Progesterone

Progesterone (Template:IPAc-en; P4) is an endogenous steroid and progestogen sex hormone involved in the menstrual cycle, pregnancy, and embryogenesis of humans and other species.<ref name="James2015" /><ref name="KingBrucker2010" /> It belongs to a group of steroid hormones called the progestogens<ref name="KingBrucker2010" /> and is the major progestogen in the body. Progesterone has a variety of important functions in the body. It is also a crucial metabolic intermediate in the production of other endogenous steroids, including the sex hormones and the corticosteroids, and plays an important role in brain function as a neurosteroid.<ref name="pmid11108866">Template:Cite journal</ref>

In addition to its role as a natural hormone, progesterone is also used as a medication, such as in combination with estrogen for contraception, to reduce the risk of uterine or cervical cancer, in hormone replacement therapy, and in feminizing hormone therapy.<ref name="pmid30608551">Template:Cite journal</ref> It was first prescribed in 1934.<ref name=Fis2006>Template:Cite book</ref> Template:TOC limit

Biological activity

Progesterone is the most important progestogen in the body. As a potent agonist of the nuclear progesterone receptor (nPR) (with an affinity of K_D = 1 nM) the resulting effects on ribosomal transcription plays a major role in regulation of female reproduction.<ref name="KingBrucker2010" /><ref name="Josimovich2013" /> In addition, progesterone is an agonist of the more recently discovered membrane progesterone receptors (mPRs),<ref name="pmid22687885">Template:Cite journal</ref> of which the expression has regulation effects in reproduction function (oocyte maturation, labor, and sperm motility) and cancer although additional research is required to further define the roles.<ref name="pmid27368976">Template:Cite journal</ref> It also functions as a ligand of the PGRMC1 (progesterone receptor membrane component 1) which impacts tumor progression, metabolic regulation, and viability control of nerve cells.<ref name="pmid9516722">Template:Cite journal</ref><ref name="pmid30087538">Template:Cite journal</ref><ref name="pmid28396637">Template:Cite journal</ref> Moreover, progesterone is also known to be an antagonist of the sigma σ₁ receptor,<ref name="pmid11744080">Template:Cite journal</ref><ref name="pmid21084640">Template:Cite journal</ref> a negative allosteric modulator of nicotinic acetylcholine receptors,<ref name="pmid11108866" /> and a potent antagonist of the mineralocorticoid receptor (MR).<ref name="pmid8282004">Template:Cite journal</ref> Progesterone prevents MR activation by binding to this receptor with an affinity exceeding even those of aldosterone and glucocorticoids such as cortisol and corticosterone,<ref name="pmid8282004" /> and produces antimineralocorticoid effects, such as natriuresis, at physiological concentrations.<ref name="pmid14667981">Template:Cite journal</ref> In addition, progesterone binds to and behaves as a partial agonist of the glucocorticoid receptor (GR), albeit with very low potency (EC₅₀ >100-fold less relative to cortisol).<ref name="pmid18060946">Template:Cite journal</ref><ref name="pmid23209664">Template:Cite journal</ref>

Progesterone, through its neurosteroid active metabolites such as 5α-dihydroprogesterone and allopregnanolone, acts indirectly as a positive allosteric modulator of the GABA_A receptor.<ref name="pmid1347506">Template:Cite journal</ref>

Progesterone and some of its metabolites, such as 5β-dihydroprogesterone, are agonists of the pregnane X receptor (PXR),<ref name="pmid12372848">Template:Cite journal</ref> albeit weakly so (EC₅₀ >10 μM).<ref name="pmid9727070">Template:Cite journal</ref> In accordance, progesterone induces several hepatic cytochrome P450 enzymes,<ref name="Meanwell2014">Template:Cite book</ref> such as CYP3A4,<ref name="LegatoBilezikian2004">Template:Cite book</ref><ref name="LemkeWilliams2012 p164">Template:Cite book</ref> especially during pregnancy when concentrations are much higher than usual.<ref name="ScholarlyEditions2013">Template:Cite book</ref> Perimenopausal women have been found to have greater CYP3A4 activity relative to men and postmenopausal women, and it has been inferred that this may be due to the higher progesterone levels present in perimenopausal women.<ref name="LegatoBilezikian2004" />

Progesterone modulates the activity of CatSper (cation channels of sperm) voltage-gated Ca²⁺ channels. Since eggs release progesterone, sperm may use progesterone as a homing signal to swim toward eggs (chemotaxis). As a result, it has been suggested that substances that block the progesterone binding site on CatSper channels could potentially be used in male contraception.<ref name="pmid21412338">Template:Cite journal</ref><ref name="pmid21412339">Template:Cite journal</ref>

Biological function

File:Estradiol and progesterone % changes across the menstrual cycle.tif

During the menstrual cycle, levels of estradiol (an estrogen) vary by 200 percent. Levels of progesterone vary by over 1200 percent.<ref name="Prior-2020">Template:Cite journal</ref>

Hormonal interactions

Progesterone has a number of physiological effects that are amplified in the presence of estrogens. Estrogens through estrogen receptors (ERs) induce or upregulate the expression of the PR.<ref name="pmid2328727">Template:Cite journal</ref> One example of this is in breast tissue, where estrogens allow progesterone to mediate lobuloalveolar development.<ref name="pmid16917139">Template:Cite journal</ref><ref name="Johnson2003">Template:Cite book</ref><ref name="CoadDunstall2011">Template:Cite book</ref>

Elevated levels of progesterone potently reduce the sodium-retaining activity of aldosterone, resulting in natriuresis and a reduction in extracellular fluid volume. Progesterone withdrawal, on the other hand, is associated with a temporary increase in sodium retention (reduced natriuresis, with an increase in extracellular fluid volume) due to the compensatory increase in aldosterone production, which combats the blockade of the mineralocorticoid receptor by the previously elevated level of progesterone.<ref name="pmid13263410">Template:Cite journal</ref>

Early sexual differentiation

Placental progesterone can be converted into 5α-dihydrotestosterone (DHT), a potent androgen that is responsible for the development of male genitalia.<ref name=wj>Template:Cite journal</ref> This can be done both by conversion into testosterone, which is then converted to DHT, and via the androgen backdoor pathway, which is particularly important for fetal development.<ref name="pmid30763313">Template:Cite journal</ref> As progesterone is the precursor for both pathways, it plays a key role in sexual differentiation.<ref name="pmid24793988">Template:Cite journal</ref><ref name="pmid8636249">Template:Cite journal</ref>

Reproductive system

File:Endometrium ocp use3.jpg

Micrograph showing changes to the endometrium due to progesterone (decidualization) H&E stain.

Progesterone has key effects via non-genomic signalling on human sperm as they migrate through the female reproductive tract before fertilization occurs, though the receptor(s) as yet remain unidentified.<ref name="pmid17447210">Template:Cite journal</ref> Detailed characterisation of the events occurring in sperm in response to progesterone has elucidated certain events including intracellular calcium transients and maintained changes,<ref name="pmid10837122">Template:Cite journal</ref> slow calcium oscillations,<ref name="pmid14606954">Template:Cite journal</ref> now thought to possibly regulate motility.<ref name="pmid15322137">Template:Cite journal</ref> It is produced by the ovaries.<ref name=Marieb>Template:Cite book</ref> Progesterone has also been shown to demonstrate effects on octopus spermatozoa.<ref name="pmid11335951">Template:Cite journal</ref>

Progesterone is sometimes called the "hormone of pregnancy",<ref name="colostate">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> and it has many roles relating to the development of the fetus:

• Progesterone converts the endometrium to its secretory stage to prepare the uterus for implantation. At the same time progesterone affects the vaginal epithelium and cervical mucus, making it thick and impenetrable to sperm. Progesterone is anti-mitogenic in endometrial epithelial cells, and as such, mitigates the tropic effects of estrogen.<ref name="pmid25406186">Template:Cite journal</ref> If pregnancy does not occur, progesterone levels will decrease, leading to menstruation. Normal menstrual bleeding is progesterone-withdrawal bleeding. If ovulation does not occur and the corpus luteum does not develop, levels of progesterone may be low, leading to anovulatory dysfunctional uterine bleeding.
• During implantation and gestation, progesterone appears to decrease the maternal immune response to allow for the acceptance of the pregnancy.<ref name="pmid27662646">Template:Cite journal</ref>
• Progesterone decreases contractility of the uterine smooth muscle.<ref name="colostate"/> This effect contributes to prevention of preterm labor.<ref name="pmid27662646" /> Studies have shown that in individuals who are pregnant with a single fetus, asymptomatic in the prenatal stage, and at a high risk of giving pre-term birth spontaneously, vaginal progesterone medication has been found to be effective in preventing spontaneous pre-term birth. Individuals who are at a high risk of giving pre-term birth spontaneously are those who have a short cervix of less than 25 mm or have previously given pre-term birth spontaneously. Although pre-term births are generally considered to be less than 37 weeks, these studies found that vaginal progesterone is associated with fewer pre-term births of less than 34 weeks.<ref name="pmid35168930">Template:Cite journal</ref>
• A drop in progesterone levels is possibly one step that facilitates the onset of labor.Template:Cn
• In addition, progesterone inhibits lactation during pregnancy. The fall in progesterone levels following delivery is one of the triggers for milk production.Template:Cn

The fetus metabolizes placental progesterone in the production of adrenal steroids.<ref name="pmid30763313"/>

Breasts

Lobuloalveolar development

Progesterone plays an important role in breast development. In conjunction with prolactin, it mediates lobuloalveolar maturation of the mammary glands during pregnancy to allow for milk production and thus lactation and breastfeeding of offspring following parturition (childbirth).<ref name="pmid22844349">Template:Cite journal</ref> Estrogen induces expression of the PR in breast tissue and hence progesterone is dependent on estrogen to mediate lobuloalveolar development.<ref name="pmid16917139" /><ref name="Johnson2003" /><ref name="CoadDunstall2011" /> It has been found that Template:Abbrlink is a critical downstream mediator of progesterone-induced lobuloalveolar maturation.<ref name="pmid26266959">Template:Cite journal</ref> RANKL knockout mice show an almost identical mammary phenotype to PR knockout mice, including normal mammary ductal development but complete failure of the development of lobuloalveolar structures.<ref name="pmid26266959" />

Ductal development

Though to a far lesser extent than estrogen, which is the major mediator of mammary ductal development (via the ERα),<ref name="StraussBarbieri2013">Template:Cite book</ref><ref name="pmid24718936">Template:Cite journal</ref> progesterone may be involved in ductal development of the mammary glands to some extent as well.<ref name="pmid23705924">Template:Cite journal</ref> PR knockout mice or mice treated with the PR antagonist mifepristone show delayed although otherwise normal mammary ductal development at puberty.<ref name="pmid23705924" /> In addition, mice modified to have overexpression of PRA display ductal hyperplasia,<ref name="pmid26266959" /> and progesterone induces ductal growth in the mouse mammary gland.<ref name="pmid23705924" /> Progesterone mediates ductal development mainly via induction of the expression of amphiregulin, the same growth factor that estrogen primarily induces the expression of to mediate ductal development.<ref name="pmid23705924" /> These animal findings suggest that, while not essential for full mammary ductal development, progesterone seems to play a potentiating or accelerating role in estrogen-mediated mammary ductal development.<ref name="pmid23705924" />

Breast cancer risk

Progesterone also appears to be involved in the pathophysiology of breast cancer, though its role, and whether it is a promoter or inhibitor of breast cancer risk, has not been fully elucidated.<ref name="pmid23336704">Template:Cite journal</ref><ref name="pmid31512725">Template:Cite journal</ref> Most progestins, or synthetic progestogens, like medroxyprogesterone acetate, have been found to increase the risk of breast cancer in postmenopausal people in combination with estrogen as a component of menopausal hormone therapy.<ref name="pmid31474332">Template:Cite journal</ref><ref name="pmid31512725" /> The combination of natural oral progesterone or the atypical progestin dydrogesterone with estrogen has been associated with less risk of breast cancer than progestins plus estrogen.<ref name="pmid29384406">Template:Cite journal</ref><ref name="pmid27456847">Template:Cite journal</ref><ref name="pmid29852797">Template:Cite journal</ref> However, this may simply be an artifact of the low progesterone levels produced with oral progesterone.<ref name="pmid23336704" /><ref name="pmid29526116">Template:Cite journal</ref> More research is needed on the role of progesterone in breast cancer.<ref name="pmid31512725" />

Skin health

The estrogen receptor, as well as the progesterone receptor, have been detected in the skin, including in keratinocytes and fibroblasts.<ref name="pmid12762829">Template:Cite journal</ref><ref name="pmid16120154">Template:Cite journal</ref> At menopause and thereafter, decreased levels of female sex hormones result in atrophy, thinning, and increased wrinkling of the skin and a reduction in skin elasticity, firmness, and strength.<ref name="pmid12762829" /><ref name="pmid16120154" /> These skin changes constitute an acceleration in skin aging and are the result of decreased collagen content, irregularities in the morphology of epidermal skin cells, decreased ground substance between skin fibers, and reduced capillaries and blood flow.<ref name="pmid12762829" /><ref name="pmid16120154" /> The skin also becomes more dry during menopause, which is due to reduced skin hydration and surface lipids (sebum production).<ref name="pmid12762829" /> Along with chronological aging and photoaging, estrogen deficiency in menopause is one of the three main factors that predominantly influences skin aging.<ref name="pmid12762829" />

Hormone replacement therapy, consisting of systemic treatment with estrogen alone or in combination with a progestogen, has well-documented and considerable beneficial effects on the skin of postmenopausal people.<ref name="pmid12762829" /><ref name="pmid16120154" /> These benefits include increased skin collagen content, skin thickness and elasticity, and skin hydration and surface lipids.<ref name="pmid12762829" /><ref name="pmid16120154" /> Topical estrogen has been found to have similar beneficial effects on the skin.<ref name="pmid12762829" /> In addition, a study has found that topical 2% progesterone cream significantly increases skin elasticity and firmness and observably decreases wrinkles in peri- and postmenopausal people.<ref name="pmid16120154" /> Skin hydration and surface lipids, on the other hand, did not significantly change with topical progesterone.<ref name="pmid16120154" />

These findings suggest that progesterone, like estrogen, also has beneficial effects on the skin, and may be independently protective against skin aging.<ref name="pmid16120154" />

Sexuality

Libido

Template:See also Progesterone and its neurosteroid active metabolite allopregnanolone appear to be importantly involved in libido in females.<ref name="King2012">Template:Cite book</ref>

Homosexuality

Dr. Diana Fleischman, of the University of Portsmouth, and colleagues looked for a relationship between progesterone and sexual attitudes in 92 women. Their research, published in the Archives of Sexual Behavior found that women who had higher levels of progesterone scored higher on a questionnaire measuring homoerotic motivation. They also found that men who had high levels of progesterone were more likely to have higher homoerotic motivation scores after affiliative priming compared to men with low levels of progesterone.<ref name="pmid25420899">Template:Cite journal</ref><ref name="UoP-News-Homos">Template:Cite news</ref><ref name="The-Telegraph-2014">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name="HuffPost-2014">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Nervous system

Progesterone, like pregnenolone and dehydroepiandrosterone (DHEA), belongs to an important group of endogenous steroids called neurosteroids. It can be metabolized within all parts of the central nervous system.<ref name="pmid558037">Template:Cite journal</ref>

Neurosteroids are neuromodulators, and are neuroprotective, neurogenic, and regulate neurotransmission and myelination.<ref name="pmid15135772">Template:Cite journal</ref> The effects of progesterone as a neurosteroid are mediated predominantly through its interactions with non-nuclear PRs, namely the mPRs and PGRMC1, as well as certain other receptors, such as the σ₁ and nACh receptors.<ref name="pmid24065876">Template:Cite journal</ref>

Brain damage

Previous studies have shown that progesterone supports the normal development of neurons in the brain, and that the hormone has a protective effect on damaged brain tissue. It has been observed in animal models that females have reduced susceptibility to traumatic brain injury and this protective effect has been hypothesized to be caused by increased circulating levels of estrogen and progesterone in females.<ref name="pmid10833057">Template:Cite journal</ref>

Proposed mechanism

The mechanism of progesterone protective effects may be the reduction of inflammation that follows brain trauma and hemorrhage.<ref name="pmid18188998">Template:Cite journal</ref><ref name="pmid27143417">Template:Cite journal</ref>

Damage incurred by traumatic brain injury is believed to be caused in part by mass depolarization leading to excitotoxicity. One way in which progesterone helps to alleviate some of this excitotoxicity is by blocking the voltage-dependent calcium channels that trigger neurotransmitter release.<ref name="pmid22101209">Template:Cite journal</ref> It does so by manipulating the signaling pathways of transcription factors involved in this release. Another method for reducing the excitotoxicity is by up-regulating the GABA_A, a widespread inhibitory neurotransmitter receptor.<ref name="pmid17826842">Template:Cite journal</ref>

Progesterone has also been shown to prevent apoptosis in neurons, a common consequence of brain injury. It does so by inhibiting enzymes involved in the apoptosis pathway specifically concerning the mitochondria, such as activated caspase 3 and cytochrome c.<ref name="pmid22088981">Template:Cite journal</ref>

Not only does progesterone help prevent further damage, it has also been shown to aid in neuroregeneration.<ref name="pmid26746666">Template:Cite journal</ref> One of the serious effects of traumatic brain injury includes edema. Animal studies show that progesterone treatment leads to a decrease in edema levels by increasing the concentration of macrophages and microglia sent to the injured tissue.<ref name="pmid22101209"/><ref name="pmid19401954">Template:Cite journal</ref> This was observed in the form of reduced leakage from the blood brain barrier in secondary recovery in progesterone treated rats. In addition, progesterone was observed to have antioxidant properties, reducing the concentration of oxygen free radicals faster than without.<ref name="pmid17826842"/> There is also evidence that the addition of progesterone can also help remyelinate damaged axons due to trauma, restoring some lost neural signal conduction.<ref name="pmid17826842"/> Another way progesterone aids in regeneration includes increasing the circulation of endothelial progenitor cells in the brain. This helps new vasculature to grow around scar tissue which helps repair the area of insult.<ref name="pmid21534727">Template:Cite journal</ref>

Addiction

Progesterone enhances the function of serotonin receptors in the brain, so an excess or deficit of progesterone has the potential to result in significant neurochemical issues. This provides an explanation for why some people resort to substances that enhance serotonin activity such as nicotine, alcohol, and cannabis when their progesterone levels fall below optimal levels.<ref name="pmid21186920">Template:Cite journal</ref>

• Sex differences in hormone levels may induce women to respond differently than men to nicotine. When women undergo cyclic changes or different hormonal transition phases (menopause, pregnancy, adolescence), there are changes in their progesterone levels.<ref name="pmid22474108">Template:Cite journal</ref> Therefore, females have an increased biological vulnerability to nicotine's reinforcing effects compared to males and progesterone may be used to counter this enhanced vulnerability. This information supports the idea that progesterone can affect behavior.<ref name="pmid21186920"/>
• Similar to nicotine, cocaine also increases the release of dopamine in the brain. The neurotransmitter is involved in the reward center and is one of the main neurotransmitters involved with substance abuse and reliance. In a study of cocaine users, it was reported that progesterone reduced craving and the feeling of being stimulated by cocaine. Thus, progesterone was suggested as an agent that decreases cocaine craving by reducing the dopaminergic properties of the drug.<ref name="pmid21796112">Template:Cite journal</ref>

Societal

In a 2012 University of Amsterdam study of 120 women, women's luteal phase (higher levels of progesterone, and increasing levels of estrogen) was correlated with a lower level of competitive behavior in gambling and math contest scenarios, while their premenstrual phase (sharply-decreasing levels of progesterone, and decreasing levels of estrogen) was correlated with a higher level of competitive behavior.<ref name="Buser-2012">Template:Cite journal</ref>

Other effects

• Progesterone also has a role in skin elasticity and bone strength, in respiration, in nerve tissue and in female sexuality, and the presence of progesterone receptors in certain muscle and fat tissue may hint at a role in sexually dimorphic proportions of those.<ref name="medicinalchem">Template:Cite book</ref>
• During pregnancy, progesterone is said to decrease uterine irritability.<ref name="Blackburn2014">Template:Cite book</ref>
• During pregnancy, progesterone helps to suppress immune responses of the mother to fetal antigens, which prevents rejection of the fetus.<ref name="Blackburn2014" />
• Progesterone raises epidermal growth factor-1 (EGF-1) levels, a factor often used to induce proliferation, and used to sustain cultures, of stem cells.<ref name="pmid17074804">Template:Cite journal</ref>
• Progesterone increases core temperature (thermogenic function) during ovulation.<ref name="GeorgiaPhysiology">Template:Cite book</ref><ref name="Rothchild-1969">Template:Citation</ref>
• Progesterone reduces spasm and relaxes smooth muscle. Bronchi are widened and mucus regulated. (PRs are widely present in submucosal tissue.)Template:Cn
• Progesterone acts as an antiinflammatory agent and regulates the immune response.Template:Cn
• Progesterone reduces gall-bladder activity.<ref name="pmid3184927">Template:Cite journal</ref>
• Progesterone normalizes blood clotting and vascular tone, zinc and copper levels, cell oxygen levels, and use of fat stores for energy.Template:Cn
• Progesterone may affect gum health, increasing risk of gingivitis (gum inflammation).<ref name="WebMD-Hormones-Oral-Health">{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref>

• Progesterone appears to prevent endometrial cancer (involving the uterine lining) by regulating the effects of estrogen.
• Progesterone plays an important role in the signaling of insulin release and pancreatic function, and may affect the susceptibility to diabetes or gestational diabetes.<ref name="pmid12438645">Template:Cite journal</ref><ref name="pmid12591170">Template:Cite journal</ref>
• Progesterone levels in the blood were found to be lower in those who had higher weight and higher BMI among those who became pregnant through in vitro fertilization.<ref name="pmid34278354">Template:Cite journal</ref>
• Current data shows that micronized progesterone, which is chemically identical to the progesterone produced in people's bodies, in combination with estrogen in menopausal hormone therapy does not seem to have significant effects on venous thromboembolism (blood clots in veins) and ischemic stroke (lack of blood flow to the brain due to blockage of a blood vessel that supplies the brain). However, more studies need to be conducted to see whether or not micronized progesterone alone or in combined menopausal hormone therapy changes the risk of myocardial infarctions (heart attacks).<ref name="pmid35112635">Template:Cite journal</ref>
• There have not been any studies done yet on the effects of micronized progesterone on hair loss due to menopause.<ref name="pmid33527841">Template:Cite journal</ref>
• Despite suggestions for using hormone therapy to prevent loss of muscle mass in post-menopausal individuals (50 and older), menopausal hormone therapy involving either estrogen alone or estrogen and progesterone has not been found to preserve muscle mass.<ref name="pmid31461147">Template:Cite journal</ref> Menopausal hormone therapy also does not result in body weight reduction, BMI reduction, or change in glucose metabolism.<ref name="pmid30477366">Template:Cite journal</ref>

Biochemistry

Biosynthesis

File:Steroidogenesis.svg

Steroidogenesis, showing progesterone among the progestogens in yellow area.<ref name="HäggströmRichfield2014">Template:Cite journal</ref>

In mammals, progesterone, like all other steroid hormones, is synthesized from pregnenolone, which itself is derived from cholesterol.Template:Cn

Cholesterol undergoes double oxidation to produce 22R-hydroxycholesterol and then 20α,22R-dihydroxycholesterol. This vicinal diol is then further oxidized with loss of the side chain starting at position C22 to produce pregnenolone. This reaction is catalyzed by cytochrome P450scc.Template:Cn

The conversion of pregnenolone to progesterone takes place in two steps. First, the 3β-hydroxyl group is oxidized to a keto group and second, the double bond is moved to C4, from C5 through a keto/enol tautomerization reaction.<ref name="isbn0-471-49641-3">Template:Cite book</ref> This reaction is catalyzed by 3β-hydroxysteroid dehydrogenase/δ^5-4-isomerase.Template:Cn

Progesterone in turn is the precursor of the mineralocorticoid aldosterone, and after conversion to 17α-hydroxyprogesterone, of cortisol and androstenedione. Androstenedione can be converted to testosterone, estrone, and estradiol, highlighting the critical role of progesterone in testosterone synthesis.Template:Cn

Pregnenolone and progesterone can also be synthesized by yeast.<ref name="pmid9487528">Template:Cite journal</ref>

Approximately 30 mg of progesterone is secreted from the ovaries per day in reproductive-age women, while the adrenal glands produce about 1 mg of progesterone per day.<ref name="LemkeWilliams2012 p1397">Template:Cite book</ref>

Distribution

Progesterone binds extensively to plasma proteins, including albumin (50–54%) and transcortin (43–48%).<ref name="Drugs.com">Template:Citation</ref> It has similar affinity for albumin relative to the PR.<ref name="Josimovich2013" />

Metabolism

The metabolism of progesterone is rapid and extensive and occurs mainly in the liver,<ref name="FalconeHurd2007">Template:Cite book</ref><ref name="Cupps1991">Template:Cite book</ref><ref name="pmid14667980" /> though enzymes that metabolize progesterone are also expressed widely in the brain, skin, and various other extrahepatic tissues.<ref name="pmid558037" /><ref name="DowdJohnson2016">Template:Cite book</ref> Progesterone has an elimination half-life of only approximately 5 minutes in circulation.<ref name="FalconeHurd2007" /> The metabolism of progesterone is complex, and it may form as many as 35 different unconjugated metabolites when it is ingested orally.<ref name="pmid14667980" /><ref name="pmid16112947" /> Progesterone is highly susceptible to enzymatic reduction via reductases and hydroxysteroid dehydrogenases due to its double bond (between the C4 and C5 positions) and its two ketones (at the C3 and C20 positions).<ref name="pmid14667980" />

The major metabolic pathway of progesterone is reduction by 5α-reductase<ref name="pmid558037" /> and 5β-reductase into the dihydrogenated 5α-dihydroprogesterone and 5β-dihydroprogesterone, respectively.<ref name="Cupps1991" /><ref name="pmid14667980">Template:Cite journal</ref><ref name="PlantZeleznik2014">Template:Cite book</ref><ref name="SantoroNeal-Perry2010">Template:Cite book</ref> This is followed by the further reduction of these metabolites via 3α-hydroxysteroid dehydrogenase and 3β-hydroxysteroid dehydrogenase into the tetrahydrogenated allopregnanolone, pregnanolone, isopregnanolone, and epipregnanolone.<ref name="pmid21094889">Template:Cite book</ref><ref name="Cupps1991" /><ref name="pmid14667980" /><ref name="PlantZeleznik2014" /> Subsequently, 20α-hydroxysteroid dehydrogenase and 20β-hydroxysteroid dehydrogenase reduce these metabolites to form the corresponding hexahydrogenated pregnanediols (eight different isomers in total),<ref name="Cupps1991" /><ref name="SantoroNeal-Perry2010" /> which are then conjugated via glucuronidation and/or sulfation, released from the liver into circulation, and excreted by the kidneys into the urine.<ref name="FalconeHurd2007" /><ref name="pmid14667980" /> The major metabolite of progesterone in the urine is the 3α,5β,20α isomer of pregnanediol glucuronide, which has been found to constitute 15 to 30% of an injection of progesterone.<ref name="Josimovich2013" /><ref name="BaulieuKelly1990">Template:Cite book</ref> Other metabolites of progesterone formed by the enzymes in this pathway include 3α-dihydroprogesterone, 3β-dihydroprogesterone, 20α-dihydroprogesterone, and 20β-dihydroprogesterone, as well as various combination products of the enzymes aside from those already mentioned.<ref name="Josimovich2013" /><ref name="pmid14667980" /><ref name="BaulieuKelly1990" /><ref name="pmid21182831">Template:Cite journal</ref> Progesterone can also first be hydroxylated (see below) and then reduced.<ref name="pmid14667980" /> Endogenous progesterone is metabolized approximately 50% into 5α-dihydroprogesterone in the corpus luteum, 35% into 3β-dihydroprogesterone in the liver, and 10% into 20α-dihydroprogesterone.<ref name="pmid15492972">Template:Cite journal</ref>

Relatively small portions of progesterone are hydroxylated via 17α-hydroxylase (CYP17A1) and 21-hydroxylase (CYP21A2) into 17α-hydroxyprogesterone and 11-deoxycorticosterone (21-hydroxyprogesterone), respectively,<ref name="pmid16112947">Template:Cite journal</ref> and pregnanetriols are formed secondarily to 17α-hydroxylation.<ref name="GreenblattBrogan2016">Template:Cite book</ref><ref name="Graham2012">Template:Cite book</ref> Even smaller amounts of progesterone may be also hydroxylated via 11β-hydroxylase (CYP11B1) and to a lesser extent via aldosterone synthase (CYP11B2) into 11β-hydroxyprogesterone.<ref name="pmid23322723">Template:Cite journal</ref><ref name="pmid29277707">Template:Cite journal</ref><ref name=wj/> In addition, progesterone can be hydroxylated in the liver by other cytochrome P450 enzymes which are not steroid-specific.<ref name="Piccinato2008">Template:Cite bookTemplate:Dead link</ref> 6β-Hydroxylation, which is catalyzed mainly by CYP3A4, is the major transformation, and is responsible for approximately 70% of cytochrome P450-mediated progesterone metabolism.<ref name="Piccinato2008" /> Other routes include 6α-, 16α-, and 16β-hydroxylation.<ref name="pmid14667980" /> However, treatment of women with ketoconazole, a strong CYP3A4 inhibitor, had minimal effects on progesterone levels, producing only a slight and non-significant increase, and this suggests that cytochrome P450 enzymes play only a small role in progesterone metabolism.<ref name="pmid1825737">Template:Cite journal</ref> Template:Progesterone metabolism

Levels

File:Progesterone levels across the normal menstrual cycle in women.png

Progesterone levels across the menstrual cycle in normally cycling and ovulatory women.<ref name="pmid16776638">Template:Cite journal</ref> The horizontal lines are the mean integrated levels for each curve. The vertical line is mid-cycle.

Progesterone levels are relatively low during the preovulatory phase of the menstrual cycle, rise after ovulation, and are elevated during the luteal phase, as shown in the diagram above. Progesterone levels tend to be less than 2 ng/mL prior to ovulation and greater than 5 ng/mL after ovulation. If pregnancy occurs, human chorionic gonadotropin is released, maintaining the corpus luteum and allowing it to maintain levels of progesterone. Between 7 and 9 weeks, the placenta begins to produce progesterone in place of the corpus luteum in a process called the luteal-placental shift.<ref name="pmid4688578">Template:Cite journal</ref>

After the luteal-placental shift, progesterone levels start to rise further and may reach 100 to 200 ng/mL at term. Whether a decrease in progesterone levels is critical for the initiation of labor has been argued and may be species-specific. After delivery of the placenta and during lactation, progesterone levels are very low.Template:Cn

Progesterone levels are low in children and postmenopausal people.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Adult males have levels similar to those in women during the follicular phase of the menstrual cycle.

Endogenous progesterone production rates and plasma progesterone levels

Group	Template:Abbr production	Template:Abbr levels
Prepubertal children	Template:Abbr	0.06–0.5 ng/mL
Pubertal girls   Tanner stage I (childhood)   Tanner stage II (ages 8–12)   Tanner stage III (ages 10–13)   Tanner stage IV (ages 11–14)   Tanner stage V (ages 12–15)     Follicular phase (days 1–14)     Luteal phase (days 15–28)	Template:Abbr Template:Abbr Template:Abbr Template:Abbr   Template:Abbr Template:Abbr	0.22 (<0.10–0.32) ng/mL 0.30 (0.10–0.51) ng/mL 0.36 (0.10–0.75) ng/mL 1.75 (<0.10–25.0) ng/mL   0.35 (0.13–0.75) ng/mL 2.0–25.0 ng/mL
Premenopausal women   Follicular phase (days 1–14)   Luteal phase (days 15–28)   Oral contraceptive (anovulatory)	0.75–5.4 mg/day 15–50 mg/day Template:Abbr	0.02–1.2 ng/mL 4–30 ng/mL 0.1–0.3 ng/mL
Postmenopausal women Oophorectomized women Oophorectomized and adrenalectomized women	Template:Abbr 1.2 mg/day <0.3 mg/day	0.03–0.3 ng/mL 0.39 ng/mL Template:Abbr
Pregnant women   First trimester (weeks 1–12)   Second trimester (weeks 13–26)   Third trimester (weeks 27–40)   Postpartum (at 24 hours)	55 mg/day 92–100 mg/day 190–563 mg/day Template:Abbr	9–75 ng/mL 17–146 ng/mL 55–255 ng/mL 19 ng/mL
Men	0.75–3 mg/day	0.1–0.3 ng/mL
Notes: Mean levels are given as a single value and ranges are given after in parentheses. Sources: <ref name="pmid945344" /><ref name="Chernecky_Berger_2012">Template:Cite book</ref><ref name="Becker_2001">Template:Cite book</ref><ref name="Josimovich2013b" /><ref name="KeepUtian2012">Template:Cite book</ref><ref name="StraussBarbieri2009">Template:Cite book</ref><ref name="Bajaj_Berman2011">Template:Cite book</ref><ref name="Lauritzen1988">Template:Cite book</ref><ref name="LittleBilliar1983">Little, A. B., & Billiar, R. B. (1983). Progestagens. In Endocrinology of Pregnancy, 3rd Edition (pp. 92–111). Harper and Row Philadelphia. https://scholar.google.com/scholar?cluster=2512291948467467634 Template:Webarchive</ref>

Ranges

Blood test results should always be interpreted using the reference ranges provided by the laboratory that performed the results. Example reference ranges are listed below.

Person type	Reference range for blood test
	Lower limit	Upper limit	Unit
Female - menstrual cycle	(see diagram below)
Female - postmenopausal	<0.2<ref name=nih2009>Progesterone Reference Ranges, Performed at the Clinical Center at the National Institutes of Health, Bethesda MD, 03Feb09</ref>	1<ref name=nih2009/>	ng/mL
	<0.6<ref name="mass-converted">Converted from mass values using molar mass of 314.46 g/mol</ref>	3<ref name="mass-converted"/>	nmol/L
Female on oral contraceptives	0.34<ref name=nih2009/>	0.92<ref name=nih2009/>	ng/mL
	1.1<ref name="mass-converted"/>	2.9<ref name="mass-converted"/>	nmol/L
Males ≥16 years	0.27<ref name=nih2009/>	0.9<ref name=nih2009/>	ng/mL
	0.86<ref name="mass-converted"/>	2.9<ref name="mass-converted"/>	nmol/L
Female or male 1–9 years	0.1<ref name=nih2009/>	4.1<ref name=nih2009/> or 4.5<ref name=nih2009/>	ng/mL
	0.3<ref name="mass-converted"/>	13<ref name="mass-converted"/>	nmol/L

File:Progesterone during menstrual cycle.png

Progesterone levels during the menstrual cycle.<ref name="Häggström2014">Template:Cite journal</ref>
• The ranges denoted By biological stage may be used in closely monitored menstrual cycles in regard to other markers of its biological progression, with the time scale being compressed or stretched to how much faster or slower, respectively, the cycle progresses compared to an average cycle.
• The ranges denoted Inter-cycle variability are more appropriate to use in non-monitored cycles with only the beginning of menstruation known, but where the woman accurately knows her average cycle lengths and time of ovulation, and that they are somewhat averagely regular, with the time scale being compressed or stretched to how much a woman's average cycle length is shorter or longer, respectively, than the average of the population.
• The ranges denoted Inter-woman variability are more appropriate to use when the average cycle lengths and time of ovulation are unknown, but only the beginning of menstruation is given.

Sources

Animal

Progesterone is produced in high amounts in the ovaries (by the corpus luteum) from the onset of puberty to menopause, and is also produced in smaller amounts by the adrenal glands after the onset of adrenarche in both males and females. To a lesser extent, progesterone is produced in nervous tissue, especially in the brain, and in adipose (fat) tissue, as well.

During human pregnancy, progesterone is produced in increasingly high amounts by the ovaries and placenta. At first, the source is the corpus luteum that has been "rescued" by the presence of human chorionic gonadotropin (hCG) from the conceptus. However, after the 8th week, production of progesterone shifts to the placenta. The placenta utilizes maternal cholesterol as the initial substrate, and most of the produced progesterone enters the maternal circulation, but some is picked up by the fetal circulation and used as substrate for fetal corticosteroids. At term the placenta produces about 250 mg progesterone per day.

An additional animal source of progesterone is milk products. After consumption of milk products the level of bioavailable progesterone goes up.<ref name="titleResult Content View">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Plants

In at least one plant, Juglans regia, progesterone has been detected.<ref name="pmid20108949">Template:Cite journal</ref> In addition, progesterone-like steroids are found in Dioscorea mexicana. Dioscorea mexicana is a plant that is part of the yam family native to Mexico.<ref name="pmid12255132">Template:Cite journal</ref> It contains a steroid called diosgenin that is taken from the plant and is converted into progesterone.<ref name="pmid16946542">Template:Cite journal</ref> Diosgenin and progesterone are also found in other Dioscorea species, as well as in other plants that are not closely related, such as fenugreek.

Another plant that contains substances readily convertible to progesterone is Dioscorea pseudojaponica native to Taiwan. Research has shown that the Taiwanese yam contains saponins — steroids that can be converted to diosgenin and thence to progesterone.<ref name="pmid14558759">Template:Cite journal</ref>

Many other Dioscorea species of the yam family contain steroidal substances from which progesterone can be produced. Among the more notable of these are Dioscorea villosa and Dioscorea polygonoides. One study showed that the Dioscorea villosa contains 3.5% diosgenin.<ref name="pmid15513824">Template:Cite journal</ref> Dioscorea polygonoides has been found to contain 2.64% diosgenin as shown by gas chromatography-mass spectrometry.<ref name="Nino-2007">Template:Cite journal</ref> Many of the Dioscorea species that originate from the yam family grow in countries that have tropical and subtropical climates.<ref name="Myoda-2005">Template:Cite journal</ref>

Medical use

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Progesterone is used as a medication. It is used in combination with estrogens mainly in hormone therapy for menopausal symptoms and low sex hormone levels.<ref name="pmid16112947" /><ref name="pmid28159148">Template:Cite journal</ref> It may also be used alone to treat menopausal symptoms. Studies have shown that transdermal progesterone (skin patch) and oral micronized progesterone are effective treatments for certain symptoms of menopause such as hot flashes and night sweats, which are otherwise referred to as vasomotor symptoms or VMS.<ref name="pmid33109992">Template:Cite journal</ref>

It is also used to support pregnancy and fertility and to treat gynecological disorders.<ref name="pmid25113944">Template:Cite journal</ref><ref name="pmid26443945">Template:Cite journal</ref><ref name="pmid26345161">Template:Cite journal</ref><ref name="pmid28989916">Template:Cite journal</ref> Progesterone has been shown to prevent miscarriage in those with 1) vaginal bleeding early in their current pregnancy and 2) a previous history of miscarriage.<ref name="pmid32609084">Template:Cite journal</ref> Progesterone can be taken by mouth, through the vagina, and by injection into muscle or fat, among other routes.<ref name="pmid16112947" />

Chemistry

File:Sample of Progesterone.jpg

A sample of progesterone

Progesterone is a naturally occurring pregnane steroid and is also known as pregn-4-ene-3,20-dione.<ref name="Elks2014">Template:Cite book</ref><ref name="IndexNominum2000">Template:Cite book</ref> It has a double bond (4-ene) between the C4 and C5 positions and two ketone groups (3,20-dione), one at the C3 position and the other at the C20 position.<ref name="Elks2014" /><ref name="IndexNominum2000" />

Synthesis

Progesterone is commercially produced by semisynthesis. Two main routes are used: one from yam diosgenin first pioneered by Marker in 1940, and one based on soy phytosterols scaled up in the 1970s. Additional (not necessarily economical) semisyntheses of progesterone have also been reported starting from a variety of steroids. For the example, cortisone can be simultaneously deoxygenated at the C-17 and C-21 position by treatment with iodotrimethylsilane in chloroform to produce 11-keto-progesterone (ketogestin), which in turn can be reduced at position-11 to yield progesterone.<ref name="pmid3815593">Template:Cite journal</ref>

Marker semisynthesis

{{#invoke:Labelled list hatnote|labelledList|Main article|Main articles|Main page|Main pages}} An economical semisynthesis of progesterone from the plant steroid diosgenin isolated from yams was developed by Russell Marker in 1940 for the Parke-Davis pharmaceutical company.<ref name="Marker1940">Template:Cite journal</ref> This synthesis is known as the Marker degradation.

File:Marker snythesis.png

The Marker semisynthesis of progesterone from diosgenin.<ref name="Marker1940"/>

The 16-DPA intermediate is important to the synthesis of many other medically important steroids. A very similar approach can produce 16-DPA from solanine.<ref name="Goswami-2003">Template:Cite journal</ref>

Soy semisynthesis

Progesterone can also be made from the stigmasterol found in soybean oil also. c.f. Percy Julian.

File:Stigmasterol to progesterone synthesis.png

CitationClass=web }}</ref>

Total synthesis

File:Progesterone Synthesis.png

The Johnson total synthesis of progesterone.<ref name="pmid5131151"/>

A total synthesis of progesterone was reported in 1971 by W.S. Johnson.<ref name="pmid5131151">Template:Cite journal</ref> The synthesis begins with reacting the phosphonium salt 7 with phenyl lithium to produce the phosphonium ylide 8. The ylide 8 is reacted with an aldehyde to produce the alkene 9. The ketal protecting groups of 9 are hydrolyzed to produce the diketone 10, which in turn is cyclized to form the cyclopentenone 11. The ketone of 11 is reacted with methyl lithium to yield the tertiary alcohol 12, which in turn is treated with acid to produce the tertiary cation 13. The key step of the synthesis is the π-cation cyclization of 13 in which the B-, C-, and D-rings of the steroid are simultaneously formed to produce 14. This step resembles the cationic cyclization reaction used in the biosynthesis of steroids and hence is referred to as biomimetic. In the next step the enol orthoester is hydrolyzed to produce the ketone 15. The cyclopentene A-ring is then opened by oxidizing with ozone to produce 16. Finally, the diketone 17 undergoes an intramolecular aldol condensation by treating with aqueous potassium hydroxide to produce progesterone.<ref name="pmid5131151"/>

History

George W. Corner and Willard M. Allen discovered the hormonal action of progesterone in 1929.<ref name="Josimovich2013" /><ref name="Corner-1929">Template:Cite journal</ref><ref name="CoutinhoSegal1999">Template:Cite book</ref><ref name="Walker2008">Template:Cite book</ref> By 1931–1932, nearly pure crystalline material of high progestational activity had been isolated from the corpus luteum of animals, and by 1934, pure crystalline progesterone had been refined and obtained and the chemical structure of progesterone was determined.<ref name="Josimovich2013" /><ref name="CoutinhoSegal1999" /> This was achieved by Adolf Butenandt at the Chemisches Institut of Technical University in Danzig, who extracted this new compound from several thousand liters of urine.<ref name="Piosik-2003">Template:Cite journal</ref>

Chemical synthesis of progesterone from stigmasterol and pregnanediol was accomplished later that year.<ref name="CoutinhoSegal1999"/><ref name="Ginsburg2012">Template:Cite book</ref> Up to this point, progesterone, known generically as corpus luteum hormone, had been being referred to by several groups by different names, including corporin, lutein, luteosterone, and progestin.<ref name="Josimovich2013" /><ref name="Rolleston1936">Template:Cite book</ref> In 1935, at the time of the Second International Conference on the Standardization of Sex Hormones in London, England, a compromise was made between the groups and the name progesterone (progestational steroidal ketone) was created.<ref name="Josimovich2013" /><ref name="pmid4922128">Template:Cite journal</ref>

Veterinary use

The use of progesterone tests in dog breeding to pinpoint ovulation is becoming more widely used. There are several tests available but the most reliable test is a blood test with blood drawn by a veterinarian and sent to a lab for processing. Results can usually be obtained with 24 to 72 hours. The rationale for using progesterone tests is that increased numbers begin in close proximity to preovulatory surge in gonadotrophins and continue through ovulation and estrus. When progesterone levels reach certain levels they can signal the stage of estrus the female is. Prediction of birth date of the pending litter can be very accurate if ovulation date is known. Puppies deliver with a day or two of 9 weeks gestation in most cases. It is not possible to determine pregnancy using progesterone tests once a breeding has taken place, however. This is due to the fact that, in dogs, progesterone levels remain elevated throughout the estrus period.<ref name="Refsal-2009">Template:Cite journal</ref>

Pricing

Pricing for progesterone can vary depending location, insurance coverage, discount coupons, quantity, shortages, manufacturers, brand or generic versions, different pharmacies, and so on. As of currently, 30 capsules of 100 mg of the generic version, Progesterone, from CVS Pharmacy is around $40 without any discounts or insurance applied. The brand version, Prometrium, is around $450 for 30 capsules without any discounts or insurance applied.<ref name="www.goodrx.com-prices">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> In comparison, Walgreens offers 30 capsules of 100 mg in the generic version for $51 without insurance or coupons applied. The brand name costs around $431 for 30 capsules of 100 mg.<ref name="www.goodrx.com-prices-2">{{#invoke:citation/CS1|citation |CitationClass=web

}}</ref>

References

• Template:Creative Commons text attribution notice

External links

• Progesterone MS Spectrum
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