Pharmacokinetics of progesterone
The pharmacokinetics of progesterone concerns the pharmacodynamics, pharmacokinetics, and various routes of administration of progesterone.
Progesterone is a naturally occurring and bioidentical progestogen, or an agonist of the progesterone receptor, the biological target of progestogens like endogenous progesterone. Progesterone also has antimineralocorticoid and inhibitory neurosteroid activity, whereas it appears to have little or no glucocorticoid or antiandrogenic activity and has no androgenic activity. Because of its progestogenic activity, progesterone has functional antiestrogenic effects in certain tissues such as the uterus, cervix, and vagina. In addition, progesterone has antigonadotropic effects due to its progestogenic activity and can inhibit fertility and suppress sex hormone production. Progesterone differs from progestins like medroxyprogesterone acetate and norethisterone, with implications for pharmacodynamics and pharmacokinetics as well as efficacy, tolerability, and safety.
Progesterone can be taken by mouth, in through the vagina, and by injection into muscle or fat, among other routes. A progesterone vaginal ring and progesterone intrauterine device are also available as pharmaceutical products.
Normal levels
Progesterone is used as part of hormone replacement therapy in people who have low progesterone levels, and for other reasons. For purposes of comparison with normal physiological circumstances, luteal phase levels of progesterone are 4 to 30 ng/mL, while follicular phase levels of progesterone are 0.02 to 0.9 ng/mL, menopausal levels are 0.03 to 0.3 ng/mL, and levels of progesterone in men are 0.12 to 0.3 ng/mL. During pregnancy, levels of progesterone in the first 4 to 8 weeks are 25 to 75 ng/mL, and levels are typically around 140 to 200 ng/mL at term. Production of progesterone in the body in late pregnancy is approximately 250 mg per day, 90% of which reaches the maternal circulation.Routes of administration
The pharmacokinetics of progesterone are dependent on its route of administration. The medication is approved in the form of oil-filled capsules containing micronized progesterone for oral administration, termed "oral micronized progesterone" or simply "oral progesterone". It is also available in the form of vaginal or rectal suppositories, vaginal gels, oil solutions for intramuscular injection, and aqueous solutions for subcutaneous injection, among others.Routes of administration that progesterone has been used include oral, intranasal, transdermal, vaginal, rectal, intramuscular, subcutaneous, and intravenous injection. Oral progesterone has been found to be inferior to vaginal and intramuscular progesterone in terms of absorption and clearance rate. Vaginal progesterone is available in the forms of progesterone gel, rings, and suppositories or pessaries. Advantages of intravaginal progesterone over oral administration include high bioavailability, rapid absorption, avoidance of first-pass metabolism, sustained plasma concentrations, and a local endometrial effect, while advantages of intravaginal progesterone relative to intramuscular injection include greater convenience and lack of injection site pain.
Intranasal progesterone as a nasal spray is effective in achieving therapeutic levels, and was not associated with nasal irritation, but was associated with an unpleasant taste of the spray. Rectal, intramuscular, and intravenous routes may be inconvenient, especially for long-term treatment. Plasma levels of progesterone are similar after vaginal and rectal administration in spite of the different routes of administration, and rectal administration is an alternative to vaginal progesterone in conditions of vaginal infection, cystitis, recent childbirth, or when barrier contraception methods are used. Intramuscular injection of progesterone may achieve much higher levels of progesterone than normal luteal phase concentrations and levels achieved with other routes.
Oral administration
Methodological issues in studies
Knowledge about the pharmacokinetics of oral progesterone has been complicated by the use of flawed analytical techniques. When progesterone is taken orally, due to first-pass metabolism, very high levels of its metabolites occur. Most previous studies have used a method known as immunoassay to measure progesterone levels. However, IA without chromatographic separation has high cross-reactivity and is unable to differentiate between progesterone and metabolites such as allopregnanolone and pregnanolone. As a result, studies that have assessed the pharmacokinetics of oral progesterone using IA have reported falsely high progesterone levels and inaccurate dependent pharmacokinetic parameters.Comparative studies using reliable and exact methods such as liquid chromatography–mass spectrometry and IA in conjunction with adequate CS have found that IA without CS overestimates levels of progesterone by 5- to 8-fold. For this reason, the use of reliable assays is mandatory when studying the pharmacokinetics of oral progesterone, and an awareness of these methodological issues is likewise essential for an accurate understanding of the pharmacokinetics of oral progesterone. Conversely, the same issues are not applicable to parenteral routes of progesterone such as vaginal administration and intramuscular injection, because these routes are not subject to a first pass and relatively low levels of progesterone metabolites are formed.
Absorption, bioavailability, and levels
The oral bioavailability of progesterone is very low. Studies using IA have generally measured the bioavailability of oral progesterone as less than 10%, with one study reporting values of 6.2 to 8.6%. However, these values are overestimations; a study using LC–MS found that the bioavailability of oral progesterone was only 2.4% relative to vaginal progesterone gel. Moreover, this was not relative to the standard of progesterone by intramuscular injection, which has much higher bioavailability than vaginal progesterone. The very low bioavailability of oral progesterone is due to the fact that it is poorly absorbed from the gastrointestinal tract and undergoes massive metabolism, resulting in almost complete inactivation during the first pass through the liver. Because of its poor oral bioavailability, very high doses of progesterone must be used by the oral route to achieve significant circulating progesterone levels. In addition, oral progesterone today is always micronized and suspended in oil. This improves the bioavailability of oral progesterone significantly compared to plain milled progesterone, and allows for it to be used at practical doses. When the term "oral progesterone" is used, what is used clinically and what is almost always being referred to, unless noted otherwise, is micronized progesterone suspended in oil.Micronization is the process of reducing the average diameter of the particles of a solid material. By micronizing progesterone, its particles are made smaller and its surface area is increased, thereby enhancing absorption from the intestines. Suspension and partial solubilization of progesterone in oil containing medium- to long-chain fatty acids likewise improves the bioavailability of oral progesterone. Progesterone is a lipophilic compound and it has been theorized that suspension of progesterone in oil may improve its absorption by the lymphatic system, thereby allowing a portion of oral progesterone to bypass the first pass through the liver and hence enhancing its bioavailability. Compared to plain milled progesterone, peak levels of progesterone following a single 200 mg oral dose were increased 1.4-fold by micronization, 1.2-fold by suspension in oil, and 3.2-fold by the combination of micronization and suspension in oil. Oral micronized progesterone suspended in oil is rapidly and almost completely absorbed from the intestines. There is wide interindividual variability in the bioavailability of oral progesterone. As progesterone was not used orally for many decades due to its poor bioavailability, oral progestins with improved metabolic stability and high oral bioavailability were developed and have been used clinically instead.
When oral progesterone is used at typical clinical dosages, only very low levels of progesterone are measured using reliable methods. Following single doses of oral progesterone, peak levels of progesterone of 1.5 to 2.4 ng/mL with 100 mg and 2.8 to 4.7 ng/mL with 200 mg have been measured using LC–MS, liquid chromatography–tandem mass spectrometry, and IA with adequate CS. In one such study, although peak levels of progesterone were 2.2 ng/mL after a single 100 mg dose of oral progesterone, levels of progesterone remained significantly elevated for less than about 4 hours, and the average progesterone levels over a period of 24 hours were only 0.14 ng/mL. For comparison, normal progesterone levels during the luteal phase of the menstrual cycle with LC–MS/MS are 6.7 to 22.2 ng/mL. When IA alone has been used to measure progesterone levels with oral progesterone, far higher peak levels of 6.5 to 10.2 ng/mL, 13.8 to 19.9 ng/mL, and 32.3 to 49.8 ng/mL have been observed after single 100, 200, and 300 mg doses, respectively. One IA-based study even reported maximal progesterone levels of 16 to 626 ng/mL with a single 300 mg dose of oral progesterone.
When oral progesterone is taken with food instead of fast, peak and overall levels of progesterone are significantly higher. A study using LC-MS/MS found that when 100 mg oral progesterone was taken within 30 minutes of starting a high-fat meal, peak levels of progesterone were 2.6-fold higher and area-under-the-curve levels were 1.8-fold higher when compared to taking it in a fasted state. In another study, peak levels of progesterone were increased by 5-fold and area-under-the-curve levels by 2-fold when 200 mg oral progesterone was taken with food. However, this study used the unreliable method of IA to quantify progesterone levels. Although the bioavailability of oral progesterone is increased if it is taken with food, its overall bioavailability is still low, even if measured using IA. It has been suggested that the improvement in progesterone levels when oral progesterone is taken with food may be due to enhanced lymphatic absorption, allowing oral progesterone to partially bypass first-pass metabolism.