Use Of Progestins Research Articles

Abstract 1585: Genetic variations in progesterone receptor (PGR)-related genes and mammographic density in premenopausal women: Are the associations mediated by circulating progesterone

Abstract BACKGROUND: Progesterone is a proliferative hormone in the breast. Combined estrogen plus progestin use in postmenopausal women increases mammographic density; a very strong risk for breast cancer. Circulating progesterone and genetic variations in progesterone receptor (PGR)-related genes are positively associated with mammographic density in postmenopausal women, but there are limited data in premenopausal women, with conflicting results. Notably, besides hormone therapy, genetic variation in PGR genes are known to modulate circulating progesterone levels. We, therefore, investigated the associations of genetic variations in PGR-related genes (PGR and Progesterone Receptor Membrane Component 1 (PGRMC1) with mammographic density in premenopausal women and determine, for the first time, whether these associations are mediated via circulating progesterone. METHODS: We genotyped 179 PGR-related single nucleotide polymorphisms (SNPs) (155 for PGR and 24 for PGRMC1 - 17 of which were synonymous variants and were filtered) in 364 cancer-free premenopausal women who had screening mammography at the Joanne Knight Breast Health Center at Washington University School of Medicine, St. Louis in 2016. We used Volpara to determine volumetric percent density, and dense volume. Variants were coded in dominant mode of inheritance. For causal mediation analysis, multivaraite linear regression models were applied to both the mediator (circulating PGR in logarithm scale) with variants and volumetric percent density, and dense volume with variant, PGR in logarithm scale and their interaction, both adjusting for age, body mass index, family history of breast cancer, and parity. The causal mediation effect, direct effect and total effect, by gentoype and averaged across genotypes were estimated with 95% confidence intervals and p values. Significance was claimed with p-value≤0.05. RESULTS: The mean age of the study participants was 47.5 years. Most participants (42.1%) had volumetric percent density between 3.5-7.5%, equivalent to BI-RADS® category b. Rs2020875 (PGR11) had a positive average direct effect (estimate=0.22, 95% CI, 0.016~0.44, p-value=0.024) and rs645213 (PGR11) had a borderline inverse direct effect (-0.25, -0.48~0.0004, p-value=0.052) on volumetric percent density. Further, rs11224565 (PGR11): 0.19, 0.04~0.34, p-value=0.028 had positive average direct effects on dense volume. None of the mediation effects were statistically signficiant. CONCLUSIONS: SNPs in PGR-related genes are associated with mammographic density in premenopausal women. Circulating progesterone levels did not mediate the associations between variants in PGR-related genes and mammographic density. Larger studies are needed to confirm our findings. Citation Format: Favour A. Akinjiyan, Yunan Han, Jingqin R. Luo, Aldi Kraja, Catherine M. Appleton, Graham A. Colditz, Adetunji T. Toriola. Genetic variations in progesterone receptor (PGR)-related genes and mammographic density in premenopausal women: Are the associations mediated by circulating progesterone [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1585.

Exogenous progestogen does not affect first-wave follicle populations and oocyte quality during ovarian stimulation with FSH in sheep

The effect of short-term administration of medroxyprogesterone acetate (MPA) or natural progesterone (P4) during ovarian stimulation with FSH on oocyte recovery was investigated in Santa Inês ewes. Ewes were treated with an intravaginal sponge containing MPA for 6 d; GnRH was applied 36 h after sponge removal and FSH was given in 3 injections (40, 24, and 16 mg, respectively) every 12 h after (D0, approximate ovulation time). At the first FSH dose, the ewes received either a new MPA sponge (n = 10) or a controlled device for internal release impregnated with P4 (n = 10) or did not receive any device (n = 10). Ovarian dynamics were assessed every 12 h by transrectal ultrasonography from D-3 to D2. Oocytes were recovered by laparoscopic ovum pick-up (LOPU) on D2 and graded by morphologic quality. The number of small, medium, and large follicles at D0 and D2 (ultrasound examinations), number of both follicles aspirated and oocytes recovered at LOPU, recovery rate, and oocyte grade did not differ (P > 0.05) among treatments. Thus, the short-term use of MPA or P4 during ovarian stimulation did not affect the first-wave follicle population or morphologic quality of oocytes. We would suggest that, in this protocol, the use of exogenous progestin is unnecessary.

Evaluation of progestogen supplementation for luteal phase support in fresh in vitro fertilization cycles

To evaluate the effectiveness of progestogen supplementation in improving clinical pregnancy rates in women undergoing fresh IVF cycles and to compare different routes, start times, durations, and estrogen coadministration regimen. Comprehensive systematic review and meta-analysis. University. Women undergoing fresh IVF cycles who did and did not receive progestogen supplementation. Summary odds ratios (ORs) were calculated by binomial logistic regression. Clinical pregnancy rates. Eighty-two articles (26,726 women) were included. Clinical pregnancy rates were increased by IM (OR = 4.57), vaginal (OR = 3.34), SC (OR = 3.36), or oral (OR = 2.57) progestogen supplementation versus no treatment. The greatest benefit was observed when progestogens were supplemented IM versus vaginally (OR = 1.37). The optimal time to commence administration was between oocyte retrieval and ET (OR = 1.31), with oocyte retrieval +1day being most beneficial. Coadministration of estrogen had no benefit (OR = 1.33), whether progestogens were coadministered vaginally or IM. Clinical pregnancy rates were equivalent when progestogen supplementation was ceased after ≤3weeks or continued for up to 12weeks (OR = 1.06). This broad-ranging meta-analysis highlights the need to reevaluate current clinical practice. The use of progestogens in fresh IVF cycles is substantially beneficial to clinical pregnancy. Critically, the use of IM progestogens should not be dismissed, as it yielded the greatest clinical pregnancy rates. Pregnancy success was impacted by initiation of therapy, with 1day after oocyte retrieval being optimal. There is little evidence to support coadministration of estrogen or prolonging progestogen treatment beyond 3weeks.

Lung cancer in African-Americans and analysis of estrogen plus progestin use.

e18258 Background: The 15-year Women’s Health Initiative (WHI) sponsored by the NIH has provided a robust dataset on health risks for post-menopausal black women (BW), including the impact of hormone therapy (HRT) on cancer risk. Women enrolled in the WHI randomized, placebo-controlled trial and taking HRT demonstrated no increase in lung cancer incidence, but a statistically significant increase in mortality. However, effects of estrogen plus progestin on non-small cell lung cancer (NSCLC) incidence and outcomes has not been extensively examined, especially in African Ancestry (AA) and smoking history. Methods: Study participants were identified who met WHI clinical trial entry criteria. Cox regression models and Kaplan-Meier method plots were utilized. Analyses adjusted for age, BMI, education, smoking status, alcohol use, health status, and physical activity. A secondary analysis was performed on BW based on AA via Affymetrix Human SNP Array. Results: 161, 808 pts were enrolled from October 1993 to December 1998 (after exclusions total analytic cohort = 142,503). 128,682 (90%) were white (WW) and 13,821 (10%) were BW. BW had lower incidence of NSCLC compared to WW (HR 0.68; P < .0001). HRT participants had a 55% increase in incidence of NSCLC (p < .0001). Former alcohol users had highest risk of NSCLC incidence (HR 2.72; p < 0.0001). Age groups (55-59 years; 60-69 years; 70-79 years) were significantly less associated with BW compared to the youngest(50-54 years; P < .0001). HRT participants were more likely BW (OR 1.17; p < .0001). More current smokers were BW compared to WW (OR 1.75; p < .0001). HRT participants had increased risk of death to NSCLC (HR 1.29; p < .001). There was a trend for survival (p = 0.3667) in WW participants compared to BW (32 vs 28.0 months, respectively). BW who had > 80% AA had a decreased incidence NSCLC trend compared to BW with < 80% AA (HR 0.81; p = 0.2806). Conclusions: BW, especially those with high levels of AA had decreased incidence of NSCLC. Those patients who received HRT had higher incidence and death from NSCLC. Further investigations are required to understand the mechanisms that AA and HRT alter risks associated with NSCLC.

Clinical utility of chlormadinone acetate (Lutoral™) in frozen-thawed embryo transfer with hormone replacement.

PurposeThe clinical utility of chlormadinone acetate tablets (Lutoral™), an orally active progestin which has been available since June 2007, was compared to an in‐house vaginal suppository formulation of progesterone used between 2006 and 2007 for assisted reproductive technology (ART).MethodsWe retrospectively evaluated the efficacy and safety of chlormadinone acetate by comparing the pregnancy rates and the incidences of birth defects and hypospadias in frozen‐thawed embryo transfer cycles using the in‐house vaginal progesterone and those using chlormadinone acetate for luteal phase support.ResultsThe pregnancy rates in the frozen‐thawed embryo transfer cycles were 31.2% (259/831) with vaginal progesterone for luteal phase support and 31.6% (4228/13 381) with chlormadinone acetate (no significant difference). In the cycles resulting in live birth following administration of chlormadinone acetate between July 2007 and December 2015, the incidence of birth defects was 2.8% (80/2893), and the incidence of hypospadias was 0.03% (1/2893).ConclusionsThese results indicate that the pregnancy rate following frozen‐thawed embryo transfer using chlormadinone acetate for luteal phase support was comparable with that using vaginal progesterone, with no increased risk of birth defects, including hypospadias, which has been a concern following the use of progestins.

Technologies for fixed-time artificial insemination and their influence on reproductive performance of Bos indicus cattle

The adaptation of Bos indicus cattle to tropical and subtropical environments has led to their widespread distribution around the world. Although artificial insemination (AI) is one of the best alternatives to introduce new genetics into Bos indicus herds, the peculiarity of their temperament and the tendency to show short oestrus (many of them during the night) greatly affects the effectiveness of genetic improvement programs. Therefore, the most useful alternative to increase the number of females that are inseminated is the use of protocols that allow for AI without the need for oestrus detection, usually called fixed-time AI (FTAI). Besides, the development of protocols to advance the resumption of cyclicity during the early postpartum period has a great impact on beef production and will allow for the inclusion of a significantly larger population of animals into genetic improvement programs. Fixed-time AI protocols using progestin devices, oestradiol and eCG have resulted in consistent pregnancy rates in suckled Bos indicus and Bos indicus × Bos taurus cows. Furthermore, fertility in the successive cycles and the overall pregnancy rates at the end of the breeding season, have been shown to be improved by the use of progestin devices at the beginning of the breeding season. In summary, exogenous control of luteal and follicular development has facilitated the application of assisted reproductive technologies in Bos indicus-influenced cattle, by offering the possibility of planning programs without the necessity of oestrus detection and may provide the opportunity to improve reproductive performance of beef cattle in tropical climates.

Medroxyprogesterone Acetate Decreases Th1, Th17, and Increases Th22 Responses via AHR Signaling Which Could Affect Susceptibility to Infections and Inflammatory Disease.

A synthetic progestin, medroxyprogesterone acetate (MPA), was used in a novel study to determine progestin effects on human purified macrophages and Th1, Th2, Th17, Th22 cells. MPA concentrations were equivalent to those in the serum of women after 6 and 9 months of progestin use. MPA has no effect on the proliferation of PBMCs and CD4+ T cell clones induced by immobilized anti-CD3 antibodies or by antigen (streptokinase). However, MPA decreases production and mRNA expression of IL-5, IL-13, IFN-γ, T-bet, RORC, and IL-17A but increases production and mRNA expression of IL-22 by CD4+ Th22 cell clones and decreases IL-22 production by Th17 cells. MPA inhibits RORC, but not T-bet and AHR, by Th17 cells but increases AHR mRNA and T-bet expression of established CD4+ Th22 cell clones. This suggests that MPA, at concentrations equivalent to those found in the serum of women after treatment for contraception and hormone replacement therapy, can directly inhibit Th1 responses (against intracellular bacteria and viruses), Th17 (against extracellular bacteria and fungi), Th2 (against parasites) but MPA therapy increases IL-22 produced by Th22 cells mediated by an increased expression of AHR and T-bet controlling inflammation. MPA could be responsible for the tissue damage limited by IL-22 in absence of IL-17A.

Use of progestins to inhibit spontaneous ovulation during ovarian stimulation: the beginning of a new era?

Advances in oocyte and embryo cryopreservation for assisted reproduction prompted new approaches to ovarian stimulation. Attention has been paid to progesterone and its derivatives to block the LH surge, as oocyte vitrification removes possible harmful effects of progestins on endometrial receptivity. This review summarizes the current status of progestin use to inhibit ovulation during ovarian stimulation compared with conventional ovarian stimulation. Progestin-primed ovarian stimulation is shown to effectively inhibit spontaneous ovulation, without affecting the number of retrieved oocytes and embryo quality. Reproductive outcomes from ovarian stimulation with progestins appear similar to those from conventional ovarian stimulation, although large trials are needed to confirm this. Use of progestins allows better control of LH concentrations, lower costs and easier (oral) administration. Therefore, progestin-primed ovarian stimulation could be the first choice for ovarian stimulation in fertility preservation, oocyte donation and preimplantation genetic testing cycles. So-called 'non-conventional' ovarian stimulation protocols (luteal and random-start, double ovarian stimulation), which always require oocyte or embryo cryopreservation, may also use progestins to inhibit the endogenous LH surge. Since the 'freeze-all' strategy with delayed transfer is mandatory, high responders undergoing IVF could benefit more from this approach. Economic advantage remains to be demonstrated, as do pregnancy and neonatal outcomes.

Metformin sensitizes endometrial cancer cells to progestin by targeting TET1 to downregulate glyoxalase I expression

Progestins has been used widely for endometrial cancer (EC) patients. However, long term use of high dose progestin often lead to progestin resistance. Our previous studies have demonstrated that metformin reversed progestin resistance through the downregulation of the expression of glyoxalase I (GLOI) in type I endometrial cancer. Recent studies have demonstrated the role of Ten-eleven translocation 1 (TET1) in endometrial cancer, but the physiological role of TET1 in GLOI-mediated progestin resistance has been poorly addressed. Immunohistochemistry was used to detect the expression of TET1, GLOI and 5hmC in various endometrium. Western blot was carried out to analyses TET1 and GLOI expression with different treatment. Cell counting kit-8 was used to evaluate cell proliferation after various treatment. Dot blot assay and HMeDIP assay were performed to detect global hydroxmethylation levels and hydroxymethylation levels in GLOI gene respectively. In current study, we found that metformin effectively sensitized progestin in endometrial cancer cell lines through the down regulation of the expression of TET1 and GLOI. Interestingly, the exogenous increase of TET1 expression enhanced total 5hmC level and hydroxymethylation modification in glyoxalase I promoter region. This effect was abated by metformin treatment. Moreover, the expression profile of TET1 and glyoxalase I in various endometrial tissue parallelized with 5hmC level. Therefore, this finding suggests that metformin sensitized progestin in endometrial cancer through the TET1-5hmC-GLOI signaling pathway.

A Tale of Two Hormones

The development of the steroid hormones currently used in contraception and menopausal hormone replacement provides an interesting story in terms of brilliant research, international rivalry, major advances and sheer serendipity. This paper provides a historical perspective on the use of oestrogens and progestogens in clinical practice from the 1920s until the present day.

A case of hepatocyte nuclear factor 1α-inactivated hepatocellular adenoma associated with low-dose estrogen progestin use

A case of hepatocyte nuclear factor 1α-inactivated hepatocellular adenoma associated with low-dose estrogen progestin use

Systematic review of efficacy with extending contraceptive implant duration.

BackgroundExtending contraceptive implant duration of use increases accessibility by maximizing the lifetime of devices.ObjectivesTo review the contraceptive efficacy during extended use of progestin implants.Search strategyPubMed and EMBASE were searched for articles in any language, 1996–2017, utilizing terms for devices and contraceptive efficacy.Selection criteriaRandomized clinical trials (RCTs), cohort studies, and case–control studies were included; abstracts, posters, and presentations were excluded. Studies evaluating Norplant and implants currently in pre‐marketing trials were excluded.Data collection and analysisTitles and abstracts of articles were reviewed; those that met inclusion and exclusion criteria underwent full text review and data abstraction.Main resultsThe search identified 2951 articles; six met inclusion and exclusion criteria. Five studies evaluated the etonogestrel implant (Implanon), and one the levonorgestrel implant (Jadelle). One RCT randomized to method, not duration; the remaining studies were prospective cohort studies. Three studies analyzed efficacy among women beyond currently approved duration separately. All studies were of poor to fair quality by United States Preventative Services Task Force (USPTF) grading. Limitations include lack of generalizability and control of important confounders.ConclusionThese studies provide limited data for extended duration of contraceptive implants.

Prenatal Progestin Exposure Is Associated With Autism Spectrum Disorders.

We have previously reported that prenatal progestin exposure induces autism-like behavior in offspring through ERβ (estrogen receptor β) suppression in the brain, indicating that progestin may induce autism spectrum disorders (ASD). In this study, we aim to investigate whether prenatal progestin exposure is associated with ASD. A population-based case-control epidemiology study was conducted in Hainan province of China. The ASD children were first screened with the Autism Behavior Checklist (ABC) questionnaire, and then diagnosed by clinical professionals using the ASD diagnosis criteria found in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). Eventually, 235 cases were identified as ASD from 37863 children aged 0–6 years old, and 682 matched control subjects with typically developing children were selected for the analysis of potential impact factors on ASD prevalence using multivariate logistic regression. Our data show that the ASD prevalence rate in Hainan was 0.62% with a boy:girl ratio of 5.4:1. Interestingly, we found that the following factors were strongly associated with ASD prevalence: use of progestin to prevent threatened abortion, use of progestin contraceptives at the time of conception, and prenatal consumption of progestin-contaminated seafood during the first trimester of pregnancy. All the above factors were directly or indirectly involved with prenatal progestin exposure. Additionally, we conducted in vivo experiments in rats to further confirm our findings. Either endogenous (progesterone) or synthetic progestin (norethindrone)-treated seafood zebrafish were used to feed pregnant dams, and the subsequent offspring showed autism-like behavior, which further demonstrated that prenatal progestin exposure may induce ASD. We conclude that prenatal progestin exposure may be associated with ASD development.

Annals for Educators - 6 November 2018.

Annals for Educators - 6 November 2018.

Effects of progestogens in women with preterm premature rupture of membranes.

Different strategies have been adopted for prevention of spontaneous preterm birth, including use of progestogens. So far, five randomized trials have been published evaluating the efficacy of progestogens in women with PPROM, including a total of 425 participants. All the five trials enrolled pregnant women with singleton pregnancies randomized between 20 and 34 weeks of gestation. In four trials women were randomized to either weekly intramuscular 250 mg 17α-hydroxyprogesterone-caproate or placebo, while Mirzaei et al. was a three arms trials in which women received weekly intramuscular 250 mg 17α-hydroxyprogesterone-caproate, or rectal progesterone 400 mg daily, or no treatment. In all the trials, latency antibiotics were used, and tocolysis was used permitted for first 48 hours at discretion of attending physician. Recently a meta-analysis including the five trials has been published. They found that when compared to placebo weekly intramuscular 250 mg 17α-hydroxyprogesterone-caproate did not alter the latency period to delivery in singleton gestations with PPROM. Additionally, there was no difference in gestational age at delivery between groups or in mode of delivery. No significant differences were reported in maternal or neonatal outcomes, with latency not significantly altered in sensitivity analyses. So far, no trials have been published evaluating natural vaginal progesterone in women with PPROM.

Differential Effects of Progestogens Used for Menopausal Hormone Therapy.

Recommendations regarding menopausal hormone therapy continue to evolve as more studies are completed. Progestogens, indicated for endometrial protection in women on estrogen therapy who have an intact uterus, seem to confer greater health risks than estrogen alone. Thus, it is important for clinicians to be well informed when prescribing these medications. This review focuses on the different types and use of progestogens in women with an intact uterus using systemic menopausal hormone therapy.

High ER-alpha predicts poor prognosis in women with deep endometriosis: a tissue micro-array study

Endometriosis is regulated by sex steroid hormones through their receptors. Progressive lesion development and resistance to treatment may be mediated by aberrant steroid receptor regulation. Reliable markers of aggressive disease are lacking and few studies have investigated the relationship between steroid receptor expression and clinical symptoms. We analyzed receptor expression using aTissue Micro-Array (TMA) to determine if levels of estrogen receptor-α, progesterone receptor, androgen receptor, aromatase or CXCL12 in deep endometriosis that can predict symptom recurrence after surgery and response to the progestin treatment. Subjects who had undergone a complete surgical excision of symptomatic deep endometriosis (N=92) were prospectively enrolled in the study between 2013 and 2015. Exclusion criteria were: incomplete surgical excision, concomitant hysterectomy and/or bilateral oophorectomy and the use of GnRH analogs 6 month before surgery. The presence and severity of dysmenorrhea, dyspareunia, dyschezia and non-menstrual pain (NMP) were assessed using a Visual Analogue Scale. Recurrence of painful symptoms at one-year follow-up evaluation was recorded. A minimum of two tissue cylinders of 3 mm diameter were punched from each endometriosis tissue block. Before inclusion in the TMA, a representative slide from each paraffin block was analyzed by two pathologists, confirming endometriosis (glands and stroma). Endometriosis was identified in 83 subjects who had >2 samples from each block. Five-micrometer transverse sections were obtained, placed on a glass slide; immunochemical staining was carried out on all samples simultaneously and scored by two blinded observers. The intensity of expression of ER-α, PR, AR, aromatase and CXCL12 were correlated with progestin use and clinical outcome using chi square and linear regression. All subjects had deep lesions and a frozen pelvis was found in 41. Remarkably, 55% of women had moderate-to-severe NMP despite 46% using chronic oral progestin (MPA 2.5 mg/day or DNG 2 mg/day) treatment at the time of surgery. Pain Recurrence rate at one-year was 19%. Higher ER-α expression increased the likelihood of experiencing moderate to severe dysmenorrhea (p<0.04) and deep dyspareunia (p<0.03) at the time of surgery in women not receiving hormonal treatment. Progestin treatment was associated with diminished ER expression. In women receiving progestin therapy, persistently high ER-α expression increased the likelihood of deep dyspareunia, severe dischezia as well as pain recurrence at one-year (P<0.02). ER expression correlated with symptom severity in deep endometriosis. Failure of progestin therapy to lower ER predicted pain recurrence within one year. ER expression may serve as a prognostic biomarker of aggressive endometriosis. Estrogen modifying rather than progestin based therapies may be targeted to patients with high ER-α, allowing for precision medicine in endometriosis care.

Current Topics in Assisted Reproduction in the Czech Republic

Abstract Assisted reproduction is a very dynamic part of reproductive gynaecology with fast changes in therapeutic approaches resulting from intensive research supported by private or public companies. This progress brings also new questions regarding ethical, legal or therapeutic issues. At the 26th Czech-Slovak symposium of assisted reproduction in Brno, several interesting topics of assisted reproduction were presented. During two days, more than 350 specialists discussed current topics related to gynaecology, embryology, andrology, genetics and sexology. From this fruitful discussion we chose the following topics that we consider to be the most important: (1) “Soft” versus “standard” stimulation protocols for IVF (2) Use of exogenous and endogenous progestins in IVF stimulation protocols (3) Cryopreservation and transplantation of ovarian tissue - state of the art and situation in the Czech Republic (4) Selection of spermatozoa with fragmented DNA: practical recommendations (5) Artificial activation of oocytes (8) Access of single and lesbian women to assisted reproduction technologies and possibility of their reproduction in the Czech Republic. Panel conclusions were presented at the end of the conference, which had great attendance, invoked lively commentaries and produced some definitive consensus. Certain issues remained inconclusive and these matters will be the subject of further discussion in future. This is a summary of the most important theses from this field in the Czech Republic in 2017.

Effect of exogenous estrogens and progestogens on the course of migraine during reproductive age: a consensus statement by the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESCRH)

We systematically reviewed data about the effect of exogenous estrogens and progestogens on the course of migraine during reproductive age. Thereafter a consensus procedure among international experts was undertaken to develop statements to support clinical decision making, in terms of possible effects on migraine course of exogenous estrogens and progestogens and on possible treatment of headache associated with the use or with the withdrawal of hormones. Overall, quality of current evidence is low. Recommendations are provided for all the compounds with available evidence including the conventional 21/7 combined hormonal contraception, the desogestrel only oral pill, combined oral contraceptives with shortened pill-free interval, combined oral contraceptives with estradiol supplementation during the pill-free interval, extended regimen of combined hormonal contraceptive with pill or patch, combined hormonal contraceptive vaginal ring, transdermal estradiol supplementation with gel, transdermal estradiol supplementation with patch, subcutaneous estrogen implant with cyclical oral progestogen. As the quality of available data is poor, further research is needed on this topic to improve the knowledge about the use of estrogens and progestogens in women with migraine. There is a need for better management of headaches related to the use of hormones or their withdrawal.

Progestogen for treating threatened miscarriage.

Miscarriage is a common complication encountered during pregnancy. It is defined as spontaneous pregnancy loss before 20 weeks' gestation. Progesterone's physiological role is to prepare the uterus for the implantation of the embryo, enhance uterine quiescence and suppress uterine contractions, hence, it may play a role in preventing rejection of the embryo. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss. This update of the Cochrane Review first published in 2007, and previously updated in 2011, investigates the evidence base for this practice. To determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage. We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (8 August 2017) and reference lists of retrieved trials. Randomised, quasi-randomised or cluster-randomised controlled trials, that compared progestogen with placebo, no treatment or any other treatment for the treatment of threatened miscarriage in women carrying singleton pregnancy. At least two review authors assessed the trials for inclusion in the review, assessed trial quality and extracted the data and graded the body of evidence. We included seven trials (involving 696 participants) in this update of the review. The included trials were conducted in different countries, covering the full spectrum of the World Bank's economic classification, which enhances the applicability of evidence drawn from this review. Two trials were conducted in Germany and Italy which are high-income countries, while four trials were conducted in upper-middle income countries; two in Iran, one in Malaysia and the fourth in Turkey, and the seventh trial was conducted in Jordan, which is a lower-middle income country. In six trials all the participants met the inclusion criteria and in the seventh study, we included in the meta-analysis only the subgroup of participants who met the inclusion criteria. We assessed the body of evidence for the main outcomes using the GRADE tool and the quality of the evidence ranged from very low to moderate. Downgrading of evidence was based on the high risk of bias in six of the seven included trials and a small number of events and wide confidence intervals for some outcomes.Treatment of miscarriage with progestogens compared to placebo or no treatment probably reduces the risk of miscarriage; (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.47 to 0.87; 7 trials; 696 women; moderate-quality evidence). Treatment with oral progestogen compared to no treatment also probably reduces the miscarriage rate (RR 0.57, 95% CI 0.38 to 0.85; 3 trials; 408 women; moderate-quality evidence). However treatment with vaginal progesterone compared to placebo, probably has little or no effect in reducing the miscarriage rate (RR 0.75, 95% CI 0.47 to 1.21; 4 trials; 288 women; moderate-quality evidence). The subgroup interaction test indicated no difference according to route of administration between the oral and vaginal subgroups of progesterone.Treatment of preterm birth with the use of progestogens compared to placebo or no treatment may have little or no effect in reducing the rate of preterm birth (RR 0.86, 95% CI 0.52 to 1.44; 5 trials; 588 women; low-quality evidence).We are uncertain if treatment of threatened miscarriage with progestogens compared to placebo or no treatment has any effect on the rate of congenital abnormalities because the quality of the evidence is very low (RR 0.70, 95% CI 0.10 to 4.82; 2 trials; 337 infants; very-low quality evidence). The results of this Cochrane Review suggest that progestogens are probably effective in the treatment of threatened miscarriage but may have little or no effect in the rate of preterm birth. The evidence on congenital abnormalities is uncertain, because the quality of the evidence for this outcome was based on only two small trials with very few events and was found to be of very low quality.