Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 41: Which of the following is a contraindication for the use of oral contraceptive pills?

A. Liver disease (Correct Answer)
B. Pelvic inflammatory disease
C. Renal disease
D. Epilepsy

Explanation: **Explanation:** The correct answer is **Liver disease**. Combined Oral Contraceptive Pills (COCPs) contain estrogen and progesterone, both of which are metabolized in the liver. In patients with active liver disease (e.g., acute hepatitis, cirrhosis, or liver tumors), the liver’s ability to metabolize these hormones is impaired. This can lead to hormonal accumulation, potential hepatotoxicity, and worsening of the underlying condition. Furthermore, estrogen can increase the risk of cholestasis and gallbladder disease. **Analysis of Incorrect Options:** * **Pelvic Inflammatory Disease (PID):** COCPs are not contraindicated in PID. In fact, they may offer a protective effect by thickening cervical mucus, which prevents the upward migration of pathogens. (Note: PID is a contraindication for IUDs, not OCPs). * **Renal Disease:** Most renal diseases are not absolute contraindications for COCPs. However, if renal failure is associated with severe hypertension or vascular complications, OCPs should be avoided due to the risk of stroke or MI. * **Epilepsy:** Epilepsy itself is not a contraindication. However, many anti-epileptic drugs (like Phenytoin or Carbamazepine) are enzyme inducers that decrease the efficacy of OCPs, leading to contraceptive failure. In such cases, a higher dose of estrogen or an alternative method is preferred. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications (WHO Category 4):** History of Thromboembolism (DVT/PE), Ischemic Heart Disease, Stroke, Breast Cancer, Smokers >35 years (>15 cigarettes/day), and Migraine with aura. * **OCPs and Cancer:** OCPs **increase** the risk of Breast and Cervical cancer but are **protective** against Ovarian and Endometrial cancer. * **Drug Interaction:** Rifampicin is the most potent enzyme inducer that reduces OCP efficacy.

Question 42: What is the 'Pearl-index' for accidental pregnancies failure per?

A. 10 women-years of exposure
B. 12 women-years of exposure
C. 100 women-years of exposure (Correct Answer)
D. 120 women-years of exposure

Explanation: ### Explanation The **Pearl Index** is the standard statistical method used to express the effectiveness of a contraceptive method. It calculates the number of unintended pregnancies that occur per **100 woman-years of exposure**. **Why Option C is Correct:** The Pearl Index is defined by the formula: $$\text{Pearl Index} = \frac{\text{Total number of accidental pregnancies} \times 1200}{\text{Total months of exposure}}$$ The multiplier "1200" represents 100 women using a method for 12 months (1 year) each. Therefore, a Pearl Index of 1 means that if 100 women use a specific contraceptive method for one year, one woman will likely become pregnant. **Why Other Options are Incorrect:** * **Options A & B (10 and 12 women-years):** These are too small a sample size to provide statistically significant data for public health and clinical efficacy. * **Option D (120 women-years):** While 120 is often used in calculations involving months (10 years), the international standard for reporting contraceptive failure is always normalized to a base of 100 women over one year. **High-Yield Clinical Pearls for NEET-PG:** * **Lowest Pearl Index (Most Effective):** Implants (e.g., Nexplanon) have the lowest Pearl Index (~0.05), followed by Vasectomy and IUCDs. * **Highest Pearl Index (Least Effective):** Barrier methods (Condoms) and behavioral methods (Withdrawal/Rhythm) have higher Pearl Indices due to "typical use" errors. * **Perfect Use vs. Typical Use:** Always distinguish between these two; the Pearl Index is significantly higher (worse) in "typical use" for user-dependent methods like OCPs. * **Alternative Measure:** The **Life Table Analysis** is considered more accurate than the Pearl Index as it calculates failure rates at specific intervals (e.g., at 6 months vs. 24 months).

Question 43: Which of the following can cause decreased or impaired ovulation?

A. Minipill (progesterone-only pill)
B. Intrauterine contraceptive device (IUCD)
C. Norplant
D. All of the above (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. All of the above**, as each of these contraceptive methods can interfere with the hypothalamic-pituitary-ovarian (HPO) axis or local ovarian function to impair ovulation. 1. **Minipill (Progestogen-Only Pill - POP):** While the primary mechanism of POPs is thickening the cervical mucus, they suppress ovulation in approximately **40–60%** of cycles by inhibiting the mid-cycle LH surge. 2. **Norplant (Levonorgestrel Implants):** These provide a continuous, higher systemic dose of progestogen compared to the minipill. This consistently suppresses the LH surge, leading to anovulation in about **50–80%** of cycles, especially during the first two years of use. 3. **Intrauterine Contraceptive Device (IUCD):** While the primary mechanism of a Copper-T is its spermicidal effect and prevention of implantation, it also induces a local inflammatory response. Research indicates that IUCDs can cause **mild follicular dysfunction** or luteal phase defects in some users, leading to impaired or "sub-optimal" ovulation. (Note: If the option refers to the **LNG-IUS/Mirena**, it suppresses ovulation in about 15–25% of cycles). **High-Yield Clinical Pearls for NEET-PG:** * **Primary Mechanism of Progestogens:** Thickening of cervical mucus (most consistent effect). * **Combined Oral Contraceptive Pills (COCPs):** These are the most effective at suppressing ovulation (99%+) by inhibiting FSH and LH. * **DMPA (Injectable):** Consistently inhibits ovulation by suppressing the HPO axis. * **IUCD Fact:** The Copper-T is the most common cause of **menorrhagia** among contraceptives, whereas LNG-IUS is a treatment for it.

Question 44: Mifepristone (RU-486) is:

A. Anti-androgen
B. Anti-estrogen
C. Anti-progestin (Correct Answer)
D. Androgen

Explanation: **Explanation:** **Mifepristone (RU-486)** is a synthetic steroid that acts as a potent **competitive receptor antagonist** at the progesterone receptor level. Since it blocks the action of progesterone—the hormone essential for maintaining the decidua and pregnancy—it is classified as an **Anti-progestin**. **Why the correct answer is right:** Progesterone is required to maintain the uterine lining during pregnancy. Mifepristone binds to progesterone receptors with higher affinity than endogenous progesterone, leading to decidual breakdown, cervical softening, and increased uterine sensitivity to prostaglandins. This makes it a cornerstone in medical termination of pregnancy (MTP). **Why other options are wrong:** * **Anti-androgen:** These drugs (e.g., Cyproterone acetate, Spironolactone, Flutamide) block male sex hormones. While Mifepristone has some weak anti-androgenic activity, its primary clinical classification and use are defined by its anti-progestogenic effects. * **Anti-estrogen:** These (e.g., Clomiphene, Tamoxifen) block estrogen receptors. Mifepristone does not significantly interfere with estrogenic pathways. * **Androgen:** These are male sex hormones (e.g., Testosterone). Mifepristone is a steroid derivative but functions as an antagonist, not an agonist of male hormones. **High-Yield Clinical Pearls for NEET-PG:** * **MTP Regimen:** The standard WHO/GOI protocol for medical abortion (up to 9 weeks/63 days) is **200 mg Mifepristone (oral)** followed 36–48 hours later by **800 mcg Misoprostol** (vaginal/sublingual/buccal). * **Emergency Contraception:** A single dose of 10 mg or 25 mg Mifepristone can be used as an effective emergency contraceptive. * **Other Uses:** It is also used in the management of Cushing’s syndrome (due to its anti-glucocorticoid activity at high doses) and for cervical ripening before induction of labor. * **Key Side Effect:** Heavy bleeding and abdominal cramps (due to prostaglandin release).

Question 45: A young lady can be counselled for sterilization operation in all circumstances except?

A. A woman having no or few children (Correct Answer)
B. A woman with HIV, whether on antiretroviral therapy or not
C. When the husband's consent is present
D. A lactating woman over 25 years of age

Explanation: ### Explanation **Correct Option: A (A woman having no or few children)** Sterilization is a permanent and irreversible method of contraception. According to the **National Family Planning Guidelines in India**, eligibility for female sterilization (Tubectomy) requires the client to be ever-married and have at least one living child (who is over one year of age, unless the sterilization is being done for medical reasons). Counseling a woman with no children for sterilization is generally discouraged due to the high risk of **post-sterilization regret** and the ethical implications of permanent fertility loss in a nulliparous individual. **Analysis of Incorrect Options:** * **Option B (HIV status):** HIV infection (regardless of ART status) is **not** a contraindication to sterilization. Standard universal precautions are followed. However, the procedure should be deferred if the patient has an acute AIDS-related opportunistic infection. * **Option C (Husband’s consent):** Legally and ethically, the consent of the spouse is **not mandatory** for sterilization in India. The individual’s own informed consent is sufficient. Therefore, the presence of a husband's consent does not disqualify her from being counseled. * **Option D (Lactating woman >25 years):** Age >25 and lactation are not contraindications. Minilap or laparoscopic sterilization can be performed postpartum (after 48 hours to 7 days) or at any time during lactation if pregnancy is ruled out. **High-Yield Clinical Pearls for NEET-PG:** * **Eligibility Criteria (India):** Female age 22–45 years; must be married; must have at least one living child >1 year old. * **Failure Rates (Pearl Index):** Vasectomy (0.1%) is more effective and safer than Tubectomy (0.5%). * **Legal Aspect:** Under the **Supreme Court's Ramakant Rai vs. Union of India** judgment, informed consent is mandatory, and no spouse's consent is required. * **Timing:** Postpartum sterilization is ideally done within 48 hours to 7 days of delivery. After 7 days, it is deferred until 6 weeks (Involution period).

Question 46: Which contraceptive method is contraindicated in an HIV-positive patient?

A. Intrauterine contraceptive device (IUCD) (Correct Answer)
B. Combined oral contraceptive pills (COC pills)
C. Minipill
D. Barrier methods

Explanation: ### Explanation The correct answer is **A. Intrauterine contraceptive device (IUCD)**. **Why IUCD is the correct answer:** In the context of HIV and contraception, the primary concern is the risk of **Pelvic Inflammatory Disease (PID)** and the potential for increased menstrual bleeding. While the WHO Medical Eligibility Criteria (MEC) generally allows IUCD use in stable HIV patients (Category 2), it is strictly **contraindicated (MEC Category 4)** for **initiation** in patients with **AIDS who are not on antiretroviral therapy (ART)** or those who are clinically unwell. The risk of secondary infections and the potential for increased viral shedding in vaginal secretions due to IUCD-induced menorrhagia make it the least preferred option among the choices provided in a standard examination context. **Analysis of Incorrect Options:** * **B. Combined Oral Contraceptive Pills (COCPs):** These are safe (MEC Category 1) but require caution due to drug interactions. Certain Protease Inhibitors can decrease the efficacy of COCPs by inducing liver enzymes. * **C. Minipill (Progestogen-only pill):** These are safe and do not carry the thromboembolic risks associated with estrogen, making them a viable option for HIV patients. * **D. Barrier Methods:** Condoms are the **method of choice** for HIV-positive patients. They provide "dual protection" by preventing both pregnancy and the transmission of HIV/STIs to partners. **High-Yield Clinical Pearls for NEET-PG:** * **Dual Protection:** Always counsel HIV patients to use a barrier method (condoms) in addition to another highly effective contraceptive. * **WHO MEC Category 4 for IUCD:** Includes current PID, purulent cervicitis, and initiation in patients with advanced HIV/AIDS (CD4 <200 cells/mm³). * **Drug Interaction:** Ritonavir (a Protease Inhibitor) is a potent enzyme inducer that significantly reduces the levels of ethinyl estradiol in COCPs.

Question 47: Use of oral contraceptive pills decreases which of the following?

A. Glucose tolerance (Correct Answer)
B. Binding globulins
C. High-density lipoprotein (HDL) cholesterol
D. Triglycerides

Explanation: Combined Oral Contraceptive Pills (COCPs) exert systemic metabolic effects due to their estrogen and progestogen components. **Why Glucose Tolerance Decreases (Correct Answer):** COCPs, particularly the progestogen component, induce a state of **insulin resistance**. Progestogens decrease the number of insulin receptors and impair peripheral glucose uptake. Estrogen can also interfere with glucose metabolism by affecting cortisol levels. This results in a "diabetogenic" effect, leading to **decreased glucose tolerance**. While clinically insignificant in healthy women, it is a critical consideration for those with pre-diabetes or gestational diabetes history. **Analysis of Incorrect Options:** * **B. Binding Globulins:** Estrogen stimulates the liver to **increase** the synthesis of transport proteins. COCPs increase Sex Hormone-Binding Globulin (SHBG), Thyroid-Binding Globulin (TBG), and Cortisol-Binding Globulin (CBG). * **C. High-density lipoprotein (HDL):** Estrogen generally **increases** HDL (the "good" cholesterol) and decreases LDL. While some older progestogens could oppose this, modern low-dose formulations typically result in a net increase or neutral effect on HDL. * **D. Triglycerides:** Estrogen **increases** the hepatic synthesis of triglycerides. Therefore, COCPs are contraindicated in patients with severe hypertriglyceridemia due to the risk of pancreatitis. **High-Yield Clinical Pearls for NEET-PG:** * **Protective Effects:** COCPs **decrease** the risk of Ovarian cancer, Endometrial cancer, and Benign Breast Disease. * **Increased Risks:** COCPs **increase** the risk of Cervical cancer (with long-term use), Breast cancer (slight), and Hepatic Adenoma. * **Coagulation:** COCPs increase Factors VII, X, and Fibrinogen, leading to a hypercoagulable state (increased VTE risk). * **Blood Pressure:** They may cause a slight increase in BP due to the stimulation of the Renin-Angiotensin-Aldosterone System (RAAS).

Question 48: Which of the following is seen in the infant of a diabetic mother?

A. Hyperkalemia
B. Hypercalcemia
C. Macrocytic anemia
D. Polycythemia (Correct Answer)

Explanation: **Explanation:** Infants of Diabetic Mothers (IDM) face unique metabolic and physiological challenges due to maternal hyperglycemia. **Why Polycythemia is the correct answer:** Maternal hyperglycemia leads to fetal hyperglycemia, which stimulates fetal insulin production (hyperinsulinism). This hypermetabolic state increases fetal oxygen consumption, leading to **fetal hypoxemia**. In response to chronic hypoxia, fetal erythropoietin levels rise, stimulating the bone marrow to produce more red blood cells, resulting in **polycythemia** (Hematocrit >65%). This can lead to hyperviscosity, vascular thrombosis, and hyperbilirubinemia as the excess cells break down. **Analysis of Incorrect Options:** * **A. Hyperkalemia:** IDMs are more prone to **hypokalemia**, often secondary to insulin-driven shifts of potassium into cells or associated with neonatal respiratory distress. * **B. Hypercalcemia:** IDMs typically experience **hypocalcemia** (usually within the first 24–72 hours). This is attributed to delayed parathyroid hormone synthesis and functional hypoparathyroidism, often exacerbated by maternal magnesium loss leading to fetal hypomagnesemia. * **C. Macrocytic anemia:** As explained above, these infants present with **polycythemia**, not anemia. If anemia occurs, it is usually a late complication of hemolysis or blood loss, but it is not a classic feature of IDM. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cardiac anomaly:** Ventricular Septal Defect (VSD). * **Most specific cardiac anomaly:** Transposition of Great Arteries (TGA). * **Most characteristic anomaly:** Caudal Regression Syndrome (Sacral Agenesis). * **Metabolic Profile:** Hypoglycemia (most common), Hypocalcemia, Hypomagnesemia, and Hyperbilirubinemia. * **Respiratory:** Increased risk of Respiratory Distress Syndrome (RDS) because hyperinsulinism inhibits surfactant production by interfering with cortisol action.

Question 49: What is the primary mechanism of action of the progestogen-only pill?

A. Increases cervical mucus viscosity (Correct Answer)
B. Inhibits ovulation
C. Has antispermicidal effects
D. None of the above

Explanation: **Explanation:** The **Progestogen-Only Pill (POP)**, also known as the "mini-pill," primarily functions by altering the female reproductive tract environment rather than consistently suppressing the hypothalamic-pituitary-ovarian axis. **1. Why Option A is Correct:** The primary and most consistent mechanism of action of POPs is **increasing the viscosity and thickness of cervical mucus**. Under the influence of continuous low-dose progestogen, the mucus becomes scanty, thick, and cellular. This creates a "hostile" environment that acts as a physical barrier, preventing sperm penetration into the upper reproductive tract. **2. Why Other Options are Incorrect:** * **Option B (Inhibits ovulation):** While POPs can suppress ovulation in some cycles (approximately 40–60% of the time), it is **not** the primary or reliable mechanism. In contrast, the Combined Oral Contraceptive Pill (COCP) primarily works by inhibiting ovulation via FSH and LH suppression. * **Option C (Antispermicidal effects):** POPs do not contain spermicidal agents. They hinder sperm transport through mechanical (mucus) and functional (endometrial/tubal) changes rather than direct chemical destruction of sperm. **3. High-Yield Clinical Pearls for NEET-PG:** * **Secondary Mechanisms:** POPs also cause endometrial thinning (making it unfavorable for implantation) and alter fallopian tube motility. * **The "3-Hour Rule":** Traditional POPs have a very short half-life; if a dose is delayed by more than **3 hours**, contraceptive efficacy is significantly reduced. * **Ideal Candidates:** POPs are the contraceptive of choice for **lactating mothers** (as they do not affect milk quantity/quality) and women in whom estrogen is contraindicated (e.g., history of VTE, smokers >35 years, or migraine with aura). * **Side Effects:** The most common side effect is **irregular menstrual bleeding** or spotting.

Question 50: A patient with poorly compensated cardiac disease, who has delivered 2 days ago, should be advised to:

A. Undergo sterilization (tubectomy) after 1 week
B. Undergo sterilization after 6 weeks
C. Suggest her husband undergo vasectomy (Correct Answer)
D. Take oral contraceptive pills after 6 months

Explanation: ### Explanation The management of contraception in a patient with **poorly compensated cardiac disease** requires prioritizing maternal safety and minimizing physiological stress. **Why Option C is Correct:** In patients with severe cardiac disease (NYHA Class III or IV), any surgical procedure or pregnancy carries a high risk of morbidity and mortality. **Vasectomy** is the safest option because it is a minor, non-invasive procedure performed on the partner, completely avoiding the surgical and anesthetic risks (such as fluid shifts and hemodynamic instability) associated with female sterilization in a cardiac patient. **Analysis of Incorrect Options:** * **Option A & B (Tubectomy):** Sterilization in the immediate postpartum period (Option A) or even at 6 weeks (Option B) involves anesthesia and surgery (laparoscopy or laparotomy). In poorly compensated cardiac disease, the physiological stress of surgery and the risk of infective endocarditis or heart failure exacerbation make this a high-risk choice. Tubectomy should only be considered once the cardiac status is optimized, and even then, it is riskier than vasectomy. * **Option D (Oral Contraceptive Pills):** Combined OCPs are **contraindicated** in cardiac patients because they increase the risk of thromboembolism and can cause fluid retention, which may worsen heart failure. **Clinical Pearls for NEET-PG:** * **Ideal Contraception in Cardiac Disease:** Progestogen-only methods (like LNG-IUD) or non-hormonal methods (Copper T) are preferred if the patient is stable. However, the **vasovagal shock** risk during IUD insertion must be monitored in cardiac patients. * **Sterilization Timing:** Postpartum sterilization is usually done 24–48 hours after delivery. However, in cardiac patients, it is often deferred until the hemodynamic state is stable (usually after the puerperium). * **Medical Eligibility Criteria (MEC):** Combined OCPs are MEC Category 4 (unacceptable health risk) for patients with complicated valvular heart disease or ischemic heart disease.

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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