Case Study: Blair
Blair is a 22-year-old transgender female. As part of the medical treatments for transitioning, she is currently taking 17-beta estradiol and spironolactone (blocks androgen receptors and alters testosterone production). Blair has come to see her GP today as she has had several episodes where she felt faint, and “may even have passed out on a couple of occasions”. It is some time since Blair attended the clinic, and you note when weighing her that she has lost a significant amount of weight and does not present as the active person you remember.
Blair mentions she doesn’t cook much and relies on the takeaway shop around the corner for most food these days.
Physical examination:
Height Weight Appearance
Temperature Blood Group
HR
BP
Respiratory rate Diet
Past patient history Social status
Urinalysis
Blood Bilirubin Urobilinogen
Ketone
Protein
Nitrite
Glucose
pH
Specific Gravity Leucocytes
178 cm
65 kg
Clean, dry skin, thin, significant muscle wastage
37.6◦C
AB+
80 bpm
105/66 mm Hg
22 bpm
Low fibre, high fat
History of depression
Living alone, lonely, lately has occasional sexual contact
-
-
0.1 mg/dL +
-
-
-
6.0 1.005 +
©ACU 2022
1
All topics and their key points listed below must be discussed in your essay
Topic 1: Reproduction (10 marks total)
Prostate tissue contains glandular structures relevant to Blair’s reproductive function. Explain the role of this glandular tissue in reproductive function, including any likely changes from normal in the secretion and resultant effects that are specific to Blair’s transition and the associated treatment. (4 marks)
Considering Blair’s current circumstances, describe the role of testosterone prior to the commencement of estradiol and spironolactone therapy and explain whether you expect her testosterone levels to be different to normal because of the therapy. Your discussion should include the homeostatic regulation of male reproductive physiology and the relevant, glands, cells, and hormones. (6 marks)
Topic 2: Cardiovascular system (5 marks total)
Consider Blair’s blood pressure result and discuss whether the mean arterial pressure is likely to be varied from normal. Blair has mentioned she sometimes feels ‘light-headed’ when standing quickly. Explain the role of baroreceptors in this situation. (5 marks)
Topic 3: Digestion/metabolism (8 marks total)
The night after consuming more carbohydrate in the one meal than the last month combined, Blair has abdominal cramps, flatulence, and diarrhea and quickly needs to find a toilet. Link these symptoms to undigested carbohydrate and explain the defecation reflex. (4.5 marks)
State the hormone that would have been MOST active in maintaining Blair’s blood glucose levels after her carbohydrate loaded dinner. Explain your answer. (3.5 marks)
Topic 4: Pharmacology (7 marks total)
Blair is taking spironolactone (which is considered a prodrug) tablets for androgen blocking as part of hormone replacement therapy.
Discuss the route of administration of spironolactone, and its likely bioavailability. Justify your response by explaining how bioavailability is impacted by hepatic first pass metabolism, and whether first pass metabolism is beneficial or detrimental to the function of spironolactone within the body. (4 marks)
Discuss the effect of spironolactone on elimination of other drugs. In your answer, you will need to relate back to the case study and clinical results for Blair. (3 marks)