Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 51: What is the preferred method of contraception for a patient with diabetes mellitus?

A. Oral Contraceptive Pills (OCPs)
B. Barrier method (Correct Answer)
C. Permanent sterilization
D. Copper-T (Intrauterine device)

Explanation: **Explanation:** The choice of contraception in a diabetic patient depends on the presence of vascular complications and the duration of the disease. **Why Barrier Method is Correct:** The **Barrier method (Condoms)** is considered the preferred and safest initial choice for diabetic patients because it is **metabolically neutral**. It does not interfere with glycemic control, carbohydrate metabolism, or lipid profiles. Furthermore, it provides protection against Pelvic Inflammatory Disease (PID), which is a significant concern in diabetic patients who are generally more prone to infections. **Analysis of Incorrect Options:** * **Oral Contraceptive Pills (OCPs):** Combined OCPs are generally avoided or used with extreme caution. The estrogen component can impair glucose tolerance, increase insulin resistance, and elevate the risk of thromboembolism and cardiovascular events, especially in patients with long-standing diabetes or vasculopathy. * **Copper-T (IUD):** While highly effective, the Copper-T is often avoided as a first-line choice in diabetic patients due to an **increased risk of pelvic infections** and delayed healing. In a state of hyperglycemia, the risk of ascending infections (PID) is higher, which can be exacerbated by the presence of a foreign body like an IUD. * **Permanent Sterilization:** This is a definitive surgical method. While effective, it is usually reserved for patients who have completed their family and is not the "preferred method" for general contraception management unless specifically indicated. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Eligibility Criteria:** For diabetics with nephropathy, retinopathy, or neuropathy, Combined Hormonal Contraceptives are **Category 3 or 4** (Risks outweigh benefits/Unacceptable risk). * **Progesterone-only pills (POPs):** These are safer than COCPs for diabetics as they have minimal impact on carbohydrate metabolism. * **Ideal Candidate for IUD:** If diabetes is well-controlled and there is no history of PID, a Levonorgestrel-releasing intrauterine system (LNG-IUS) may be considered, but barrier methods remain the safest metabolic choice.

Question 52: Which of the following is an absolute contraindication for combined oral contraceptive pills, EXCEPT?

A. Smoking women over 35 years of age
B. Women aged greater than 35 years (Correct Answer)
C. Lactation
D. Breast cancer

Explanation: This question tests your knowledge of the **WHO Medical Eligibility Criteria (MEC)** for contraceptive use. Combined Oral Contraceptive Pills (COCPs) contain estrogen, which increases the risk of thromboembolism and cardiovascular events. ### **Explanation of the Correct Answer** **Option B (Women aged >35 years)** is the correct answer because age alone is **not** an absolute contraindication. According to WHO MEC, age >35 in a non-smoker is categorized as **MEC 2** (Advantages generally outweigh risks). Therefore, a healthy, non-smoking 38-year-old woman can safely use COCPs. ### **Analysis of Incorrect Options (Absolute Contraindications)** * **A. Smoking women >35 years:** This is **MEC 4** (Absolute contraindication). The synergistic effect of age, smoking, and estrogen significantly spikes the risk of myocardial infarction and stroke. (Note: Smoking <15 cigarettes/day is MEC 3; ≥15 cigarettes/day is MEC 4). * **C. Lactation:** Estrogen suppresses prolactin and reduces milk quantity/quality. In the first **6 weeks postpartum**, it is **MEC 4** due to the high risk of VTE and lactation interference. * **D. Breast Cancer:** Current breast cancer is **MEC 4** because it is a hormone-sensitive tumor; estrogen may promote tumor growth. ### **High-Yield Clinical Pearls for NEET-PG** * **MEC 4 (Never Use):** Undiagnosed vaginal bleeding, history of DVT/PE, Migraine with aura, Ischemic heart disease, Liver cirrhosis/adenoma, and uncontrolled Hypertension (>160/100). * **MEC 3 (Exercise Caution):** Well-controlled hypertension, Migraine without aura (in women >35), and concurrent use of anticonvulsants (enzyme inducers). * **Drug of Choice:** For lactating mothers, the Progesterone Only Pill (POP) or Centchroman (Saheli) is preferred.

Question 53: Which of the following drugs is NOT used as a post-coital contraceptive?

A. Danazol
B. Ethinyl estradiol
C. Levonorgestrel
D. Misoprostol (Correct Answer)

Explanation: **Explanation:** The correct answer is **Misoprostol**. Post-coital (emergency) contraception aims to prevent pregnancy by delaying ovulation or interfering with fertilization/implantation *before* pregnancy is established. **Why Misoprostol is the correct answer:** Misoprostol is a synthetic Prostaglandin E1 (PGE1) analogue. It causes uterine contractions and cervical ripening. It is used for **medical abortion** (terminating an established pregnancy), induction of labor, and management of PPH. It is **not** used as an emergency contraceptive because it does not prevent conception; it acts as an abortifacient. **Analysis of other options:** * **Danazol:** Historically used as an emergency contraceptive (high-dose ethisterone derivative). While rarely used now due to side effects, it is pharmacologically categorized as a post-coital agent. * **Ethinyl Estradiol:** Used in the **Yuzpe Regimen** (combined oral contraceptive pills containing Ethinyl Estradiol + Levonorgestrel). * **Levonorgestrel (LNG):** The current "gold standard" for hormonal emergency contraception (e.g., i-Pill, 1.5mg single dose). It works primarily by inhibiting the LH surge and delaying ovulation. **High-Yield Clinical Pearls for NEET-PG:** * **Most effective emergency contraceptive:** Copper-T (IUD) inserted within 5 days (120 hours). * **Most effective oral agent:** Ulipristal acetate (Selective Progesterone Receptor Modulator). * **Time limit:** Most oral emergency contraceptives are effective up to 72 hours, though Ulipristal and Copper-T are effective up to 120 hours. * **Yuzpe Regimen:** 100 mcg Ethinyl Estradiol + 0.5 mg LNG, repeated after 12 hours.

Question 54: A primipara with a history of myocardial infarction (MI) presents on the 40th day postpartum requesting contraception. What is the contraceptive of choice?

A. Condom with spermicidal jelly (Correct Answer)
B. Combined oral contraceptive pill
C. Intrauterine contraceptive device
D. Laparoscopic sterilization

Explanation: **Explanation:** The primary consideration in this case is the patient’s history of **Myocardial Infarction (MI)**, which makes her a **WHO Medical Eligibility Criteria (MEC) Category 4** (unacceptable health risk) for any estrogen-containing contraceptives. **Why Option A is Correct:** Barrier methods like **condoms with spermicidal jelly** are the safest choice for this patient. They have no systemic side effects, do not affect cardiovascular hemodynamics, and do not increase the risk of thromboembolism or vasospasm. In a patient with a recent MI, avoiding hormonal fluctuations and invasive procedures that might cause a vasovagal response or infection is prioritized. **Why Other Options are Incorrect:** * **B. Combined Oral Contraceptive Pill (COCP):** These are strictly contraindicated (MEC 4) in patients with ischemic heart disease or a history of MI. The estrogen component increases the risk of arterial thrombosis and further cardiac events. * **C. Intrauterine Contraceptive Device (IUCD):** While not strictly contraindicated, the insertion of an IUCD can trigger a **vasovagal attack**, which may be poorly tolerated in a patient with a compromised myocardium. Furthermore, if the patient is on anticoagulants or antiplatelets post-MI, there is an increased risk of menorrhagia. * **D. Laparoscopic Sterilization:** This is a permanent method and generally not the first choice for a primipara. Additionally, the **pneumoperitoneum** created during laparoscopy increases intra-abdominal pressure, which can decrease venous return and put undue stress on a recovering heart. **High-Yield Clinical Pearls for NEET-PG:** * **WHO MEC 4 for COCPs:** History of MI, stroke, complicated valvular heart disease, smoking >15 cigarettes/day (age >35), and migraine with aura. * **Postpartum Timing:** At 40 days (approx. 6 weeks), the patient has completed the puerperium. While Progesterone-Only Pills (POPs) could be considered, barrier methods remain the safest non-systemic option in acute cardiac recovery. * **Lactational Amenorrhea Method (LAM):** Only reliable for the first 6 months if the patient is exclusively breastfeeding and remains amenorrheic.

Question 55: A pregnant patient who is using a Copper T intrauterine device wishes to terminate the pregnancy. What is the treatment of choice?

A. Continue the pregnancy
B. Remove the Copper T and continue the pregnancy
C. Perform abortion with the Copper T in situ
D. Menstrual regulation and sterilization (Correct Answer)

Explanation: **Explanation:** The correct answer is **Menstrual regulation and sterilization**. This question addresses the management of a contraceptive failure in a patient who no longer desires the pregnancy. **1. Why Option D is Correct:** When a patient becomes pregnant with a Copper T (Cu-T) in situ and expresses a desire to terminate the pregnancy, the standard management is to perform a termination of pregnancy (TOP). In early pregnancy, this is often referred to as **Menstrual Regulation (MR)**. Since the pregnancy occurred despite using an effective long-acting reversible contraceptive (LARC), it indicates a contraceptive failure. If the patient has completed her family, **sterilization** is offered as a permanent method to prevent future unintended pregnancies. **2. Why the other options are incorrect:** * **Option A & B:** These are incorrect because the patient specifically wishes to **terminate** the pregnancy. While removing the Cu-T is mandatory if a patient chooses to *continue* a pregnancy (to reduce the risk of septic abortion and preterm labor), it does not apply here. * **Option C:** Performing an abortion with the Cu-T in situ is technically difficult and increases the risk of uterine trauma or incomplete evacuation. The device must be removed during the procedure. **High-Yield Clinical Pearls for NEET-PG:** * **Ectopic Risk:** If a patient conceives with a Cu-T in situ, the absolute risk of pregnancy is low, but the *relative* risk of the pregnancy being **ectopic** is significantly increased (approx. 3–4%). Always rule out ectopic pregnancy via ultrasound. * **Management if continuing pregnancy:** If the patient wants to keep the baby, the Cu-T should be removed if the strings are visible. This reduces the risk of spontaneous abortion from 50% to about 25%. * **Mechanism of Cu-T:** It primarily acts as a spermicide by causing a sterile inflammatory response in the endometrium.

Question 56: Which of the following is NOT a benefit of oral contraceptive pills (OCPs)?

A. Improve menstrual abnormalities
B. Protection against unwanted pregnancy
C. Protection from breast cancer (Correct Answer)
D. Protection from endometrial cancer

Explanation: **Explanation:** The correct answer is **C (Protection from breast cancer)**. Combined Oral Contraceptive Pills (COCPs) do not provide protection against breast cancer; in fact, epidemiological data suggests a slight, transient increase in the relative risk of breast cancer among current and recent users. This risk returns to baseline approximately 10 years after discontinuation. **Why other options are incorrect:** * **Option A:** OCPs are a first-line treatment for **menstrual abnormalities** like menorrhagia and dysmenorrhea. They induce a predictable withdrawal bleed and thin the endometrial lining, reducing blood loss. * **Option B:** Their primary function is **protection against unwanted pregnancy** by inhibiting ovulation through the suppression of FSH and LH. * **Option D:** OCPs provide significant **protection from endometrial cancer** (risk reduced by ~50%) and **ovarian cancer** (risk reduced by ~40%). This protective effect persists for 15–20 years after stopping the pill. **High-Yield Clinical Pearls for NEET-PG:** * **Cancer Protection:** OCPs reduce the risk of three major cancers: **Endometrial, Ovarian, and Colorectal cancer.** * **Cancer Risk:** OCPs are associated with a slight increase in the risk of **Breast cancer** and **Cervical cancer** (especially with >5 years of use). * **Non-Contraceptive Benefits:** Reduced incidence of Benign Prostatic Hyperplasia (BPH) is NOT a benefit, but reduced **Benign Breast Disease** (like fibroadenoma) and **Functional Ovarian Cysts** are. * **Mechanism:** OCPs prevent pregnancy primarily by **preventing ovulation**, thickening cervical mucus, and making the endometrium unfavorable for implantation.

Question 57: Oral contraceptive pills (OCPs) are a risk factor for the development of all EXCEPT:

A. Deep vein thrombosis (DVT)
B. Pulmonary embolism
C. Ectopic pregnancy (Correct Answer)
D. Breast cancer

Explanation: **Explanation:** The correct answer is **C. Ectopic pregnancy**. Combined Oral Contraceptive Pills (OCPs) primarily work by suppressing ovulation through the inhibition of the hypothalamic-pituitary-ovarian axis. Since ovulation is prevented, the risk of any pregnancy—including ectopic pregnancy—is significantly **decreased** compared to the general population. While progesterone-only pills (POPs) or Levonorgestrel-IUDs may have a higher *proportion* of pregnancies being ectopic if failure occurs, OCPs are overall protective against ectopic pregnancy. **Analysis of Incorrect Options:** * **Deep Vein Thrombosis (DVT) & Pulmonary Embolism (Options A & B):** The estrogen component (Ethinyl Estradiol) in OCPs increases the hepatic synthesis of clotting factors (II, VII, IX, X) and decreases anticoagulants like Protein S and Antithrombin III. This creates a hypercoagulable state, significantly increasing the risk of venous thromboembolism (VTE). * **Breast Cancer (Option D):** Long-term use of OCPs is associated with a slight, transient increase in the relative risk of breast cancer. However, this risk typically returns to baseline 10 years after discontinuing the pill. **High-Yield Facts for NEET-PG:** * **Protective Effects of OCPs:** OCPs significantly reduce the risk of **Ovarian cancer** (by 50%), **Endometrial cancer** (by 50%), and **Colorectal cancer**. They also reduce the incidence of Benign Breast Disease and Pelvic Inflammatory Disease (PID). * **Increased Risks:** OCPs increase the risk of **Cervical cancer** (especially with >5 years of use) and **Hepatic adenomas**. * **Absolute Contraindications:** History of VTE, smokers >35 years old (>15 cigarettes/day), undiagnosed vaginal bleeding, and estrogen-dependent tumors.

Question 58: During which phase of the menstrual cycle is the chance of expulsion of an intra-uterine device least?

A. During menstruation (Correct Answer)
B. Secretory phase
C. Both menstruation and secretory phase
D. Neither menstruation nor secretory phase

Explanation: **Explanation:** The timing of Intra-Uterine Device (IUD) insertion is critical to ensure both contraceptive efficacy and patient compliance. **Why Option A is correct:** The risk of expulsion is **least** when the IUD is inserted **during menstruation** (usually within the first 7 days of the cycle). This is due to several physiological factors: 1. **Cervical Patency:** During menstruation, the cervical canal is naturally slightly dilated to allow the passage of menstrual blood, making insertion easier and less traumatic. 2. **Uterine Environment:** The uterus is less irritable during this phase compared to the luteal phase. 3. **Pregnancy Status:** Insertion during menses provides practical confirmation that the patient is not pregnant. **Why other options are incorrect:** * **Option B (Secretory Phase):** During the secretory (luteal) phase, the endometrium is thick and vascular. Insertion during this time carries a higher risk of displacing an early undiagnosed pregnancy and a higher rate of expulsion due to increased uterine contractility as the cycle nears menses. * **Options C & D:** These are incorrect as the expulsion rates are not uniform across the cycle; the follicular/menstrual phase is clinically superior for retention. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Time for Insertion:** Within 10 days of the LMP (preferably during menses). * **Post-Abortal Insertion:** Can be done immediately (First trimester) or after 4–6 weeks (Second trimester). * **Post-Partum Insertion:** Ideally within 48 hours (PPIUCD) or after 6 weeks (involution complete). Insertion between 48 hours and 6 weeks is avoided due to high perforation risk. * **Most Common Side Effect:** Bleeding (Menorrhagia) is the most common reason for removal, while **pain** is the second most common. * **Expulsion:** Most common in the first few months after insertion and in nulliparous women.

Question 59: What is the progesterone release rate in Progestasert?

A. 25 mg/day
B. 40 mg/day
C. 65 mg/day (Correct Answer)
D. 80 mg/day

Explanation: **Explanation:** **Progestasert** is a first-generation hormone-releasing Intrauterine System (IUS). It is a T-shaped device made of ethylene-vinyl acetate copolymer. The vertical stem contains a reservoir of **38 mg of natural progesterone** mixed with barium sulfate (for radiopacity) and silicone oil. 1. **Why Option C is Correct:** The device is designed to release progesterone at a steady, controlled rate of **65 µg/day** (micrograms per day) directly into the uterine cavity. This local release causes endometrial atrophy and thickens cervical mucus, providing contraception for a period of **one year**, after which it must be replaced. 2. **Why Other Options are Incorrect:** * **Options A, B, and D:** These values (25, 40, and 80) do not correspond to the pharmacokinetics of Progestasert. It is crucial to note the unit: the release is in **micrograms (µg)**, not milligrams (mg). A release of 65 mg/day would be a massive overdose, as the total reservoir itself only contains 38 mg. 3. **High-Yield Clinical Pearls for NEET-PG:** * **Comparison with LNG-IUD (Mirena):** While Progestasert releases 65 µg/day of natural progesterone and lasts 1 year, Mirena releases **20 µg/day of Levonorgestrel** and is effective for 5–8 years. * **Mechanism:** Primarily local; it does not consistently inhibit ovulation. * **Side Effects:** A common disadvantage of Progestasert compared to Copper-T is a higher incidence of intermenstrual spotting and the requirement for annual replacement. * **Status:** Progestasert has largely been replaced by the more effective and longer-lasting LNG-IUS (Mirena) in clinical practice.

Question 60: Induction of abortion is best achieved by which of the following methods?

A. Oxytocin
B. PGE2 gel (Correct Answer)
C. Stripping of the membranes
D. Estrogen

Explanation: **Explanation:** The induction of abortion (specifically in the second trimester) or induction of labor requires two physiological processes: **cervical ripening** (effacement and softening) and **uterine contractions**. **Why PGE2 (Dinoprostone) is the correct answer:** Prostaglandins are the most effective agents for induction because they act on both components. **PGE2 gel** (or vaginal inserts) directly promotes cervical ripening by breaking down collagen networks and increasing submucosal water content. Simultaneously, it sensitizes the myometrium to oxytocin and triggers uterine contractions. In the context of mid-trimester abortion, prostaglandins are significantly more effective than oxytocin because the uterus has a low density of oxytocin receptors before the third trimester. **Analysis of Incorrect Options:** * **Oxytocin (A):** While used for labor induction at term, it is ineffective for early or mid-trimester abortion. The uterine sensitivity to oxytocin is low in early pregnancy due to a lack of oxytocin receptors, which only increase significantly near term. * **Stripping of the membranes (C):** This is a mechanical method used to initiate labor at or near term by releasing endogenous prostaglandins. It is not a primary or reliable method for inducing abortion. * **Estrogen (D):** Estrogens may increase the number of oxytocin receptors, but they do not directly induce uterine contractions or cervical ripening effectively enough to be used for abortion. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice:** While PGE2 is excellent for ripening, **Misoprostol (PGE1)** is now more commonly used in clinical practice for medical abortion due to its stability at room temperature and low cost. * **Mifepristone (RU-486):** Often used in combination with Misoprostol; it is an anti-progestogen that sensitizes the uterus to prostaglandins. * **Contraindication:** Avoid prostaglandins in patients with a history of previous classical Cesarean section or extensive uterine surgery due to the risk of uterine rupture.

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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