Contraception and Family Planning — MCQs

A 26-year-old G1, P0 presents to the OBGYN department with a complaint of moderate vaginal bleeding noticed while bathing. On examination, there are no uterine contractions, pain, or abdominal cramps. Vital signs are: Blood pressure 120/76 mmHg, Pulse rate 84/min, temperature 37.6°C, Respiratory rate 16/min. Speculum examination reveals a small clot at the vault, with no active bleeding or abnormal mass. The cervix is closed. Bimanual examination is unremarkable. What is the most likely diagnosis?

Q466Easy

What is the most ideal site for sterilization by tubectomy?

Q467Easy

DMPA causes all the following except?

Q468Easy

Which antiprogestin is used for emergency contraception?

Q469Medium

Which of the following neoplasms has been associated with the use of oral contraceptives?

Q470Easy

Which intrauterine contraceptive device (IUCD) has the shortest lifespan?

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 461: Progestogen-only pills (POPs) carry a risk of:

A. Hypertension
B. Embolism
C. Irregular bleeding
D. Ectopic pregnancy (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Ectopic pregnancy**. **Why it is correct:** Progestogen-only pills (POPs), often called the "mini-pill," primarily work by thickening the cervical mucus and thinning the endometrium. Unlike combined oral contraceptives, they do not consistently suppress ovulation (ovulation occurs in about 40–60% of cycles). However, progestogens significantly decrease **fallopian tube motility** (ciliary action). If fertilization occurs despite the contraceptive effect, the slowed tubal transport increases the risk that the blastocyst will implant within the tube rather than the uterus. While the *absolute* risk of any pregnancy is low, if a woman becomes pregnant while taking POPs, there is a higher *relative* risk that the pregnancy will be ectopic. **Why other options are wrong:** * **A & B (Hypertension and Embolism):** These are classic side effects associated with the **estrogen** component of combined oral contraceptives (COCs). Estrogen increases the synthesis of clotting factors and angiotensinogen. POPs do not contain estrogen and are generally considered safe for women with a history of VTE or hypertension. * **C (Irregular bleeding):** While irregular "breakthrough" bleeding is the **most common side effect** of POPs and a frequent reason for discontinuation, it is considered a side effect/nuisance rather than a significant clinical "risk" or complication in the context of this specific question's hierarchy. **High-Yield Pearls for NEET-PG:** * **Mechanism of POPs:** Thickening of cervical mucus (most important), endometrial changes, and altered tubal motility. * **Ideal Candidate:** Lactating mothers (POPs do not affect milk quantity/quality) and women with contraindications to estrogen (smokers >35 years, migraine with aura, history of VTE). * **Failure Rate:** Higher than COCs, especially if not taken at the same time every day (strict 3-hour window for traditional POPs). * **Centchroman (Saheli):** A non-steroidal, once-a-week pill (SERM) developed in India (CDRI, Lucknow), often compared with POPs in exams.

Question 462: Which one of the following is the ideal contraceptive for a patient with heart disease?

A. IUCD
B. Depo-Provera
C. Diaphragm (Correct Answer)
D. Oral contraceptive pills

Explanation: **Explanation:** In patients with heart disease, the primary goal of contraception is to avoid methods that increase hemodynamic stress, thromboembolic risk, or the risk of infection. **Why Diaphragm is the Correct Answer:** The **Diaphragm (Barrier method)** is considered the safest option because it is non-hormonal and non-invasive. It has **zero systemic side effects**, does not alter blood pressure, and carries no risk of thromboembolism. For cardiac patients, particularly those with valvular heart disease or arrhythmias, avoiding systemic physiological changes is paramount. **Why Other Options are Incorrect:** * **Oral Contraceptive Pills (OCPs):** These are generally **contraindicated** in heart disease (especially those with valvular issues, hypertension, or history of stroke) because the estrogen component increases the risk of thromboembolism and can worsen hypertension. * **IUCD (Intrauterine Contraceptive Device):** While non-hormonal (Copper-T), it is avoided in certain cardiac conditions due to the risk of **vasovagal shock** during insertion. Additionally, there is a theoretical risk of pelvic infection which could lead to **subacute bacterial endocarditis (SBE)** in patients with structural heart defects. * **Depo-Provera (DMPA):** This progestogen-only injectable can cause fluid retention and negatively impact lipid profiles, which is undesirable in cardiac patients. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Eligibility Criteria:** Most barrier methods are Category 1 (no restriction) for heart disease. * **Sterilization:** While highly effective, the surgical stress of tubal ligation may be risky; therefore, **Vasectomy** (for the partner) is often the preferred permanent method. * **Progestogen-only pills (POPs):** These are safer than COCs if a hormonal method is absolutely necessary, as they do not carry the same thromboembolic risk. * **Infective Endocarditis Prophylaxis:** No longer routinely recommended for IUCD insertion according to latest AHA guidelines, but many clinicians still prefer barrier methods to avoid the risk entirely.

Question 463: Which of the following is used as emergency contraception?

A. Mala-N
B. 0.75mg Levonorgestrel (LNG)
C. Copper T
D. All of the above (Correct Answer)

Explanation: **Explanation:** Emergency contraception (EC) refers to methods used to prevent pregnancy after unprotected intercourse, contraceptive failure, or sexual assault. The correct answer is **"All of the above"** because each option represents a valid EC regimen used in clinical practice. 1. **Levonorgestrel (LNG) 0.75mg:** This is the progestogen-only pill (POP) method. The standard dose is **1.5 mg** taken as a single dose or two doses of **0.75 mg** 12 hours apart. It works primarily by delaying ovulation and is most effective when taken within 72 hours (up to 120 hours). 2. **Mala-N (Combined Oral Contraceptive Pills):** This represents the **Yuzpe Regimen**. While Mala-N is typically used for daily contraception, taking a specific high dose (100 mcg Ethinyl Estradiol + 0.5 mg LNG, repeated after 12 hours) acts as emergency contraception. Though less effective and associated with more nausea than LNG-only pills, it remains a recognized method. 3. **Copper T (Cu-IUD):** This is the **most effective** method of emergency contraception (failure rate <0.1%). It can be inserted up to 5 days after unprotected intercourse (or up to 5 days after the earliest expected date of ovulation) and provides the added benefit of long-term reversible contraception. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard/Most Effective EC:** Copper T 380A. * **Drug of Choice (Hormonal):** Levonorgestrel 1.5mg (Single dose). * **Ulipristal Acetate (30mg):** A Selective Progesterone Receptor Modulator (SPRM) that is more effective than LNG, especially between 72–120 hours. * **Mifepristone:** Can be used as EC in low doses (10–25 mg). * **Note:** EC prevents pregnancy; it is **not** an abortifacient and will not disrupt an established pregnancy.

Question 464: Which contraceptive method should be avoided in patients with epilepsy?

A. Oral contraceptives (Correct Answer)
B. Condoms
C. Intrauterine contraceptive devices
D. Post-coital pills

Explanation: **Explanation:** The primary concern in managing contraception for patients with epilepsy is the **pharmacokinetic interaction** between antiepileptic drugs (AEDs) and hormonal contraceptives. **1. Why Oral Contraceptives (OCPs) are avoided:** Most traditional AEDs (e.g., Phenytoin, Carbamazepine, Phenobarbital, Primidone) are **potent hepatic enzyme inducers** (Cytochrome P450 system). These enzymes accelerate the metabolism of estrogen and progesterone in OCPs, significantly reducing their serum concentrations. This leads to a high risk of **contraceptive failure** and unintended pregnancy. Conversely, OCPs can lower the serum levels of certain AEDs like **Lamotrigine**, potentially triggering breakthrough seizures. **2. Analysis of Incorrect Options:** * **Condoms (Barrier Methods):** These do not involve systemic hormones or hepatic metabolism; therefore, there is no drug interaction. * **Intrauterine Contraceptive Devices (IUCDs):** Copper T or Levonorgestrel-releasing IUS (Mirena) act locally. They are considered the **gold standard** for women on enzyme-inducing AEDs because their efficacy is not affected by liver enzymes. * **Post-coital pills:** While emergency contraception (EC) can be used, it is not "avoided" in the same sense as maintenance OCPs. However, a double dose (3mg Levonorgestrel) is often recommended if the patient is on enzyme-inducers. **Clinical Pearls for NEET-PG:** * **Drug of Choice:** The Copper IUCD or LNG-IUS are the most reliable methods for epileptic patients. * **DMPA (Injectable):** Can be used, but the injection interval is sometimes shortened to 10 weeks instead of 12. * **Non-inducing AEDs:** Valproate, Levetiracetam, and Gabapentin do not significantly interact with OCPs, but OCPs are still generally avoided as a first-line precaution in epilepsy management.

Question 465: A 26-year-old G1, P0 presents to the OBGYN department with a complaint of moderate vaginal bleeding noticed while bathing. On examination, there are no uterine contractions, pain, or abdominal cramps. Vital signs are: Blood pressure 120/76 mmHg, Pulse rate 84/min, temperature 37.6°C, Respiratory rate 16/min. Speculum examination reveals a small clot at the vault, with no active bleeding or abnormal mass. The cervix is closed. Bimanual examination is unremarkable. What is the most likely diagnosis?

A. Threatened abortion (Correct Answer)
B. Missed abortion
C. Inevitable abortion
D. Incomplete abortion

Explanation: ### Explanation **Correct Answer: A. Threatened Abortion** **Medical Concept:** Threatened abortion is characterized by vaginal bleeding occurring before 20 weeks of gestation in the presence of a **closed cervical os**. The hallmark of this condition is that the pregnancy is still viable, and the bleeding occurs without the expulsion of products of conception (POC). In this clinical scenario, the patient presents with moderate bleeding but lacks uterine contractions or pain. The speculum examination confirms a **closed cervix** and no active bleeding or masses, which is the pathognomonic finding for threatened abortion. **Why Other Options are Incorrect:** * **B. Missed Abortion:** This involves the death of the fetus in utero where the POC are retained for a prolonged period. While the cervix is closed, it is usually associated with a regression of pregnancy symptoms and an ultrasound showing no fetal heart activity. * **C. Inevitable Abortion:** In this state, the clinical features (bleeding and pain) have progressed to a point where miscarriage cannot be prevented. The defining feature is an **open cervical os** (internal os), often accompanied by rupture of membranes. * **D. Incomplete Abortion:** This occurs when some, but not all, products of conception have been expelled. It is characterized by heavy bleeding, severe cramps, and an **open cervical os** with tissue felt in the canal. **NEET-PG High-Yield Pearls:** * **Cervical Os Status:** The most critical step in differentiating types of abortion is checking if the internal os is **open** (Inevitable, Incomplete, Complete) or **closed** (Threatened, Missed). * **Management of Threatened Abortion:** Conservative management ("Wait and Watch") and bed rest are traditionally advised, though evidence for bed rest is limited. Progesterone supplementation may be used. * **Prognosis:** Approximately 50% of threatened abortions proceed to a normal pregnancy. * **Investigation of Choice:** Transvaginal Ultrasound (TVS) to confirm fetal viability.

Question 466: What is the most ideal site for sterilization by tubectomy?

A. Ampulla
B. Isthmus (Correct Answer)
C. Fimbriated extremity
D. Interstitial portion

Explanation: The **isthmus** is the most ideal site for tubal sterilization (tubectomy) because it is the narrowest and least vascular part of the Fallopian tube. ### Why Isthmus is the Correct Answer: 1. **Anatomical Advantage:** The isthmus has a thick muscular wall and a narrow lumen. This makes it technically easier to ligate and excise (as in the Pomeroy technique) or to apply mechanical devices like clips or rings. 2. **Vascularity:** It is relatively less vascular compared to the ampulla, minimizing the risk of intraoperative bleeding and hematoma formation. 3. **Reversibility:** Because the isthmus is narrow, a tubectomy here destroys the least amount of tubal tissue. If a patient requests tubal re-anastomosis (reversal) later, the isthmic-isthmic repair offers the highest success rates due to the matching luminal diameters. ### Why Other Options are Incorrect: * **Ampulla:** This is the widest and most vascular part of the tube. Sterilization here carries a higher risk of bleeding and requires destroying a larger segment of the tube, making future reversal difficult. * **Fimbriated extremity:** Removing the fimbria (fimbriectomy) is highly effective but makes the procedure virtually irreversible. * **Interstitial portion:** This is the segment that traverses the uterine wall. Surgery here is technically difficult, carries a high risk of uterine bleeding, and increases the risk of cornual pregnancy if failure occurs. ### Clinical Pearls for NEET-PG: * **Pomeroy’s Method:** The most common technique used worldwide; it involves ligating a loop of the isthmus with absorbable suture. * **Failure Rate:** The Pearl Index for tubectomy is approximately **0.5 per 100 woman-years**. * **Madlener Technique:** Avoided today due to high failure rates (re-canalization). * **Irving and Uchida Techniques:** Have the lowest failure rates but are surgically more complex.

Question 467: DMPA causes all the following except?

A. Weight gain
B. Irregular cycles
C. Amenorrhea
D. Thromboembolism (Correct Answer)

Explanation: **Explanation:** **DMPA (Depot Medroxyprogesterone Acetate)** is a progestogen-only injectable contraceptive. The correct answer is **Thromboembolism** because, unlike combined oral contraceptives (COCs) which contain estrogen, progestogen-only methods like DMPA do not significantly increase the risk of venous thromboembolism (VTE), stroke, or myocardial infarction. Estrogen is the component responsible for increasing hepatic synthesis of clotting factors. **Analysis of Options:** * **Weight Gain (A):** This is a common side effect unique to DMPA compared to other hormonal methods. It is attributed to its glucocorticoid-like activity, which increases appetite and fat storage. * **Irregular Cycles (B):** In the initial months of use, the most common side effect is breakthrough bleeding or spotting due to the thinning of the endometrial lining. * **Amenorrhea (C):** This is a hallmark of long-term DMPA use. After one year, approximately 50-75% of users develop amenorrhea due to profound endometrial atrophy. **High-Yield Clinical Pearls for NEET-PG:** * **Dose:** 150 mg intramuscularly every 3 months (12 weeks). * **Mechanism:** Primarily inhibits ovulation by suppressing the LH surge. * **Bone Mineral Density (BMD):** DMPA causes a reversible decrease in BMD due to hypoestrogenism; hence, it should be used with caution in adolescents and women over 45. * **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 pelvic inflammatory disease (PID).

Question 468: Which antiprogestin is used for emergency contraception?

A. Mifepristone (Correct Answer)
B. Misoprostal
C. Methotrexate
D. Norethisterone

Explanation: **Explanation:** **Mifepristone (Option A)** is a potent competitive progesterone receptor antagonist (antiprogestin). In the context of emergency contraception (EC), it works primarily by inhibiting or delaying ovulation. If taken post-ovulation, it may also alter the endometrium to prevent implantation. A single low dose (10 mg or 25 mg) is highly effective as an EC if taken within 120 hours (5 days) of unprotected intercourse. **Analysis of Incorrect Options:** * **Misoprostol (Option B):** A synthetic Prostaglandin E1 (PGE1) analog. It is used for medical abortion (in combination with Mifepristone), induction of labor, and management of PPH, but it has no role as an emergency contraceptive. * **Methotrexate (Option C):** A folate antagonist and cytotoxic drug. It is the medical treatment of choice for unruptured ectopic pregnancy and is used in some regimens for early medical abortion, but not for EC. * **Norethisterone (Option D):** A first-generation synthetic progestin. While progestins like **Levonorgestrel (LNG)** are used for EC, Norethisterone is typically used for cycle regulation, dysfunctional uterine bleeding, or as a daily oral contraceptive pill. **High-Yield NEET-PG Pearls:** * **Ulipristal Acetate:** A Selective Progesterone Receptor Modulator (SPRM) and currently the most effective oral EC, effective up to 120 hours. * **Levonorgestrel (LNG):** The most commonly used EC (1.5 mg single dose); most effective when taken within 72 hours. * **Copper T 380A:** The **most effective** method of emergency contraception overall if inserted within 5 days of unprotected intercourse. * **Yuzpe Regimen:** An older method using combined oral contraceptive pills (Ethinylestradiol + LNG); it is less effective and has more side effects (nausea/vomiting) than LNG-only pills.

Question 469: Which of the following neoplasms has been associated with the use of oral contraceptives?

A. Breast cancer
B. Ovarian cancer
C. Endometrial cancer
D. Hepatic adenoma (Correct Answer)

Explanation: **Explanation:** The correct answer is **Hepatic Adenoma**. Combined Oral Contraceptive Pills (COCPs) contain synthetic estrogen and progesterone. Estrogen, in particular, has a trophic effect on hepatocytes and the hepatic vasculature. Long-term use of COCPs is a well-established risk factor for the development of **Hepatic Adenoma** (a benign but potentially serious liver tumor). These tumors are highly vascular and carry a risk of spontaneous rupture and life-threatening intraperitoneal hemorrhage, especially during pregnancy or continued pill use. **Analysis of Incorrect Options:** * **Ovarian Cancer:** COCPs are actually **protective** against epithelial ovarian cancer. The suppression of "incessant ovulation" reduces the risk by approximately 50% after 5 years of use, and this protection persists for decades after discontinuation. * **Endometrial Cancer:** COCPs are **protective** against endometrial cancer. The progestogen component counteracts the proliferative effect of estrogen on the endometrium, reducing the risk by about 50%. * **Breast Cancer:** While there is a slight, transient increase in the relative risk of breast cancer diagnosis during current use (which returns to baseline 10 years after stopping), the association is less definitive and less "classically" linked in exam scenarios compared to the specific association with hepatic adenoma. **High-Yield NEET-PG Pearls:** * **Cancers Decreased by COCPs:** Ovarian, Endometrial, and Colorectal cancer. * **Cancers Increased by COCPs:** Cervical cancer (risk increases with >5 years of use) and Hepatic Adenoma. * **Management of Hepatic Adenoma:** Small adenomas (<5 cm) may regress upon discontinuation of COCPs; larger ones may require surgical resection due to the risk of rupture or malignant transformation to Hepatocellular Carcinoma (HCC).

Question 470: Which intrauterine contraceptive device (IUCD) has the shortest lifespan?

A. Lippes loop
B. Copper-T
C. Multiload device
D. Progestasert (Correct Answer)

Explanation: **Explanation:** The lifespan of an Intrauterine Contraceptive Device (IUCD) is determined by the rate at which its active component (copper or hormone) is depleted or by its design. **Why Progestasert is correct:** Progestasert is a first-generation **hormone-releasing IUCD** that releases progesterone at a rate of 65 µg/day. Because it contains a limited reservoir of natural progesterone (38 mg) which is released relatively rapidly, it has a lifespan of only **1 year**. This necessitates annual replacement, making it the IUCD with the shortest clinical duration. **Analysis of Incorrect Options:** * **Lippes Loop:** This is a non-medicated (inert) IUCD made of polyethylene. Since it does not rely on the depletion of a drug or metal, it can theoretically remain in the uterus **indefinitely** (as long as it is tolerated). * **Copper-T:** The most common variant, Cu-T 380A, has a lifespan of **10 years**. Other variants like Cu-T 200 last for 3 years. * **Multiload Device:** The Multiload-250 typically lasts for 3 years, while the Multiload-375 is effective for **5 years**. **High-Yield Clinical Pearls for NEET-PG:** * **Mirena (LNG-20):** Unlike Progestasert, Mirena releases Levonorgestrel and has a much longer lifespan of **5–8 years**. * **Mechanism of Action:** Progestasert works primarily by thickening cervical mucus and causing endometrial atrophy. * **Ideal Candidate:** IUCDs are best suited for parous women in stable monogamous relationships. * **Most common side effect:** For Copper-T, it is **bleeding** (menorrhagia); for Progestasert/Mirena, it is often **intermenstrual spotting** or amenorrhea.

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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