P25 Progesterone Cream

Dosage for progesterone varies significantly based on the condition being treated and the route of administration. According to clinical guidelines, typical adult dosages include:

• For Hormone Replacement Therapy (Prevention of Endometrial Hyperplasia): When taken in conjunction with estrogen, the standard dose of micronized oral progesterone is typically 200 mg daily for 12 sequential days per 28-day cycle. Alternatively, a continuous dose of 100 mg daily may be prescribed.
• For Secondary Amenorrhea: The usual dose is 400 mg of micronized oral progesterone daily, taken at bedtime for 10 days.
• For Assisted Reproductive Technology (IVF Support): Vaginal inserts (e.g., 100 mg two to three times daily) or vaginal gels (e.g., 8% gel once daily) are typically started the day after egg retrieval and continued for up to 10-12 weeks of pregnancy.
• For Prevention of Preterm Birth: Vaginal progesterone (200 mg daily) is often administered starting between 16 and 24 weeks of gestation and continued until 36 weeks.

Progesterone is generally not indicated for use in pediatric populations before the onset of puberty. It is not approved for use in children who have not reached menarche (the first menstrual period). If used for specific endocrine disorders in adolescents, dosing must be strictly supervised by a pediatric endocrinologist.

Renal Impairment

Specific dosage adjustments for patients with kidney disease have not been established. However, because progesterone metabolites are primarily excreted through the urine, patients with significant renal impairment should be monitored closely by their healthcare provider for potential accumulation of metabolites.

Hepatic Impairment

Progesterone is contraindicated (should not be used) in patients with active liver disease or significantly impaired liver function. The liver is the primary site of progesterone metabolism; impaired function can lead to dangerously high levels of the hormone in the bloodstream.

Elderly Patients

In women over 65, progesterone use is primarily limited to hormone replacement therapy. Clinical trials like the Women's Health Initiative (WHI) suggest that older women may face higher risks of cardiovascular events or dementia when using hormone therapy. Healthcare providers typically use the lowest effective dose for the shortest duration possible.

To ensure maximum safety and efficacy, follow these specific instructions:

• Oral Administration: Micronized progesterone capsules should be taken at bedtime. Taking it with food can significantly increase absorption (bioavailability), so consistency is key—take it the same way every night. Because it can cause significant drowsiness, it should never be taken during the day if you need to drive or operate machinery.
• Vaginal Administration: Gels and inserts should be applied as directed. If using a gel, you may notice a small amount of 'leakage' or discharge, which is normal. Ensure the applicator is cleaned or disposed of according to the package instructions.
• Storage: Store all forms of progesterone at room temperature (68°F to 77°F or 20°C to 25°C), away from moisture, heat, and direct light. Keep out of reach of children.

If you miss a dose of progesterone, take it as soon as you remember. However, if it is almost time for your next scheduled dose, skip the missed dose and resume your regular schedule. Do not 'double up' or take two doses at once to make up for a missed one. Frequent missed doses in pregnancy support can be serious; contact your fertility clinic immediately if you miss more than one dose.

Signs of a progesterone overdose may include extreme dizziness, severe somnolence (sleepiness), nausea, or vomiting. In the event of a suspected overdose, contact your local poison control center or seek emergency medical attention immediately. While progesterone has a relatively low acute toxicity, excessive levels can cause profound central nervous system depression.

> Important: Follow your healthcare provider's dosing instructions precisely. Do not adjust your dose or stop taking the medication without medical guidance, especially during pregnancy.

Most patients taking progesterone will experience some degree of side effects, particularly when starting therapy. Common reactions include:

• Drowsiness and Dizziness: Especially with oral forms, as progesterone metabolites act on the brain's calming receptors. This usually peaks 1 to 3 hours after ingestion.
• Breast Tenderness: Similar to the feeling experienced just before a menstrual period, caused by the hormone's effect on breast tissue.
• Bloating and Abdominal Cramping: Progesterone can slow down the digestive tract, leading to gas and water retention.
• Mood Fluctuations: Some women report feeling irritable, anxious, or 'blue' shortly after starting treatment.
• Headache: Mild to moderate headaches are frequently reported during the first few weeks of therapy.

• Vaginal Discharge or Irritation: Specific to vaginal gels or inserts; may include a white, clumpy discharge as the medication carrier is expelled.
• Changes in Appetite: Some patients report increased hunger or cravings.
• Acne or Skin Rashes: Hormonal shifts can trigger minor breakouts or oily skin.
• Nausea: Mild stomach upset, which can often be mitigated by taking the medication with a small snack (for oral forms).

• Galactorrhea: Unexpected nipple discharge.
• Hirsutism: Growth of dark or coarse hair in a male-like pattern (face, chest, back).
• Alopecia: Thinning of scalp hair.
• Vision Changes: Blurred vision or difficulty wearing contact lenses due to changes in corneal shape.

> Warning: Stop taking Progesterone and call your doctor immediately if you experience any of these symptoms. They may indicate a life-threatening condition.

• Blood Clots (Thromboembolism): Symptoms include sudden shortness of breath, sharp chest pain, coughing up blood, or pain, swelling, and redness in one leg (Deep Vein Thrombosis).
• Liver Dysfunction (Cholestatic Jaundice): Symptoms include yellowing of the skin or eyes (jaundice), dark urine, and severe itching.
• Stroke or Heart Attack: Symptoms include sudden numbness or weakness (especially on one side of the body), severe headache, slurred speech, or crushing chest pain.
• Severe Allergic Reaction (Anaphylaxis): Symptoms include hives, swelling of the face or throat, and difficulty breathing. Note that some progesterone injections are in peanut oil; patients with peanut allergies must avoid these.
• Depression: Seek help if you experience suicidal thoughts or profound changes in mental health.

When used for years, particularly in combination with estrogen for postmenopausal therapy, progesterone is associated with specific long-term considerations:

• Breast Cancer Risk: Large-scale studies like the WHI have shown an increased risk of breast cancer when progestogens are added to estrogen therapy compared to estrogen alone.
• Bone Mineral Density: While progesterone is generally neutral or slightly positive for bone health, long-term hormonal shifts require monitoring.
• Dementia Risk: In women over 65, prolonged use of combination hormone therapy may increase the risk of developing dementia.

Progesterone, when used in combination with estrogens, carries FDA-mandated 'Black Box Warnings' (the highest level of warning):

1. 1Cardiovascular Disorders: Estrogen plus progestin therapy should not be used for the prevention of cardiovascular disease. It has been associated with increased risks of heart attack, stroke, and blood clots.
2. 2Breast Cancer: There is an increased risk of invasive breast cancer in postmenopausal women using combination therapy.
3. 3Dementia: The Women's Health Initiative Memory Study found an increased risk of developing probable dementia in postmenopausal women 65 years of age or older.

Report any unusual symptoms to your healthcare provider immediately. Regular follow-ups and screenings (like mammograms) are essential during long-term therapy.

Progesterone is a potent hormone that affects multiple organ systems. It is essential to disclose your full medical history to your doctor before beginning treatment. Progesterone can mask the symptoms of the onset of menopause or other underlying gynecological conditions. It should only be used for the specific indications for which it was prescribed.

As noted in the side effects section, the FDA requires a boxed warning for progesterone products used in hormone replacement therapy. This warning emphasizes that progestogens should not be used to prevent heart disease or dementia and highlights the increased risk of stroke, blood clots, and breast cancer when used with estrogen. The lowest effective dose should be used for the shortest duration consistent with treatment goals.

• Allergic Reactions: Some liquid forms of progesterone (injections) are formulated with peanut oil. If you have a known peanut allergy, you must inform your doctor, as this can cause fatal anaphylaxis. Other formulations may contain different oils or excipients.
• Fluid Retention: Because progesterone can cause some degree of fluid retention, conditions that might be influenced by this (such as epilepsy, migraine, asthma, cardiac dysfunction, or renal dysfunction) require careful observation.
• Visual Abnormalities: Discontinue medication immediately and seek an ophthalmic exam if there is a sudden partial or complete loss of vision, or if there is a sudden onset of proptosis (bulging eyes), diplopia (double vision), or migraine.
• Depression: Patients with a history of clinical depression should be closely monitored. If the depression recurs to a serious degree, the drug should be discontinued.
• Glucose Tolerance: A decrease in glucose tolerance has been observed in some patients on estrogen-progestin combination therapy. Diabetic patients should be monitored closely for changes in blood sugar levels.

While taking progesterone, your healthcare provider will likely require the following:

• Annual Physical Exams: Including blood pressure checks and clinical breast exams.
• Mammography: Regular screenings as recommended based on your age and risk factors.
• Liver Function Tests (LFTs): Especially if you have a history of liver issues or develop symptoms of jaundice.
• Endometrial Sampling: If undiagnosed vaginal bleeding occurs during therapy, a biopsy may be needed to rule out malignancy.

Progesterone, particularly the oral micronized form, can cause significant somnolence (sleepiness) and dizziness. It is highly recommended to take oral progesterone at bedtime. Do not drive, operate heavy machinery, or engage in hazardous activities until you know how the medication affects you. The sedative effect is often most pronounced during the first few days of treatment.

Alcohol can potentiate the sedative effects of progesterone. Consuming alcohol while taking progesterone may lead to extreme drowsiness and an increased risk of falls or accidents. It is generally advised to limit or avoid alcohol consumption while on this medication.

Stopping progesterone suddenly is generally not associated with a dangerous 'withdrawal syndrome' like that of benzodiazepines, but it can cause immediate 'withdrawal bleeding' (similar to a period) as the uterine lining is no longer supported. In pregnancy support, stopping progesterone prematurely can lead to pregnancy loss. Always consult your doctor before stopping the medication.

> Important: Discuss all your medical conditions, including any history of blood clots, liver disease, or cancer, with your healthcare provider before starting Progesterone.

While few drugs are strictly contraindicated, certain combinations are avoided due to extreme risks:

• Active Venous Thromboembolism (VTE): Progesterone should not be used in patients currently taking medications for active blood clots unless specifically directed by a specialist, as it may exacerbate the condition.
• Known or Suspected Malignancy of the Breast or Genital Organs: Progesterone can stimulate the growth of certain hormone-sensitive tumors.

• CYP3A4 Inducers (e.g., Rifampin, Phenytoin, Carbamazepine): These medications speed up the liver's metabolism of progesterone. This can significantly lower the levels of progesterone in your blood, making the treatment less effective. If you are taking these for seizures or infections, your progesterone dose may need to be adjusted.
• CYP3A4 Inhibitors (e.g., Ketoconazole, Itraconazole, Clarithromycin): These drugs slow down the metabolism of progesterone, leading to higher-than-intended levels in the body. This can increase the risk of side effects like extreme sedation or breast tenderness.
• Antidiabetic Agents: Progesterone may decrease insulin sensitivity. Patients on insulin or oral hypoglycemics (like Metformin) may need to monitor their blood glucose more frequently and adjust their dosages under medical supervision.

• Thyroid Replacement Therapy: Estrogens and progestogens can increase the levels of thyroid-binding globulin. Women on thyroid medications (like Levothyroxine) may need an increase in their thyroid dose after starting progesterone. Monitoring of TSH levels is recommended.
• Warfarin and Anticoagulants: Hormones can sometimes interfere with the effectiveness of blood thinners. Close monitoring of the INR (a measure of blood clotting time) is necessary.

• High-Fat Meals: Taking oral micronized progesterone with a high-fat meal significantly increases its absorption (bioavailability). To maintain steady levels in your blood, you should be consistent in how you take it (always with food or always without).
• Grapefruit Juice: Grapefruit is a known inhibitor of the CYP3A4 enzyme. Consuming grapefruit or its juice can lead to increased levels of progesterone and a higher risk of side effects.

• St. John's Wort: This herbal supplement is a potent inducer of liver enzymes. It can significantly reduce the effectiveness of progesterone, which is particularly dangerous for women using it to prevent endometrial overgrowth or support a pregnancy.
• Soy Isoflavones / Red Clover: These contain phytoestrogens which may interfere with the hormonal balance progesterone is trying to achieve. Consult your doctor before combining herbal hormonal supplements.

Progesterone can affect the results of several laboratory tests, including:

• Liver Function Tests: May show elevated transaminases.
• Coagulation Tests: May show changes in factors VII, VIII, IX, and X.
• Pregnanediol Determination: Progesterone administration will naturally increase these levels.
• Thyroid Function: As mentioned, it may affect protein-bound iodine (PBI) and T4 levels.

> Important: Tell your doctor about ALL medications, supplements, and herbal products you are taking. Even 'natural' products can have significant interactions with hormone therapy.

Progesterone must NEVER be used in the following circumstances:

• Current or Past Blood Clots: This includes deep vein thrombosis (DVT), pulmonary embolism (PE), or a history of these conditions. Progesterone can increase the blood's tendency to clot.
• Active or Past Breast Cancer: Progesterone can stimulate the growth of hormone-dependent tumors.
• Undiagnosed Vaginal Bleeding: Before starting progesterone, the cause of any unusual bleeding must be determined to rule out uterine cancer.
• Severe Liver Disease: Including active hepatitis or cirrhosis, as the liver cannot process the hormone, leading to toxicity.
• Known or Suspected Pregnancy: Except when specifically used as part of assisted reproductive technology (ART) under specialist care. In other contexts, it is not used during pregnancy.
• Peanut Allergy: Specifically for the injection forms that use peanut oil as a carrier.
• Hypersensitivity: Any previous severe allergic reaction to progesterone or its components.

These conditions require a careful risk-benefit analysis by a physician:

• Hypertension (High Blood Pressure): Progesterone can cause fluid retention, which may worsen blood pressure control.
• Diabetes Mellitus: Due to potential effects on insulin sensitivity.
• Migraine with Aura: Hormonal shifts can trigger or worsen severe migraines.
• Systemic Lupus Erythematosus (SLE): Hormones can sometimes trigger 'flares' of autoimmune conditions.

Patients who are sensitive to other progestogens (like medroxyprogesterone or norethindrone) may also react to progesterone, though natural progesterone is often better tolerated than synthetic versions. Patients with a history of 'pregnancy herpes' (pemphigoid gestationis) or jaundice during pregnancy should use progesterone with extreme caution.

> Important: Your healthcare provider will evaluate your complete medical history before prescribing Progesterone. Never share this medication with others.

Progesterone is unique in that it is both a hormone of pregnancy and a medication used to support it.

• In Fertility Treatment: It is essential for supporting the luteal phase and early pregnancy in IVF cycles. It is generally considered safe and necessary in this specific context.
• Teratogenicity: Most studies have not shown an increased risk of birth defects when progesterone is used in early pregnancy. However, it should only be used under the strict guidance of a reproductive specialist.
• Category: While the old FDA letter categories are being phased out, it was traditionally viewed as safe for its indicated uses in pregnancy support but contraindicated for other uses (like HRT) during pregnancy.

Progesterone is excreted in human breast milk. While small amounts are unlikely to harm a nursing infant, high doses of exogenous progesterone could potentially interfere with the quality or quantity of milk production. If you are breastfeeding, discuss the timing and necessity of progesterone therapy with your doctor.

Progesterone is not approved for use in children before the onset of puberty. Its use in adolescents is limited to specific cases of secondary amenorrhea or hormonal imbalances and must be managed by an endocrinologist to ensure it does not interfere with normal growth and development.

In women over 65, the primary concern is the increased risk of cardiovascular events and dementia. The Women's Health Initiative (WHI) data suggest that the risks of combination hormone therapy (estrogen + progestogen) may outweigh the benefits for many older women. If used, it should be at the lowest dose for the shortest time, with frequent re-evaluation (every 3-6 months).

There are no specific guidelines for GFR-based (Glomerular Filtration Rate) adjustments. However, since the kidneys excrete the majority of progesterone metabolites, patients with Stage 4 or 5 chronic kidney disease should be monitored for increased side effects like somnolence or edema.

Progesterone is strictly contraindicated in patients with significant hepatic impairment (Child-Pugh Class B or C). In patients with mild impairment (Class A), it should be used with extreme caution, as the decreased clearance can lead to significantly elevated plasma concentrations and increased risk of serious side effects.

> Important: Special populations require individualized medical assessment. Always inform your specialist about your age, pregnancy status, and any organ-related health issues.

Progesterone is a genomic acting hormone. It diffuses into cells and binds to the Progesterone Receptor (PR), which exists in two main isoforms: PR-A and PR-B. Upon binding, the receptor dissociates from heat-shock proteins, dimerizes, and moves into the nucleus. There, it binds to Progesterone Response Elements (PREs) on the DNA. This action recruits co-activators or co-repressors to the promoter region of target genes, thereby regulating the expression of mRNA and subsequent protein synthesis.

In addition to these 'slow' genomic effects, progesterone also exerts 'fast' non-genomic effects by interacting with membrane-bound receptors (mPRs) and GABA-A receptors in the brain. The interaction with GABA-A receptors is responsible for its rapid sedative and anesthetic-like effects.

The primary pharmacodynamic effect is the induction of secretory changes in the estrogen-primed endometrium. It also decreases the frequency of GnRH (Gonadotropin-Releasing Hormone) pulses from the hypothalamus, which can inhibit ovulation at high doses. In the breasts, it promotes the development of acinar and lobular tissue.

| Parameter | Value |

|---|---|

| Bioavailability | <10% (Oral, non-micronized); ~10-15% (Oral, micronized with food) |

| Protein Binding | 96% - 99% (Albumin and CBG) |

| Half-life | 5 - 20 minutes (Plasma); 18 - 24 hours (Terminal phase) |

| Tmax | 1 - 3 hours (Oral); 4 - 8 hours (Vaginal) |

| Metabolism | Hepatic (CYP3A4); converted to pregnanediols and pregnanolones |

| Excretion | Renal (50-60%), Fecal (10%) |

• Molecular Formula: C21H30O2
• Molecular Weight: 314.46 g/mol
• Solubility: Practically insoluble in water; soluble in alcohol, acetone, and dioxane; sparingly soluble in vegetable oils.
• Structure: A pregnane (21-carbon) steroid with a ketone group at positions 3 and 20, and a double bond between C4 and C5.

Progesterone is classified as a naturally occurring progestogen and a steroid hormone. It is the prototype of the progestogen class. Related medications include synthetic progestins such as Medroxyprogesterone acetate, Norethindrone, and Drospirenone.