Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 491: Which among the following findings is the earliest to be detected by antenatal ultrasonography?

A. Anencephaly (Correct Answer)
B. Down's syndrome
C. Gender determination
D. Cleft palate

Explanation: **Explanation:** The correct answer is **Anencephaly (Option A)**. Anencephaly is a lethal neural tube defect characterized by the absence of the cranial vault and cerebral hemispheres. It can be diagnosed as early as **10 to 14 weeks** of gestation (late first trimester) using transvaginal or transabdominal ultrasound. The classic sonographic signs include the "Frog-eye appearance" (due to prominent orbits) and the absence of the "calvarial halo." **Analysis of Options:** * **Down’s Syndrome (Option B):** While screening via Nuchal Translucency (NT) occurs between 11–13.6 weeks, NT is a *marker*, not a definitive structural diagnosis. Definitive morphological features or associated anomalies are usually detected during the Level II scan (18–20 weeks). * **Gender Determination (Option C):** External genitalia differentiation is complete by 12 weeks, but reliable sonographic identification is typically accurate only after **14–16 weeks**. (Note: Prenatal sex determination is illegal in India under the PCPNDT Act). * **Cleft Palate (Option D):** This is a subtle facial defect. While the lip can be seen earlier, a definitive diagnosis of the palate usually requires a detailed anomaly scan in the **second trimester (18–22 weeks)**. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest sign of pregnancy on USG:** Gestational sac (4.5–5 weeks). * **Earliest sign of viability:** Fetal heart rate (5.5–6 weeks via TVS). * **Most accurate parameter for dating:** Crown-Rump Length (CRL) in the first trimester. * **Anencephaly:** Associated with polyhydramnios (due to failure of fetal swallowing) and elevated Maternal Serum Alpha-Fetoprotein (MSAFP).

Question 492: What is an absolute contraindication for oral contraceptive pills (OCPs)?

A. Breast cancer (Correct Answer)
B. Mentally ill
C. Migraine
D. Fibroid

Explanation: **Explanation:** The correct answer is **Breast cancer**. Combined Oral Contraceptive Pills (COCPs) contain estrogen and progesterone. Since breast cancer is often a hormone-sensitive malignancy, exogenous estrogen can stimulate the proliferation of cancer cells. According to the WHO Medical Eligibility Criteria (MEC), **current breast cancer is classified as MEC Category 4**, meaning it represents an unacceptable health risk and is an absolute contraindication. **Analysis of Options:** * **Mentally ill:** This is not a contraindication. However, providers must ensure the patient can adhere to a daily regimen or consider long-acting reversible contraceptives (LARCs) if compliance is an issue. * **Migraine:** This is a relative or absolute contraindication depending on the type. Migraine **with aura** at any age is MEC 4 (Absolute Contraindication) due to the high risk of ischemic stroke. Migraine **without aura** is MEC 2 or 3 depending on age. Since "Migraine" is listed generally, Breast Cancer remains the more definitive absolute contraindication. * **Fibroid:** Fibroids are not a contraindication (MEC 1). In fact, OCPs are often used to manage the heavy menstrual bleeding associated with leiomyomas. **High-Yield Clinical Pearls for NEET-PG:** * **MEC 4 (Absolute Contraindications) for OCPs:** * Smokers >35 years old (≥15 cigarettes/day). * History of Thromboembolism (DVT/PE) or Stroke. * Current Breast Cancer. * Uncontrolled Hypertension (>160/100 mmHg). * Migraine with Aura. * Active Liver Disease (Hepatitis, Cirrhosis, or Tumors). * **Protective Effect:** OCPs significantly reduce the risk of **Ovarian and Endometrial cancers**. * **Drug Interactions:** Enzyme inducers like **Rifampicin** and **Antiepileptics** (Phenytoin, Carbamazepine) decrease OCP efficacy.

Question 493: A 27-year-old P2L2 presents to the OPD for contraceptive advice. She delivered a male child 3 weeks ago and is presently lactating. She has no contraindications to hormone use. What contraceptive method can be given?

A. DMPA (Depot medroxyprogesterone acetate)
B. Minipill (Progestin-only pill) (Correct Answer)
C. Levonorgestrel implants
D. Combined oral contraceptive pills (OCPs)

Explanation: **Explanation:** The primary concern in postpartum contraception for a lactating woman is the effect of hormones on the **quantity and quality of breast milk**, as well as the risk of **venous thromboembolism (VTE)**. **1. Why Option B (Minipill) is Correct:** Progestin-only pills (POPs) are the preferred hormonal method for breastfeeding women. According to the WHO Medical Eligibility Criteria (MEC), POPs can be started as early as **immediately postpartum** (Category 2 if <6 weeks; Category 1 if >6 weeks). They do not suppress lactation or affect the nutritional quality of milk, making them safe for both the mother and the infant. **2. Why the other options are incorrect:** * **Option D (Combined OCPs):** These are **contraindicated** in the first 3–6 weeks postpartum. Estrogen suppresses prolactin, leading to decreased milk production. Furthermore, the postpartum period is a hypercoagulable state; estrogen increases the risk of VTE. (MEC Category 4 if <3 weeks; Category 3 if 3–6 weeks). * **Option A & C (DMPA and Implants):** While these are progestin-only methods, the WHO MEC traditionally suggests waiting until **6 weeks** postpartum for DMPA in breastfeeding women (Category 2) to avoid theoretical concerns regarding high-dose steroid exposure to the neonate during early development. The Minipill is considered a more immediate option at 3 weeks. **Clinical Pearls for NEET-PG:** * **Lactational Amenorrhea Method (LAM):** Effective only if the mother is exclusively breastfeeding, is amenorrheic, and the baby is <6 months old. * **IUCD (Cu-T):** Can be inserted within 48 hours (Postpartum IUCD) or after 6 weeks (Interval IUCD). It should *not* be inserted between 48 hours and 6 weeks due to high perforation/expulsion risks. * **Ideal Postpartum Sterilization:** Usually performed within 24–48 hours or after 6 weeks.

Question 494: What is the typical daily dose of ethinyl estradiol in low-dose oral contraceptive pills?

A. 30µg
B. 25µg
C. 20µg (Correct Answer)
D. 15µg

Explanation: ### Explanation **Correct Answer: C. 20µg** **Medical Concept:** The evolution of Combined Oral Contraceptive Pills (COCPs) has focused on reducing the dose of **Ethinyl Estradiol (EE)** to minimize estrogen-related side effects (such as nausea, breast tenderness, and life-threatening thromboembolic events) while maintaining contraceptive efficacy and cycle control. * **Conventional/Standard dose:** Contains 30–35µg of EE. * **Low-dose/Ultra-low dose:** Modern formulations typically contain **20µg** of EE. These are preferred in clinical practice to reduce the risk of Venous Thromboembolism (VTE). **Analysis of Options:** * **Option A (30µg):** This is considered a **standard dose** pill. While widely used, it is not classified as the "low-dose" threshold in modern nomenclature. * **Option B (25µg):** Some formulations exist at this strength, but it is not the standard definition for low-dose pills in most clinical guidelines or standard textbooks (like Williams or Dutta). * **Option D (15µg):** This is an **ultra-low dose**. While it further reduces side effects, it is associated with a higher incidence of breakthrough bleeding and is less commonly used as the "typical" low-dose reference. **High-Yield NEET-PG Pearls:** 1. **Mechanism of Action:** Estrogen inhibits **FSH** (preventing follicular development), while Progesterone inhibits **LH** (preventing the LH surge and ovulation). Progesterone also thickens cervical mucus. 2. **VTE Risk:** The risk of thromboembolism is directly proportional to the dose of Ethinyl Estradiol. 3. **Centchroman (Saheli):** A high-yield Indian context topic; it is a Non-steroidal, Selective Estrogen Receptor Modulator (SERM) taken twice weekly for 3 months, then once weekly. 4. **Failure Rate:** The typical use failure rate of COCPs is approximately 9%, but the perfect use failure rate is 0.3%.

Question 495: What is the content of ethinyl estradiol in very low dose oral contraceptives?

A. 30 ug
B. 25 ug
C. 20 ug (Correct Answer)
D. 15 ug

Explanation: **Explanation:** The classification of Combined Oral Contraceptive (COC) pills is primarily based on the dosage of the estrogenic component, **Ethinyl Estradiol (EE)**. This is because while the progestogen prevents pregnancy, the estrogen stabilizes the endometrium and controls the bleeding profile. * **High Dose:** Contains $\geq$ 50 µg of EE. These are rarely used today due to a significantly higher risk of venous thromboembolism (VTE). * **Low Dose:** Contains 30–35 µg of EE. This is currently the standard dose used in most conventional COCs (e.g., Mala-N, Mala-D). * **Very Low Dose:** Contains **20 µg** of EE. These were developed to further minimize estrogen-related side effects like nausea, breast tenderness, and the risk of VTE. **Analysis of Options:** * **Option A (30 µg):** This is the standard **Low Dose** pill. It provides excellent cycle control but is not classified as "very low dose." * **Option B (25 µg):** While some formulations exist at this strength, it is not the standard definition for the "very low dose" category in medical textbooks. * **Option C (20 µg):** **Correct.** This is the threshold for "very low dose" pills. While they have fewer side effects, they are associated with a higher incidence of breakthrough bleeding (spotting) compared to 30 µg pills. * **Option D (15 µg):** These are "ultra-low dose" pills. They are less commonly used as they carry a higher risk of follicular escape and cycle irregularity. **High-Yield Clinical Pearls for NEET-PG:** 1. **Mechanism of Action:** The primary mechanism of COCs is the **inhibition of ovulation** by suppressing LH and FSH. 2. **Mala-N & Mala-D:** These contain 30 µg Ethinyl Estradiol + 150 µg Levonorgestrel. 3. **Centchroman (Saheli):** A non-steroidal, Selective Estrogen Receptor Modulator (SERM). Dose: 30 mg twice weekly for 3 months, then once weekly. 4. **VTE Risk:** The risk of venous thromboembolism is dose-dependent on the estrogen component. Always screen for smoking and age >35 before prescribing.

Question 496: What is the earliest fetal anomaly detectable by ultrasound?

A. Hydrocephalus
B. Anencephaly (Correct Answer)
C. Achondroplasia
D. Spina bifida

Explanation: **Explanation:** **Anencephaly** is the correct answer because it is the earliest fetal anomaly detectable by ultrasound, typically identifiable by the **10th to 12th week** of gestation (late first trimester). It is a lethal neural tube defect characterized by the absence of the cranial vault and cerebral hemispheres. On ultrasound, it presents with the classic **"Frog-eye appearance"** (Mickey Mouse sign) due to prominent orbits and the absence of the calvarium above the level of the orbits. **Analysis of Incorrect Options:** * **Hydrocephalus:** This involves the enlargement of cerebral ventricles. It is generally not diagnosed until the **second trimester** (usually after 18 weeks) because the choroid plexus normally fills the ventricles in the first trimester, making early detection difficult. * **Achondroplasia:** This is the most common form of skeletal dysplasia. It is typically diagnosed in the **third trimester** (after 26–28 weeks) when the characteristic rhizomelic (proximal) limb shortening becomes ultrasonographically evident. * **Spina Bifida:** While screening begins with the "Lemon" and "Banana" signs in the early second trimester (16–20 weeks), it is rarely diagnosed as early as anencephaly because the ossification of the spine is incomplete in the first trimester. **High-Yield Clinical Pearls for NEET-PG:** * **Folic Acid:** 400 mcg/day (standard) or 4 mg/day (previous history) prevents 70% of neural tube defects. * **AFP Levels:** Anencephaly is associated with significantly **elevated Maternal Serum Alpha-Fetoprotein (MSAFP)**. * **Polyhydramnios:** This is a common complication of anencephaly due to the failure of the fetus to swallow amniotic fluid.

Question 497: Which of the following statements is TRUE regarding spermicides found in vaginal foams, creams, and suppositories?

A. The active agent in these spermicides is nonoxynol-9. (Correct Answer)
B. The active agent in these spermicides is levonorgestrel.
C. Effectiveness is higher in younger users.
D. Effectiveness is higher than that of the diaphragm.

Explanation: **Explanation:** **1. Why Option A is Correct:** The primary active ingredient in most commercially available spermicides (foams, creams, gels, and suppositories) is **Nonoxynol-9**. It is a non-ionic surfactant that works by disrupting the sperm cell membrane (lipids), leading to loss of motility and eventual cell death. This prevents the sperm from reaching and fertilizing the ovum. **2. Why the Other Options are Incorrect:** * **Option B:** **Levonorgestrel** is a synthetic progestogen used in hormonal contraceptives (like the LNG-IUS, POPs, or emergency contraceptive pills), not in chemical spermicides. * **Option C:** Effectiveness is generally **lower in younger users**. This is because younger populations are typically more fertile and have a higher coital frequency, leading to a higher failure rate compared to older users. * **Option D:** Spermicides used alone have a high failure rate (approximately 18–28% with typical use). Their effectiveness is **lower than the diaphragm** and other barrier methods. For optimal efficacy, spermicides are recommended to be used in conjunction with a diaphragm or condom. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Nonoxynol-9 acts as a detergent that destroys the sperm's plasma membrane. * **HIV Risk:** Frequent use of Nonoxynol-9 can cause vaginal and cervical irritation/epithelial disruption, which may actually **increase the risk of HIV transmission** and other STIs. * **Application:** Spermicides must be applied high in the vagina near the cervix, usually 10–30 minutes before intercourse, and their effect lasts for about one hour. * **Pearl:** Spermicides do not protect against STIs; in fact, the WHO does not recommend Nonoxynol-9 for women at high risk of HIV.

Question 498: What is the primary mechanism of action of oral contraceptives containing ethinyl estradiol and a progestin?

A. Inhibition of ovulation (Correct Answer)
B. Inhibition of implantation
C. Thickening of cervical mucus
D. None of the above

Explanation: Combined Oral Contraceptive Pills (COCPs) containing both ethinyl estradiol and a progestin act via multiple mechanisms, but their **primary** mechanism of action is the **inhibition of ovulation**. ### Why Option A is Correct The combination of hormones exerts negative feedback on the hypothalamic-pituitary-ovarian axis: * **Estrogen** suppresses the release of **FSH** (Follicle Stimulating Hormone), which prevents the recruitment and maturation of a dominant follicle. * **Progestin** suppresses the release of **LH** (Luteinizing Hormone), thereby preventing the LH surge required for ovulation. Without follicle maturation or an LH surge, ovulation cannot occur. ### Why Other Options are Incorrect * **Option B (Inhibition of implantation):** While COCPs cause endometrial atrophy (making it less receptive), this is a secondary/backup effect, not the primary mechanism. * **Option C (Thickening of cervical mucus):** This is the **primary** mechanism for **Progestogen-Only Pills (POPs)** and the Minipill. In COCPs, this is a secondary mechanism that prevents sperm penetration. ### High-Yield NEET-PG Pearls * **Most potent component for ovulation inhibition:** Progestin (it is responsible for the mid-cycle LH suppression). * **Pearl on Failure Rate:** The "Perfect Use" failure rate of COCPs is **0.3%**, while "Typical Use" is approximately **9%**. * **Non-contraceptive benefits:** COCPs reduce the risk of **Ovarian and Endometrial cancers** (protective effect). * **Contraindication:** Avoid in women >35 years who smoke (increased risk of venous thromboembolism).

Question 499: What are the contraindications to oral contraceptive pills?

A. Heart disease
B. Epilepsy
C. Liver failure
D. All of the above (Correct Answer)

Explanation: Combined Oral Contraceptive Pills (COCPs) contain estrogen and progestogen, which significantly impact systemic physiology, particularly the cardiovascular and hepatic systems. **Explanation of the Correct Answer:** The correct answer is **D (All of the above)** because each condition listed represents a significant risk or interaction: * **Heart Disease:** Estrogen increases the synthesis of clotting factors and promotes a hypercoagulable state. In patients with ischemic heart disease, valvular heart disease (with complications), or uncontrolled hypertension, COCPs significantly increase the risk of myocardial infarction and thromboembolism. * **Liver Failure:** Steroid hormones are metabolized in the liver. In active liver disease, cirrhosis, or hepatoma, the liver cannot process these hormones, leading to toxicity. Furthermore, COCPs are associated with an increased risk of hepatic adenomas. * **Epilepsy:** While not a direct physiological contraindication like the others, many anti-epileptic drugs (AEDs) like Phenytoin and Carbamazepine are **enzyme inducers**. They accelerate the metabolism of oral contraceptives, leading to contraceptive failure. Conversely, COCPs can lower the seizure threshold in some patients. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Medical Eligibility Criteria (MEC) Category 4 (Absolute Contraindications):** * Smokers >35 years (>15 cigarettes/day). * History of DVT/PE or major surgery with prolonged immobilization. * Migraine with aura (increased stroke risk). * Breast cancer (current). * Uncontrolled hypertension (>160/100 mmHg). * **Drug Interactions:** Rifampicin is the most potent enzyme inducer that decreases COCP efficacy. * **Beneficial Effects:** COCPs reduce the risk of Ovarian and Endometrial cancers (Protective effect).

Question 500: Which of the following statements is FALSE with respect to Progestasert?

A. It releases 65 mcg of progesterone per day
B. Effective life is 1 year
C. It is a subdermal implant (Correct Answer)
D. It reduces menstrual blood loss

Explanation: **Explanation:** The correct answer is **C (It is a subdermal implant)** because Progestasert is actually a **first-generation hormone-releasing Intrauterine Contraceptive Device (IUCD)**, not a subdermal implant. It is a T-shaped device made of ethylene-vinyl acetate copolymer. **Analysis of Options:** * **Option A (65 mcg/day):** This is a true statement. Progestasert contains 38 mg of natural progesterone in its stem, which is released at a rate of 65 micrograms per day directly into the uterine cavity. * **Option B (Effective life 1 year):** This is true. Due to the relatively high daily release rate and limited reservoir of natural progesterone, the device must be replaced annually. This is a major disadvantage compared to the LNG-IUD (Mirena), which lasts for 5–8 years. * **Option D (Reduces menstrual blood loss):** This is true. Progesterone causes atrophy of the endometrial glands and stroma, leading to a significant reduction in the volume and duration of menstrual flow. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** Progestasert works primarily by local endometrial changes (atrophy), making the endometrium unfavorable for implantation, and by thickening the cervical mucus. * **Comparison:** Unlike the **LNG-IUD (Mirena)**, which uses Levonorgestrel (a synthetic progestogen), Progestasert uses **natural progesterone**. * **Side Effects:** While it reduces blood loss, it is associated with a higher incidence of intermenstrual spotting and a slightly higher risk of ectopic pregnancy compared to non-hormonal IUDs. * **Status:** It is largely obsolete now, replaced by the more effective and longer-lasting LNG-IUD.

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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