Gynaecology and family planning

In short

Gynaecology covers disorders of the non-pregnant female reproductive tract — menstrual disorders, infections, benign tumours, infertility, genital malignancy, menopause and pelvic floor problems — while family planning covers the methods and the national programme that let couples decide the number and spacing of children. Both are high-yield in the MBBS final-year Obstetrics and Gynaecology paper, in NEET-PG/INI-CET, and in service-recruitment interviews (NHM Medical Officer, CHO, ESIC, state PSC, Army/Railways). India's programme content is defined by statute and guidelines — the MTP (Amendment) Act 2021, the PCPNDT Act 1994, the National Family Planning programme basket (condom, OCP, IUCD, Antara, Chhaya, sterilisation), Mission Parivar Vikas and the NP-NCD cervical/breast screening protocol. NFHS-5 (2019–21) put India's TFR at 2.0 — below replacement — with modern contraceptive prevalence about 56% and unmet need about 9%, which shifts the programme's focus from limiting to spacing and quality of care.

Explained

Menstrual cycle and its disorders

• Normal cycle: 24–38 days, flow 2–8 days, blood loss under 80 mL. Controlled by the hypothalamo-pituitary-ovarian axis: GnRH (pulsatile) → FSH/LH → ovarian oestradiol and progesterone.
• Ovarian cycle: follicular phase (variable length, oestradiol rises) → LH surge → ovulation (~36 h after surge onset) → luteal phase (fixed ~14 days, progesterone from corpus luteum). Endometrial cycle: proliferative → secretory → menstrual.
• FIGO terminology replaced old terms: use *heavy menstrual bleeding* (not menorrhagia), *intermenstrual bleeding* (not metrorrhagia), *infrequent/frequent bleeding* (not oligo-/polymenorrhoea).
• PALM-COEIN classification of abnormal uterine bleeding (AUB): structural — Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia; non-structural — Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified.
• Amenorrhoea: *primary* — no menses by 15 years (or by 13 with no secondary sexual characters); *secondary* — absent 3 months (regular cycles) or 6 months (irregular). Work up in compartments: outflow tract (Müllerian agenesis, Asherman), ovary (POI, high FSH), pituitary (prolactinoma), hypothalamus (weight loss, exercise, stress). Always exclude pregnancy first.
• Dysmenorrhoea: primary (prostaglandin-mediated, starts 6–12 months after menarche, normal pelvis) treated with NSAIDs ± combined pill; secondary (endometriosis, adenomyosis, PID, IUCD) needs imaging.
• PCOS — Rotterdam criteria (any 2 of 3): oligo-/anovulation; clinical or biochemical hyperandrogenism; polycystic ovarian morphology (≥20 follicles 2–9 mm per ovary or ovarian volume ≥10 mL). Management: weight loss 5–10%, combined pill for cycle control and hirsutism, metformin for insulin resistance, letrozole first line for ovulation induction.

Benign gynaecological conditions and infections

• Leiomyoma (fibroid): oestrogen/progesterone-dependent smooth-muscle tumour; FIGO types 0–8 (0–2 submucous, 3–5 intramural, 6–7 subserous, 8 other e.g. cervical). Submucous fibroids cause the most bleeding and infertility. Options: tranexamic acid/LNG-IUS for bleeding, GnRH agonist pre-operatively, myomectomy (fertility desired), hysterectomy, uterine artery embolisation.
• Adenomyosis: endometrial glands within myometrium; bulky tender uterus, heavy painful periods; MRI/USG junctional-zone thickening.
• Endometriosis: ectopic endometrium (ovary — chocolate cyst, pouch of Douglas, uterosacrals). Triad of dysmenorrhoea, dyspareunia, dyschezia with infertility; definitive diagnosis by laparoscopy; treat with progestins, combined pill, GnRH analogues, or excision/ablation.
• Pelvic inflammatory disease: polymicrobial ascending infection (*Neisseria gonorrhoeae*, *Chlamydia trachomatis*, anaerobes). Sequelae: tubal infertility, ectopic pregnancy, chronic pelvic pain, Fitz-Hugh-Curtis perihepatitis. Treat per NACO syndromic kits — Kit 1 (grey, urethral/cervical discharge: azithromycin + cefixime), Kit 2 (green, vaginitis: fluconazole + secnidazole), Kits 6 and 7 (lower abdominal pain/PID: azithromycin + cefixime, plus metronidazole + doxycycline).
• Vaginal discharge: bacterial vaginosis (thin grey, fishy, clue cells, pH >4.5, Amsel criteria), candidiasis (curdy white, itching, pH normal), trichomoniasis (frothy greenish, strawberry cervix). Genital tuberculosis is an important Indian cause of infertility and scanty menses.
• Pelvic organ prolapse: graded by POP-Q (points Aa, Ba, C, D, Ap, Bp against the hymen) or Baden-Walker. Risks: vaginal delivery, high parity, chronic cough, obesity, menopause. Treatment: pelvic floor exercises, ring pessary, vaginal hysterectomy with pelvic floor repair, sacrocolpopexy, Fothergill (Manchester) operation for young women wanting uterine conservation.
• Menopause: permanent cessation of menses, confirmed after 12 months of amenorrhoea; Indian mean age ~46–48 years (earlier than Western 51). Oestrogen deficiency causes vasomotor symptoms, genitourinary syndrome, osteoporosis and adverse lipids. Menopausal hormone therapy is best started within 10 years of menopause in women under 60, with a progestogen added if the uterus is present; contraindicated in breast cancer, active thromboembolism, undiagnosed bleeding, coronary disease.

Gynaecological oncology and screening

• Cervical cancer: the second commonest cancer in Indian women; cause is persistent high-risk HPV (16, 18 ≈ 70%). Precursor lesions: LSIL/HSIL (CIN 1–3).
• Screening in India (NP-NCD/Operational Framework): women 30–65 years, VIA every 5 years at HWC/PHC level by trained ANM/CHO; HPV DNA testing is the preferred test where available and cytology is used opportunistically. Positive screen → colposcopy and biopsy; "see-and-treat" thermal ablation or cryotherapy for eligible ablative lesions, LEEP/conisation otherwise.
• HPV vaccination: quadrivalent/bivalent and the Indian quadrivalent CERVAVAC; two doses for ages 9–14, three doses from 15 years or if immunocompromised. Introduction into the universal immunisation schedule for girls has been announced in phases — check the current national rollout status.
• FIGO 2018 cervical staging is clinical plus imaging and nodal status: IA microinvasive (IA1 ≤3 mm, IA2 >3–5 mm depth), IB confined to cervix, II beyond uterus (IIA upper vagina, IIB parametrium), III lower vagina/pelvic wall/hydronephrosis, IIIC nodal (IIIC1 pelvic, IIIC2 para-aortic), IVA bladder/rectum, IVB distant. Treatment: surgery (radical hysterectomy, Wertheim) up to IB2/IIA1; concurrent chemoradiation with cisplatin for locally advanced disease.
• Endometrial carcinoma: postmenopausal bleeding is the cardinal symptom; unopposed oestrogen, obesity, PCOS, nulliparity, tamoxifen, Lynch syndrome. Evaluate with TVS endometrial thickness (>4 mm postmenopausal) and endometrial biopsy; stage surgically.
• Ovarian cancer: presents late with mass, ascites and raised CA-125; epithelial (serous commonest), germ cell in young women (AFP, hCG, LDH), sex-cord stromal. Surgical staging with cytoreduction plus platinum-taxane chemotherapy; BRCA testing guides PARP inhibitors.
• Gestational trophoblastic disease: molar pregnancy (snowstorm on USG, very high hCG), invasive mole, choriocarcinoma; serial hCG follow-up with contraception during follow-up, methotrexate/EMA-CO for neoplasia.

Infertility

• Definition: failure to conceive after 12 months of unprotected intercourse (evaluate earlier if the woman is over 35, or there is known pathology). Primary = never conceived; secondary = previous conception.
• Causes, roughly: male factor 30–40%, tubal/peritoneal 25–35% (high in India from genital TB and PID), ovulatory 15–25%, uterine/cervical and unexplained the rest.
• Basic workup: semen analysis (WHO 2021 reference values), confirmation of ovulation (mid-luteal progesterone, cycle tracking), ovarian reserve (AMH, antral follicle count), tubal patency (hysterosalpingography or laparoscopy with chromopertubation), TSH and prolactin.
• Treatment ladder: lifestyle and timed intercourse → ovulation induction (letrozole, clomiphene, gonadotropins) → intrauterine insemination → IVF/ICSI. Surgery for fibroids, septum, endometrioma, tubal disease.
• Legal framework: the Assisted Reproductive Technology (Regulation) Act, 2021 registers ART clinics and banks and sets donor/consent rules; the Surrogacy (Regulation) Act, 2021 permits only altruistic surrogacy for eligible Indian couples and bans commercial surrogacy.

Contraception — the method basket

• Barrier: male condom (also prevents STI/HIV), female condom, diaphragm with spermicide. Nirodh is supplied free and through social marketing.
• Hormonal combined: combined oral pill (Mala-N free supply, Mala-D social marketing) — ethinyl oestradiol + progestogen, 21 active + 7 iron/placebo; acts mainly by suppressing ovulation. Non-contraceptive benefits: lighter periods, less dysmenorrhoea, reduced ovarian and endometrial cancer risk. Contraindications (WHO MEC category 4): migraine with aura, smoker over 35, uncontrolled hypertension, VTE, breast cancer, active liver disease, under 6 weeks postpartum breastfeeding.
• Progestogen-only: Antara — injectable DMPA 150 mg IM (or 104 mg subcutaneous) every 3 months, free in the public programme; delayed return of fertility and bone mineral density loss are counselling points. Progestogen-only pills for lactating women. LNG-IUS (Mirena-type) is also a treatment for heavy menstrual bleeding and adenomyosis.
• Non-hormonal pill: Chhaya — centchroman (ormeloxifene) 30 mg, a SERM, twice weekly for 12 weeks then once weekly; Indian-developed, safe in lactation.
• Intrauterine: CuT 380A (effective 10 years) and CuT 375; postpartum IUCD (PPIUCD) within 48 hours or at 6 weeks; post-abortion IUCD. Copper ions are spermicidal and the device causes a sterile inflammatory reaction. Side effects: bleeding, pain, expulsion (~2–10%), displacement; absolute contraindications include pregnancy, active PID, unexplained bleeding, distorted cavity, genital malignancy.
• Emergency contraception: levonorgestrel 1.5 mg within 72 hours (effective up to 120 h with falling efficacy) — free as Ezy-pill in the programme; ulipristal acetate; copper IUCD within 5 days is the most effective option. It does not disturb an established pregnancy and is not an abortifacient.
• Permanent methods: minilap/laparoscopic tubectomy and no-scalpel vasectomy (NSV — simpler, safer, cheaper, but low uptake; male sterilisation is under 1% of the method mix). Written informed consent is mandatory, targets are prohibited, and the Family Planning Indemnity Scheme compensates death, failure and complications. *Devika Biswas v. Union of India* (2016) ordered the end of sterilisation camps and target-driven practice.
• Natural methods: lactational amenorrhoea method (valid only if under 6 months, exclusively breastfeeding, amenorrhoeic), standard days/cycle beads, basal body temperature, withdrawal — all with high typical-use failure.
• Programme context: Mission Parivar Vikas in high-fertility districts, ASHA home delivery of contraceptives, the postpartum family planning package, and "ensure spacing at birth" incentives. Male involvement and quality of care, not targets, drive current policy.

Medical termination of pregnancy and the law

• MTP Act 1971, amended 2021 (rules 2021): termination up to 20 weeks on the opinion of one registered medical practitioner; 20 to 24 weeks on the opinion of two RMPs for specified categories of women (survivors of rape or incest, minors, change of marital status, disability, mental illness, fetal malformation, humanitarian/disaster settings). Beyond 24 weeks only for substantial fetal abnormality, on the approval of a State-level Medical Board.
• Grounds: risk to the woman's life or grave injury to physical or mental health, substantial fetal abnormality, failure of contraception (presumed grave mental injury), and pregnancy from rape.
• Consent: the woman's own consent suffices if she is 18 or more and of sound mind; guardian's consent if a minor or mentally ill. Identity and particulars are confidential — disclosure is punishable.
• Methods: medical abortion up to 9 weeks (63 days) with mifepristone 200 mg orally followed by misoprostol 800 µg — not permitted over the counter without a provider and follow-up; surgical — manual vacuum aspiration/suction evacuation up to 12 weeks, dilatation and evacuation or induction thereafter. Always offer post-abortion contraception.
• PCPNDT Act, 1994 (amended 2003): prohibits sex determination and its advertisement; mandates registration of ultrasound clinics, Form F records, and display of the "sex determination is prohibited" notice. Punishment up to 3 years and ₹10,000 fine for the first offence (higher on repeat), with suspension of medical registration. It does not prohibit lawful MTP — a common confusion.
• Related statutes: POCSO Act 2012 (mandatory reporting of a pregnancy in a minor), Prohibition of Child Marriage Act 2006, Clinical Establishments Act 2010, and the National Medical Commission's professional conduct regulations.

Key points

• PALM-COEIN — FIGO's structural/non-structural classification of abnormal uterine bleeding.
• Rotterdam criteria — 2 of 3 (anovulation, hyperandrogenism, PCOM) diagnose PCOS after excluding mimics.
• Luteal phase — fixed at ~14 days; cycle-length variation comes from the follicular phase.
• Postmenopausal bleeding — always investigate for endometrial carcinoma (TVS + biopsy).
• VIA every 5 years, 30–65 years — India's field screening test for cervical cancer; HPV DNA where available.
• FIGO 2018 stage IIIC — nodal disease, the key change from the 2009 cervical staging.
• CuT 380A — copper IUCD effective for 10 years; can be inserted within 48 h postpartum (PPIUCD).
• Antara — DMPA injectable every 3 months; Chhaya — weekly centchroman, non-hormonal.
• Emergency contraception — LNG 1.5 mg within 72 h; copper IUCD within 5 days is most effective.
• LAM — reliable only when all three conditions hold: <6 months, exclusive breastfeeding, amenorrhoea.
• Pearl Index — pregnancies per 100 woman-years of exposure; lower is better.
• Couple protection rate — percentage of eligible couples effectively protected; needs about 60% for replacement fertility.
• Eligible couple — currently married couple with the wife normally 15–45 years; roughly 15–18% of a population.
• MTP 2021 — 20 weeks (one RMP), 20–24 weeks (two RMPs, specified categories), beyond 24 weeks only via Medical Board.
• PCPNDT 1994 — bans sex determination and its advertisement; Form F is compulsory.
• No targets — sterilisation must be voluntary, informed and camp-free (*Devika Biswas*, 2016); Family Planning Indemnity Scheme covers failure and complications.
• NFHS-5 — TFR 2.0, modern contraceptive prevalence ~56%, unmet need ~9%; female sterilisation still dominates the method mix.
• Syndromic STI management — NACO colour-coded kits 1–7 at PHC level, with partner treatment.

Formulas and examples

Example 1 — Pearl Index of an IUCD trial. 800 women use CuT 380A for 1 full year; 10 pregnancies occur.

• Total exposure = 800 × 12 = 9,600 woman-months.
• PI = (10 × 1200) / 9,600 = 12,000/9,600 = 1.25 pregnancies per 100 woman-years.
• Interpretation: consistent with the quoted CuT 380A failure of 0.6–2 per 100 woman-years.

Example 2 — Couple protection rate of a PHC. Population 30,000. Records show 1,850 tubectomies/vasectomies, 420 IUCD users, 310 OCP users, 180 condom users and 140 Antara users currently protected.

• Eligible couples = 0.15 × 30,000 = 4,500.
• Protected couples = 1,850 + 420 + 310 + 180 + 140 = 2,900.
• CPR = (2,900 × 100)/4,500 = 64.4% — above the ~60% associated with replacement-level fertility, so the PHC's effort should shift to spacing methods and quality of counselling.

Example 3 — CYP from a sub-centre's annual distribution. 6,000 condoms, 650 OCP cycles, 20 CuT 380A insertions, 48 Antara doses.

• Condoms: 6,000/120 = 50 CYP. OCP: 650/13 = 50 CYP.
• IUCD: 20 × 3.5 = 70 CYP. Antara: 48/4 = 12 CYP.
• Total = 50 + 50 + 70 + 12 = 182 CYP — the IUCD gives the most protection per unit of effort.

Example 4 — TFR from age-specific fertility rates. ASFRs (per 1,000 women): 15–19 → 40; 20–24 → 150; 25–29 → 130; 30–34 → 60; 35–39 → 20; 40–44 → 6; 45–49 → 2.

• Σ ASFR = 40+150+130+60+20+6+2 = 408.
• TFR = 5 × 408 / 1000 = 2.04 children per woman — essentially at replacement level (~2.1), matching the NFHS-5 national figure of 2.0.

Example 5 — MTP decision. A 17-year-old survivor of sexual assault presents at 22 weeks with a viable intrauterine pregnancy.

• Gestation is in the 20–24 week window and she falls in a specified category (minor and survivor of rape) → two RMPs' opinion suffices; no Medical Board is needed.
• Consent: she is a minor, so the guardian's written consent is required along with her assent.
• Mandatory POCSO reporting to police; identity kept confidential in all MTP records (Form III register).
• Method: induction with mifepristone-misoprostol or D&E by a trained provider; offer post-abortion contraception (PPIUCD or Antara) before discharge.

Where it is used

• Public health service: NHM Medical Officers, CHOs at Health and Wellness Centres and ANMs run contraceptive counselling, PPIUCD insertion, Antara injections, VIA screening and fixed-day static sterilisation services.
• District and medical college hospitals: gynaecology OPD and theatre work — hysteroscopy, laparoscopy, vaginal hysterectomy, oncology referral under the National Programme for Prevention and Control of NCDs.
• Private sector and ART: IVF chains and fertility clinics regulated under the ART Act 2021; ultrasound clinics operating under PCPNDT registration with Form F audits.
• NGOs and social marketing: FPAI, PSI/Population Services, Marie Stopes-type organisations and the Nirodh/Mala-D social marketing channels in high-fertility districts under Mission Parivar Vikas.
• Pharmaceutical and device industry: Indian manufacture of centchroman, DMPA-SC, CuT 380A, HPV vaccine CERVAVAC (Serum Institute) — roles in medical affairs, clinical research and pharmacovigilance.
• Insurance, audit and medico-legal work: claim scrutiny under the Family Planning Indemnity Scheme and PMJAY gynaecology packages, maternal death and sterilisation-failure reviews, PCPNDT prosecutions.

Interview questions

• Q: State the Rotterdam criteria for PCOS. A: Any two of oligo-ovulation/anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology on ultrasound (≥20 follicles of 2–9 mm per ovary or ovarian volume ≥10 mL), after excluding thyroid disease, hyperprolactinaemia, CAH and Cushing's.
• Q: How do you classify abnormal uterine bleeding? A: By the FIGO PALM-COEIN system — structural causes polyp, adenomyosis, leiomyoma, malignancy/hyperplasia, and non-structural coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not yet classified.
• Q: What are the gestational limits under the MTP (Amendment) Act, 2021? A: Up to 20 weeks on one registered practitioner's opinion; 20–24 weeks on two practitioners' opinion for specified categories such as survivors of rape, minors and fetal abnormality; beyond 24 weeks only with State Medical Board approval for substantial fetal abnormality.
• Q: How does the copper IUCD work and when can it be inserted postpartum? A: Copper ions are spermicidal and the device provokes a sterile inflammatory endometrial reaction preventing fertilisation and implantation; it can be inserted within 48 hours of delivery (PPIUCD) or deferred to 6 weeks, avoiding the 48-hour-to-6-week interval.
• Q: What is the Pearl Index and what is its main drawback? A: Pregnancies per 100 woman-years, calculated as pregnancies × 1200 ÷ months of exposure; it assumes a constant failure rate and ignores that failures cluster early and that continuing users are a self-selected group — life-table analysis is better for long follow-up.
• Q: A couple wants spacing for two years and the woman is breastfeeding a 3-month-old. What do you offer? A: LAM is partly protective but unreliable alone; offer a progestogen-only method — PPIUCD/CuT if not already inserted, Antara (DMPA), progestogen-only pills or Chhaya — and avoid the combined oral pill in early lactation.
• Q: Which cervical cancer screening test does India's programme use and in whom? A: Visual inspection with acetic acid every five years for women aged 30–65 at health and wellness centres by trained CHO/ANM, with HPV DNA testing preferred where it is available and colposcopy with biopsy for positives.
• Q: Does the PCPNDT Act prohibit abortion? A: No — it prohibits prenatal sex determination and its advertisement and regulates diagnostic ultrasound; lawful termination under the MTP Act is unaffected.
• Q: Why is male sterilisation preferred technically yet under-used in India? A: No-scalpel vasectomy is quicker, safer, cheaper and has a lower failure rate than tubectomy, but it accounts for under 1% of the method mix because of myths about potency, poor male counselling and a programme historically focused on women.
• Q: How do you evaluate a couple with primary infertility of two years? A: Semen analysis and confirmation of ovulation first, then ovarian reserve (AMH/antral follicle count), tubal patency by HSG or laparoscopy, plus TSH and prolactin — remembering that genital tuberculosis is a frequent tubal cause in India.
• Q: Give three absolute contraindications to the combined oral contraceptive pill. A: Migraine with aura, active or past venous thromboembolism, and current breast cancer; others include uncontrolled hypertension, smoking above 35 years and active liver disease.
• Q: What compensation exists if a sterilisation fails? A: The Family Planning Indemnity Scheme pays defined amounts for failure, complications and death following a programme sterilisation, provided consent and eligibility criteria were met — the exact amounts are revised periodically, so quote the current NHM circular.

Common mistakes

• Treating abnormal bleeding hormonally in a perimenopausal or postmenopausal woman without first excluding endometrial carcinoma by biopsy.
• Using obsolete terms (menorrhagia, metrorrhagia, DUB) instead of FIGO/PALM-COEIN terminology in theory papers.
• Quoting stale MTP limits — "12 and 20 weeks" with one/two doctors — instead of the 2021 Amendment's 20/24-week structure and Medical Board route.
• Confusing emergency contraception with medical abortion, and claiming that levonorgestrel disrupts an established pregnancy.
• Forgetting the denominator in programme indicators — reporting "2,900 couples protected" without the eligible-couple total, or mixing woman-months with woman-years in the Pearl Index.
• Assuming lactational amenorrhoea is protective beyond six months or with mixed feeding, and omitting postpartum contraception at discharge.
• Describing sterilisation as reversible or conducting it without documented informed consent — and still thinking in terms of "targets", which have been prohibited since the *Devika Biswas* judgment.

Related topics

Obstetrics: antenatal care, labour and complications · Paediatrics: growth, nutrition, immunisation and newborn care · Reproductive and child health under NHM · Sexually transmitted infections and NACO programme · Cancer screening under NP-NCD · Medical ethics, consent and health legislation in India