PLAB 1 & UKMLA Clinical Scenario: Hair Loss in Gender-Affirming Therapy (November 2025 Exam)
Topic: Dermatology / Transgender Health GMC MLA Content Map: Endocrine / Skin / Health Promotion
The November 2025 PLAB 1 exam was a turning point. For the first time, we saw a significant number of candidates struggle with questions that were previously considered "low yield" or outside the traditional blueprint.
One major area of expansion in the UKMLA (Medical Licensing Assessment) is inclusive healthcare, specifically Transgender Health.
Below, we break down a specific question written by our team to test this high-yield concept. This question caught many students off-guard because outdated question banks did not cover it.
The Clinical Scenario
A 24-year-old transgender woman attends the Gender Identity Clinic for a review. She started gender-affirming hormone therapy (GAHT) 3 months ago.
Current Medication:
Oestradiol valerate 2 mg daily
Spironolactone 100 mg daily
She is distressed because she has noticed significantly increased hair shedding when brushing or showering over the last 4 weeks. She describes the hair coming out "in clumps" but has no scalp inflammation or scarring.
Vitals & Labs:
Testosterone: 1.5 nmol/L (Suppressed within female range)
Oestradiol: 350 pmol/L (Therapeutic range)
Potassium: 4.8 mmol/L (Normal)
Which of the following is the most likely diagnosis?
A. Acute telogen effluvium
B. Anagen effluvium
C. Oestradiol-induced androgenic alopecia
D. Progression of male-pattern baldness
E. Spironolactone toxicity
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The Correct Answer & Explanation
✅ Correct Answer: A. Acute telogen effluvium
Why is this the correct answer? This is a classic presentation of Telogen Effluvium (TE) triggered by a major physiological shift.
To answer this, you need to connect the timeline with the mechanism:
The Trigger (3 Months Ago): The patient started Gender-Affirming Hormone Therapy (GAHT). This causes a rapid, systemic shift in hormone levels—testosterone is suppressed, and oestradiol is introduced.
The Shock: This hormonal "shock" prematurely pushes actively growing hair follicles (Anagen phase) into the resting phase (Telogen phase).
The Lag Period: Hair stays in the resting phase for about 3 months before falling out.
The Shedding (Now): Exactly 3 months after starting therapy, the new hair pushes the old "resting" hair out, resulting in diffuse shedding or "clumps."
Key Takeaway: Any major hormonal change (starting GAHT, stopping the pill, childbirth) can trigger Telogen Effluvium. The 3-month lag is the biggest clue.
Why Are the Other Answers Wrong?
This question tricked many candidates because they assumed the drugs were causing direct harm.
❌ B. Anagen Effluvium: This is the shedding of actively growing hair. It happens within days or weeks of a toxic insult, most commonly chemotherapy or radiation. It does not fit the 3-month timeline.
❌ C. Oestradiol-induced androgenic alopecia: This is physiologically impossible. Oestrogen prolongs the anagen (growth) phase and is protective against hair loss. It treats hair loss; it doesn't cause it.
❌ D. Progression of male-pattern baldness: Look at her labs. Her testosterone is 1.5 nmol/L (very low). Male-pattern baldness is driven by DHT (a derivative of testosterone). Since her testosterone is suppressed and she is on Spironolactone (an anti-androgen), her genetic hair loss should be halting, not accelerating.
❌ E. Spironolactone toxicity: While Spironolactone can cause hyperkalaemia (high potassium) or dizziness, it does not cause hair loss. In fact, Spironolactone is a standard treatment for female-pattern hair loss because it blocks androgens. The shedding is a reaction to the change in hormones, not a side effect of the drug molecule itself.
The "New Standard" for the PLAB/UKMLA
This question highlights a critical shift in the exam.
The "Old" PLAB: Focused heavily on common emergencies (Heart Attack, Asthma, Sepsis). The "New" UKMLA: Still tests emergencies, but now integrates Health Promotion and Transgender Care, etc, as core topics.
Many UK graduates sitting the MLA and International graduates sitting the PLAB failed to recognise this pattern because they relied on older, legacy resources. The passing score for recent exams has fluctuated, reflecting this increased difficulty and broader syllabus.
This isn't the only area getting tougher. Check out our analysis of the recent Hypertension Guideline Changes to see how chronic conditions are being tested.
Prepare with a Question Bank that Evolves
At MedRevisions since 2019, we don't just recycle old questions. We actively monitor the GMC MLA Content Map to ensure new topics—like Transgender Health, Genetic Counselling, and Palliative Care regulations—are covered in depth.
Don't get caught out by the new curriculum. Access our library of 5,000+ questions, including the latest 2025 exam topics that other banks are missing.
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