Effect of injectable progestin-only contraceptives, depot medroxyprogesterone acetate and norethisterone enanthate, on cytokine production during T-cell activation.

PROBLEM: There is paucity of human data about the effects of depot medroxyprogesterone (DMPA) and norethisterone enanthate (Net-En) use on systemic immune function, which may have implications for reproductive tract infection susceptibility and transmissibility. We sought to evaluate the impact of injectable contraceptive use on T-cell responsiveness using T cells exposed in vivo and tested ex vivo. METHODS: Peripheral blood mononuclear cells were obtained from healthy, HIV-negative women after 30, 90 and 180 days of DMPA, norethisterone enanthate (Net-En) or copper intrauterine device (Cu-IUD) contraceptive use. Cells were stimulated ex vivo with phorbol myristate acetate and ionomycin, stained and analysed using flow cytometry. Mixed-effects linear models were used to evaluate change in proportions of T cells producing IFN-γ, TNF-α, IL-4 and IL-13. RESULTS: Compared with baseline, decreased proportions of IFN-γ-producing CD4+ and CD8+ T cells (p = .003, p = .006, respectively) and TNF-α-producing CD4+ and CD8+ T cells (p = .039, p = .034, respectively) were observed after 180 days of DMPA use. Decreased IL-4-producing CD4+ and CD8+ T cells (p = .045 and p = .024, respectively) were noted after 180 days of Net-En use. Decreased IL-4-producing CD4+ T cells were observed after 30 days (p = .035) and not after 180 days of DMPA use (p = .49). There were no changes in proportion of T cells producing IL-13 in DMPA users, nor any changes in IFN-γ, TNF-α and IL-13 in Net-En and Cu-IUD users. CONCLUSION: In vivo exposure of CD4+ and CD8+ T cells to typical pharmacologic concentrations of DMPA does not cause broad suppression to stimuli; however, depletion of specific cytokine-producing T cells may occur after prolonged DMPA use.

Clinical characteristics of exogenous progestogen hypersensitivity.

BACKGROUND: Autoimmune progesterone dermatitis is a rare disease characterized by eruption recurrence in the luteal phase of each menstrual cycle. As synthetic progesterones are increasingly used for assisted reproductive techniques (ARTs) for infertility or prevention of abortion, cases of dermatitis caused by exogenous progesterone have been reported. OBJECTIVE: To investigate the clinical characteristics of exogenous progestogen hypersensitivity (PH). METHODS: We retrospectively reviewed data from patients presenting with dermatitis induced by exogenous progesterone between 2011 and 2016. RESULTS: Nine patients had exogenous PH. Six patients were treated with progesterone for threatened abortion, and three for ARTs. Their mean age was 33.6 years, and their mean body mass index was 26.3 kg/m2. They had never experienced an adverse drug reaction. The mean latency to symptom onset was 5.8 days (range 1 h to 11 days). The patients complained of hives, erythema and itching, and one developed anaphylaxis. All patients were treated with antihistamines, and six patients were treated with systemic corticosteroids. Epinephrine was administered to one patient with hypotension. The symptom duration was 1-14 days. Skin tests were performed in four patients; all were positive. Two patients were treated successfully by progesterone desensitization. CONCLUSIONS: The clinical features of exogenous PH were similar to those of type I hypersensitivity reactions, but tended to develop later and did not respond to antihistamines or steroids. As use of progesterone increases, an understanding of the clinical features of exogenous PH becomes ever-more important.

Application of precision medicine to the treatment of anaphylaxis.

PURPOSE OF REVIEW: Recognize the presentation of anaphylaxis for prompt management and treatment and to provide tools for the diagnosis of the underlying cause(s) and set up a long-term treatment to prevent recurrence of anaphylaxis. RECENT FINDINGS: The recent description of phenotypes provides new insight and understanding into the mechanisms and causes of anaphylaxis through a better understanding of endotypes and biomarkers for broad clinical use. SUMMARY: Anaphylaxis is the most severe hypersensitivity reaction and can lead to death. Epinephrine is the first-line treatment of anaphylaxis and it is life-saving. Patients with first-line therapy-induced anaphylaxis are candidates for desensitization to increase their quality of life and life expectancy. Desensitization is a breakthrough novel treatment for patients with anaphylaxis in need of first-line therapy, including chemotherapy, mAbs, aspirin and others. Ultrarush with venom immunotherapy should be considered in patients who present with life-threatening anaphylaxis after Hymenoptera sting with evidence of IgE-mediated mechanisms. Food desensitization is currently being expanded to provide increased safety to adults and children with food-induced anaphylaxis.

Progestogen Hypersensitivity: An Evidence-Based Approach to Diagnosis and Management in Clinical Practice.

Heterogeneous presentations of disease pose particular diagnostic and management challenges to the clinician. Progestogen hypersensitivity (PH) classically consists of hypersensitivity symptoms to endogenous progesterone during the luteal phase of the menstrual cycle. However, with the rise of assisted fertility and the exponential growth in the use of exogenous progestins for contraception, PH's prevalence and symptom heterogeneity have increased. In this article, we focus on the clinical approach to PH diagnosis with an emphasis on key elements of the history, physical, and testing modalities. We also review the current evidence for successful management and treatment across a broad range of patients.

Evidence of an immunosuppressive effect of progesterone upon in vitro secretion of proinflammatory and prodegradative factors in a model of choriodecidual infection.

OBJECTIVE: To evaluate whether progesterone (P4) is able to modulate the secretion of tumour necrosis factor α (TNF-α), interleukin-1ß (IL-1ß), IL-6, IL-8, IL-10 and matrix metalloproteinase-9 (MMP-9) after choriodecidual stimulation with lipopolysaccharide (LPS). DESIGN: Chorioamnionitis-elicited preterm delivery is associated with an uncontrolled secretion of proinflammatory cytokines that may induce MMPs, which modify the fine immunological and structural equilibrium at the fetal-maternal interface. SETTING: Instituto Nacional de Perinatología 'Isidro Espinosa de los Reyes', Mexico City. SAMPLE: Twelve human fetal membranes at term from healthy patients were placed in a two-chamber culture system. METHODS: Choriodecidual and amniotic regions were preincubated with 1.0, 0.1, or 0.01 µmol/l P4 for 24 hours; after which the choriodecidual region was costimulated with 1000 ng/ml of LPS for 24 hours. MAIN OUTCOME MEASURES: Descriptive statistics were obtained for each variable. Data distribution was tested for normality using Kolmogorov-Smirnoff and Shapiro-Wilk tests. When distribution was normal, Student's t test was used to analyse for differences among groups. Mann-Whitney's U test was used when data were not normally distributed. RESULTS: Pretreatment with 1.0 µmol/l P4 significantly blunted the secretion of TNF-α, IL-1ß, IL-6, IL-8 and IL-10. MMP-9 was inhibited with 0.1 µmol/l P4. Mifepristone (RU486) blocked the immunosuppressive effect of P4, suggesting a P4 effect mediated by its receptor. CONCLUSION: These results offer evidence to support the concept that P4 can protect the fetal-placental unit through a compensatory mechanism that partially limits the secretion of proinflammatory and prodegradative modulators.

Immunosuppressive effect of progesterone on dendritic cells in mice.

Progesterone has been demonstrated to be involved in maintaining pregnancy by regulating immunocytes. Dendritic cells (DCs), the most potent triggers of the adaptive immune response, express receptors for steroid hormones and are regarded as one of the primary targets of progesterone. However, the functional modification of DCs by progesterone remains poorly understood. Here, we report that progesterone does not affect the morphology or apoptosis of murine bone marrow-derived DCs. Progesterone-treated DCs were characterized by decreased expression of Ia (MHC class II), CD80 and CD86, increased production of IL-10, and decreased secretion of IL-12. Compared with mature DCs (mDCs), activated progesterone-treated DCs had a reduced capacity to stimulate CD4(+) T cell proliferation. The observation that progesterone-treated DCs could attenuate delayed-type hypersensitivity (DTH) responses in vivo suggests that progesterone mediates suppressive DC activity. However, transfer of progesterone-treated DCs into the peritoneal cavity of mice did not elevate the percentage of CD4(+)CD25(+)Foxp3(+) regulatory T cells in the spleen. Overall, our study helps to increase understanding of the role of DCs exposed to progesterone in the maintenance of pregnancy.

Progesterone promotes differentiation of human cord blood fetal T cells into T regulatory cells but suppresses their differentiation into Th17 cells.

Progesterone, a key female sex hormone with pleiotropic functions in maintenance of pregnancy, has profound effects on regulation of immune responses. We report in this work a novel function of progesterone in regulation of naive cord blood (CB) fetal T cell differentiation into key T regulatory cell (Treg) subsets. Progesterone drives allogeneic activation-induced differentiation of CB naive, but not adult peripheral blood, T cells into immune-suppressive Tregs, many of which express FoxP3. Compared with those induced in the absence of progesterone, the FoxP3(+) T cells induced in the presence of progesterone highly expressed memory T cell markers. In this regard, the Treg compartment in progesterone-rich CB is enriched with memory-type FoxP3(+) T cells. Moreover, CB APCs were more efficient than their peripheral blood counterparts in inducing FoxP3(+) T cells. Another related function of progesterone that we discovered was to suppress the differentiation of CB CD4(+) T cells into inflammation-associated Th17 cells. Progesterone enhanced activation of STAT5 in response to IL-2, whereas it decreased STAT3 activation in response to IL-6, which is in line with the selective activity of progesterone in generation of Tregs versus Th17 cells. Additionally, progesterone has a suppressive function on the expression of the IL-6 receptor by T cells. The results identified a novel role of progesterone in regulation of fetal T cell differentiation for promotion of immune tolerance.

Gestagens and glucocorticoids in chicken eggs.

Avian eggs contain a variety of steroid hormones, which have been attributed as a tool for maternal phenotypic engineering. The majority of studies focuses on androgens, but also significant amounts of progesterone as well as other steroid hormones have been measured. The question if corticosterone is also present in eggs of chickens is currently under debate. The only analytical validation performed so far has failed to demonstrate corticosterone in the yolk of chickens, suggesting that antibodies for corticosterone measurement cross-react with other steroids present in the yolk. In order to investigate this assumption and to characterise potential cross-reacting hormones in more detail, we performed high-performance liquid chromatographic (HPLC) analyses of chicken yolk extracts and determined the concentration of immunoreactive corticosterone, progesterone and cortisol. The progesterone antibody revealed several immunoreactive substances, including progesterone, pregnenolone and two substances with lower polarity. The corticosterone enzyme immunoassay detected immunoreactive substances at exactly the same elution positions as the progesterone assay and a very small peak at the elution position of corticosterone. Immunoreactive cortisol was not found. In addition, inner and outer regions of the yolk sphere were analysed separately via HPLC. We found different concentrations of immunoreactive substances between the inner and outer yolk regions, probably reflecting the steroidogenic activity of the follicle cells during oocyte growth. We conclude that in homogenised yolk extracts without previous clean-up, the measured corticosterone concentrations may actually reflect those of progesterone and its precursors, most probably being 5 alpha- and 5 beta-pregnanes and pregnenolone.

The role of glucocorticoids and progestins in inflammatory, autoimmune, and infectious disease.

A bidirectional communication exists between the CNS and the immune system. The autonomic nervous system, through neurotransmitters and neuropeptides, works in parallel with the hypothalamic-pituitary-adrenal axis through the actions of glucocorticoids to modulate inflammatory events. The immune system, through the action of cytokines and other factors, in turn, activates the CNS to orchestrate negative-feedback mechanisms that keep the immune response in check. Disruption of these interactions has been associated with a number of syndromes including inflammatory, autoimmune, and cardiovascular diseases, metabolic and psychiatric disorders, and the development of shock. The hypothalamic-pituitary-gonadal axis also plays an important part in regulating immunity through the secretion of sex hormones. Although numerous studies have established a role for immunomodulation by estrogen and testosterone, the role of progesterone is less well understood. Progesterone is crucial for reproductive organ development and maintenance of pregnancy, and more recent studies have clearly shown its role as an important immune regulator. The main focus of this review will be about the role of steroid hormones, specifically glucocorticoids and progesterone, in inflammatory responses and infectious diseases and how dysregulation of their actions may contribute to development of autoimmune and inflammatory disease.

Interactions of sex steroids with mechanisms of inflammation.

Differential sex-specific liability to inflammatory and autoimmune diseases, and changes in symptom severity in association with physiological fluctuations in gonadal secretions are indicative of significant contribution of sex hormones to the regulation of immune responsiveness. Apart from a postulated role in sex-specific organization of the immune system during ontogeny, gonadal steroids may influence the immune response in numerous ways. This review analyzes existing concepts, experimental and clinical data, aiming at the definition of cellular and molecular mechanisms which may serve as suitable targets for discovery of immunomodulatory drugs whose principal feature is specific interaction with sex hormone receptors. Separation of immunomodulatory effects of sex steroids from those which are exerted by glucocorticoids, and subsequent identification of sex-hormone-specific molecular targets appear to be crucial for the justification of drug discovery on the basis of sex steroid receptor ligands.

Calcitonin expression in rat anterior pituitary gland is regulated by ovarian steroid hormones.

Gonadotroph-derived calcitonin-like peptide (pit-CT) is a potent inhibitor of lactotroph function. We investigated the effect of ovarian hormones on pit-CT mRNA expression in the anterior pituitary (AP) gland of cycling female rats. Levels of mRNAs for pit-CT, CT receptor, prolactin (PRL), and beta-LH during 4-d estrous cycle were determined. In a second study, the effects of estrogens and progesterone on pit-CT and PRL mRNA levels were investigated. In a third group, the effect of estrogen or progesterone depletion on pit-CT mRNA expression was studied. In a fourth group, the effect of passive pit-CT immunization on PRL and LH mRNA expression was examined. Pit-CT mRNA levels varied during estrous cycle. They were highest in diestrus, but lowest in the evening of proestrus. CT-receptor mRNA levels displayed smaller fluctuations. Estrogen repletion caused a decline in pit-CT mRNA expression in ovariectomized rats, but progesterone produced a marked increase. ICI 182,780 prevented the decline of pit-CT mRNA levels during late proestrus-estrus, but RU 486 attenuated pit-CT mRNA levels. Passive CT immunization in diestrus altered PRL and LH mRNA expression, and advanced the estrus cycle. These results suggest that pit-CT mRNA expression is regulated by ovarian hormones, and depletion of pit-CT advances their estrous cycle.

Comparison of different progestagen assays for measuring progesterone metabolites in faeces of the bitch.

From 12 bitches of various breeds with fertile oestrus cycles faecal samples were collected daily from the onset of pro-oestrus till 20 days after the start of vulval bleeding, then once per week till about 1 week before term. Immunoreactive progesterone metabolites were extracted from the samples using methanol and measured using immunoassays. In a first experiment four different assays were compared in regard to the amounts of immunoreactive substances measured: the enzyme immunoassay against 20-oxo-3-hydroxypregnanes showed twice to four times higher values of immunoreactive material than another using an antibody against 6 beta-hydroxyprogesterone. An enzyme immunoassay for pregnanediol measured only low concentrations of immunoreactive material. Also a radio immunoassay using an antibody against 11 beta-hydroxyprogesterone detected only small amounts of reacting material. High performance liquid chromatography showed that in faeces of bitches the immunoreactive progesterone metabolites were present in unconjugated form, mainly as 3 alpha/beta hydroxylated progestagens with a 20-oxo group. In the second experiment the samples were measured with the assay system using the 20-oxo-3-hydroxypregnane antibody. A few days before mating the concentration of progesterone metabolites increased, reaching 5.77 mumol/kg faeces (median) at the day of mating. High levels (10.45 mumol/kg faeces) were measured till the end of the first month after mating. Thereafter, the concentrations decreased, reaching 2.68 mumol/kg (median) at the end of the second month.

Specific interactions of progestins and anti-progestins with progesterone antibodies, plasma binding proteins and the human recombinant receptor.

This structure-activity study compares the affinity of a series of progestins, progesterone metabolites and anti-progestins for a panel of monoclonal antibodies to progesterone, coypu (Myocastor coypus) or guinea pig plasma progesterone-binding proteins (PPBPs) and the human recombinant progesterone receptor A form (PR-A). The compounds tested were progesterone, Promegestone (R5020), Mifepristone (RU486), ZK98,734, Onapristone (ZK98,299), 11 alpha-hydroxyprogesterone, 11 alpha-progesterone hemisuccinate, androsterone, etiocholanolone, 5 alpha- and 5 beta-pregnane-3,20-diones, and 20 alpha- and 20 beta-hydroxyprogesterones. The Ki values for these ligands were determined by competitive binding assays using radiolabelled progesterone as the binding site ligand. For anti-progesterone antibodies (e.g. DB3 and 11/32), only progesterone (3.6-8.8 nM), the 11 alpha-derivatives (1.0-5.5 nM) used to prepare the immunogen and the two 5-pregnanediones (20.9-45.1 nM) were bound with high affinity. For PR-A, high affinity binding was found with receptor agonists (Ki = 1.1-6.2 nM), both 5- and 20-reduced metabolites, and antagonists (0.6-28.0 nM), but not with the 11 alpha-derivatives (950 nM-1.0 microM). In contrast, the PPBPs displayed high affinity interactions with progesterone (3.5-4.2 nM) and both 5 alpha- and 20 alpha-reduced metabolites (2.4-3.4 nM). Binding with the beta-isomers and R5020 was less pronounced (22-170 nM) and there was no evidence of high affinity binding with PR antagonists (> 1.0 microM). Analogs with the 17-keto group did not bind to any of the binders studied. Thus, commonalities among the three types of protein binders were their comparable binding affinities for progesterone (3.5-8.8 nM) and 5-pregnanedione isomers (2.4-330 nM), and a lack of binding for two C17-keto steroids (androsterone and etiocholanolone). The results imply that the tertiary features of the binding domain of these three types of proteins are sufficiently different to result in unique binding structures.

Localization and regulation of estrogen, progestin and androgen receptors in the seminal vesicle of the rhesus monkey.

We have used monoclonal antibodies against the estrogen (E), progestin (P) and androgen (A) receptors (R) to study receptor localization and regulation in the seminal vesicles of rhesus monkeys under different hormonal conditions. The antibodies caused substantial shifts of the appropriately labeled receptors on sucrose gradients. ER levels were lower in intact males than in immature, castrate, and estrogen-treated castrates. With immunocytochemistry, ER were detectable only in stromal and smooth muscle cells, not the epithelium. The number of ER-positive stromal cells was significantly lower in intact males than in immature, castrate, and estrogen-treated castrates, and low in a DHT-treated castrate animal. Androgen receptors were localized in epithelial as well as stromal and smooth muscle cells, and the number of AR-positive stromal cells was highest in intact adults and lowest in castrated and immature animals. Estrogen treatment at the time of castration induced PR in the ER-positive stromal cells, prevented a decline in the number of AR-positive stromal cells, and caused stromal hypertrophy. In summary, in the seminal vesicle, as in the prostate, ER is restricted to the fibromuscular stroma, is suppressed by androgens, and can mediate induction of PR on estrogen treatment. Androgen receptors are present in epithelial as well as stromal and smooth muscle cells, but variations in hormonal state appear to affect regulation of AR more in the stroma than the epithelium.

Sex hormones and autoimmune disease.

Evidence for the influence of sex hormones--androgens, oestrogens and progestogens--on autoimmune disease is reviewed. Androgens and, perhaps, progestogens may protect from autoimmune disease; oestrogens seem to protect from rheumatoid arthritis but to be deleterious in systemic lupus erythematosus.

Rat pregnancy induces two suppressor cell activities.

Pregnancy in rat is able to stimulate two suppressor cell activities. One is specific to the paternal histocompatibility antigens and it resides in the T-lymphocyte population. The second is nonspecific and is of non-T nature. The use of various methods for pseudopregnancy and deciduoma installation has allowed the demonstration of two inducing circuits: (a) the presence of fertilized ova in the female genital tract and (b) the progestation hormonal status.

Rat pregnancy immunoregulatory circuits are progestation hormonal status, decidual tissue, embryo-trophoblast and late pregnancy changes dependent.

We have tested the spleen cells of rats for their reactivity to mating and unrelated (third party) strain alloantigens during pregnancy, pseudopregnancy, and traumatic deciduoma installation. By cytotoxic T-lymphocyte assays, after 7-day one-way mixed lymphocyte cultures (MLC), we detected the presence of many immunoregulatory circuits among rat pregnancy and postpartum. They are progestation hormonal status, decidual tissue, embryo-trophoblast, late-pregnancy-parturition-associated changes, and lactation-hormonal-status dependent.