Progesterone (medication)

Progesterone is used in combination with an estrogen as a component of menopausal hormone therapy for the treatment of menopausal symptoms.[17] A progestogen is needed to prevent endometrial hyperplasia and increased risk of endometrial cancer caused by unopposed estrogens in women who have intact uteruses.[17] In addition, progestogens, including progesterone, are able to treat and improve hot flashes.[17] Progesterone, both alone and in combination with an estrogen, also has beneficial effects on skin health and is able to slow the rate of skin aging in postmenopausal women.[33][34]

Based on animal research, progesterone may be involved in sexual function in women.[35][36] However, very limited clinical research suggests that progesterone does not improve sexual desire or function in women.[37]

Progesterone is used as a component of feminizing hormone therapy for transgender women in combination with estrogens and antiandrogens.[38][18] However, the addition of progestogens to HRT for transgender women is controversial and their role is unclear.[38][18] Some patients and clinicians believe anecdotally that progesterone may enhance breast development, improve mood, and increase sex drive.[18] However, there is a lack of evidence from well-designed studies to support these notions at present.[18] In addition, progestogens can produce undesirable side effects, although bioidentical progesterone may be safer and better tolerated than synthetic progestogens like medroxyprogesterone acetate.[38][39]

Because some believe that progestogens are necessary for full breast development, progesterone is sometimes used in transgender women with the intention of enhancing breast development.[38][40][39] However, a 2014 review concluded the following on the topic of progesterone for enhancing breast development in transgender women:[40]

"Our knowledge concerning the natural history and effects of different cross-sex hormone therapies on breast development in [transgender] women is extremely sparse and based on low quality of evidence. Current evidence does not provide evidence that progestogens enhance breast development in [transgender] women. Neither do they prove the absence of such an effect. This prevents us from drawing any firm conclusion at this moment and demonstrates the need for further research to clarify these important clinical questions."[40]

While the influence of progesterone on breast development is uncertain, it is known that progesterone can cause temporary breast enlargement due to local fluid retention in the breasts, and this may give a misleading appearance of breast growth.[41][42] Aside from a hypothetical involvement in breast development, progestogens are not otherwise known to be involved in physical feminization.[39][38]

Vaginally dosed progesterone is being investigated as potentially beneficial in preventing preterm birth in women at risk for preterm birth. The initial study by Fonseca suggested that vaginal progesterone could prevent preterm birth in women with a history of preterm birth.[43] According to a recent study, women with a short cervix that received hormonal treatment with a progesterone gel had their risk of prematurely giving birth reduced. The hormone treatment was administered vaginally every day during the second half of a pregnancy.[44] A subsequent and larger study showed that vaginal progesterone was no better than placebo in preventing recurrent preterm birth in women with a history of a previous preterm birth,[45] but a planned secondary analysis of the data in this trial showed that women with a short cervix at baseline in the trial had benefit in two ways: a reduction in births less than 32 weeks and a reduction in both the frequency and the time their babies were in intensive care.[46]

In another trial, vaginal progesterone was shown to be better than placebo in reducing preterm birth prior to 34 weeks in women with an extremely short cervix at baseline.[47] An editorial by Roberto Romero discusses the role of sonographic cervical length in identifying patients who may benefit from progesterone treatment.[48] A meta-analysis published in 2011 found that vaginal progesterone cut the risk of premature births by 42 percent in women with short cervixes.[49] The meta-analysis, which pooled published results of five large clinical trials, also found that the treatment cut the rate of breathing problems and reduced the need for placing a baby on a ventilator.[50]

Progesterone is used for luteal support in assisted reproductive technology (ART) cycles such as in vitro fertilization (IVF).[21][51] It is also used to correct luteal phase deficiency to prepare the endometrium for implantation in infertility therapy and is used to support early pregnancy.[52][53]

A progesterone vaginal ring is available for birth control when breastfeeding in a number of areas of the world.[23] An intrauterine device containing progesterone has also been marketed under the brand name Progestasert for birth control, including previously in the United States.[54]

Progesterone is used to control persistent anovulatory bleeding.[55][56][57] It is used in non-pregnant women with a delayed menstruation of one or more weeks, in order to allow the thickened endometrial lining to slough off. This process is termed a progesterone withdrawal bleed. Progesterone is taken orally for a short time (usually one week), after which it is discontinued and bleeding should occur.

Progesterone is of unclear benefit for the reversal of mifepristone-induced abortion.[58] Evidence is insufficient to support use in traumatic brain injury.[59]

Progesterone has been used as a topical medication applied to the scalp to treat female and male pattern hair loss.[60][61][62][63] Variable effectiveness has been reported, but overall its effectiveness for this indication in both sexes has been poor.[61][62][64]

Progesterone is approved under the brand name Progestogel as a 1% topical gel for local application to the breasts to treat breast pain in certain countries.[65][66][67] It is not approved for systemic therapy.[68][65] It has been found in clinical studies to inhibit estrogen-induced proliferation of breast epithelial cells and to abolish breast pain and tenderness in women with the condition.[67] However, in one small study in women with cyclic breast pain it was ineffective.[69] Vaginal progesterone has also been found to be effective in the treatment of breast pain and tenderness.[69]

Historically, progesterone has been widely used in the treatment of premenstrual syndrome.[70] A 2012 Cochrane review found insufficient evidence for or against the effectiveness of progesterone for this indication.[71] Another review of 10 studies found that progesterone was not effective for this condition, although it stated that insufficient evidence is available currently to make a definitive statement on progesterone in premenstrual syndrome.[70][72]

Progesterone can be used to treat catamenial epilepsy by supplementation during certain periods of the menstrual cycle.[73]

Progesterone is available in a variety of different forms, including oral capsules, sublingual tablets, vaginal capsules, tablets, gels, suppositories, and rings; rectal suppositories; oil solutions for intramuscular injection; and aqueous solutions for subcutaneous injection.[74][17] A 1% topical progesterone gel is approved for local application to the breasts to treat breast pain, but is not indicated for systemic therapy.[68][65] Progesterone was previously available as an intrauterine device for use in hormonal contraception, but this formulation was discontinued.[74] Progesterone is also limitedly available in combination with estrogens such as estradiol and estradiol benzoate for use by intramuscular injection.[75][76]

In addition to approved pharmaceutical products, progesterone is available in unregulated custom compounded and over-the-counter formulations like systemic transdermal creams and other preparations.[77][78][79][80][81] The systemic efficacy of transdermal/topical progesterone is controversial and has not been demonstrated.[79][80][81]

The combination of an estrogen and progesterone has not been found to increase the risk of breast cancer in postmenopausal women.[87][88][89][90] In contrast, all assessed progestins except the atypical progestin dydrogesterone have been associated with a significantly increased risk of breast cancer when used in combination with an estrogen in menopausal hormone therapy.[87][89][88][90] On the other hand, progesterone is associated with a significantly increased risk of endometrial cancer in combination with an estrogen, while this is not true with any progestin.[91][90] However, this does not appear to be the case with vaginal progesterone, which achieves high local concentrations of progesterone in the uterus that are likely fully sufficient for endometrial protection.[91] Whereas the combination of an estrogen and a progestin is associated with an increased risk of venous thromboembolism relative to estrogen alone, there is no further increase in the risk of venous thromboembolism with the combination of an estrogen and oral progesterone relative to estrogen only.[91] In addition, the combination of transdermal estradiol with oral progesterone is not associated with any increased risk of venous thromboembolism (RR = 0.93).[92] The reasons for these differences between progesterone and progestins are not entirely clear, but may be due to the relatively low potency of oral progesterone and a potentially inadequate progestogenic effect of this medication.[91][90]

Progesterone is a progestogen, or an agonist of the nuclear progesterone receptors (PRs), the PR-A, PR-B, and PR-C.[17] In addition, progesterone is an agonist of the membrane progesterone receptors (mPRs), including the mPRα, mPRβ, mPRγ, mPRδ, and mPRϵ.[107][108] Aside from the PRs and mPRs, progesterone is a potent antimineralocorticoid, or antagonist of the mineralocorticoid receptor, the biological target of the mineralocorticoid aldosterone.[109][110] In addition to its activity as a steroid hormone, progesterone is a neurosteroid.[111] Among other neurosteroid activities, and via its active metabolites allopregnanolone and pregnanolone, progesterone is a potent positive allosteric modulator of the GABA_A receptor, the major signaling receptor of the inhibitory neurotransmitter γ-aminobutyric acid (GABA).[112]

The PRs are expressed widely throughout the body, including in the uterus, cervix, vagina, fallopian tubes, breasts, fat, skin, pituitary gland, hypothalamus, and in other areas of the brain.[17][113] In accordance, progesterone has numerous effects throughout the body.[17] Among other effects, progesterone produces changes in the female reproductive system, the breasts, and the brain.[17][113] Progesterone has functional antiestrogenic effects due to its progestogenic activity, including in the uterus, cervix, and vagina.[17] The effects of progesterone may influence health in both positive and negative ways.[17] In addition to the aforementioned effects, progesterone has antigonadotropic effects due to its progestogenic activity, and can inhibit ovulation and suppress gonadal sex hormone production.[17]

The activities of progesterone besides those mediated by the PRs and mPRs are also of significance.[17] Progesterone lowers blood pressure and reduces water and salt retention among other effects via its antimineralocorticoid activity.[17][114] In addition, progesterone can produce sedative, hypnotic, anxiolytic, euphoric, cognitive-, memory-, and motor-impairing, anticonvulsant, and even anesthetic effects via formation of sufficiently high concentrations of its neurosteroid metabolites and consequent GABA_A receptor potentiation in the brain.[25][84][85][115]

There are differences between progesterone and other progestogens, such as progestins like medroxyprogesterone acetate and norethisterone, with implications for pharmacodynamics and pharmacokinetics as well as efficacy, tolerability, and safety.[17]

The pharmacokinetics of progesterone are dependent on its route of administration. The medications is approved in the form of oil-filled capsules containing micronized progesterone for oral administration, termed oral micronized progesterone or OMP.[116] It is also available in the form of vaginal or rectal suppositories or pessaries, topical creams and gels,[117] oil solutions for intramuscular injection, and aqueous solutions for subcutaneous injection.[116][13][118]

Routes of administration that progesterone has been used by include oral, intranasal, transdermal/topical, vaginal, rectal, intramuscular, subcutaneous, and intravenous injection.[13] Vaginal progesterone is available in the form of progesterone capsules, tablets or inserts, gels, suppositories or pessaries, and rings.[13]

A large number of progestins, or synthetic progestogens, have been derived from progesterone.[119][17] They can be categorized into several structural groups, including derivatives of retroprogesterone, 17α-hydroxyprogesterone, 17α-methylprogesterone, and 19-norprogesterone, with a respective example from each group including dydrogesterone, medroxyprogesterone acetate, medrogestone, and promegestone.[17] The progesterone ethers quingestrone (progesterone 3-cyclopentyl enol ether) and progesterone 3-acetyl enol ether are among the only examples that do not belong to any of these groups.[113][121] Another major group of progestins, the 19-nortestosterone derivatives, exemplified by norethisterone (norethindrone) and levonorgestrel, are not derived from progesterone but rather from testosterone.[17]

A variety of synthetic inhibitory neurosteroids have been derived from progesterone and its neurosteroid metabolites, allopregnanolone and pregnanolone.[119] Examples include alfadolone, alfaxolone, ganaxolone, hydroxydione, minaxolone, and renanolone.[119] In addition, C3 and C20 conjugates of progesterone, such as progesterone carboxymethyloxime (progesterone 3-(O-carboxymethyl)oxime; P4-3-CMO), P1-185 (progesterone 3-O-(L-valine)-E-oxime), EIDD-1723 (progesterone 20E-[O-[(phosphonooxy)methyl]oxime] sodium salt), EIDD-036 (progesterone 20-oxime; P4-20-O), and VOLT-02 (chemical structure unreleased), have been developed as water-soluble prodrugs of progesterone and neurosteroids.[122][123][124][125][126][127]

Chemical syntheses of progesterone have been published.[128]

The first study of oral progesterone in humans was published in 1949.[132][133] It found that oral progesterone produced significant progestational effects on the endometrium in women.[132] Prior to this study, animal research had suggested that oral progesterone was inactive, and for this reason, oral progesterone had never been evaluated in humans.[132][133] A variety of other early studies of oral progesterone in humans were also published in the 1950s and 1960s.[133][134][135][136][137][138][139][140][141][142] These studies generally reported oral progesterone to be only very weakly active.[133][138][137]

Progesterone was the first progestogen that was found to inhibit ovulation, both in animals and in women.[143] Injections of progesterone were first shown to inhibit ovulation between 1937 and 1939.[144][143][145][146] Inhibition of fertilization by administration of progesterone during the luteal phase was also demonstrated in animals between 1947 and 1949.[144] Ovulation inhibition by progesterone in animals was subsequently re-confirmed and expanded on by Gregory Pincus and colleagues in 1953 and 1954.[143][147][148] Findings on inhibition of ovulation by progesterone in women were first presented at the Fifth International Conference on Planned Parenthood in Tokyo, Japan in October 1955.[142][149] Three different research groups presented findings on ovulation inhibition by oral progesterone at this conference.[142][149] They included Pincus (in conjunction with John Rock, who did not attend the conference); a nine-member Japanese group led by Masaomi Ishikawa; and the two-member team of Abraham Stone and Herbert Kupperman.[142][149][150][151][152] The conference marked the beginning of a new era in the history of birth control.[149] The findings of ovulation inhibition by oral progesterone were subsequently published in scientific journals in 1956 in the case of Pincus and in 1957 in the case of Ishikawa and colleagues.[153][154][155] Rock and Pincus also subsequently described findings from 1952 that "pseudopregnancy" therapy with a combination of high doses of diethylstilbestrol and oral progesterone prevented ovulation and pregnancy in women.[139][156][157][158][159][160]

Unfortunately, the use of oral progesterone as a hormonal contraceptive was plagued by problems.[143][158] These included the large and by extension expensive doses required, incomplete inhibition of ovulation even at such high doses, and a frequent incidence of breakthrough bleeding.[143][158] At the 1955 Tokyo conference, Pincus had also presented the first findings of ovulation inhibition by oral progestins in animals, specifically 19-nortestosterone derivatives like noretynodrel and norethisterone.[158][142] These progestins were far more potent than progesterone, requiring much smaller doses orally.[158][142] By December 1955, inhibition of ovulation by oral noretynodrel and norethisterone had been demonstrated in women.[158] The findings of ovulation inhibition by the 19-nortestosterone progestins in animals and women were published in 1956.[161][162] These progestins did not show the problems associated with oral progesterone; in the manners used in the studies, they fully inhibited ovulation and did not produce menstruation-related side effects.[158] In relation to this, oral progesterone was abandoned as a hormonal contraceptive in women.[143][158] The first birth control pills to be introduced were a noretynodrel-containing product in 1957 and a norethisterone-containing product in 1963, followed by numerous others containing a diversity of progestins.[163] Progesterone itself has never been introduced for use in birth control pills.[164]

More modern clinical studies of oral progesterone demonstrating elevated levels of progesterone and end-organ responses, specifically progestational endometrial changes, were published between 1980 and 1983.[165][166][167][168] Up to this point, many clinicians and researchers still believed that oral progesterone was inactive.[168][169][170] It was not until almost half a century after the introduction of progesterone in medicine that an oral formulation of progesterone was marketed.[171] Micronization of progesterone and suspension in oil-filled capsules, which allowed progesterone to be absorbed several-fold more efficiently by the oral route, was first studied in the late 1970s and described in literature in 1982.[172][167][173] This formulation, known as oral micronized progesterone (OMP), was then introduced for medical use under the brand name Utrogestan in France in 1982.[167][31][30][19] Subsequently, oral micronized progesterone was introduced under the brand name Prometrium in the United States in 1998.[174][175] By 1999, oral micronized progesterone had been marketed in more than 35 countries.[174] In 2019, the first combination of oral estradiol and progesterone was introduced under the brand name Bijuva in the United States.[8][176]

Vaginal progesterone suppositories were first studied in women by Robert Greenblatt in 1954.[177][178][179] Shortly thereafter, vaginal progesterone suppositories were introduced for medical use under the brand name Colprosterone in 1955.[180][178] Rectal progesterone suppositories were first studied in men and women by Christian Hamburger in 1965.[181][179] Vaginal and rectal progesterone suppositories were introduced for use under the brand name Cyclogest by 1976.[182][183][184] Vaginal micronized progesterone gels and capsules were introduced for medical use under brand names such as Utrogestan and Crinone in the early 1990s.[171][185] Progesterone was approved in the United States as a vaginal gel in 1997 and as a vaginal insert in 2007.[186][187] A progesterone contraceptive vaginal ring known as Progering was first studied in women in 1985 and continued to be researched through the 1990s.[188][189] It was approved for use as a contraceptive in lactating mothers in Latin America by 2004.[188] A second progesterone vaginal ring known as Fertiring was developed as a progesterone supplement for use during assisted reproduction and was approved in Latin America by 2007.[190][191]

Development of a progesterone-containing intrauterine device (IUD) for contraception began in the 1960s.[192] Incorporation of progesterone into IUDs was initially studied to help reduce the risk of IUD expulsion.[192] However, while addition of progesterone to IUDs showed no benefit on expulsion rates, it was unexpectedly found by Antonio Scommegna to induce endometrial atrophy.[192] This led to the development and introduction of Progestasert, a progesterone-containing product and the first progestogen-containing IUD, in 1976.[54][192][24] Unfortunately, the product had various problems that limited its use.[192][24][54] These included a short duration of efficacy of only one year, a high cost, a relatively high 2.9% failure rate, a lack of protection against ectopic pregnancy, and difficult and sometimes painful insertions that could necessitate use of a local anesthetic or analgesic.[192][24][54] As a result of these issues, Progestasert never became widely used, and was discontinued in 2001.[192][24][54] It was used mostly in the United States and France while it was marketed.[24]

A topical gel formulation of progesterone for direct application to the breasts in local treatment of breast disorders such as mastodynia was introduced under the brand name Progestogel in Europe by 1972.[193] No transdermal formulations of progesterone have been successfully marketed for systemic use, despite efforts of pharmaceutical companies towards this goal.[79][67][194]

Sublingual progesterone in women was first studied in 1944 by Greenblatt.[195][196][178][132] Transmucosal progesterone tablets, for use by buccal or sublingual administration, were marketed under the brand names Progesterone Lingusorbs and Progesterone Membrettes by 1951.[197][198][199] The first studies of transmucosal progesterone were published in 1953.[200][136] A sublingual tablet formulation of progesterone has been marketed under the brand name Luteina in Poland and Ukraine.[75][76]

Subcutaneous pellet implants of progesterone were first studied in women in the late 1930s.[201][202][203][204][205] They were reported to be extruded out of the skin within a few weeks at high rates and produced frequent inflammatory reactions at the site of implantation.[203][178] Consequently, they were soon abandoned.[178][206] However, subcutaneous pellet implants of progesterone were later studied as a form of birth control in women in the 1980s and early 1990s.[207][208][209][210]

Macrocrystalline aqueous suspensions of progesterone as well as microspheres of progesterone were investigated as potential progestogen-only injectable contraceptives and combined injectable contraceptives (with estradiol) by the late 1980s and early 1990s but were never marketed.[211][212][213][214][214][215]

An aqueous solution of progesterone complexed with cyclodextrin to increase its water solubility was introduced for use by once-daily subcutaneous injection in Europe under the brand name Prolutex in the mid-2010s.[216][13]

Progesterone is the generic name of the drug in English and its INN, USAN, USP, BAN, DCIT, and JAN, while progestérone is its name in French and its DCF.[75][119][120][217] It is also referred to as progesteronum in Latin, progesterona in Spanish and Portuguese, and progesteron in German.[75][120]

Prometrium 100 mg oral capsule.

Progesterone is marketed under a large number of brand names throughout the world.[75][120] Examples of major brand names under which progesterone has been marketed include Crinone, Crinone 8%, Cyclogest, Endogest, Endometrin, Estima, Geslutin, Gesterol, Gestone, Luteina, Luteinol, Lutigest, Lutinus, Microgest, Progeffik, Progelan, Progendo, Progering, Progest, Progestaject, Progestan, Progesterone, Progestin, Progestogel, Prolutex, Proluton, Prometrium, Prontogest, Strone, Susten, Utrogest, and Utrogestan.[75][120]

Progesterone is widely available in countries throughout the world in a variety of formulations.[75][76] Progesterone in the form of oral capsules; vaginal capsules, tablets/inserts, and gels; and intramuscular oil have widespread availability.[75][76] The following formulations/routes of progesterone have selective or more limited availability:[75][76]

• A tablet of micronized progesterone which is marketed under the brand name Luteina is indicated for sublingual administration in addition to vaginal administration and is available in Poland and Ukraine.[75][76]
• A progesterone suppository which is marketed under the brand name Cyclogest is indicated for rectal administration in addition to vaginal administration and is available in Cyprus, Hong Kong, India, Malaysia, Malta, Oman, Singapore, South Africa, Thailand, Tunisia, Turkey, the United Kingdom, and Vietnam.[75][76]
• An aqueous solution of progesterone complexed with β-cyclodextrin for subcutaneous injection is marketed under the brand name Prolutex in the Czech Republic, Hungary, Italy, Poland, Portugal, Slovakia, Spain, and Switzerland.[75][76]
• A non-systemic topical gel formulation of progesterone for local application to the breasts to treat breast pain is marketed under the brand name Progestogel and is available in Belgium, Bulgaria, Colombia, Ecuador, France, Georgia, Germany, Hong Kong, Lebanon, Peru, Romania, Russia, Serbia, Switzerland, Tunisia, Venezuela, and Vietnam.[75][76] It was also formerly available in Italy, Portugal, and Spain, but was discontinued in these countries.[76]
• A progesterone intrauterine device was previously marketed under the brand name Progestasert and was available in Canada, France, the United States, and possibly other countries, but was discontinued.[76][218]
• Progesterone vaginal rings are marketed under the brand names Fertiring and Progering and are available in Chile, Ecuador, and Peru.[75][76]

In addition to single-drug formulations, the following progesterone combination formulations are or have been marketed, albeit with limited availability:[75][76]

• A combination pack of progesterone capsules for oral use and estradiol gel for transdermal use is marketed under the brand name Estrogel Propak in Canada.[75][76]
• A combination pack of progesterone capsules and estradiol tablets for oral use is marketed in an under the brand name Duogestan in Belgium.[75][76]
• Progesterone and estradiol in an aqueous suspension for use by intramuscular injection is marketed under the brand name Cristerona FP in Argentina.[75][76]
• Progesterone and estradiol in microspheres in an oil solution for use by intramuscular injection is marketed under the brand name Juvenum in Mexico.[75][76][219]
• Progesterone and estradiol benzoate in an oil solution for use by intramuscular injection is marketed under the brand names Duogynon, Duoton Fort T P, Emmenovis, Gestrygen, Lutofolone, Menovis, Mestrolar, Metrigen Fuerte, Nomestrol, Phenokinon-F, Prodiol, Pro-Estramon-S, Proger F, Progestediol, and Vermagest and is available in Belize, Egypt, El Salvador, Ethiopia, Guatemala, Honduras, Italy, Lebanon, Malaysia, Mexico, Nicaragua, Taiwan, Thailand, and Turkey.[75][76]
• Progesterone and estradiol hemisuccinate in an oil solution for use by intramuscular injection is marketed under the brand name Hosterona in Argentina.[75][76]
• Progesterone and estrone for use by intramuscular injection is marketed under the brand name Synergon in Monaco.[75]

As of November 2016, progesterone is available in the United States in the following formulations:[74]

• Oral: Capsules: Prometrium (100 mg, 200 mg, 300 mg)
• Vaginal: Tablets: Endometrin (100 mg); Gels: Crinone (4%, 8%)
• Intramuscular injection: Oil: Progesterone (50 mg/mL)

A 25 mg/mL concentration of progesterone oil for intramuscular injection and a 38 mg/device progesterone intrauterine device (Progestasert) have been discontinued.[74]

An oral combination formulation of micronized progesterone and estradiol in oil-filled capsules (developmental code name TX-001HR) is currently under development in the United States for the treatment of menopausal symptoms and endometrial hyperplasia, though it has yet to be approved or introduced.[220][8]

Progesterone is also available in unregulated custom preparations from compounding pharmacies in the United States.[77][78] In addition, transdermal progesterone is available over-the-counter in the United States, although the clinical efficacy of transdermal progesterone is controversial.[79][80][81]