Contraception and Family Planning Practice Questions

Q: Which of the following is true regarding depot medroxy progesterone acetate?

It is known to diminish bone mineral density.. **Explanation:** **Depot Medroxyprogesterone Acetate (DMPA)**, commonly known by the brand name **Antara** (in the government supply) or **Depo-Provera**, is a long-acting injectable contraceptive. **Why Option C is correct:** DMPA works by suppressing the hypothalamic-pituitary-ovarian axis, which inhibits gonadotropin secretion (LH and FSH). This leads to the suppression of ovulation and a subsequent **hypoestrogenic state**. Since estrogen is essential for maintaining bone mass, prolonged use of DMPA leads to a **reduction in Bone Mineral Density (BMD)**. The FDA has issued a "Black Box Warning" stating that DMPA should generally not be used for more than 2 years unless other methods are inadequate, although BMD usually recovers after discontinuation. **Why other options are incorrect:** * **Option A:** DMPA is an **injectable** contraceptive, not a subdermal implant. (Example of a subdermal implant is *Nexplanon*). * **Option B:** The standard dose is **150 mg given Intramuscularly (IM)** every 3 months (90 days). There is also a subcutaneous version (DMPA-SC) at a dose of 104 mg. It is never given intravenously. * **Option D:** DMPA actually **decreases the risk of endometrial cancer** by approximately 80% due to the protective effect of progestin, which causes endometrial atrophy. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Primarily inhibits ovulation; also increases cervical mucus viscosity. * **Side Effects:** Amenorrhea (most common), weight gain, and delayed return to fertility (average 7–10 months). * **Beneficial Effects:** Reduces risk of PID, ectopic pregnancy, and iron deficiency anemia. * **Contraindication:** Current breast cancer and undiagnosed abnormal uterine bleeding.

Q: Which of the following is NOT a side effect of Depot Medroxyprogesterone Acetate (Depot MPA)?

Hepatitis. **Explanation:** **Depot Medroxyprogesterone Acetate (DMPA)**, commonly known as the "Antara" program injection in India, is a progestogen-only injectable contraceptive. **Why Hepatitis is the Correct Answer:** Hepatitis is not a side effect of DMPA. In fact, unlike oral contraceptive pills (OCPs) which undergo first-pass metabolism in the liver and can exacerbate cholestatic jaundice or liver adenomas, DMPA is administered parenterally. It does not adversely affect liver function and is not associated with hepatotoxicity. **Analysis of Incorrect Options:** * **Weight Gain (A):** This is a very common side effect. DMPA is the only contraceptive consistently linked to significant weight gain (average 1–2 kg/year), primarily due to its glucocorticoid-like activity and increased appetite. * **Irregular Bleeding (B):** During the first 3–6 months of use, breakthrough bleeding or spotting is the most common reason for discontinuation. * **Amenorrhea (C):** This is a hallmark of long-term DMPA use. Due to the profound suppression of the endometrium, approximately 50-70% of women become amenorrheic after one year of use. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Inhibits ovulation by suppressing the LH surge. * **Dose:** 150 mg IM every 3 months (12 weeks). * **Black Box Warning:** Long-term use is associated with **reversible loss of Bone Mineral Density (BMD)**. * **Return to Fertility:** There is a characteristic **delayed return to fertility** (average 7–10 months after the last injection). * **Non-contraceptive benefit:** Reduces the risk of endometrial cancer and helps in managing endometriosis and dysmenorrhea.

Q: Which of the following is NOT a side effect or complication of the Copper-T intrauterine device?

Ectopic pregnancy. ### Explanation The correct answer is **C. Ectopic pregnancy**. **Why Ectopic Pregnancy is NOT a side effect:** The Copper-T (Cu-T) is a highly effective contraceptive. While it does not provide 100% protection, it significantly reduces the **absolute risk** of both intrauterine and ectopic pregnancies compared to women using no contraception. If a woman becomes pregnant with a Cu-T in situ, the *relative* risk of that pregnancy being ectopic is higher, but the *overall* incidence of ectopic pregnancy is much lower than in the general population. Therefore, it is considered a protective factor rather than a side effect. **Analysis of Incorrect Options:** * **A. Menorrhagia:** This is the **most common side effect** and the most frequent reason for removal. The copper ions cause a local inflammatory response in the endometrium, leading to increased menstrual blood loss. * **B. Dysmenorrhea:** Increased uterine cramping and painful menstruation are common side effects, often occurring alongside menorrhagia due to increased prostaglandin synthesis. * **D. Perforation:** This is a serious but rare **iatrogenic complication**, usually occurring during insertion (incidence approx. 1 in 1000). It is most common in women with a retroverted uterus or those who are lactating (due to a soft, thinned uterine wall). **High-Yield Clinical Pearls for NEET-PG:** * **Most common side effect:** Bleeding (Menorrhagia). * **Most common cause for removal:** Bleeding and pain. * **Ideal time for insertion:** Within 10 days of the onset of menstruation (to ensure the patient is not pregnant and the cervix is slightly dilated). * **Mechanism of Action:** Primarily **spermicidal** (sterile inflammatory response is toxic to sperm); it also prevents fertilization and implantation. * **Emergency Contraception:** Cu-T is the most effective method of emergency contraception if inserted within 5 days of unprotected intercourse.

Q: Which of the following oral contraceptive pills contains the least amount of estrogen?

Femilon. **Explanation:** The concentration of estrogen (Ethinyl Estradiol) in Combined Oral Contraceptive Pills (COCPs) is a critical factor in determining their side-effect profile, particularly regarding thromboembolic risks and nausea. **1. Why Femilon is Correct:** **Femilon** is a "low-dose" third-generation COCP. It contains **20 mcg of Ethinyl Estradiol** (EE) combined with 150 mcg of Desogestrel. Currently, 20 mcg is among the lowest standard doses used in clinical practice to maintain contraceptive efficacy while minimizing estrogenic side effects. **2. Analysis of Incorrect Options:** * **Mala N:** This is a second-generation pill provided under the National Family Welfare Programme. It contains **30 mcg of EE** and 0.15 mg of Levonorgestrel. * **Novelon:** Also a third-generation pill containing Desogestrel (150 mcg), but it contains a higher dose of estrogen—**30 mcg of EE**. * **Triquilar:** This is a triphasic pill. The estrogen content varies throughout the cycle (30 mcg, 40 mcg, and 30 mcg), but the average and minimum doses are higher than those in Femilon. **3. High-Yield Clinical Pearls for NEET-PG:** * **Generation Classification:** COCPs are often classified by their progestogen component. Desogestrel (in Femilon/Novelon) is a **3rd generation** progestogen, which has less androgenic side effects (less acne/hirsutism) but a slightly higher risk of Venous Thromboembolism (VTE) compared to 2nd generation pills. * **Ultra-low dose:** Pills containing **<30 mcg** of EE are termed "low-dose" or "ultra-low dose." * **Centchroman (Saheli):** Remember that this is a Non-Steroidal, Selective Estrogen Receptor Modulator (SERM) and contains **zero** estrogen. It is the "Once-a-week" pill developed by CDRI, Lucknow. * **Mala D vs. Mala N:** Both contain 30 mcg EE; the difference is that Mala D is a paid brand, while Mala N is supplied free in government health centers.

Q: Progestin-only pills should not be taken by women with which of the following conditions?

Migraine headache without aura. **Explanation:** The question asks for the condition where Progestin-Only Pills (POPs) are **NOT** contraindicated. According to the WHO Medical Eligibility Criteria (MEC), **Migraine without aura** is classified as **MEC Category 2** (advantages generally outweigh risks) for POPs. Therefore, it is safe for these women to use them. **Why the correct answer is right:** Unlike combined oral contraceptives (COCs), which contain estrogen and are contraindicated in migraine patients due to an increased risk of ischemic stroke, POPs do not contain estrogen. They do not significantly alter coagulation factors or blood pressure, making them a safe alternative for women with migraines (without aura). **Why the other options are wrong:** * **Unexplained uterine bleeding (MEC 4):** This is a contraindication because the bleeding may be due to an undiagnosed malignancy (e.g., endometrial cancer) which must be ruled out before starting hormonal therapy. * **Breast Cancer (MEC 4):** Current breast cancer is a strict contraindication for all hormonal contraceptives, as progestins can stimulate the growth of hormone-sensitive tumor cells. * **Severe active liver disease (MEC 3/4):** Steroid hormones are metabolized in the liver. In cases of acute hepatitis, decompensated cirrhosis, or liver tumors (adenomas/hepatomas), POPs are contraindicated as they may worsen the condition or fail to be metabolized correctly. **High-Yield Clinical Pearls for NEET-PG:** * **MEC 4 (Absolute Contraindication):** Current Breast Cancer is the most high-yield MEC 4 for POPs. * **Migraine with Aura:** While COCs are MEC 4, POPs are generally considered MEC 2. * **Lactation:** POPs are the hormonal contraceptive of choice for breastfeeding mothers (MEC 1) as they do not suppress milk production, unlike COCs. * **Efficacy:** POPs must be taken at the same time every day; a delay of >3 hours is considered a "missed pill."

Q: A 30-year-old woman is on warfarin for deep vein thrombosis. Which contraceptive should be advised to her?

Intrauterine contraceptive device (IUCD). **Explanation:** The primary concern for a patient on **Warfarin** for Deep Vein Thrombosis (DVT) is the high risk of recurrent thromboembolism. In such cases, the selection of contraception is guided by the **WHO Medical Eligibility Criteria (MEC)**. **1. Why IUCD is the Correct Choice:** The **Intrauterine Contraceptive Device (IUCD)**, specifically the Copper-T (Cu-T), is categorized as **WHO MEC 1** (no restriction) for women with a history of DVT or those on anticoagulant therapy. It is a non-hormonal method that does not increase the risk of thrombosis. While anticoagulants can increase menstrual bleeding, the Cu-T remains the safest long-term option. Note: The Levonorgestrel-IUS (Mirena) is also an excellent choice as it reduces the heavy menstrual bleeding often caused by Warfarin. **2. Why Other Options are Incorrect:** * **Progesterone-only pills (POPs), Levonorgestrel implants, and Implanon:** These are generally categorized as **WHO MEC 2** for patients with current DVT or those on anticoagulants. While they do not contain estrogen (the primary culprit in thrombosis), they are considered secondary to IUCDs in this specific clinical scenario. * **Combined Oral Contraceptive Pills (COCPs):** (Though not an option here) These are strictly **Contraindicated (WHO MEC 4)** because estrogen increases clotting factors and the risk of recurrent DVT. **Clinical Pearls for NEET-PG:** * **Gold Standard:** For any patient with a history of thromboembolism, **Non-hormonal methods (Cu-T)** or **Progestogen-only methods** are preferred. * **MEC 4 (Absolute Contraindication) for COCPs:** History of DVT/PE, Migraine with aura, Smoking >15 cigarettes/day in women >35 years, and Breast Cancer. * **Warfarin & Pregnancy:** Warfarin is **teratogenic** (causes fetal warfarin syndrome/chondrodysplasia punctata); hence, highly effective contraception like an IUCD is mandatory.

Q: All of the following are used for contraception in patients with sickle cell anemia except?

Oral contraceptive pills. **Explanation:** The primary concern in managing contraception for patients with **Sickle Cell Anemia (SCA)** is the risk of triggering a vaso-occlusive crisis or thromboembolic events. **1. Why Oral Contraceptive Pills (OCPs) are the Correct Answer:** Combined Oral Contraceptive Pills contain **Estrogen**, which is known to increase the synthesis of clotting factors and enhance platelet aggregation. In patients with SCA, who are already at a baseline hypercoagulable state and prone to vascular stasis, the addition of estrogen significantly increases the risk of **thromboembolism and stroke**. Therefore, estrogen-containing methods are generally avoided (WHO MEC Category 4 or 3 depending on severity). **2. Analysis of Other Options:** * **IUCD (Option B):** Copper IUCDs are safe as they are non-hormonal. However, Levonorgestrel-IUS (Mirena) is often preferred as it reduces menstrual blood loss, helping with the anemia common in SCA. * **Progestin-only Pills (Option C) & Progesterone Implants (Option D):** Progesterone-only methods do not carry the same thromboembolic risks as estrogen. In fact, **Depot Medroxyprogesterone Acetate (DMPA)** is often considered a "gold standard" for SCA because it has been shown to stabilize red cell membranes and reduce the frequency of painful crises. **Clinical Pearls for NEET-PG:** * **Best Choice:** DMPA (Injectable) is highly recommended for SCA as it reduces sickling and crises. * **Avoid:** Any combined hormonal contraceptive (Pills, Patch, Ring) due to the estrogen component. * **WHO MEC:** For Sickle Cell Disease, Combined Hormonal Contraceptives are Category 4 (Unacceptable health risk).

Question 1

Which of the following is true regarding depot medroxy progesterone acetate?

Accepted Answer

It is known to diminish bone mineral density.

Answer

It is a subdermal progestin implant.

Answer

It is a 150 mg dose given intravenously every 90 days.

Answer

It increases the risk of endometrial cancer.

Question 2

A woman with an intrauterine contraceptive device (IUCD) develops pelvic inflammatory disease. What is the recommended initial management?

Accepted Answer

Maintain the IUCD, initiate antibiotic therapy, and assess the response before deciding on IUCD removal.

Answer

Start antibiotics and then remove the IUCD.

Answer

Remove the IUCD and then start antibiotics.

Answer

Delay intervention until the next menstrual cycle.

Question 3

Which of the following is NOT a side effect of Depot Medroxyprogesterone Acetate (Depot MPA)?

Accepted Answer

Hepatitis

Answer

Weight gain

Answer

Irregular bleeding

Answer

Amenorrhea

Question 4

Which of the following is NOT a side effect or complication of the Copper-T intrauterine device?

Accepted Answer

Ectopic pregnancy

Answer

Menorrhagia

Answer

Dysmenorrhea

Answer

Perforation

Question 5

Which of the following oral contraceptive pills contains the least amount of estrogen?

Accepted Answer

Femilon

Answer

Mala N

Answer

Triquilar

Answer

Novelon

Question 6

Progestin-only pills should not be taken by women with which of the following conditions?

Accepted Answer

Migraine headache without aura

Answer

Unexplained uterine bleeding

Answer

Breast cancer

Answer

Severe active liver disease

Question 7

A 25-year-old woman with an IUD inserted 2 years ago presents with fever. On examination, actinomyces is positive in cervical cytology. What would you advise regarding the IUD?

Accepted Answer

Remove the IUD and give intensive antibiotic therapy.

Answer

Continue some contraception; no need for treatment.

Answer

Hysterectomy

Answer

Leave the IUD in place and start an antibiotic course.

Question 8

A 30-year-old woman is on warfarin for deep vein thrombosis. Which contraceptive should be advised to her?

Accepted Answer

Intrauterine contraceptive device (IUCD)

Answer

Progesterone-only pills

Answer

Levonorgestrel implant

Answer

Implanon

Question 9

All of the following are used for contraception in patients with sickle cell anemia except?

Accepted Answer

Oral contraceptive pills

Answer

Intrauterine contraceptive device (IUCD)

Answer

Progestin-only pills

Answer

Progesterone implants

Question 10

A 26-year-old female on a progestin-only pill contraceptive attends the gynecology OPD concerned about not taking her pill at the same time every day. She took her pill daily at 10 a.m. except for one day when she took it at 5 p.m. What is your advice?

Accepted Answer

Use an additional form of contraceptive for the next 48 hours.

Answer

No need to worry, continue the same contraceptive.

Answer

Change over to combined oral contraceptive pills.

Answer

Take a double dose of the pill the next morning.

Contraception and Family Planning — MCQs

Contraception and Family Planning — MCQs

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