1. Topic: Estrogen-Progestogen Strip

Correct Answer: B. Of a combined mini-dose

Explanation: A combined mini-dose pill (B) refers to an oral contraceptive that contains a low dose of both estrogen and progestogen. In this case, the 21 identical pills each containing 30 micrograms of ethinyl estradiol and a progestogen qualify as a combined mini-dose pill. It is not a classic pill (A), micropill (D), sequential (C), or biphasic mini-dose (E).

2. Topic: Maternal-Fetal Blood Immunization

Correct Answer: C. Mother group O rhesus – negative indirect Coombs test child group 0 Rh+

Explanation: Anti-D Rh immunoglobulin is administered to prevent hemolytic disease of the newborn when there is a risk of Rh incompatibility. This is necessary when an Rh-negative mother (O rhesus -) has an Rh-positive child (0 Rh+), particularly if the mother has a negative indirect Coombs test, indicating she has not yet developed antibodies. In option C, the mother is Rh-negative with a negative Coombs test and the child is Rh-positive, making this the correct scenario for administering anti-D immunoglobulin to prevent sensitization.

3. Topic: Tumor of the Breast

Correct Answer: B. Cytopunction

Explanation: When a woman presents with a breast lump, especially in the upper outer quadrant, and a mammogram has been performed, cytopunction (fine needle aspiration or biopsy) is the essential next step. This procedure allows for the extraction of cells or tissue from the lump for cytological examination, helping to confirm the diagnosis and guide further treatment. While other tests like ultrasound can provide additional imaging, cytopunction is crucial for a definitive diagnosis.

4. Topic: Paget’s Disease

Correct Answer: C. Glomerular nephropathy

Explanation: Paget’s disease primarily affects the bones, leading to complications such as sarcomatous degeneration (a type of bone cancer), spontaneous fractures due to weakened bone structure, congestive heart failure from the increased cardiac workload, and spinal compression due to bone deformities. However, glomerular nephropathy (a kidney condition) is not associated with Paget’s disease, making it the incorrect answer in this context.

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5. Topic: Infectious Disease During Pregnancy

Correct Answer: E. Specific immunoglobulin and hepatitis B vaccination

Explanation: Newborns born to mothers who are positive for both HBsAg and HBeAg have a high risk of hepatitis B infection. The recommended preventive treatment is the administration of specific hepatitis B immunoglobulin immediately after birth, along with the initiation of the hepatitis B vaccination series. This combined approach provides immediate passive immunity and helps the newborn develop active immunity against the virus, significantly reducing the risk of chronic hepatitis B infection.

6. Topic: Ovulation and Menstrual Cycle

Correct Answer: C. 18 days

Explanation: For a woman with a regular menstrual cycle of 32 days, the luteal phase (post-ovulatory phase) typically lasts 14 days. To calculate the date of ovulation, the luteal phase length is subtracted from the total cycle length. Therefore, the pre-ovulatory phase would be 32 – 14 = 18 days. This means that ovulation occurs approximately 18 days before the next expected period.

7. Topic: Menopause Symptoms

Correct Answer: D. Breast tension

Explanation: Menopause is commonly associated with symptoms such as paresthesia of the extremities, insomnia, vaginal dryness, and sweating due to hormonal changes. However, breast tension is not typically a manifestation of menopause; in fact, it is more often associated with the menstrual cycle or hormonal fluctuations prior to menopause.

8. Topic: Vulvar Lesions

Correct Answer: C. Genital herpes

Explanation: The presence of clustered blisters on the labia majora, some of which are broken, along with painful symptoms, ipsilateral inguinal adenopathies, and fever (38°C) are classic signs of genital herpes. This condition is caused by the herpes simplex virus and is characterized by painful blisters and ulcers in the genital area. The other conditions listed do not typically present with these specific symptoms.

9. Topic: Breast Tumor Classification

Correct Answer: B. T1 N1 MX

Explanation: In this scenario, the tumor is 2 cm in diameter, which places it in the T1 category (tumor ≤2 cm). The presence of clinically immobile ipsilateral axillary lymphadenopathy suggests N1 (regional lymph nodes involved). Since no metastatic assessment has been conducted, the MX classification is used, indicating that the presence of distant metastasis cannot be evaluated. Thus, the tumor is classified as T1 N1 MX.

10. Topic: Female Genital Trichomoniasis

Correct Answer: B. It is easily diagnosed on smears taken from the cervix

Explanation: Trichomoniasis is a sexually transmitted infection (STI) that is typically diagnosed using a wet mount or culture from vaginal secretions rather than cervical smears. While the other statements about trichomoniasis being a venereal disease, responding well to Flagyl treatment, requiring partner treatment, and possibly being associated with vaginal candidiasis are correct, diagnosis from cervical smears is not typically accurate, making statement B incorrect.

11. Topic: Acute Salpingitis

Correct Answer: C. ABDE

Explanation: Acute salpingitis, which is an inflammation of the fallopian tubes, can lead to several complications and remote effects, including: Dyspareunia (A): Painful intercourse. Abdominal pain (B): Common symptom due to inflammation. Ectopic pregnancy (D): Resulting from scarring and adhesions that obstruct the fallopian tube. Tubal sterility (E): Due to scarring that can block the fallopian tubes, affecting fertility. However, chronic urinary tract infections (C) are not directly caused by acute salpingitis. Therefore, the correct set of consequences includes A, B, D, and E.

12. Topic: Kleihauer Test

Correct Answer: C. Look for the presence of fetal red blood cells in the maternal blood

Explanation: The Kleihauer test is used to detect and quantify fetal red blood cells in the maternal circulation. This test is particularly useful in assessing the extent of fetal-maternal hemorrhage, which can help in managing cases such as Rh incompatibility and in determining the need for additional doses of anti-D immunoglobulin.

13. Topic: Diagnosis of Endometrial Cancer

Correct Answer: E. Biopsy E- curettage

Explanation: A biopsy with curettage is the most definitive method for diagnosing endometrial cancer. This procedure involves obtaining a tissue sample from the endometrium for histological examination, which can confirm the presence of cancerous cells with high accuracy. Other methods like ultrasound or endometrial smear can suggest abnormalities but are not as definitive as biopsy and curettage.

14. Topic: Breast Cancer Screening

Correct Answer: B. Mammography

Explanation: Mammography is the most sensitive and widely used method for breast cancer screening. It can detect early signs of cancer, such as microcalcifications, before they become palpable. While other methods like ultrasound can be useful in specific cases, mammography remains the gold standard for routine screening due to its ability to detect small, asymptomatic tumors.

15. Topic: Confirming Pregnancy Viability

Correct Answer: E. Ultrasound

Explanation: Ultrasound is the most reliable method to confirm the viability of a pregnancy, especially in cases of amenorrhea with bleeding. It allows direct visualization of the gestational sac, fetal heartbeat, and the overall development of the embryo or fetus, providing clear evidence of whether the pregnancy is progressing normally. Other tests, such as HCG levels, can indicate pregnancy but do not confirm its viability as effectively as an ultrasound.

16. Topic: Cervical Cancer and Infectious Agents

Correct Answer: D. Papillomavirus

Explanation: Human papillomavirus (HPV) is the primary infectious agent linked to the development of cervical cancer. Persistent infection with high-risk HPV strains, particularly types 16 and 18, is a significant factor in the pathogenesis of cervical cancer. Other listed pathogens, such as Trichomonas, Gonococcus, Chlamydia, and Mycoplasma, are associated with other genital infections but are not directly involved in the genesis of cervical cancer.

17. Topic: Postmenopausal Screening

Correct Answer: D. A mammogram

Explanation: A mammogram is routinely recommended for postmenopausal women as part of breast cancer screening. Early detection through mammography can significantly improve outcomes in breast cancer treatment. While bone density assessments, such as a lumbar spine X-ray, are also important, they are typically used to diagnose osteoporosis rather than being a systematic screening tool for all postmenopausal women. Hormone level testing like FSH or estrogen dosage and procedures like hysterography are not standard screenings for this population.

18. Topic: Stage IB Cervical Cancer

Correct Answer: C. Micro invasive cancer

Explanation: Stage IB cervical cancer is characterized by a visible lesion that is confined to the cervix, including both squamous cell carcinoma and adenocarcinoma. However, it does not include microinvasive cancer, which is classified under Stage IA. Microinvasive cancer refers to very early-stage cancer where invasion is minimal, typically less than 5 mm deep and less than 7 mm in horizontal spread. Stage IB cancers can show more extensive invasion, but still limited to the cervix, with potential lymphatic involvement.

19. Topic: Fibroids and Pregnancy

Correct Answer: B. If there is a fibroid in the 3rd trimester of pregnancy a myomectomy must be performed

Explanation: Myomectomy, the surgical removal of fibroids, is generally not recommended during the third trimester of pregnancy due to the high risk of complications such as bleeding and preterm labor. The preferred approach is to manage the pregnancy conservatively and plan for the fibroid’s removal after childbirth if necessary. The other statements regarding fibroids interfering with early pregnancy diagnosis, causing aseptic necrobiosis, leading to abnormal fetal presentations, and potentially obstructing childbirth are accurate.

20. Topic: Newborn Care for HBsAg and HBeAg Positive Mother

Correct Answer: E. Serovaccination

Explanation: For a newborn born to an HBsAg and HBeAg positive mother, the recommended care involves serovaccination, which includes the administration of both specific hepatitis B immunoglobulins (HBIG) and the hepatitis B vaccine. This combined approach provides immediate passive immunity from the immunoglobulins and active immunity through the vaccine, significantly reducing the risk of the newborn developing hepatitis B infection.

21. Topic: Risk Factors for Upper Genital Tract Infection

Correct Answer: B. Increased the risk by taking a progestogen

Explanation: The correct statement is that taking a progestogen does not increase the risk of upper genital tract infections. In fact, progestogens may help thicken cervical mucus, potentially reducing the risk of infection. The other factors mentioned, such as age, nulliparity, IUD use, and local contraceptives, are correctly identified as influencing the risk of upper genital tract infections.

22. Topic: Ovarian Cancer Symptoms

Correct Answer: C. An increase in the volume of the abdomen

Explanation: The most common symptom revealing ovarian cancer is an increase in the volume of the abdomen. This often results from ascites or a growing mass. Other symptoms like metrorrhagia, signs of rectal or bladder compression, and supraclavicular lymphadenopathy can occur, but they are less common as initial presenting signs.

23. Topic: Pregnancy and Blood Pressure

Correct Answer: B. Blood pressure rises during normal pregnancy

Explanation: During normal pregnancy, blood pressure typically decreases due to increased plasma volume and decreased peripheral resistance. An increase in blood pressure during pregnancy is not normal and may indicate conditions such as preeclampsia. The other statements are accurate: plasma volume increases, peripheral resistance decreases, there is a link between hypertension and fetal growth disorders, and a salt-free diet is not generally recommended for managing pregnancy-induced hypertension.

24. Topic: Monitoring Treated Cervical Cancer

Correct Answer: D. Regular surveillance smears

Explanation: For monitoring treated cervical cancer, regular surveillance smears (Pap smears) are crucial to detect any residual or recurrent disease. This method allows for early identification of abnormalities that might indicate a return of cancer. While clinical examination is important, surveillance smears provide specific information about cervical cell changes. Beta2-macroglobulin and alpha-fetoprotein are not typically used for cervical cancer monitoring, and bone scans are used primarily to assess metastatic spread rather than for routine follow-up.

25. Topic: Complications of Estrogen Deficiency in Menopause

Correct Answer: E. AC (Vaginal atrophy and Breast involution)

Explanation: Estrogen deficiency during menopause can lead to vaginal atrophy, which causes thinning and dryness of the vaginal walls. Breast involution, or the reduction of breast tissue, also occurs due to decreased estrogen levels. Endometrial hyperplasia and increased cervical mucus secretion are more associated with other hormonal imbalances or conditions, rather than directly with estrogen deficiency.

26. Topic: Fundal Height Measurement

Correct Answer: B. Fetal hypotrophy

Explanation: A fundal height of 26 cm at 34 weeks of amenorrhea is below the expected range for this stage of pregnancy, which is typically around 30-32 cm. This discrepancy suggests fetal hypotrophy (growth restriction) rather than a normal pregnancy. Twin pregnancies and hydramnios generally cause increased fundal height, while hypertrophy of the placenta might cause height changes but is less commonly diagnosed solely by fundal measurement.

27. Topic: Suspected Ectopic Pregnancy

Correct Answer: C. Ask for a beta HCG assay and an ultrasound

Explanation: When clinical examination is inconclusive in a suspected ectopic pregnancy, a beta HCG assay and ultrasound are essential to confirm the diagnosis. These tests help assess the levels of pregnancy hormones and visualize the location of the pregnancy. Laparoscopy or immediate surgery is not indicated unless there are signs of acute complications or the tests confirm an ectopic pregnancy.

28. Topic: Presentation Engagement in Labor

Correct Answer: B. Has crossed the upper strait

Explanation: Engagement of a presentation refers to the fetal presenting part (typically the head) entering and descending through the pelvic inlet (upper strait). Once the largest diameter of the presenting part has crossed the upper strait, it is considered engaged. This does not mean it has passed through the entire pelvis or reached the vulva; that would indicate further progress in labor.

29. Topic: Diagnosis of Genital Prolapse

Correct Answer: A. On clinical examination

Explanation: Genital prolapse is primarily diagnosed through a clinical examination where the physician can observe and assess the presence of prolapse. Although imaging techniques like ultrasound and hysterography can be used for further evaluation, the initial diagnosis is typically made during a physical examination.

30. Topic: Low Insertion of the Placenta

Correct Answer: E. Ultrasound can make the diagnosis at 35 weeks

Explanation: A low insertion of the placenta, also known as placenta previa, is typically diagnosed using ultrasound imaging, which can accurately assess the placental position. This diagnosis is usually confirmed around 35 weeks of gestation. While other complications related to low placental insertion, such as bleeding, can occur, the definitive diagnosis is made through ultrasound.

31. Topic: Treatment of Threatened Preterm Labor

Correct Answer: C. Beta blocker

Explanation: In the treatment of threatened preterm labor, common medications include progesterone (to support the pregnancy), aspirin (to reduce inflammation and improve blood flow), indomethacin (a nonsteroidal anti-inflammatory drug that can inhibit contractions), and salbutamol (a beta-agonist that can help relax the uterus). However, beta blockers are not typically used for this purpose and are not effective in preventing preterm labor.

32. Topic: Ectopic Pregnancy

Correct Answer: B. It is favored by taking estrogen-progestogen contraceptive pills

Explanation: Ectopic pregnancy is more common in women with a history of tubal infertility treatments and can be associated with conditions that affect the fallopian tubes. A normal pelvic ultrasound does not completely rule out ectopic pregnancy, and a beta HCG plasma level below 5 IU can help in excluding it. Isthmic tubal pregnancies are indeed at a higher risk of catastrophic rupture. However, estrogen-progestogen contraceptive pills are not typically associated with an increased risk of ectopic pregnancy.

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33. Topic: Asymptomatic Bacteriuria in Pregnancy

Correct Answer: A. Must be treated with appropriate anti-infectives

Explanation: Asymptomatic bacteriuria in pregnant women, even if it does not present symptoms, should be treated with appropriate antibiotics. This is because untreated bacteriuria can lead to complications such as pyelonephritis and adverse outcomes for both the mother and the fetus. Urography and cystography are not typically required in this scenario, and indwelling catheters and bed rest are not standard treatments for asymptomatic bacteriuria.

34. Topic: Fetal Complications from Urinary Tract Infections in Pregnancy

Correct Answer: B. Prematurity

Explanation: Urinary tract infections (UTIs) during pregnancy can lead to several fetal complications, with prematurity being one of the most common. UTIs can cause preterm labor, leading to premature birth. Other complications like intrauterine fetal death, retroplacental hematoma, and macrosomia are less directly linked to UTIs compared to prematurity.

35. Topic: Monitoring Pregnancy with Vascular-Renal Risk

Correct Answer: C. Uremia

Explanation: In pregnancies with vascular-renal risk, monitoring typically involves assessing serum creatinine, uricemia, 24-hour proteinuria, and blood pressure. Uremia is not commonly used as a routine monitoring parameter in this context; instead, serum creatinine and other markers provide more immediate information on renal function.

36. Topic: Seizures in Pregnant Women with Hypertension

Correct Answer: D. Eclampsia

Explanation: Epileptic seizures in a pregnant woman at the 9th month, especially with hypertension, most commonly suggest eclampsia. Eclampsia is a severe complication of preeclampsia, characterized by seizures in addition to high blood pressure. Other conditions, like cerebral hemorrhage or thrombosis, could also cause seizures but are less directly linked to the combination of late pregnancy and hypertension.

37. Topic: Assessing Prognosis of Toxaemia of Pregnancy

Correct Answer: D. Uricemia

Explanation: Uricemia (elevated uric acid levels) is a key laboratory test used to assess the prognosis of toxaemia of pregnancy, which includes preeclampsia and eclampsia. Elevated uric acid levels are associated with worsening of the condition and can help in evaluating the severity and prognosis. While creatinine levels can also be important, uricemia is more specifically linked to the progression of toxaemia.

38. Topic: Most Common Cause of Spontaneous Abortion in the 1st Trimester

Correct Answer: E. Chromosomal abnormalities of the egg

Explanation: Chromosomal abnormalities of the egg are the most common cause of spontaneous abortion in the 1st trimester of pregnancy. These abnormalities often lead to non-viable pregnancies, resulting in early miscarriage. While hormonal causes, uterine malformations, and fibroids can contribute to pregnancy loss, chromosomal abnormalities are the leading factor in early pregnancy loss.

39. Topic: Risk Factors for Ectopic Pregnancy

Correct Answer: B. BA ECB

Explanation: The risk factors for ectopic pregnancy include:Progestogen-only pill (A): This method is not a significant risk factor for ectopic pregnancy. History of salpingitis (B): Previous infection of the fallopian tubes increases the risk of ectopic pregnancy. History of pelvic surgery (C): Prior pelvic surgery can lead to scarring and increase the risk of ectopic pregnancy. Ovarian cyst (D): Not a risk factor for ectopic pregnancy. Intrauterine device (IUD) (E): Although it primarily prevents pregnancy, if pregnancy occurs with an IUD in place, there is an increased risk of ectopic pregnancy. Thus, the correct risk factors are B, C, and E.

40. Topic: Causes of Ectopic Pregnancy (GEU)

Correct Answer: A. AA BDE

Explanation: The correct causes of ectopic pregnancy (GEU) include: Sequelae of salpingitis (A): Inflammation of the fallopian tubes can cause scarring, leading to an increased risk of ectopic pregnancy. Tubal endometriosis (B): Endometriosis affecting the fallopian tubes can interfere with normal egg movement, increasing the risk of ectopic pregnancy. Unilateral tubal stenosis (D): Narrowing of one fallopian tube can prevent the egg from reaching the uterus, leading to an ectopic pregnancy. Prolonged egg migration (E): If the egg takes too long to travel through the fallopian tube, it may implant outside the uterus. Thus, the correct answers are A, B, D, and E.

41. Topic: Contraindications to Contraception

Correct Answer: D. Endometrial hyperplasia

Explanation: Endometrial hyperplasia, a condition characterized by the thickening of the uterine lining, is a contraindication to contraception, particularly hormonal contraceptives. These contraceptives can exacerbate the condition, increasing the risk of developing endometrial cancer. The other conditions listed (luteinic cyst, uterine fibroid, endometriosis) are not absolute contraindications to contraception, but their management may require special consideration. Thus, the correct answer is D.

42. Topic: Contraindications to Estrogen-Progestin

Correct Answer: C. Uterine fibroid

Explanation: Uterine fibroids are not a formal contraindication for the use of estrogen-progestin contraceptives. In fact, hormonal contraceptives can sometimes be used to manage symptoms associated with fibroids, such as heavy menstrual bleeding. On the other hand, malignant tumors of the breast and uterus, thromboembolic accidents, cholestatic hepatitis, and pituitary adenoma are considered contraindications due to the potential for exacerbating these conditions. Therefore, the correct answer is C.

43. Topic: Contraindications to Oral Contraception by Estrogen-Progestogen

Correct Answer: A. Multiparity

Explanation: Multiparity (having given birth to more than one child) is not a contraindication for the use of estrogen-progestogen oral contraceptives. However, conditions such as arterial hypertension, deep phlebitis, cholestatic hepatitis, and uterine fibroids are considered either absolute or relative contraindications due to the increased risk of complications. Therefore, the correct answer is A.

44. Topic: Risk Factors for Breast Cancer

Correct Answer: C. BCDE

Explanation: The risk factors for breast cancer include proliferating mastotic lesions (B), lack of breastfeeding (C), late menopause (D), and early first menstruation (E). However, early age at first pregnancy (A) is generally associated with a lower risk of breast cancer, so it is not included among the risk factors. Therefore, the correct answer is C (BCDE).

45. Topic: Prognosis in Cervical Cancer

Correct Answer: B. Cancer stage

Explanation: The most critical factor for the 5-year survival prognosis after appropriate treatment for cervical cancer is the stage of the cancer at the time of diagnosis. The cancer stage determines the extent of the disease and guides treatment options, making it the most significant predictor of survival outcomes. While other factors like HPV strain, patient age, histological grade, and lymph node involvement are important, they do not outweigh the impact of the cancer stage on prognosis.

46. Topic: Fetal Red Blood Cell Production

Correct Answer: D. Liver

Explanation: At the 24th week of gestation, the primary site of red blood cell production in the fetus is the liver. The liver is the main hematopoietic organ during this stage of development, taking over from the yolk sac, which is involved earlier in gestation. Eventually, the bone marrow will become the dominant site of red blood cell production as the fetus matures, but at 24 weeks, the liver remains the primary source.

47. Topic: Lung Maturity Enhancement in Preterm Labor

Correct Answer: B. Betamethasone

Explanation: Betamethasone is a corticosteroid commonly used to enhance fetal lung maturity in cases of preterm labor. Administering this drug accelerates the production of surfactant, a substance that helps keep the airways open in the lungs, significantly reducing the risk of respiratory distress syndrome (RDS) in preterm infants. The other options do not serve this specific function.

48. Topic: Screening for Fetal Well-being in a High-Risk Pregnancy

Correct Answer: E. Biophysical profile of the fetus

Explanation: The biophysical profile (BPP) is the best test for assessing fetal well-being in a high-risk pregnancy, such as in a woman with type 2 diabetes mellitus and chronic hypertension. The BPP combines an ultrasound evaluation of the fetus with a non-stress test (NST) to assess various parameters like fetal breathing movements, gross body movements, fetal tone, amniotic fluid volume, and fetal heart rate. This comprehensive test provides a better overall assessment of fetal health compared to the other options.

49. Topic: Risk Factors for Breast Cancer

Correct Answer: E. Having a mother with a history of breast cancer

Explanation: Having a mother with a history of breast cancer is associated with the greatest lifetime risk of developing the disease. This familial link significantly increases the likelihood due to shared genetic factors, such as mutations in the BRCA1 or BRCA2 genes. While factors like early menarche, late menopause, obesity, and age also contribute to breast cancer risk, a family history, particularly a first-degree relative like a mother, is the most significant predictor.

50. Topic: Types of Breast Cancer

Correct Answer: D. Infiltrating ductal carcinoma

Explanation: Infiltrating ductal carcinoma (IDC) is the most common type of breast cancer. It starts in the ducts of the breast and invades the surrounding tissue. Other types, such as inflammatory carcinoma, lobular carcinoma in situ, lobular infiltrating carcinoma, and ductal carcinoma in situ, are less common or represent different stages or forms of the disease. IDC accounts for the majority of breast cancer cases and is characterized by its ability to spread to other parts of the body.

51. Topic: Causes of Vaginal Discharge

Correct Answer: B. Trichomonas vaginitis

Explanation: Trichomonas vaginitis typically presents with a vaginal discharge that may cause burning and itching, and the pH of the discharge is often elevated, usually above 4.5. In this case, the pH of 4.5 is on the higher side, suggesting an infection like trichomoniasis.

52. Topic: Investigation of Symptoms in a Young Woman

Correct Answer: E. Tests for chlamydia research

Explanation: In a young woman presenting with dysuria, vaginal discharge, and pelvic pain, the most appropriate investigation is testing for sexually transmitted infections, such as chlamydia. These symptoms are often associated with infections like chlamydia and gonorrhea.

53. Topic: Amenorrhea in a Young Woman After Stopping Birth Control Pills

Correct Answer: A. Dosage of serum prolactin level

Explanation: In a young woman with amenorrhea following discontinuation of birth control pills, and with otherwise good health, evaluating serum prolactin levels is important to rule out hyperprolactinemia, which can cause amenorrhea.

54. Topic: Metrorrhagia in a Woman on Oral Contraceptives

Correct Answer: D. Dilation and curettage

Explanation: In a woman with metrorrhagia while on oral contraceptives, dilation and curettage (D&C) is often performed to investigate the cause of abnormal bleeding, especially if the bleeding is persistent or unexplained.