Side Effects and Complications of Contraceptives — MCQs
With the use of DMPA contraceptive, the side effects are all of the following except:
What is the recommended interval for administering DMPA, an injectable contraceptive?
The progestogenic emergency contraceptive pills act by:
Which of the following is a side effect of Progestin Only Pills (POPs)?
The most common complication of intrauterine contraceptive devices is:
The mechanism of action of emergency contraception includes the following except:
Which contraceptive method has the least failure rate?
Which of the following are absolute contraindications of Combined Oral Contraceptive (COCs)? 1. Arterial or venous thrombosis history 2. Severe hypertension 3. Gestational trophoblastic neoplasia 4. Diabetes with vascular complications
Highest Contraceptive failure is reported in
Indication for removal of IUDs include which of the following ? 1. Perforation of uterus 2. Pregnancy with device in situ 3. One year after menopause 4. Persistent migraine Select the correct answer using the code given below :
Side Effects and Complications of Contraceptives Indian Medical PG Practice Questions and MCQs
Question 1: With the use of DMPA contraceptive, the side effects are all of the following except:
- A. Weight gain
- B. Irregular bleeding
- C. Change in quantity and quality of breast milk (Correct Answer)
- D. Decreased bone mineral density
Explanation: ***Change in quantity and quality of breast milk*** - **DMPA (depot medroxyprogesterone acetate)** has **no significant impact** on the quality or quantity of breast milk. It is considered safe for use in breastfeeding mothers. - Progestin-only contraceptives like DMPA do not interfere with lactation and can be used without affecting infant feeding or growth. - **WHO MEC Category 2** for breastfeeding women after 6 weeks postpartum, indicating benefits generally outweigh risks. *Weight gain* - **Weight gain** is a common side effect reported by many users of DMPA due to its hormonal effects, particularly increased appetite and fluid retention. - Studies have shown an average **weight increase of 2-5 kg** over the first year of use, with continued weight gain in long-term users. *Irregular bleeding* - **Irregular bleeding**, including spotting, prolonged bleeding, or amenorrhea, is a very common side effect, especially during the initial months of DMPA use. - This is due to the hormonal influence on the **endometrial lining**, causing unpredictable shedding. - Approximately **40-50% of users develop amenorrhea** by one year of use. *Decreased bone mineral density* - **Decreased bone mineral density (BMD)** is a well-documented side effect of DMPA, prompting an FDA black box warning. - The decrease is generally **reversible after discontinuation**, with BMD recovery occurring over 2-3 years. - This effect is due to the **hypoestrogenic state** induced by DMPA, affecting calcium metabolism and bone remodeling.
Question 2: What is the recommended interval for administering DMPA, an injectable contraceptive?
- A. Three weeks
- B. Two months
- C. Three months (Correct Answer)
- D. Two years
Explanation: ***Three months*** - **Depot medroxyprogesterone acetate (DMPA)** is a long-acting reversible injectable contraceptive containing 150 mg of medroxyprogesterone acetate. - The standard administration schedule is **every 12 weeks (3 months)**, with a grace period allowing administration up to 13-15 weeks to maintain contraceptive effectiveness. - DMPA works by **suppressing ovulation** through sustained progestogen levels, and the 3-month interval is based on its pharmacokinetics to maintain therapeutic levels. *Three weeks* - A three-week interval is typical for **combined oral contraceptive pill packs** (21 active pills followed by 7-day break), not for DMPA. - Administering DMPA at this frequency would lead to **excessive progestogen exposure** and unnecessary side effects, as the injection maintains contraceptive levels for 12-13 weeks. *Two months* - While a two-month interval provides longer protection than oral contraceptives, it is **not the standard recommended interval** for DMPA. - This interval would result in **premature readministration** before the previous dose's effect wanes, leading to unnecessary injections and potential side effects. *Two years* - A two-year interval is far too long for DMPA, which has a **duration of action of approximately 12-14 weeks** per injection. - Such an interval would result in **complete loss of contraceptive protection** within 3-4 months, with return of ovulation and risk of unintended pregnancy.
Question 3: The progestogenic emergency contraceptive pills act by:
- A. Prevention of implantation of a fertilized egg
- B. Prevention of ovulation if not already occurred (Correct Answer)
- C. Induction of endometrial shedding
- D. Modification of cervical mucus to reduce sperm penetration
Explanation: ***Prevention of ovulation if not already occurred*** - Progestogenic emergency contraceptive pills primarily work by **delaying or inhibiting ovulation**, thereby preventing the release of an egg for fertilization. - This mechanism is effective when taken before the surge of **luteinizing hormone (LH)**, which triggers ovulation. - According to **WHO and FIGO guidelines**, this is the primary and most well-established mechanism of action. *Prevention of implantation of a fertilized egg* - Current scientific evidence from **WHO (2015)** and **ICMR guidelines** clearly establishes that progestogenic emergency contraceptives (like levonorgestrel) do **NOT prevent implantation** of a fertilized egg. - Studies show these pills are ineffective once fertilization has occurred, confirming they work solely through **pre-fertilization mechanisms** (primarily ovulation inhibition). - This distinction is important for understanding that progestogenic ECs are **contraceptives, not abortifacients**. *Induction of endometrial shedding* - This is a mechanism associated with **mifepristone (RU-486)**, an abortifacient, which causes shedding of the uterine lining, not with progestogenic emergency contraceptives. - Progestogenic emergency contraceptives do not induce endometrial shedding as their mode of action. *Modification of cervical mucus to reduce sperm penetration* - This is a known effect of **regular progestin-only contraceptives** (e.g., mini-pills taken daily) but is not the primary mechanism by which progestogenic emergency contraceptive pills prevent pregnancy. - While some cervical mucus thickening may occur, the main efficacy is due to **ovulation inhibition**, as the single high dose used in emergency contraception works differently than continuous low-dose regimens.
Question 4: Which of the following is a side effect of Progestin Only Pills (POPs)?
- A. Ovarian cysts (Correct Answer)
- B. Venous thromboembolism
- C. Increased risk of diabetes mellitus
- D. Ectopic pregnancy
Explanation: ***Ovarian cysts*** - **Functional ovarian cysts** are a known side effect of Progestin Only Pills (**POPs**), as POPs can alter the normal ovulatory cycle but usually do not completely suppress follicular development. - While generally benign and self-resolving, they can cause pain and discomfort. *Venous thromboembolism* - **POPs** are not significantly associated with an increased risk of **venous thromboembolism** due to the absence of estrogen, unlike combined hormonal contraceptives. - This is a key advantage of POPs, making them suitable for individuals at risk for thromboembolic events. *Increased risk of diabetes mellitus* - There is generally **no significant increased risk** of **diabetes mellitus** associated with POPs. - While some hormonal contraceptives *may* have minor effects on glucose metabolism, this is not a prominent or clinically significant side effect of POPs. *Ectopic pregnancy* - POPs **do not increase the risk of ectopic pregnancy**. In fact, they **reduce the overall pregnancy rate**, including ectopic pregnancies, by preventing ovulation. - However, if a pregnancy does occur while on POPs, there is a *slightly higher proportion* of those pregnancies that may be ectopic compared to unaided conceptions, but the *absolute risk* remains low.
Question 5: The most common complication of intrauterine contraceptive devices is:
- A. Bleeding (Correct Answer)
- B. Ectopic pregnancy
- C. Backache
- D. Cervical stenosis
Explanation: ***Bleeding*** - **Irregular bleeding** and **heavier menstrual periods (menorrhagia)** are the most common reasons for IUD discontinuation. - This is particularly true for **non-hormonal copper IUDs**, which can increase menstrual blood loss and dysmenorrhea. *Ectopic pregnancy* - While IUDs significantly reduce the overall risk of pregnancy, if a pregnancy does occur with an IUD in place, there is a **higher relative risk** that it will be **ectopic**. - However, the **absolute number** of ectopic pregnancies is low due to the high effectiveness of IUDs in preventing pregnancy altogether. *Backache* - Backache is **not a common complication** directly attributed to IUD use. - It could be a general discomfort but isn't specifically caused by the device itself or its mechanism of action. *Cervical stenosis* - **Cervical stenosis** is a narrowing of the cervical canal, which is **not typically caused by IUD insertion or presence**. - More commonly, it results from **surgical procedures** on the cervix, infection, or radiation.
Question 6: The mechanism of action of emergency contraception includes the following except:
- A. Degeneration of corpus luteum (Correct Answer)
- B. Prevention of implantation of fertilized egg.
- C. Inhibition of fertilization
- D. By preventing or delaying ovulation
Explanation: ***Degeneration of corpus luteum*** - Emergency contraception primarily works by interfering with ovulation and fertilization. It does **not directly cause degeneration of the corpus luteum**. - The **corpus luteum** forms after ovulation, and its degradation is a natural process (luteolysis) if pregnancy does not occur. Emergency contraception acts earlier in the reproductive process and does not target the corpus luteum. - This is the **correct answer** as it is NOT a mechanism of emergency contraception. *By preventing or delaying ovulation* - This is the **primary mechanism** of action for most forms of emergency contraception, particularly those containing **levonorgestrel (LNG)** and **ulipristal acetate (UPA)**. - By delaying the release of an egg from the ovary, it prevents the possibility of fertilization. - This is the most established and clinically significant mechanism. *Inhibition of fertilization* - Emergency contraception may affect fertilization by altering **cervical mucus** thickness, making it less penetrable to sperm. - Some evidence suggests effects on **sperm motility** or function, though this mechanism is less well-established than ovulation inhibition. - This represents a possible secondary mechanism. *Prevention of implantation of fertilized egg* - **Current evidence does NOT support this as a mechanism** for levonorgestrel or ulipristal acetate emergency contraception. - Studies by **WHO, ACOG, FIGO, and ICMR** have shown that LNG-EC is ineffective once fertilization has occurred. - The **copper IUD** used for emergency contraception may have some anti-implantation effects due to its inflammatory action on the endometrium. - However, for hormonal EC (the most common form), prevention of implantation is **not an established mechanism** based on current medical evidence.
Question 7: Which contraceptive method has the least failure rate?
- A. Condom
- B. DMPA
- C. OC pills
- D. IUDs (Correct Answer)
Explanation: ***IUDs*** - **Intrauterine Devices (IUDs)**, both hormonal and copper, are highly effective long-acting reversible contraceptives with a typical use failure rate of less than 1%. - Their effectiveness stems from their **low user dependency**, as they remain in place for several years after insertion. *OC pills* - **Oral contraceptive (OC) pills** have a typical use failure rate of around 7-9%, primarily due to **inconsistent or incorrect usage**. - Their effectiveness depends heavily on **daily adherence** at roughly the same time each day. *Condom* - **Condoms** have a typical use failure rate of around 13-18%, largely due to **improper use, breakage, or slippage**. - Their effectiveness is highly **user-dependent** and relies on correct application during every sexual encounter. *DMPA* - **Depot Medroxyprogesterone Acetate (DMPA)**, or the contraceptive injection, has a typical use failure rate of about 4-6%. - While highly effective when administered on schedule, missed or delayed injections can significantly **reduce its efficacy**.
Question 8: Which of the following are absolute contraindications of Combined Oral Contraceptive (COCs)? 1. Arterial or venous thrombosis history 2. Severe hypertension 3. Gestational trophoblastic neoplasia 4. Diabetes with vascular complications
- A. 1, 2 and 4 (Correct Answer)
- B. 1, 3 and 4
- C. 2, 3 and 4
- D. 1, 2 and 3
Explanation: ***1, 2 and 4*** - A history of **arterial or venous thrombosis** (e.g., deep vein thrombosis, pulmonary embolism, stroke, myocardial infarction) is an absolute contraindication due to the increased risk of clotting associated with estrogen in COCs. - **Severe hypertension** (systolic ≥160 mmHg or diastolic ≥100 mmHg) is a contraindication because COCs can exacerbate blood pressure control and increase the risk of cardiovascular events. - **Diabetes with vascular complications** (e.g., nephropathy, retinopathy, neuropathy, macrovascular disease) indicates advanced microvascular or macrovascular disease, making COCs unsafe due to increased cardiovascular risk. *1, 3 and 4* - While a history of **arterial or venous thrombosis** and **diabetes with vascular complications** are absolute contraindications, **gestational trophoblastic neoplasia** itself is generally not an absolute contraindication to COCs once the disease is in remission or resolved. - The primary concern with gestational trophoblastic neoplasia is avoiding pregnancy during the monitoring period, for which COCs can be used, although other methods may be preferred. *2, 3 and 4* - **Severe hypertension** and **diabetes with vascular complications** are absolute contraindications, but **gestational trophoblastic neoplasia** is not. - The use of COCs in gestational trophoblastic neoplasia is generally considered acceptable after successful treatment and during the follow-up period to prevent pregnancy. *1, 2 and 3* - **Arterial or venous thrombosis history** and **severe hypertension** are absolute contraindications. - However, **gestational trophoblastic neoplasia** is not an absolute contraindication for COCs once the patient has been successfully treated and is being monitored.
Question 9: Highest Contraceptive failure is reported in
- A. Implant
- B. IUD
- C. Oral contraceptive pills
- D. Spermicidal methods (Correct Answer)
Explanation: ***Spermicidal methods*** - **Spermicides** have a significantly higher failure rate compared to other contraceptive methods because their effectiveness relies heavily on **correct and consistent application** before each act of intercourse. - Their efficacy is often compromised by improper use, short duration of action, or failure to adequately kill sperm, leading to a higher chance of **unintended pregnancy**. *Implant* - Contraceptive **implants** (e.g., etonogestrel implant) are among the most effective contraceptive methods, with a very low failure rate due to **continuous hormone release**. - They offer **long-acting reversible contraception (LARC)**, eliminating user error upon insertion. *IUD* - **Intrauterine devices (IUDs)**, both hormonal and copper, are highly effective LARC methods with very low failure rates. - Their effectiveness is independent of user adherence after insertion, making them **highly reliable**. *Oral contraceptive pills* - **Oral contraceptive pills** are effective when used perfectly, but their typical use effectiveness is lower than implants or IUDs due to the possibility of **user error**, such as missing pills. - **Adherence** to a daily regimen is crucial for their efficacy.
Question 10: Indication for removal of IUDs include which of the following ? 1. Perforation of uterus 2. Pregnancy with device in situ 3. One year after menopause 4. Persistent migraine Select the correct answer using the code given below :
- A. 2, 3 and 4
- B. 1, 2 and 4 (Correct Answer)
- C. 1, 2 and 3
- D. 1 and 3 only
Explanation: ***Correct Answer: 1, 2 and 4*** **Statement 1 - Perforation of uterus:** ✅ **Valid indication** - Uterine perforation is a serious complication where the IUD punctures the uterine wall - This is an **absolute indication** for immediate removal to prevent further damage, infection, or injury to adjacent organs - Requires prompt surgical intervention **Statement 2 - Pregnancy with device in situ:** ✅ **Valid indication** - IUD should be removed if the strings are visible and removal is feasible - Removal reduces risks of **spontaneous abortion** (50% vs 25%), **septic abortion**, **preterm labor**, and **chorioamnionitis** - If strings are not visible, removal attempts may cause more harm than leaving it in place **Statement 4 - Persistent migraine:** ✅ **Valid indication (especially for hormonal IUDs)** - Relevant primarily for **levonorgestrel-releasing IUDs** (LNG-IUS) - Some women experience exacerbated or new-onset migraines due to hormonal fluctuations - Persistent or worsening migraines, especially **migraines with aura**, may warrant IUD removal - Less relevant for copper IUDs which have no hormonal effects *Statement 3 - One year after menopause:* ❌ **NOT an absolute indication** - While general guidelines suggest removal 1 year after menopause (if inserted after age 40), this is **NOT mandatory** - **Copper IUDs** can remain in place until age 55 if inserted after age 40, providing continued contraception - **LNG-IUS** may be retained for **endometrial protection** in women receiving estrogen replacement therapy - Removal is only necessary if the device is past its effective lifespan or causing symptoms - The decision should be individualized based on patient circumstances
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