Does Progesterone Have Neuroprotective Properties?

Novel actions of progesterone: what we know today and what will be the scenario in the future?

Objectives

This article is aimed to review the novel actions of progesterone, which otherwise is considered as a female reproductive hormone. The article focuses on its important physiological actions in males too and gives an overview of its novel perspectives in disorders of central and peripheral nervous system.

Key findings

Progesterone may have a potential benefit in treatment of traumatic brain injury, various neurological disorders and male related diseases like benign prostatic hypertrophy (BPH), prostate cancer and osteoporosis. Norethisterone (NETA), a progesterone derivative, decreases bone mineral loss in male castrated mice suggesting its role in osteoporosis. In the future, progesterone may find use as a male contraceptive too, but still needs confirmatory trials for safety, tolerability and acceptability. Megestrol acetate, a progesterone derivative is preferred in prostatic cancer. Further, it may find utility in nicotine addiction, traumatic brain injury (recently entered Phase III trial) and Alzheimer's disease, diabetic neuropathy and crush injuries. Studies also suggest role of progesterone in stroke, for which further clinical trials are needed. The non genomic actions of progesterone may be in part responsible for these novel actions.

Summary

Although progesterone has shown promising role in various non-hormonal benefits, further clinical studies are needed to prove its usefulness in conditions like stroke, traumatic brain injury, neuropathy and crush injury. In male related illnesses like BPH and prostatic Ca, it may prove a boon in near future. New era of hormonal male contraception may be initiated by use of progesterone along with testosterone.

Limiting spinal cord injury by pharmacological intervention

The direct primary mechanical trauma to neurons, glia and blood vessels that occurs with spinal cord injury (SCI) is followed by a complex cascade of biochemical and cellular changes which serve to increase the size of the injury site and the extent of cellular and axonal loss. The aim of neuroprotective strategies in SCI is to limit the extent of this secondary cell loss by inhibiting key components of the evolving injury cascade. In this review we will briefly outline the pathophysiological events that occur in SCI, and then review the wide range of neuroprotective agents that have been evaluated in preclinical SCI models. Agents will be considered under the following categories: antioxidants, erythropoietin and derivatives, lipids, riluzole, opioid antagonists, hormones, anti-inflammatory agents, statins, calpain inhibitors, hypothermia, and emerging strategies. Several clinical trials of neuroprotective agents have already taken place and have generally had disappointing results. In attempting to identify promising new treatments, we will therefore highlight agents with (1) low known risks or established clinical use, (2) behavioral data gained in clinically relevant animal models, (3) efficacy when administered after the injury, and (4) robust effects seen in more than one laboratory and/or more than one model of SCI.

The role of estrogen and progesterone, administered alone and in combination, in modulating cytokine concentration following traumatic brain injury

Cytokines play an important role in the pathophysiology of traumatic brain injury (TBI). This study was designed to determine the effects of administering progesterone (P) and estrogen (E), alone and in combination, on brain water content, blood-brain barrier (BBB) disturbance, and brain level of cytokines following diffuse TBI. Ovariectomized rats were divided into 9 groups, treated with vehicle, E1, E2, P1, P2, E1+P1, E1+P2, E2+P1, and E2+P2. Levels of BBB disruption (5 h), cytokines, and water content (24 h) were evaluated after TBI induced by the Marmarou method. Physiological (E1 and P1) and pharmacological (E2 and P2) doses of estrogen and progesterone were administered 30 min after TBI. Water content in the E1+P2-treated group was higher than in the E1-treated group. The inhibitory effect of E2 on water content was reduced by adding progesterone. The inhibitory effect of E1 and E2 on Evans blue content was reduced by treatment with E1+P1 and E2+P2, respectively. The brain level of IL-1β was reduced in E1 and E2, after TBI. In the E2+P2-treated group, this level was higher than in the E2-treated group. The brain level of TGF-β was also elevated by the administration of progesterone and estrogen alone, and reduced when the hormones were administered in combination. In conclusion, a combined administration of progesterone and estrogen inhibited the decreasing effects of administration of progesterone and estrogen alone on water content and BBB disruption that mediated to change the proinflammatory cytokines.

Decision making after pediatric traumatic brain injury: trajectory of recovery and relationship to age and gender

The aim of the study was to examine longitudinal patterns of decision making based on risk and reward using a modified version of the Iowa Gambling Task (IGT) in children who had sustained traumatic brain injury (TBI) and children with orthopedic injury (OI). Participants were 135 children and adolescents with TBI (n=71) or OI (n=64) who were 7-17 years at the time of injury were enrolled and assessed prospectively at baseline and at follow-up intervals of 3, 12, 18, and 24 months after injury. Groups were similar in age, socioeconomic status, and gender. Participants chose from four decks of cards with the aim of maximizing earnings across 100 trials. Two of the decks offered relatively small rewards and relatively small losses, but were advantageous over the course of the experiment. The other two decks offered large rewards, but also introduced occasional large losses, and were considered disadvantageous over the course of the experiment. The variable of interest was the proportion of advantageous decks chosen across trials. Longitudinal analysis of the pattern of change across 2 years revealed a three-way interaction among injury group, age, and the quadratic term of interval-since-injury. In this interaction, the effect of age weakened in the TBI group across time, as compared to the OI group, which showed stronger quadratic patterns across the recovery intervals that differed by age. The OI group generally outperformed the TBI group. In addition, analyses revealed a three-way interaction among group, gender and the cubic term of post-injury interval, such that overall, males improved a great deal with time, but females showed small gains, regardless of injury group.

Study of effectiveness of mifepristone for glioma cell line growth suppression

OBJECTIVE

Glioblastoma multiforme is a malignant primary brain tumour with very limited treatment options. Any addition to existing treatment options which can improve prognosis and life expectancy is useful. In our study, we look at the usefulness of anti-progestogen mifepristone in causing growth suppression of glioma cell lines in the laboratory.

METHODS

We cultured five cell lines in the lab and exposed them to mifepristone in different doses for a total of 96 h. Five different doses of mifepristone were used. Progesterone and dexamethasone were also used as growth stimulants. Immunostaining was used to identify progesterone receptors (PRs) in the cell lines.

RESULTS

U257/7 and IN1265 showed statistically significant growth suppression (36% and 11%, P = 0.001 and 0.03 respectively), maximal at 96 h. Growth suppression in U257/7 showed a dose response progression except with the lowest dose which was not explicable. The response of IN1265 was seen only with the highest dose of mifepristone. There was no significant growth stimulation with either dexamethasone or progesterone. None of the cell lines showed any significant positivity for PRs.

CONCLUSION

We were able to produce enough growth suppression of glioma cell lines using mifepristone. This is in keeping with some of the published results in literature. This raises the possibility of using mifepristone in treating GBMs which have very limited treatment options. This, however, needs further work probably on primary glioma cultures first followed by in vivo studies before it can be used in patients.

Is progesterone a worthy candidate as a novel therapy for traumatic brain injury?

Although progesterone is critical to a healthy pregnancy, it is now known to have other important functions as well. Recent research demonstrates that this hormone is also a potent neurosteroid that can protect damaged cells in the central and peripheral nervous systems and has rapid actions that go well beyond its effects on the classical intranuclear progesterone receptor. Based on years of preclinical research demonstrating its safety and effectiveness in animal models of central nervous system injury the hormone was recently tested in two Phase II clinical trials for traumatic brain injury (TBI). A US National Institutes of Health-sponsored, nationwide Phase III clinical trial is now evaluating progesterone for moderate-to-severe TBI in 1200 patients. An industry-sponsored Phase III international trial is also under way, and planning for a trial using progesterone to treat pediatric brain injury has begun. Preclinical data suggest that progesterone may also be effective in stroke and some neurodegenerative disorders.

Modulation of traumatic brain injury using progesterone and the role of glial cells on its neuroprotective actions

TBI is a complex disease process caused by a cascade of systemic events. Attention is now turning to drugs that act on multiple pathways to enhance survival and functional outcomes. Progesterone has been found to be beneficial in several animal species, different models of brain injury, and in two preliminary human clinical trials. It holds promise as a treatment for TBI. Progesterone's multiple mechanisms of action may work synergistically to prevent the death of neurons and glia, leading to reduced morbidity and mortality. This review highlights the importance of glial cells as mediators of progesterone's actions on the CNS and describes progesterone's pleiotrophic effects on immune enhancement and neuroprotection in TBI.

Progestogens influence cognitive processes in aging

Steroid hormones may alter mnemonic processes. The majority of investigations have focused on the effects of 17β-estradiol (E(2)) to mediate learning. However, progesterone (P(4)), which varies across endogenous hormonal milieu with E(2), may also have effects on cognitive processes. P(4) may have effects in the hippocampus, prefrontal cortex (PFC) and/or striatum to enhance cognitive performance. Cognitive performance/learning has been assessed using tasks that are mediated by the hippocampus (water maze), PFC (object recognition) and striatum (conditioning). Our findings suggest that progestogens can have pervasive effects to enhance cognitive performance and learning in tasks mediated by the hippocampus, PFC and striatum and that these effects may be in part independent of actions at intracellular progestin receptors. Progestogens may therefore influence cognitive processes.

Acute serum hormone levels: characterization and prognosis after severe traumatic brain injury

Experimental traumatic brain injury (TBI) studies report the neuroprotective effects of female sex steroids on multiple mechanisms of injury, with the clinical assumption that women have hormonally mediated neuroprotection because of the endogenous presence of these hormones. Other literature indicates that testosterone may exacerbate injury. Further, stress hormone abnormalities that accompany critical illness may both amplify or blunt sex steroid levels. To better understand the role of sex steroid exposure in mediating TBI, we 1) characterized temporal profiles of serum gonadal and stress hormones in a population with severe TBI during the acute phases of their injury; and 2) used a biological systems approach to evaluate these hormones as biomarkers predicting global outcome. The study population was 117 adults (28 women; 89 men) with severe TBI. Serum samples (n=536) were collected for 7 days post-TBI for cortisol, progesterone, testosterone, estradiol, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). Hormone data were linked with clinical data, including acute care mortality and Glasgow Outcome Scale (GOS) scores at 6 months. Hormone levels after TBI were compared to those in healthy controls (n=14). Group based trajectory analysis (TRAJ) was used to develop temporal hormone profiles that delineate distinct subpopulations in the cohort. Structural equations models were used to determine inter-relationships between hormones and outcomes within a multivariate model. Compared to controls, acute serum hormone levels were significantly altered after severe TBI. Changes in the post-TBI adrenal response and peripheral aromatization influenced hormone TRAJ profiles and contributed to the abnormalities, including increased estradiol in men and increased testosterone in women. In addition to older age and greater injury severity, increased estradiol and testosterone levels over time were associated with increased mortality and worse global outcome for both men and women. These findings represent a paradigm shift when thinking about the role of sex steroids in neuroprotection clinically after TBI.

Gender influences cerebral oxygenation after red blood cell transfusion in patients with severe traumatic brain injury

BACKGROUND

Important differences with respect to gender exist in the prognosis and mortality of traumatic brain injury (TBI) patients. The objective of this study was to assess the role of gender as an independent factor in cerebral oxygenation variations following red blood cell transfusion (RBCT).

METHODS

This retrospective analysis of a prospective study was conducted on patients with severe TBI. Hemoglobin levels were measured at baseline and 6 h after transfusion. Brain tissue oxygen pressure (PbrO(2)), cerebral perfusion pressure (CPP), intracranial pressure (ICP), and mean arterial pressure (MAP) were measured at baseline, at the end of RBCT and at 1, 2, 3, 4, 5, and 6 h after transfusion. After the patients were stratified into two groups according to gender, the effect of RBCT on PbrO(2) (cerebral oxygenation) was analyzed using a multivariate analysis of variance with repeated measures (MANOVA). The MANOVA was repeated after adjusting for all covariables with baseline differences between groups.

RESULTS

At baseline, we found differences in age (P = 0.01), weight (P = 0.03), MAP (P = 0.01), ISS (P = 0.05), and CCP (P = 0.01) between the groups. After adjusting for these co-variables, we observed that gender and age were related to the increase in PbrO(2) (P = 0.05 and P = 0.04, respectively).

CONCLUSIONS

Our results suggest that the effect of RBCT on cerebral oxygenation, as measured by PbrO(2), is greater in women than in men.

Vitamin D deficiency reduces the benefits of progesterone treatment after brain injury in aged rats

Administration of the neurosteroid progesterone (PROG) has been shown to be beneficial in a number of brain injury models and in two recent clinical trials. Given widespread vitamin D deficiency and increasing traumatic brain injuries (TBIs) in the elderly, we investigated the interaction of vitamin D deficiency and PROG with cortical contusion injury in aged rats. Vitamin D deficient (VitD-deficient) animals showed elevated inflammatory proteins (TNFα, IL-1β, IL-6, NFκB p65) in the brain even without injury. VitD-deficient rats with TBI, whether given PROG or vehicle, showed increased inflammation and greater open-field behavioral deficits compared to VitD-normal animals. Although PROG was beneficial in injured VitD-normal animals, in VitD-deficient subjects neurosteroid treatment conferred no improvement over vehicle. A supplemental dose of 1,25-dihydroxyvitamin D(3) (VDH) given with the first PROG treatment dramatically improved results in VitD-deficient rats, but treatment with VDH alone did not. Our results suggest that VitD-deficiency can increase baseline brain inflammation, exacerbate the effects of TBI, and attenuate the benefits of PROG treatment; these effects may be reversed if the deficiency is corrected.

Progesterone prevents development of neuropathic pain in a rat model: Timing and duration of treatment are critical

BACKGROUND

Progesterone is emerging as an important protective agent against various injuries to the nervous system. Neuroprotective and remyelinating effects have been documented for this neurosteroid, which is synthesized by, and acts on, the central and peripheral nervous systems. Neuropathic pain is a severe, persistent condition that is generally resistant to treatment, and poses major personal, social, and economic burdens. The purpose of this study was to determine if single-dose or repeated progesterone administration would alleviate tactile hypersensitivity in a rat model of neuropathic pain, and to determine if early versus late initiation of treatment has an effect on the outcome.

METHODS

Rats were unilaterally implanted with a polyethylene cuff around the sciatic nerve, and sensitivity to von Frey filament stimulation was measured over approximately 12 weeks.

RESULTS

Rats given progesterone starting one hour after cuff implantation, and daily until day 4, exhibited tactile hypersensitivity similar to that of vehicle-treated rats for the duration of the study. When progesterone was started one hour after cuff implantation and given daily until day 10, rats exhibited no tactile hypersensitivity in the later part of the study, after treatment had stopped. When progesterone treatment was initiated at 20 days, once the model had been fully established, and given daily for 4 or even 11 days, no differences in withdrawal thresholds were observed compared with controls. Progesterone did not have any effect on withdrawal thresholds when given as a single dose, as measured at 30, 60 and 90 minutes after administration.

CONCLUSION

These results indicate that progesterone, when administered immediately after nerve injury, and for a sufficient period of time, can prevent the development of neuropathic pain, and may offer new strategies for the treatment of this highly debilitating condition.

Female survival advantage relates to male inferiority rather than female superiority: A hypothesis based on the impact of age and stroke severity on 1-week to 1-year case fatality in 40,155 men and women

BACKGROUND

It is generally believed that differences in age, stroke characteristics, and cardiovascular risk factors account for observed sex-specific differences in stroke survival.

OBJECTIVES

We aimed to study female stroke survival advantage before and after the average age of menopause, and whether female survival advantage applies only to patients for whom stroke is the most likely cause of death.

METHODS

The Danish National Indicator Project, a registry designed to list all hospitalized stroke patients in Denmark beginning in March 2001, had 40,155 registered patients as of February 2007. All registered patients had undergone evaluation including stroke severity (as measured by the Scandinavian Stroke Scale [SSS], using a total score of 0-58, in which lower scores indicate more severe strokes), computed tomography, and cardiovascular risk factors. Patients were followed from admission until death or censoring. Case fatality (stratified by 1 week, 1 month, 3 months, and 1 year) in men and women was correlated with age and stroke severity. Adjustment for cardiovascular risk factors was performed by means of multivariate regression analysis.

RESULTS

A total of 20,854 (51.9%) men and 19,301 (48.1%) women were registered. Women were significantly older than men at the time of stroke (74.5 vs 69.7 years, respectively; P < 0.001) and had signficantly more severe strokes, as expressed by the mean SSS score (39.6 vs 43.3; P < 0.001). Stratification of 1-week to 1-year case fatality according to age and stroke severity indicated that women survived significantly better than men from the mid-fifties onward, when controlling for age, stroke severity, and cardiovascular risk factor profile. The observed female survival advantage increased with age. The female survival advantage was seen in patients with severe as well as mild strokes, but not in those younger than age 50 years.

CONCLUSIONS

Our findings dispute the effects of female sex hormones as the underlying cause of female survival superiority over men. Instead, we propose the hypothesis that the progressive deficiency of male sex hormones (testosterone), beginning in men in middle age, is the underlying cause of the gap in survival rates between men and women. Accordingly, the female survival advantage is rooted in male inferiority rather than innate female superiority.

Neuroprotective actions of neurosteroids

Neurosteroids were initially defined as steroid hormones locally synthesized within the nervous tissue. Subsequently, they were described as steroid hormone derivatives that devoid hormonal action but still affect neuronal excitability through modulation of ionotropic receptors. Neurosteroids are further subdivided into natural (produced in the brain) and synthetic. Some authors distinguish between hormonal and regular neurosteroids in the group of natural ones. The latter group, including hormone metabolites like allopregnanolone or tetrahydrodeoxycorticosterone, is devoid of hormonal activity. Both hormones and their derivatives share, however, most of the physiological functions. It is usually very difficult to distinguish the effects of hormones and their metabolites. All these substances may influence seizure phenomena and exhibit neuroprotective effects. Neuroprotection offered by steroid hormones may be realized in both genomic and non-genomic mechanisms and involve regulation of the pro- and anti-apoptotic factors expression, intracellular signaling pathways, neurotransmission, oxidative, and inflammatory processes. Since regular neurosteroids show no affinity for steroid receptors, they may act only in a non-genomic mode. Multiple studies have been conducted so far to show efficacy of neurosteroids in the treatment of the central and peripheral nervous system injury, ischemia, neurodegenerative diseases, or seizures. In this review we focused primarily on neurosteroid mechanisms of action and their role in the process of neurodegeneration. Most of the data refers to results obtained in experimental studies. However, it should be realized that knowledge about neuroactive steroids remains still incomplete and requires confirmation in clinical conditions.

The reproductive-cell cycle theory of aging: an update

The Reproductive-Cell Cycle Theory posits that the hormones that regulate reproduction act in an antagonistic pleiotrophic manner to control aging via cell cycle signaling; promoting growth and development early in life in order to achieve reproduction, but later in life, in a futile attempt to maintain reproduction, become dysregulated and drive senescence. Since reproduction is the most important function of an organism from the perspective of the survival of the species, if reproductive-cell cycle signaling factors determine the rate of growth, determine the rate of development, determine the rate of reproduction, and determine the rate of senescence, then by definition they determine the rate of aging and thus lifespan. The theory is able to explain: 1) the simultaneous regulation of the rate of aging and reproduction as evidenced by the fact that environmental conditions and experimental interventions known to extend longevity are associated with decreased reproductive-cell cycle signaling factors, thereby slowing aging and preserving fertility in a hostile reproductive environment; 2) two phenomena that are closely related to species lifespan-the rate of growth and development and the ultimate size of the animal; 3). the apparent paradox that size is directly proportional to lifespan and inversely proportional to fertility between species but vice versa within a species; 4). how differing rates of reproduction between species is associated with differences in their lifespan; 5). why we develop aging-related diseases; and 6). an evolutionarily credible reason for why and how aging occurs-these hormones act in an antagonistic pleiotrophic manner via cell cycle signaling; promoting growth and development early in life in order to achieve reproduction, but later in life, in a futile attempt to maintain reproduction, become dysregulated and drive senescence (dyosis). In essence, the Reproductive-Cell Cycle Theory can explain aging in all sexually reproductive life forms.

The pregnancy hormones human chorionic gonadotropin and progesterone induce human embryonic stem cell proliferation and differentiation into neuroectodermal rosettes

INTRODUCTION

The physiological signals that direct the division and differentiation of the zygote to form a blastocyst, and subsequent embryonic stem cell division and differentiation during early embryogenesis, are unknown. Although a number of growth factors, including the pregnancy-associated hormone human chorionic gonadotropin (hCG) are secreted by trophoblasts that lie adjacent to the embryoblast in the blastocyst, it is not known whether these growth factors directly signal human embryonic stem cells (hESCs).

METHODS

Here we used hESCs as a model of inner cell mass differentiation to examine the hormonal requirements for the formation of embryoid bodies (EB's; akin to blastulation) and neuroectodermal rosettes (akin to neurulation).

RESULTS

We found that hCG promotes the division of hESCs and their differentiation into EB's and neuroectodermal rosettes. Inhibition of luteinizing hormone/chorionic gonadotropin receptor (LHCGR) signaling suppresses hESC proliferation, an effect that is reversed by treatment with hCG. hCG treatment rapidly upregulates steroidogenic acute regulatory protein (StAR)-mediated cholesterol transport and the synthesis of progesterone (P4). hESCs express P4 receptor A, and treatment of hESC colonies with P4 induces neurulation, as demonstrated by the expression of nestin and the formation of columnar neuroectodermal cells that organize into neural tubelike rosettes. Suppression of P4 signaling by withdrawing P4 or treating with the P4-receptor antagonist RU-486 inhibits the differentiation of hESC colonies into EB's and rosettes.

CONCLUSIONS

Our findings indicate that hCG signaling via LHCGR on hESC promotes proliferation and differentiation during blastulation and neurulation. These findings suggest that trophoblastic hCG secretion and signaling to the adjacent embryoblast could be the commencement of trophic support by placental tissues in the growth and development of the human embryo.

Progesterone intoxication inducing marked sedation in a cat

A 3-year-old, male castrated domestic shorthair cat presented for sudden onset of severe lethargy and loss of balance a few hours after potentially ingesting capsules containing progesterone. Elevated serum progesterone was confirmed. Supportive care and time resulted in complete resolution of the clinical signs with no long-term complications or recurrence of clinical signs noticed after 1-month follow-up. This is the first description of progesterone intoxication inducing neurological signs in a cat.

Traumatic brain injury and aging: is a combination of progesterone and vitamin D hormone a simple solution to a complex problem?

Although progress is being made in the development of new clinical treatments for traumatic brain injury (TBI), little is known about whether such treatments are effective in older patients, in whom frailty, prior medical conditions, altered metabolism, and changing sensitivity to medications all can affect outcomes following a brain injury. In this review we consider TBI to be a complex, highly variable, and systemic disorder that may require a new pharmacotherapeutic approach, one using combinations or cocktails of drugs to treat the many components of the injury cascade. We review some recent research on the role of vitamin D hormone and vitamin D deficiency in older subjects, and on the interactions of these factors with progesterone, the only treatment for TBI that has shown clinical effectiveness. Progesterone is now in phase III multicenter trial testing in the United States. We also discuss some of the potential mechanisms and pathways through which the combination of hormones may work, singly and in synergy, to enhance survival and recovery after TBI.

Sex-specific responses to stroke

Stroke is a sexually dimorphic disease, with differences between males and females observed both clinically and in the laboratory. While males have a higher incidence of stroke throughout much of the lifespan, aged females have a higher burden of stroke. Sex differences in stroke result from a combination of factors, including elements intrinsic to the sex chromosomes as well as the effects of sex hormone exposure throughout the lifespan. Research investigating the sexual dimorphism of stroke is only in the beginning stages, but early findings suggest that different cell death pathways are activated in males and females after ischemic stroke. A greater understanding of the mechanisms underlying sex differences in stroke will lead to more appropriate treatment strategies for patients of both sexes.

Progesterone treatment for brain injury: an update

Traumatic brain injury is a significant clinical problem for which there is still no effective treatment. Recent laboratory and clinical data demonstrate a potentially beneficial role for neurosteroids, such as progesterone and allopregnanolone, in the treatment of traumatic brain injury, ischemic stroke and some neurodegenerative disorders. Unlike single-target agents, progesterone affects many of the molecular and physiological processes in the cascade of secondary damage after a traumatic brain injury. This article updates a 2006 Future Neurology review of the research on progesterone and its metabolites in the treatment of traumatic brain injury, and presents new evidence that vitamin D deficiency can reduce progesterone neuroprotection, while combining progesterone with vitamin D produces better functional outcomes after TBI compared with eithertreatment alone.

Combined 17beta-oestradiol and progesterone treatment prevents neuronal cell injury in cortical but not midbrain neurones or neuroblastoma cells

Oestrogens are powerful endogenous and exogenous neuroprotective hormones in animal models of brain injury, including focal cerebral ischaemia. This protective effect has been demonstrated under a variety of different treatments and injury paradigms, such as in vivo and in vitro stroke conditions. Neuroprotection in the central nervous system by progesterone is less defined. In the present study, cultured cortical and midbrain mouse neurones and human neuroblastoma cells (SH-SY5Y) were exposed to combined glucose-serum deprivation (CGSD), which is regarded as a reliable model mimicking the effects of ischaemia in vitro. Cell viability was assayed using lactate dehydrogenase release and metabolic activity. Conditions for CGSD treatment were chosen to yield half-maximal cell death rates. The validity of CGSD in vitro was compared with permanent middle cerebral artery occlusion (MCAO) in vivo. CGSD for 4 h induced half-maximal neuronal cell death. MCAO in vivo for the same period resulted in significant neuronal loss, also suggesting the validity of CGSD as a suitable stroke-like in vitro model. Combined steroid treatment (17beta-oestradiol and progesterone) but not the application of single steroids abolished CGSD-induced cell death of cortical neurones in vitro. By contrast, no cell protection was found in midbrain neurones or neuroblastoma cells. The co-application of oestrogen (ICI 182,780) or progesterone (RU-486) receptor antagonists did not obviously counteract the protective steroid effects. This suggests the operation of nonclassical steroid mechanisms and their implication in mediation of hormonal effects. The surplus of combined protective hormonal effects might be a result of the observed influence of progesterone application on neuronal oestradiol synthesis. The data obtained in the present study clearly highlight the potential of a combined steroid treatment under toxic degenerative brain pathologies.

Opioid and progesterone signaling is obligatory for early human embryogenesis

The growth factors that drive the division and differentiation of stem cells during early human embryogenesis are unknown. The secretion of endorphins, progesterone (P(4)), human chorionic gonadotropin, 17beta-estradiol, and gonadotropin-releasing hormone by trophoblasts that lie adjacent to the embryoblast in the blastocyst suggests that these pregnancy-associated factors may directly signal the growth and development of the embryoblast. To test this hypothesis, we treated embryoblast-derived human embryonic stem cells (hESCs) with ICI 174,864, a delta-opioid receptor antagonist, and RU-486 (mifepristone), a P(4) receptor competitive antagonist. Both antagonists potently inhibited the differentiation of hESC into embryoid bodies, an in vitro structure akin to the blastocyst containing all three germ layers. Furthermore, these agents prevented the differentiation of hESC aggregates into columnar neuroectodermal cells and their organization into neural tube-like rosettes as determined morphologically. Immunoblot analyses confirmed the obligatory role of these hormones; both antagonists inhibited nestin expression, an early marker of neural precursor cells normally detected during rosette formation. Conversely, addition of P(4) to hESC aggregates induced nestin expression and the formation of neuroectodermal rosettes. These results demonstrate that trophoblast-associated hormones induce blastulation and neurulation during early human embryogenesis.

Combination treatment with progesterone and vitamin D hormone may be more effective than monotherapy for nervous system injury and disease

More than two decades of pre-clinical research and two recent clinical trials have shown that progesterone (PROG) and its metabolites exert beneficial effects after traumatic brain injury (TBI) through a number of metabolic and physiological pathways that can reduce damage in many different tissues and organ systems. Emerging data on 1,25-dihydroxyvitamin D(3) (VDH), itself a steroid hormone, have begun to provide evidence that, like PROG, it too is neuroprotective, although some of its actions may involve different pathways. Both agents have high safety profiles, act on many different injury and pathological mechanisms, and are clinically relevant, easy to administer, and inexpensive. Furthermore, vitamin D deficiency is prevalent in a large segment of the population, especially the elderly and institutionalized, and can significantly affect recovery after CNS injury. The combination of PROG and VDH in pre-clinical and clinical studies is a novel and compelling approach to TBI treatment.

Progesterone neuroprotection in traumatic CNS injury and motoneuron degeneration

Studies on the neuroprotective and promyelinating effects of progesterone in the nervous system are of great interest due to their potential clinical connotations. In peripheral neuropathies, progesterone and reduced derivatives promote remyelination, axonal regeneration and the recovery of function. In traumatic brain injury (TBI), progesterone has the ability to reduce edema and inflammatory cytokines, prevent neuronal loss and improve functional outcomes. Clinical trials have shown that short-and long-term progesterone treatment induces a significant improvement in the level of disability among patients with brain injury. In experimental spinal cord injury (SCI), molecular markers of functional motoneurons become impaired, including brain-derived neurotrophic factor (BDNF) mRNA, Na,K-ATPase mRNA, microtubule-associated protein 2 and choline acetyltransferase (ChAT). SCI also produces motoneuron chromatolysis. Progesterone treatment restores the expression of these molecules while chromatolysis subsided. SCI also causes oligodendrocyte loss and demyelination. In this case, a short progesterone treatment enhances proliferation and differentiation of oligodendrocyte progenitors into mature myelin-producing cells, whereas prolonged treatment increases a transcription factor (Olig1) needed to repair injury-induced demyelination. Progesterone neuroprotection has also been shown in motoneuron neurodegeneration. In Wobbler mice spinal cord, progesterone reverses the impaired expression of BDNF, ChAT and Na,K-ATPase, prevents vacuolar motoneuron degeneration and the development of mitochondrial abnormalities, while functionally increases muscle strength and the survival of Wobbler mice. Multiple mechanisms contribute to these progesterone effects, and the role played by classical nuclear receptors, extra nuclear receptors, membrane receptors, and the reduced metabolites of progesterone in neuroprotection and myelin formation remain an exciting field worth of exploration.

Impact of sex steroids on neuroinflammatory processes and experimental multiple sclerosis

Synthetic and natural estrogens as well as progestins modulate neuronal development and activity. Neurons and glia are endowed with high-affinity steroid receptors. Besides regulating brain physiology, both steroids conciliate neuroprotection against toxicity and neurodegeneration. The majority of data derive from in vitro studies, although more recently, animal models have proven the efficaciousness of steroids as neuroprotective factors. Indications for a safeguarding role also emerge from first clinical trials. Gender-specific prevalence of degenerative disorders might be associated with the loss of hormonal activity or steroid malfunctions. Our studies and evidence from the literature support the view that steroids attenuate neuroinflammation by reducing the pro-inflammatory property of astrocytes. This effect appears variable depending on the brain region and toxic condition. Both hormones can individually mediate protection, but they are more effective in cooperation. A second research line, using an animal model for multiple sclerosis, provides evidence that steroids achieve remyelination after demyelination. The underlying cellular mechanisms involve interactions with astroglia, insulin-like growth factor-1 responses, and the recruitment of oligodendrocytes.

Combination therapies for traumatic brain injury: prospective considerations

Traumatic brain injury (TBI) initiates a cascade of numerous pathophysiological events that evolve over time.Despite the complexity of TBI, research aimed at therapy development has almost exclusively focused on single therapies, all of which have failed in multicenter clinical trials. Therefore, in February 2008 the National Institute of Neurological Disorders and Stroke, with support from the National Institute of Child Health and Development, the National Heart, Lung, and Blood Institute, and the Department of Veterans Affairs, convened a workshop to discuss the opportunities and challenges of testing combination therapies for TBI. Workshop participants included clinicians and scientists from a variety of disciplines, institutions, and agencies. The objectives of the workshop were to: (1) identify the most promising combinations of therapies for TBI; (2) identify challenges of testing combination therapies in clinical and pre-clinical studies; and (3) propose research methodologies and study designs to overcome these challenges. Several promising combination therapies were discussed, but no one combination was identified as being the most promising. Rather, the general recommendation was to combine agents with complementary targets and effects (e.g., mechanisms and time-points), rather than focusing on a single target with multiple agents. In addition, it was recommended that clinical management guidelines be carefully considered when designing pre-clinical studies for therapeutic development.To overcome the challenges of testing combination therapies it was recommended that statisticians and the U.S. Food and Drug Administration be included in early discussions of experimental design. Furthermore, it was agreed that an efficient and validated screening platform for candidate therapeutics, sensitive and clinically relevant biomarkers and outcome measures, and standardization and data sharing across centers would greatly facilitate the development of successful combination therapies for TBI. Overall there was great enthusiasm for working collaboratively to act on these recommendations.

Identification of a regulatory loop for the synthesis of neurosteroids: a steroidogenic acute regulatory protein-dependent mechanism involving hypothalamic-pituitary-gonadal axis receptors

Brain sex steroids are derived from both peripheral (primarily gonadal) and local (neurosteroids) sources and are crucial for neurogenesis, neural differentiation and neural function. The mechanism(s) regulating the production of neurosteroids is not understood. To determine whether hypothalamic-pituitary-gonadal axis components previously detected in the extra-hypothalamic brain comprise a feedback loop to regulate neuro-sex steroid (NSS) production, we assessed dynamic changes in expression patterns of steroidogenic acute regulatory (StAR) protein, a key regulator of steroidogenesis, and key hypothalamic-pituitary-gonadal endocrine receptors, by modulating peripheral sex hormone levels in female mice. Ovariectomy (OVX; high serum gonadotropins, low serum sex steroids) had a differential effect on StAR protein levels in the extrahypothalamic brain; increasing the 30- and 32-kDa variants but decreasing the 37-kDa variant and is indicative of cholesterol transport into mitochondria for steroidogenesis. Treatment of OVX animals with E(2), P(4), or E(2) + P(4) for 3 days, which decreases OVX-induced increases in GnRH/gonadotropin production, reversed this pattern. Suppression of gonadotropin levels in OVX mice using the GnRH agonist leuprolide acetate inhibited the processing of the 37-kDa StAR protein into the 30-kDa StAR protein, confirming that the differential processing of brain StAR protein is regulated by gonadotropins. OVX dramatically suppressed extra-hypothalamic brain gonadotropin-releasing hormone 1 receptor expression, and was further suppressed in E(2)- or P(4)-treated OVX mice. Together, these data indicate the existence of endocrine and autocrine/paracrine feedback loops that regulate NSS synthesis. Further delineation of these feedback loops that regulate NSS production will aid in developing therapies to maintain brain sex steroid levels and cognition.

Emerging treatments for traumatic brain injury

BACKGROUND

This review summarizes promising approaches for the treatment of traumatic brain injury (TBI) that are in either preclinical or clinical trials.

OBJECTIVE

The pathophysiology underlying neurological deficits after TBI is described. An overview of select therapies for TBI with neuroprotective and neurorestorative effects is presented.

METHODS

A literature review of preclinical TBI studies and clinical TBI trials related to neuroprotective and neurorestorative therapeutic approaches is provided.

RESULTS/CONCLUSION

Nearly all Phase II/III clinical trials in neuroprotection have failed to show any consistent improvement in outcome for TBI patients. The next decade will witness an increasing number of clinical trials that seek to translate preclinical research discoveries to the clinic. Promising drug- or cell-based therapeutic approaches include erythropoietin and its carbamylated form, statins, bone marrow stromal cells, stem cells singularly or in combination or with biomaterials to reduce brain injury via neuroprotection and promote brain remodeling via angiogenesis, neurogenesis, and synaptogenesis with a final goal to improve functional outcome of TBI patients. In addition, enriched environment and voluntary physical exercise show promise in promoting functional outcome after TBI, and should be evaluated alone or in combination with other treatments as therapeutic approaches for TBI.

Is progesterone a candidate neuroprotective factor for treatment following ischemic stroke?

Gender differences in stroke outcome have implicated steroid hormones as potential neuroprotective candidates. However, no clinical trials examining hormone replacement therapy on outcome following ischemic stroke have investigated the effect of progesterone-only treatment. In this review the authors examine the experimental evidence for the neuroprotective potential of progesterone and give an insight into potential mechanisms of action following ischemic stroke. To date, 17 experimental studies have investigated the neuroprotective potential of progesterone for ischemic stroke in terms of ability to both reduce cell loss and increase functional outcome. Of these 17 published studies the majority reported a beneficial effect with three studies reporting a nil effect and only one study reporting a negative effect. However, there are important issues that the authors address in this review in terms of the methodological quality of studies in relation to the STAIR recommendations. In terms of the proposed mechanisms of progesterone neuroprotection we show that progesterone is versatile and acts at multiple targets to facilitate neuronal survival and minimize cell damage and loss. A large amount of experimental evidence indicates that progesterone is a neuroprotective candidate for ischemic stroke; however, to progress to clinical trial a number of key experimental studies remain outstanding.

Sex-dependent regulation of hypoxic ventilation in mice and humans is mediated by erythropoietin

Acclimatization to hypoxic exposure relies on an elevated ventilation and erythropoietic activity. We recently proposed that erythropoietin (Epo) links both responses: apart from red blood cell production, cerebral and plasma Epo interact with the central and peripheral respiratory centers. Knowing that women cope better than men with reduced oxygen supply (as observed at high altitude), we analyzed the hypoxic ventilatory response in Epo-overexpressing transgenic male and female mice with high Epo levels in brain and plasma (Tg6) or in wild-type animals injected with recombinant human Epo (rhEpo). Exposure to moderate and severe hypoxia as well as to hyperoxia and injection of domperidone, a potent peripheral ventilatory stimulant, revealed that the presence of transgenic or rhEpo extensively increased the hypoxic ventilatory response in female mice compared with their corresponding male siblings. Alterations of catecholamines in the brain stem's respiratory centers were also sex dependent. In a proof-of-concept study, human volunteers were intravenously injected with 5,000 units rhEpo and subsequently exposed to 10% oxygen. Compared with men, the hypoxic ventilatory response was significantly increased in women. We conclude that Epo exerts a sex-dependent impact on hypoxic ventilation improving the response in female mice and in women that most probably involves sexual hormones. Our data provides an explanation as to why women are less susceptible to hypoxia-associated syndromes than men.

The neuroprotective effects of progesterone on experimental diabetic neuropathy in rats

This study was conducted to investigate the neuroprotective effects of progesterone (PROG) on electrophysiological and histomorphometrical alternation in STZ-induced diabetic neuropathy starting from 4 weeks after the diabetic induction. Thirty adult male Sprague-Dawley rats were randomly divided into 3 groups (with 10 rats in each), control (nondiabetic), untreated diabetic and diabetic PROG-treated. Diabetes was induced in adult male rats by a single dose injection of streptozotocin (STZ, 55 mg kg(-1), i.p.). In the PROG-treated group, 4 weeks after induce of diabetes; rats were treated with PROG (8 mg kg(-1), i.p., every two days) for 6 weeks. Diabetic rats showed a significant reduction in motor nerve conduction velocity (MNCV), mean myelinated fibers (MFs) diameter, axon diameter and myelin sheath thickness in the sciatic nerve after 6 weeks. In the untreated diabetic group endoneurial edema was observed in sciatic nerve and the numbers of MFs with infolding into the axoplasm, irregularity of fibers, myelin sheath with unclear boundaries and alteration in myelin compaction were also increased. Long-term treatment with PROG increased MNCV significantly and prevented all these abnormalities in treated diabetic rats. Our findings indicated that PROG as a therapeutic approach can protect neurophysiologic and histomorphologic alterations induced by peripheral diabetic neuropathy.

[Influence of age, gender, and severity on recovery of patients with brain injury]

PURPOSE

This study was conducted to investigate the individual and cross influences of age, gender, and severity on recovery of patients with brain injury.

METHODS

For the purpose of the study, traumatic or spontaneous brain injury patients admitted to the intensive care unit (ICU) were conveniently selected. The data regarding outcomes were collected 3 months after admission.

RESULTS

Individual influences of the study variables on patients' recovery were significant, except for gender. But while the individual influence of gender on recovery was not significant, cross influence of gender and age was significant, but only for the sub-dimension of 'arousalbility and awareness'. The study results also showed that 3-way cross influence of gender, age, and severity was only significant on the sub-dimension of 'arousalbility and awareness'.

CONCLUSION

The sub-dimension of recovery cross influenced by the demographic factors of gender and age, and severity was 'arousalbility and awareness'. This might indicate that the study variables that cross influencing recovery had more influence on consciousness compared to physical function and psycho-social adaptation.

FOXL2: at the crossroads of female sex determination and ovarian function

The gene FOXL2 encodes a forkhead transcription factor whose mutations are responsible for the blepharophimosis ptosis epicanthus-inversus syndrome. This genetic disorder is characterized by eyelid and mild craniofacial abnormalities often in association with premature ovarian failure. FOXL2 orthologs are found throughout the animal phylum and its sequence is highly conserved in vertebrates. FOXL2 is one of the earliest ovarian markers and it offers, alongwith its targets, a model to study ovarian development and function. In this chapter, we review recent data concemingits mutations, targets, regulation and functions. Studies of the cellular consequences of FOXL2 mutations seem to indicate that aggregation is a common pathogenic mechanism. However, no reliable genotype/phenotype correlation has been established to predict the exact impact of point mutations in the coding region of FOXL2. FOXL2 has been suggested to be involved in the regulation of cholesterol homeostasis, steroid metabolism, apoptosis, reactive oxygen species detoxification and inflammation processes. Interestingly, all these processes are not equally affected by FOXL2 mutations. The elucidation of the impact of the FOXL2 function in the ovary will allow a better understanding of normal ovarian development and function as well as the pathogenic mechanisms underlying BPES.

Neuroprotection in traumatic brain injury

The management of traumatic brain injury (TBI) is challenging and there is a need for neuroprotective therapies. A better understanding of the pathomechanism of TBI, particularly of the evolution of secondary damage, is providing targets for new approaches and selected ones in clinical development are described. Clinical trials that have been discontinued in the past for lack of efficacy or other reasons are also listed. One of the problems has been the translation of promising animal experimental results into clinically successful therapies. The complexity of sequelae of TBI requires a multifaceted approach. In addition to the investigation of drugs for neuroprotective effect in TBI, new technologies based on cell/gene therapies, biomarkers and nanobiotechnology are being employed for the integration of neuroprotection with neuroregeneration and are promising.

Efficacy of progesterone following a moderate unilateral cortical contusion injury

Traumatic brain injury (TBI) results in an accumulation of edema and loss of brain tissue. Progesterone (PROG) has been reported to reduce edema and cortical tissue loss in a bilateral prefrontal cortex injury. This study tests the hypothesis that PROG is neuroprotective following a unilateral parietal cortical contusion injury (CCI). Adult male Sprague-Dawley rats were subjected to a moderate unilateral TBI using the CCI model. Rats were given 8 mg/kg PROG 15 min post-injury with four subsequent injections (6 h, and days 1, 2, and 3). Edema was determined 3 days post-injury, while cortical tissue sparing was also evaluated at 7 days post-injury. Animals were injured and given one of four treatments: (I) vehicle; (II) low dose: 8 mg/kg PROG; (III) high dose: 16 mg/kg PROG; (IV) tapered: 8 mg/kg PROG. Animals were given an initial injection within 15 min, followed by five injections (6 h, and days 1, 2, 3, and 4). Group IV received two additional injections (4 mg/kg on day 5; 2 mg/kg on day 6). PROG failed to alter both cortical edema and tissue sparing at any dose. Failure to modify two major sequelae associated with TBI brings into question the clinical usefulness of PROG as an effective treatment for all types of brain injury.

Estrogen and SERM neuroprotection in animal models of Parkinson's disease

A higher prevalence and incidence of Parkinson disease (PD) is observed in men and beneficial motor effects of estrogens are observed in parkinsonian women. Lesion of the dopamine (DA) nigrostriatal pathway in animals with 1-methyl 4-phenyl-1,2,3,6 tetrahydropyridine (MPTP) provides a model of PD and this is based on its use in humans as side-product of a drug abuse. Presently treatment of PD is mainly symptomatic. The MPTP mouse is used to study the neuroprotective roles of estrogenic drugs on the DA system. Estrogens, but not androgens, are active neuroprotectants as well as progesterone and dehydroepiandrosterone. An estrogen receptor agonist PPT and the selective estrogen receptor modulator raloxifene are also neuroprotective. Striatal DA neurons of estrogen receptor alpha knockout mice are more susceptible to MPTP toxicity than wild-type mice and neuroprotection by estradiol is associated with the activation of the PI3-K pathway involving Akt, GSK3beta, Bcl2 and BAD.

Traumatic brain injury and gender: what is known and what is not

This work seeks to provide a brief review of the present state of knowledge of gender differences in traumatic brain injury and the role of sex hormones in the injury and recovery process. A full appreciation of the extent of the laboratory and clinically important differences remains to be defined. The role such differences will play in designing clinical trials and eventual clinical treatment is part of an exciting future in this arena of research.

The injured nervous system: a Darwinian perspective

Much of the permanent damage that occurs in response to nervous system damage (trauma, infection, ischemia, etc.) is mediated by endogenous secondary processes that can contribute to cell death and tissue damage (excitotoxicity, oxidative damage and inflammation). For humans to evolve mechanisms to minimize secondary pathophysiological events following CNS injuries, selection must occur for individuals who survive such insults. Two major factors limit the selection for beneficial responses to CNS insults: for many CNS disease states the principal risk factor is advanced, post-reproductive age and virtually all severe CNS traumas are fatal in the absence of modern medical intervention. An alternative hypothesis for the persistence of apparently maladaptive responses to CNS damage is that the secondary exacerbation of damage is the result of unavoidable evolutionary constraints. That is, the nervous system could not function under normal conditions if the mechanisms that caused secondary damage (e.g., excitotoxicity) in response to injury were decreased or eliminated. However, some vertebrate species normally inhabit environments (e.g., hypoxia in underground burrows) that could potentially damage their nervous systems. Yet, neuroprotective mechanisms have evolved in these animals indicating that natural selection can occur for traits that protect animals from nervous system damage. Many of the secondary processes and regeneration-inhibitory factors that exacerbate injuries likely persist because they have been adaptive over evolutionary time in the healthy nervous system. Therefore, it remains important that researchers consider the role of the processes in the healthy or developing nervous system to understand how they become dysregulated following injury.

Progesterone in traumatic brain injury: time to move on to phase III trials

There are several candidate neuroprotective agents that have been shown in preclinical testing to improve outcomes following traumatic brain injury (TBI). Xiao and colleagues have performed an in hospital, double blind, randomized, controlled clinical trial utilizing progesterone in the treatment of patients sustaining TBI evaluating safety and long term clinical outcomes. These data, combined with the results of the previously published ProTECT trial, show progesterone to be safe and potentially efficacious in the treatment of TBI. Larger phase III trials will be necessary to verify results prior to clinical implementation. Clinical trials networks devoted to the study of TBI are vital to the timely clinical testing of these candidate agents and need to be supported.

17beta-estradiol protects the neonatal brain from hypoxia-ischemia

Hypoxia-ischemia is relatively common in human infants. Hypoxia-ischemia can occur as a result of complications associated with prematurity or birth, frequently leading to altered brain development and cognitive and behavioral deficits that persist throughout life. Despite the relative frequency of neonatal hypoxic-ischemic encephalopathy, the immature brain sustains relatively less damage than an adult who experiences a similar crisis of oxygen and nutrient deprivation. Therefore, factors may be present that protect the developing brain. During late gestation, the infant brain encounters high levels of the steroid hormone 17beta-estradiol. This observation, combined with evidence supporting 17beta-estradiol as a neuroprotective agent, led us to hypothesize that increasing the basal level of 17beta-estradiol would reduce the amount of hypoxia-ischemia induced injury to the neonatal brain. To test that hypothesis we administered 17beta-estradiol using either a repeated dosing paradigm or a single dose paradigm to immature male and female rats. Here we show that the repeated dosing paradigm (three doses of 17beta-estradiol) provided approximately 70% protection of the hippocampus, basal ganglia, and amygdala. By contrast, a single administration of 17beta-estradiol 24 h prior to hypoxia-ischemia conferred little protection. The only exception was the pyramidal layer of the female hippocampus, which was modestly protected (16% reduction in damage). The protection afforded by the multiple administrations of 17beta-estradiol was similar for females and males, with the only exception being the male amygdala, which displayed less damage than the female amgydala. We conclude that 17beta-estradiol acts as a potent neuroprotective agent against hypoxia-ischemia induced damage to the developing brain, and that pretreating infants at risk for hypoxic-ischemic injury may be advisable.