1. Contraception during Lactation : Contraception MCQ

Which one of the following hormonal contraceptives can not be used during lactation?

a) Mini-pill

b) Norplant

c) DMPA

d) Combined oral contraceptive pill

e) Low estrogen combined oral contraceptive pill

Correct Answer: d and e. Estrogen containing contraceptive pill either it is standard dose or low dose, it reduces the volume of breast milk. Progestin-only contraceptives are safe for use by breast-feeding mothers. Doses of estrogen >=30mcg are known to decrease breast milk production. Low dose estrogen containing 20mcg may not produce this effect but available evidence does not recommend its use. Also it is secreted in breast milk in small quantity and few adverse effects on the child have been reported like jaundice and breast enlargement. So till we have good evidence to support its use during lactation, it is not to be used.

2. Most suitable contraceptive for a lactating mother with one child

a) Laparoscopic sterilization

b) Combined Oral contraceptive pills

c) Progesterone only pills

d) Condom

e) Intrauterine Device

Correct Answer: e) Intrauterine Device. While choosing a method of contraception, it is important that it not interfere with lactation or have negative effects on the infant. IUCD is more effective than condoms and progesterone only pills. COC suppresses milk production.

3. Most effective Contraception

Lowest pregnancy rate in 100 women using the method of contraception for 1 year :

a) IUCD

b) OCP

c) Condom

d) Diaphragm

e) Spermicidal cream

f) Mirena

Correct Answer: f) Mirena IUCD. Percentage of women experiencing an unintended pregnancy within the first year of perfect use of contraception : Condom - 2, OCP -0.3, Diaphragm - 6, Spermicidal cream - 18, IUCD (Mirena) - 0.2, IUCD (CuT) - 0.6.

4. OC Pills : Contraception MCQ

The combined oral contraceptive pill, besides being used as a method of contraception, can be used to treat the following, EXCEPT:

a) Endometriosis.

b) Ovulation pain.

c) Menorrhagia.

d) Dysmenorrhea.

e) Mucinous ovarian cyst.

f) Functional ovarian cyst

Correct Answer: e and f. Although widely used for treating functional ovarian cysts, combined oral contraceptives appear to be of no benefit. Watchful waiting for two or three cycles is appropriate. Should cysts persist, surgical management is often indicated. ( Ref: Cochrane 2014).

5. Oral contraceptive pill : Contraception MCQ

You have been asked to prescribe a combined oral contraceptive pill to a 26-yr-old woman with acne and hirsutism. She is known to have PCOS. What is the best available option?

a) Cerazette (desogestrel)

b) Ethinylestradiol / norgestimate

c) Ethinylestradiol / norethisterone

d) Ethinylestradiol / levonorgestrel

e) Yasmin (ethinylestradiol / drosperinone)

Correct Answer: e) Yasmin. From the options provided Yasmin is more beneficial in terms of management of acne and hirsuitism, along with PCOS. Women with PCOS may be further maintained on ethinylestradiol + desogestrel for contraception.

Yasmin contains 3 mg of drosperinone, which has some antiandrogenic properties. Dianette (cyproterone acetate, ethinylestradiol) is also useful because it contains cyproterone acetate, which is also an antiandrogenic agent. Care must be taken for women with a high body mass index.

Mirena (levonorgestrel) is a good option for contraception in women with PCOS because it provides protection to the endometrium (by opposing the unopposed estrogen in PCOS).

6. Combined OC pills : Contraception MCQ

a) Reduce risk of endometrial cancer.

b) Increase risk of ovarian cancer.

c) Reduce risk of breast cancer

d) Reduce risk of cervical cancer.

e) Worsen endometriosis as it contains estrogen

Correct Answer: a) Reduce risk of endometrial cancer. A number of studies suggest that current use of OC's appears to slightly increase the risk of breast cancer, especially among younger women.

Women who use OC's have reduced risks of ovarian and endometrial cancer. This protective effect increases with the length of time oral contraceptives are used.

OC's use is associated with an increased risk of cervical cancer; however, this increased risk may be because sexually active women have a higher risk of becoming infected with HPV.

7. NuvaRing is combined hormonal contraceptive vaginal ring

a) True

b) False - It is progesterone only ring

Correct Answer: a) True. NuvaRing is a flexible plastic (ethylene-vinyl acetate copolymer) ring that releases a low dose of a progestin and estrogen over three weeks. Like all combined hormonal contraceptives, NuvaRing works primarily by preventing ovulation. Approved NuvaRing regimen specifies insertion of the ring into the vagina for a three-week period, then removal of the ring for one week, during which the user will experience a menstrual period.

8. DMPA : Contraception MCQ

If DMPA is taken more than four weeks late Depot-medroxyprogesterone acetate (DMPA) must be injected into the thigh or buttocks or deltoid four times a year (every 11 to 13 weeks or 3 months).

a) Give double dose of DMPA

b) Provide emergency contraception - e.g. I-pill

c) Insert Copper-T

d) Start oral contraceptive pill

Correct Answer: b) Provide emergency contraception - e.g. I-pill. Also if norethisterone enanthate (NET-EN) progestogen-only injection taken more than two weeks late I-pill should be administered.

9. Pearl index : Contraception MCQ

With regards to contraception failure, the pearl index refers to:

a) Numbers of Pregnancies in years.

b) Number of pregnancies in 1 woman-year.

c) Number of pregnancies in 100 woman-year.

d) Number of pregnancies in 100 woman-years over pregnancy losses.

e) Number of Pregnancy losses in 100 woman-years.

Correct Answer: c) Number of pregnancies per 100 women–years of use. Life table methods (Decrement tables) are often used to study birth control effectiveness. In this role, they are an alternative to the Pearl Index.

As used in birth control studies, a decrement table calculates a separate effectiveness rate for each month of the study, as well as for a standard period of time (usually 12 months). Use of life table methods eliminates time-related biases (i.e. the most fertile couples getting pregnant and dropping out of the study early, and couples becoming more skilled at using the method as time goes on), and in this way is superior to the Pearl Index.

10. Side effects of OC Pills : Contraception MCQ

The following conditions are aggravated by combined oral contraceptive pills

a) Hirsutisum

b) Endometriosis

c) Dysmenorrhoea

d) Pre-menstrual syndrome

e) Genital fungal infection

Correct Answer: e) Genital fungal infection. Birth control pills may lead to women developing yeast infections because they increase estrogen levels in a woman’s body. However, newer forms of birth control are less likely to cause a yeast infection. Oral contraceptives with higher doses of estrogen can lead to Genital fungal infection. The change in vaginal pH leads to yeast infections with birth control pill use.

11. Mechanisms of Oral Contraceptive Pills include all of the following EXCEPT

a) Ovulation suppression

b) Enhanced ovarian androgen production

c) Altered cervical mucus

d) Altered endometrium

e) Altered tubal motility

Correct Answer: b) Enhanced ovarian androgen production. Combined hormonal contraceptives, including COCPs, inhibit follicular development and prevent ovulation as a primary mechanism of action. Another primary mechanism of action of all progestogen-containing contraceptives is inhibition of sperm penetration through the cervix into the upper genital tract (uterus and fallopian tubes) by decreasing the water content and increasing the viscosity of the cervical mucus. Other mechanisms are......

Slowing tubal motility and ova transport, which may interfere with fertilization.

Endometrial atrophy and alteration of metalloproteinase content, which may impede sperm motility and viability, or theoretically inhibit implantation.

Endometrial edema, which may affect implantation.

12. Contraindications for OC Pills : Contraception MCQ

The following is an absolute contraindications to the combined oral contraceptive pills

a) Varicose veins

b) Previous history of viral hepatitis

c) Prosthetic heart valve

d) Diabetes mellitus

e) Age above 35 years

Correct Answer: c) Prosthetic heart valve because of the higher thrombogenic risk. Combined oral contraceptives are generally accepted to be contraindicated in women with pre-existing cardiovascular disease, in women who have a familial tendency to form blood clots (such as familial factor V Leiden), women with severe obesity and/or hypercholesterolemia (high cholesterol level), and in smokers over age 40.

COC are also contraindicated for women with liver tumors, hepatic adenoma or severe cirrhosis of the liver, those who have migraine with aura and for those with known or suspected breast cancer. (WHO category 4).

13. Regarding injectable progesterone contraception, all of the following is true, EXCEPT

a) Medroxyparogesterone acetate is the most commonly used

b) May cause irregular uterine bleeding

c) May cause amenorrhoea

d) Should not be given to lactating mother

e) Does not carry a risk of venous thrombosis

Correct Answer: d) Should not be given to lactating mother. DMPA may be used by breast-feeding mothers. Heavy bleeding is possible if given in the immediate postpartum time and is best delayed until six weeks after birth. It may be used within five days if not breast feeding. While a study showed “no significant difference in birth weights or incidence of birth defects” and “no significant alternation of immunity to infectious disease caused by breast milk containing DMPA”, a subgroup of babies whose started Depo-Provera at 2 days postpartum had a 75% higher incidence of doctor visits for infectious diseases during their first year of life.

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