rate among the following contraceptive methods?

A. Oral Contraceptive Pill (OCP)
B. Condom (Correct Answer)
C. Intrauterine Copper T (Cu-T)
D. Depot Injection

Explanation: The failure rate of a contraceptive method is typically measured using the **Pearl Index** (number of pregnancies per 100 woman-years). Failure rates are categorized into "Perfect Use" (theoretical) and "Typical Use" (actual practice). ### **Why Condoms have the highest failure rate:** The **Condom** has the highest failure rate among the given options because its efficacy is highly dependent on **user compliance and technique**. In "Typical Use," the failure rate for male condoms is approximately **18%**, compared to only 2% in "Perfect Use." Common reasons for failure include inconsistent use, slippage, breakage, or improper application. Unlike the other options, it is a coitus-dependent method, increasing the margin for human error. ### **Analysis of Incorrect Options:** * **Oral Contraceptive Pills (OCP):** While they also depend on user compliance (daily intake), the typical failure rate is around **9%**, which is significantly lower than condoms. * **Depot Injection (DMPA):** This is a long-acting injectable. Since it only requires an injection every 3 months, user error is minimized. The typical failure rate is approximately **6%**. * **Intrauterine Copper T (Cu-T):** This is a Long-Acting Reversible Contraceptive (LARC). It is "user-independent," meaning once inserted, it works continuously. It has the lowest failure rate among the options, at approximately **0.8%**. ### **NEET-PG High-Yield Pearls:** * **Lowest Failure Rate (Most Effective):** Implant (0.05%), followed by Vasectomy (0.15%) and Cu-T 380A. * **Highest Failure Rate (Least Effective):** Natural methods (Calendar/Rhythm method) have the highest failure rates (~24%), followed by the Condom among modern methods. * **Ideal Contraceptive for Lactating Mothers:** Progestogen-only pills (POPs) or Cu-T (inserted post-placental or after 6 weeks). * **Pearl Index Formula:** (Total number of pregnancies × 1200) / (Total months of exposure).

Question 459: Intermenstrual bleeding is a frequent side effect seen with which of the following?

A. Progestin-only pills during early months of use.
B. Combined OCPs throughout use.
C. Progestin-only pills where AUB never occurs.
D. Combined OCPs during early months of use. (Correct Answer)

Explanation: **Explanation:** **1. Why Option D is Correct:** Intermenstrual bleeding (also known as breakthrough bleeding) is the most common side effect of **Combined Oral Contraceptive Pills (COCPs)**, particularly during the **first 3 months** of use. This occurs because the exogenous hormones (estrogen and progestin) take time to stabilize the endometrium. The low dose of estrogen in modern pills may initially be insufficient to maintain the endometrial lining, leading to asynchronous shedding. In most cases, this resolves spontaneously as the body adapts to the hormonal cycle. **2. Analysis of Incorrect Options:** * **Option A:** While Progestin-only pills (POPs) are notorious for causing irregular bleeding, the pattern is more often characterized by unpredictable spotting or prolonged bleeding rather than classic "intermenstrual" cycles. However, the question specifically targets the most common clinical association tested in exams regarding COCP initiation. * **Option B:** Breakthrough bleeding usually decreases significantly after the first three cycles. Persistent bleeding throughout use is uncommon and usually necessitates a change in the pill formulation (e.g., increasing the estrogen dose). * **Option C:** This is factually incorrect. Abnormal Uterine Bleeding (AUB) is the primary reason for the discontinuation of POPs. **3. Clinical Pearls for NEET-PG:** * **Management:** If breakthrough bleeding occurs in the first 3 months, the patient should be **reassured** and advised to continue the pill. If it persists beyond 3 months, investigate for missed pills, drug interactions, or cervical pathology. * **Most common side effect of COCPs:** Breakthrough bleeding (early months). * **Most common side effect of IUCDs:** Menorrhagia (heavy menstrual bleeding). * **Most common cause of discontinuation of IUCD/POPs:** Bleeding/Irregularity. * **Beneficial effect:** COCPs reduce the risk of Ovarian and Endometrial cancers.

Question 460: Oral contraceptives primarily act by which of the following mechanisms?

A. Inducing aseptic inflammation
B. Altering endometrial fluid composition
C. Triggering a foreign body reaction
D. Preventing ovulation (Correct Answer)

Explanation: **Explanation:** The primary mechanism of action of Combined Oral Contraceptive Pills (COCPs) is the **prevention of ovulation**. This is achieved through the suppression of the Hypothalamic-Pituitary-Ovarian (HPO) axis. The estrogen component inhibits the release of Follicle Stimulating Hormone (FSH), preventing follicular development, while the progestogen component suppresses the Luteinizing Hormone (LH) surge, thereby preventing ovulation. **Analysis of Options:** * **Option D (Correct):** Ovulation inhibition is the most effective and primary mechanism. Secondary mechanisms include thickening of cervical mucus (making it hostile to sperm) and altering the endometrium to make it unreceptive to implantation. * **Options A, B, and C (Incorrect):** These mechanisms are characteristic of **Intrauterine Devices (IUDs)**. Non-medicated IUDs (like Lippes Loop) and Copper-T induce a local biochemical change, causing **aseptic inflammation** and a **foreign body reaction** in the uterine cavity. This environment is spermicidal and prevents fertilization/implantation. **High-Yield Clinical Pearls for NEET-PG:** * **Progesterone-Only Pills (POPs):** Their primary mechanism is **thickening of cervical mucus**, though they may also inhibit ovulation in about 50% of cycles. * **Emergency Contraception (Levonorgestrel):** Acts primarily by **delaying or inhibiting ovulation**; it is not an abortifacient. * **Centchroman (Saheli):** A SERM (Selective Estrogen Receptor Modulator) that acts by preventing implantation (asynchronous maturation of the endometrium). * **Pearl Index:** Used to measure contraceptive failure rates. For COCPs, the theoretical failure rate is as low as 0.1 per 100 woman-years.

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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