Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 61: What is true about a complete mole?

A. Presence of fetal parts and cardiac activity
B. Normal uterine size (Correct Answer)
C. Beta-hCG doubling time is 7-10 days
D. Preeclampsia at <24 weeks

Explanation: **Explanation:** Hydatidiform mole is a gestational trophoblastic disease characterized by the proliferation of trophoblastic tissue. **1. Why the Correct Answer is Right:** In a **Complete Mole**, the uterine size is classically described as **"larger than the period of gestation"** in about 50% of cases due to exuberant trophoblastic proliferation and retained blood. However, in the remaining cases, the uterus can be **normal for dates** or even smaller than expected (if the mole is undergoing regression or evacuation). Among the given options, "Normal uterine size" is the most plausible clinical finding, as the other options contain definitive pathological inaccuracies. **2. Why the Incorrect Options are Wrong:** * **Option A:** Fetal parts and cardiac activity are **absent** in a complete mole. Complete moles are diploid (46,XX or 46,XY) and entirely paternal in origin, resulting in no fetal development. Fetal parts are only seen in **Partial Moles**. * **Option C:** In a molar pregnancy, Beta-hCG levels are **pathologically elevated** (often >100,000 mIU/mL) and do not follow the normal doubling time of 48–72 hours seen in early viable pregnancies. * **Option D:** While preeclampsia is a known complication of molar pregnancy, it typically presents **before 20 weeks** of gestation. Developing preeclampsia in the first or early second trimester is a classic "red flag" for a complete mole. **3. High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** Complete Mole is 46,XX (90%, androgenetic); Partial Mole is Triploid (69,XXY). * **USG Sign:** "Snowstorm appearance" (Complete Mole) vs. "Swiss cheese appearance" of the placenta (Partial Mole). * **Theca Lutein Cysts:** Frequently associated with complete moles due to very high hCG levels. * **Risk of Malignancy:** Higher in Complete Mole (15–20%) compared to Partial Mole (<5%).

Question 62: Combined oral contraceptive pills act mainly by which mechanism?

A. Inhibition of ovulation (Correct Answer)
B. Increased motility of fallopian tubes
C. Early transport of the sperm and ovum to the uterine cavity
D. None of the above

Explanation: **Explanation:** **1. Why the Correct Answer is Right:** Combined Oral Contraceptive Pills (COCPs) contain both Estrogen (usually Ethinyl Estradiol) and Progestogen. Their primary mechanism of action is the **inhibition of ovulation** via negative feedback on the hypothalamo-pituitary-ovarian axis. * **Estrogen** suppresses **FSH** (Follicle Stimulating Hormone), which prevents the selection and maturation of a dominant follicle. * **Progestogen** suppresses the **LH surge** (Luteinizing Hormone), which is essential for the release of the ovum. While COCPs also cause thickening of cervical mucus and endometrial thinning, the **primary/main** mechanism is the suppression of ovulation. **2. Why Incorrect Options are Wrong:** * **Options B & C:** These are physiologically incorrect. COCPs actually **decrease** fallopian tube motility (due to the progestogen component), which slows the transport of the ovum. Early transport to the uterus would not prevent pregnancy; rather, a "hostile" endometrium or altered tubal transport are secondary effects, but they do not involve "increased motility." **3. NEET-PG High-Yield Pearls:** * **Most common side effect:** Breakthrough bleeding (especially with low-dose pills). * **Most serious side effect:** Venous Thromboembolism (VTE) due to the estrogen component (increases clotting factors II, VII, IX, and X). * **Non-contraceptive benefits:** Reduced risk of Ovarian and Endometrial cancers (protective effect persists for years), reduced PID, and improvement in dysmenorrhea. * **Drug Interactions:** Enzyme inducers like **Rifampicin** and anti-epileptics (Phenytoin, Carbamazepine) decrease the efficacy of COCPs. * **WHO Eligibility Criteria (Category 4 - Absolute Contraindication):** Smokers >35 years (>15 cigarettes/day), history of VTE, Migraine with aura, and Breast Cancer.

Question 63: Which contraceptive method should be avoided in patients with epilepsy?

A. Oral contraceptive pills (OCPs) (Correct Answer)
B. Condom
C. Intrauterine contraceptive device (IUCD)
D. Levonorgestrel-releasing intrauterine system (Mirena)

Explanation: **Explanation:** The primary concern in managing contraception for patients with epilepsy is the **pharmacokinetic interaction** between antiepileptic drugs (AEDs) and hormonal contraceptives. **Why OCPs are avoided:** Most traditional antiepileptics (e.g., Phenytoin, Carbamazepine, Phenobarbital, Primidone) are **potent hepatic enzyme inducers** (Cytochrome P450 system). These enzymes accelerate the metabolism of estrogen and progestogen in Oral Contraceptive Pills, 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. **Why other options are incorrect:** * **Condoms (Barrier methods):** These do not involve systemic hormones and have no interaction with AEDs. However, they have a higher typical-use failure rate compared to LARC (Long-Acting Reversible Contraception). * **IUCD (Copper-T):** This is often the **method of choice** for women on enzyme-inducing AEDs as it is non-hormonal and its efficacy is completely unaffected by liver enzymes. * **LNG-IUS (Mirena):** While it contains hormones, its action is primarily local on the endometrium. Because it does not rely on high systemic plasma levels for efficacy, it is considered safe and effective for patients with epilepsy. **Clinical Pearls for NEET-PG:** * **Drug of Choice:** The Copper-T IUCD or LNG-IUS are preferred for epileptic patients. * **Dose Adjustment:** If a patient *must* use OCPs, a high-dose preparation containing at least **50μg of Ethinyl Estradiol** is recommended to compensate for increased metabolism, though LARC is still superior. * **Injectables:** DMPA (Depo-Provera) is safe but should be given at shorter intervals (every 10 weeks instead of 12) if the patient is on enzyme-inducers. * **Valproate Exception:** Sodium Valproate is an enzyme *inhibitor*, not an inducer, and does not decrease OCP efficacy.

Question 64: Mifepristone is not used in which of the following conditions?

A. Threatened abortion (Correct Answer)
B. Fibroid
C. Ectopic pregnancy
D. Molar pregnancy

Explanation: **Explanation:** **Mifepristone** is a potent **progesterone receptor antagonist**. Since progesterone is the "hormone of pregnancy" essential for maintaining the decidua and uterine quiescence, blocking its receptors leads to decidual breakdown, cervical softening, and increased uterine contractility. 1. **Why Threatened Abortion is the Correct Answer:** In a **threatened abortion**, the goal of management is to **save the pregnancy**. Progesterone supplementation is often used to support the pregnancy. Administering Mifepristone (an anti-progesterone) would actively promote the detachment of the embryo and induce uterine contractions, leading to an inevitable or complete abortion. Therefore, it is strictly contraindicated. 2. **Analysis of Other Options:** * **Fibroids (Leiomyoma):** Mifepristone is used off-label to reduce the size of fibroids and control heavy menstrual bleeding by inhibiting progesterone-dependent growth of the myoma. * **Ectopic Pregnancy:** While Methotrexate is the primary medical management, Mifepristone is sometimes used as an adjunct to increase the success rate of tubal resolution by causing trophoblastic degeneration. * **Molar Pregnancy:** Mifepristone can be used as a priming agent to soften the cervix before suction evacuation, although its use is more common in second-trimester terminations. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Competitive antagonist at progesterone and glucocorticoid receptors. * **Medical Abortion Regimen:** 200 mg Mifepristone (oral) followed by 800 mcg Misoprostol (vaginal/sublingual) after 24–48 hours. Effective up to 9 weeks (63 days) of gestation. * **Other Uses:** Emergency contraception (10 mg dose), induction of labor (in intrauterine fetal death), and management of Cushing’s Syndrome. * **Side Effects:** Nausea, abdominal cramps, and heavy bleeding.

Question 65: Oral contraceptive pills intake causes all EXCEPT:

A. Decreased risk of ovarian tumor
B. Increased risk of fibroadenosis
C. Increased risk of liver adenoma
D. Increased risk of fibroadenoma (Correct Answer)

Explanation: **Explanation:** The correct answer is **D (Increased risk of fibroadenoma)** because Combined Oral Contraceptive Pills (COCPs) are actually associated with a **decreased risk** of benign breast diseases, including fibroadenoma and fibrocystic disease (fibroadenosis). **1. Why Option D is the correct answer (The Exception):** COCPs exert a protective effect on the breast parenchyma against benign proliferative changes. Large-scale epidemiological studies have consistently shown that long-term use of OCPs reduces the incidence of fibroadenomas. Therefore, stating that OCPs *increase* the risk is factually incorrect, making it the "Except" option. **2. Analysis of Incorrect Options:** * **A. Decreased risk of ovarian tumor:** This is a well-established benefit. OCPs suppress ovulation, reducing "incessant ovulation" trauma. They reduce the risk of epithelial ovarian cancer by approximately 40-50%, and this protection persists for years after discontinuation. * **B. Increased risk of fibroadenosis:** While OCPs generally protect against benign breast disease, some older literature and specific formulations noted a complex relationship with fibroadenosis (chronic cystic mastitis). However, in the context of this standard MCQ, the definitive "protective" link is strongest for fibroadenoma, making D the clear outlier. * **C. Increased risk of liver adenoma:** This is a classic side effect. Estrogen in OCPs can stimulate the growth of hepatic adenomas (benign but vascular tumors). Though rare, the risk increases with the duration of use and higher estrogen doses. **NEET-PG High-Yield Pearls:** * **Protective Effects of OCPs:** Decreased risk of Endometrial cancer, Ovarian cancer, PID, Ectopic pregnancy, and Benign Breast Disease. * **Increased Risks of OCPs:** Increased risk of Cervical cancer (due to HPV persistence/behavioral factors), Breast cancer (slight transient increase), and Hepatic adenoma. * **Non-contraceptive benefits:** OCPs are the first-line treatment for Dysmenorrhea and Menorrhagia (DUB).

Question 66: All of the following are features of progesterone-only pills except?

A. Alters cervical mucous secretion
B. Inhibits ovulation
C. Failure rate is equal to that seen with combined oral contraceptive pills (Correct Answer)
D. Irregular bleeding is a known complication

Explanation: **Explanation:** Progesterone-only pills (POPs), also known as the "mini-pill," function differently from Combined Oral Contraceptive Pills (COCPs) and have a distinct clinical profile. **Why Option C is the correct answer (The Exception):** The failure rate of POPs is **higher** than that of COCPs. In typical use, the failure rate of POPs is approximately **9%**, whereas COCPs have a failure rate of around **7%** (and significantly lower with perfect use). This is primarily because POPs have a very narrow margin for error; they must be taken at the exact same time every day (within a 3-hour window) to maintain efficacy, unlike COCPs which offer a more forgiving 12-hour window. **Analysis of Incorrect Options:** * **Option A:** This is the **primary mechanism of action** for POPs. They thicken the cervical mucus, making it hostile to sperm penetration. * **Option B:** While not the primary mechanism, POPs inhibit ovulation in approximately **40-60%** of cycles. (Note: Desogestrel-only pills inhibit ovulation in 97% of cycles, but traditional POPs do not do so consistently). * **Option C:** Irregular spotting or breakthrough bleeding is the **most common side effect** and the leading reason for discontinuation. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Candidates:** Lactating mothers (POPs do not suppress milk production), women with contraindications to estrogen (e.g., history of VTE, smokers >35 years, or migraine with aura). * **Time Sensitivity:** If a dose is missed by >3 hours (>12 hours for Desogestrel), backup contraception is required for the next 48 hours. * **Endometrial Effect:** POPs also cause endometrial thinning (atrophy), which prevents implantation.

Question 67: What is the most common side effect of progestin-only pills (POPs)?

A. Deep vein thrombosis (DVT)
B. Irregular bleeding (Correct Answer)
C. Acne
D. Hypertension

Explanation: **Explanation:** The most common side effect of **Progestin-Only Pills (POPs)**, also known as the "mini-pill," is **irregular menstrual bleeding**. Unlike combined oral contraceptives (COCs), POPs do not contain estrogen. Estrogen is responsible for stabilizing the endometrium; without it, the endometrial lining becomes thin and unstable, leading to breakthrough bleeding, spotting, or amenorrhea. This is the primary reason for patient dissatisfaction and discontinuation of the method. **Analysis of Options:** * **A. Deep Vein Thrombosis (DVT):** This is a risk associated with **estrogen-containing** contraceptives. Estrogen increases the synthesis of clotting factors in the liver. Progestin-only methods do not significantly increase the risk of venous thromboembolism and are often the preferred choice for women with a history of DVT. * **C. Acne:** While some older progestins with androgenic activity can worsen acne, it is not the *most common* side effect. In fact, many modern progestins have minimal impact on skin. * **D. Hypertension:** Estrogen is the component primarily linked to blood pressure elevation via the renin-angiotensin-aldosterone system. POPs are generally considered safe for women with controlled hypertension. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** POPs primarily work by **thickening the cervical mucus**, preventing sperm penetration. They also cause endometrial thinning and, in some cycles, suppress ovulation. * **The "3-Hour Rule":** Traditional POPs (e.g., Norethindrone) must be taken at the same time every day. If a dose is delayed by **>3 hours**, it is considered a "missed pill," and backup contraception is required for 48 hours. * **Ideal Candidates:** POPs are the contraceptive of choice for **lactating mothers** (as they do not suppress milk production) and women with contraindications to estrogen (e.g., smokers >35 years, migraine with aura, or history of VTE).

Question 68: Oral contraceptive pills should be initiated on which day of the menstrual cycle?

A. The 5th day
B. The 3rd day
C. The 1st day (Correct Answer)
D. When menses cease

Explanation: **Explanation:** The initiation of Combined Oral Contraceptive Pills (COCPs) has evolved in clinical guidelines to ensure immediate efficacy and better compliance. **Why the 1st Day is Correct:** According to the latest WHO and national guidelines, the **1st day of the menstrual cycle** (the first day of bleeding) is the ideal time to start OCPs. This is known as the "Day 1 Start." Starting on the first day provides **immediate contraceptive protection**, eliminating the need for a back-up method (like condoms) because it effectively suppresses follicle-stimulating hormone (FSH) and prevents the selection of a dominant follicle right from the start of the cycle. **Analysis of Incorrect Options:** * **The 5th Day (Option A):** Historically, the "Day 5 Start" was standard. However, if a woman has a short cycle, starting on Day 5 might allow for early follicular development, meaning the pill may not be effective for the first 7 days. * **The 3rd Day (Option B):** While starting on Day 3 is acceptable, it does not guarantee the same immediate suppression as Day 1 and is not the primary recommendation. * **When menses cease (Option D):** Menses duration varies; waiting until they cease (often Day 5–7) increases the risk of "escape ovulation" if a back-up method is not used. **High-Yield Clinical Pearls for NEET-PG:** * **Quick Start Method:** OCPs can be started at *any* time if the clinician is reasonably certain the patient is not pregnant. However, if started after Day 5, a back-up method (condoms) is required for the first **7 days**. * **Post-Abortion:** Start immediately (within 24 hours). * **Post-Partum:** If not breastfeeding, start at **3 weeks** (due to VTE risk). If breastfeeding, COCPs are contraindicated for 6 months (use POPs instead). * **Missed Pill Rule:** If one pill is missed, take it as soon as remembered; no back-up is needed. If two or more are missed, take the last missed pill, continue the pack, and use back-up for 7 days.

Question 69: All of the following can be used for emergency contraception except?

A. Low dose oral contraceptive pills (Correct Answer)
B. Levonorgestrel
C. Mifepristone
D. Ulipristal

Explanation: **Explanation:** Emergency contraception (EC) is intended to prevent pregnancy after unprotected intercourse. The correct answer is **A (Low-dose OCPs)** because standard low-dose oral contraceptive pills, when taken in their usual daily dosage, do not provide the high hormonal concentration required to inhibit or delay ovulation effectively in an emergency window. While the **Yuzpe Regimen** uses combined OCPs for emergency contraception, it requires a specific **high dose** (100 mcg of Ethinyl Estradiol + 0.5 mg of Levonorgestrel, repeated after 12 hours). A single "low dose" pill is insufficient. **Analysis of other options:** * **Levonorgestrel (LNG):** The "Gold Standard" progestogen-only EC. It is most effective when taken within 72 hours (1.5 mg single dose or 0.75 mg two doses). * **Ulipristal Acetate:** A selective progesterone receptor modulator (SPRM). It is currently the most effective oral EC and can be used up to 120 hours (5 days) after intercourse. * **Mifepristone:** An anti-progestogen used in low doses (10–25 mg) for EC. It is highly effective with fewer side effects than the Yuzpe regimen. **High-Yield Clinical Pearls for NEET-PG:** * **Most Effective EC:** Copper-T 380A (IUD) inserted within 5 days is the most effective method overall (failure rate <0.1%). * **Mechanism of Action:** Most hormonal ECs work primarily by **inhibiting or delaying ovulation**. They do not disrupt an established pregnancy (not abortifacients). * **Time Frame:** LNG is preferred within 72 hours; Ulipristal and Copper-IUD are preferred up to 120 hours. * **Yuzpe Regimen Side Effect:** Nausea and vomiting are most common due to the high estrogen content.

Question 70: Oral contraceptive pills are known to prevent which of the following conditions, except?

A. Colon cancer
B. Endometrial cancer
C. Anorectal cancer
D. Cervical cancer (Correct Answer)

Explanation: **Explanation:** The correct answer is **Cervical cancer**. While Combined Oral Contraceptive Pills (COCPs) offer significant protection against several malignancies, they are associated with an **increased risk** of cervical cancer, especially with long-term use (typically >5 years) in women who are HPV-positive. The risk is thought to be due to hormonal influences on the cervical transformation zone, making it more susceptible to persistent HPV infection. **Analysis of Options:** * **Colon cancer (A):** COCPs are known to have a protective effect against colorectal cancer. Studies suggest a risk reduction of approximately 15-20% among ever-users. * **Endometrial cancer (B):** This is one of the most significant benefits of COCPs. The progestogen component antagonizes the proliferative effect of estrogen on the endometrium, reducing the risk by nearly 50%. This protection persists for decades after discontinuation. * **Anorectal cancer (C):** Similar to colon cancer, epidemiological data indicates that oral contraceptives reduce the risk of cancers of the rectum and anus. **High-Yield NEET-PG Pearls:** 1. **Protective Effects:** COCPs reduce the risk of **Ovarian cancer** (by 40-50%), **Endometrial cancer**, and **Colorectal cancer**. They also protect against Benign Breast Disease (BBD), Pelvic Inflammatory Disease (PID), and ectopic pregnancy. 2. **Increased Risks:** COCPs are associated with an increased risk of **Cervical cancer**, **Breast cancer** (slight increase while using), and **Hepatic adenoma**. 3. **Ovarian Cancer:** The protection against epithelial ovarian cancer is one of the most high-yield facts; the longer the duration of use, the greater the protection. 4. **Contraindication:** COCPs are strictly contraindicated in patients with a history of breast cancer or undiagnosed vaginal bleeding.

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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