Oxytocin: Its Mechanism of Action and Receptor Signalling in The Myometrium

Received Date : 04-Feb-2014
Accepted Article Revised Date : 14-Mar-2014
Accepted Date : 28-Mar-2014
Article type : Review Article
Oxytocin: its mechanism of action and receptor signalling in the myometrium
Sarah Arrowsmith PhD, Department of Cellular and Molecular Physiology, Institute of Translational
Medicine, University of Liverpool, Liverpool, UK
Susan Wray, PhD, Department of Cellular and Molecular Physiology, Institute of Translational
Medicine, University of Liverpool, Liverpool, UK
Corresponding author Dr Sarah Arrowsmith
Department of Cellular and Molecular Physiology
Institute of Translational Medicine
University of Liverpool
Liverpool
UK
Telephone: +44 (0)151 794 5341
Fax: +44 (0)151 794 5321
Email: s.arrowsmith@liv.ac.uk
This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jne.12154
This article is protected by copyright. All rights reserved.
Abstract:
Accepted Article
Oxytocin is a nonapeptide hormone that has a central role in the regulation of parturition and
lactation. In this review, we address oxytocin receptor (OTR) signalling and its role in the
myometrium during pregnancy and in labour. The OTR belongs to the rhodopsin-type (Class 1) of the
G-protein coupled receptor (GPCR) superfamily and is regulated by changes in receptor expression,
receptor desensitisation and local changes in oxytocin concentration. Receptor activation triggers a
number of signalling events to stimulate contraction, primarily by elevating intracellular calcium
(Ca). This includes; inositol-tris-phosphate-mediated store calcium release, store-operated Ca entry
and voltage-operated Ca entry. We discuss each mechanism in turn and also discuss Ca-independent
mechanisms such as Ca sensitisation. Since oxytocin induces contraction in the myometrium, both
the activation and the inhibition of its receptor have long been targets in the management of
dysfunctional and preterm labours respectively. . We discuss current and novel OTR agonists and
antagonists and their use and potential benefit in obstetric practice. In this regard, we highlight the
following clinical scenarios: dysfunctional labour, postpartum haemorrhage and preterm birth.
Short running title: Oxytocin receptor signalling in the myometrium
Key words: Oxytocin, vasopressin, myometrium, labour, tocolysis
Oxytocin overview
In 1906, Sir Henry Dale discovered that extracts from the human posterior pituitary gland were able
to contract the uterus of a pregnant cat (1). The peptide responsible, termed oxytocin, was later
sequenced and synthesised by du Vigneaud in 1953 (2).

Oxytocin has both central and peripheral actions, with roles in many physiological and pathological
Accepted Article processes including reproduction, for example; parturition (which is the focus of this review),
lactation, maternal behaviour, erectile dysfunction and ejaculation. Oxytocin can also modulate
social behaviour via increasing empathy, trust and pair bonding (3). It is a nine amino acid
hypophysial neuropeptide hormone, synthesised by the magnocellular neurons of the supraoptic
and paraventricular nuclei of the hypothalamus, whose axons terminate within the posterior lobe of
the pituitary gland. It is produced as a pre-propeptide which is subjected to a number of
modifications to produce the mature peptide. These modifications take place during axonal
transport towards the terminals, from where it is released via exocytosis into the circulation in
response to a variety of stimuli (4-6). Oxytocin is also synthesised by peripheral tissues including the
lining of the uterus (decidua/uterine epithelium during pregnancy), corpus luteum, amnion and
placenta, as well as by the testes.
Oxytocin’s effects on myometrium
As stimulation of the uterus is one of oxytocin’s longest known functions, its role in parturition in
humans and animals has been studied extensively. It is therefore somewhat surprising that the exact
mechanism of how this stimulation is accomplished has not yet been clearly defined. The oxytocin
receptor (OTR) belongs to the rhodopsin-type (Class 1) of the G-protein coupled receptor (GPCR)
superfamily. In the uterus, the Gαq/11 protein couples to phospholipase -β (PLC-β) which controls the
hydrolysis of phosphoinositide-bis-phoshate (PIP2) into inositol-tris-phosphate (IP3) and
diacylglycerol (DAG). In turn, these control the mobilisation of Ca from intracellular stores
(sarcoplasmic reticulum, SR) and activation of protein kinase type C (PKC), respectively. Release of Ca
from the SR brings about smooth muscle contractions via stimulation of Ca-dependent calmodulin
which in turn, activates myosin light chain kinase (MLCK). Subsequent phosphorylation of the

regulatory myosin light chains by MLCK brings about cross-bridge cycling and generation of force (7)
Accepted Article (see figure).
The above mechanism, i.e. release of Ca from intracellular stores and the Ca-dependent activation of
calmodulin and MLCK is considered the canonical pathway of uterine stimulation by oxytocin.
However when examined more carefully, it is clear that the mechanism of oxytocin’s action is more
complex (8, 9).
Ca entry
There is evidence to suggest that Ca from extracellular sources also contributes to the oxytocin-
induced rise in intracellular free Ca ([Ca]i) as the oxytocin-stimulated rise in [Ca]i is reduced in the
absence of external Ca in immortalized myometrial cells and intact human myometrium (10). A
number of Ca influx mechanisms could be responsible for this.
Voltage-operated Ca channels (VOCCs), also referred to as L-type Ca channels, are the major Ca
channels involved in Ca entry in the myometrium and are essential for phasic, spontaneous activity
(11). Changes in membrane potential such as during action potentials result in opening of these
channels and Ca entry. However, there are conflicting data regarding the contribution of VOCC
activity with oxytocin stimulation in myometrial cells. Early studies showed that oxytocin elicits a
small increase in the inward current which would lead to the opening of L-type channels and thus
increase Ca entry (12). In freshly dispersed myometrial cells from pregnant rats, Arnaudeau et al .,
(1994) (13) also found that the Ca channel blocker oxodipine decreased the calcium transient and
sustained rise in [Ca]i elicited by oxytocin and concluded that Ca influx via VOCCs participates in the
global Ca response induced by oxytocin. The extent of their contribution however has been
questioned. Inoue et al., (1992) showed inhibition of L-type current by oxytocin in pregnant rat
myomterial cells (14), and data from an immortalised myometrial-derived cell line suggest that
oxytocin-stimulated calcium influx is independent of VOCCs, as inhibition of these channels using

nifedipine did not have any effect on the increase in [Ca]i under oxytocin-stimulation (15). However
Accepted Article the latter study can be criticised as the immortalised cells no longer express VOCCs (16). We suggest
it is likely that oxytocin affects L-type channel activity indirectly, such as via the opening of other
cation channels (e.g. Ca-activated Cl- channels) or capacitative Ca entry, which would then lead to
depolarisation and subsequent VOCC opening.
Capacitative Ca entry
There is now substantial evidence to support the hypothesis that oxytocin augments Ca entry via a
process known as capacitative Ca entry (or store-operated Ca entry, SOCE) which is distinct from
voltage operated Ca entry, and describes a process whereby depletion of internal Ca stores is
coupled to Ca entry pathways. It can be stimulated by inhibition of Ca store pumps (i.e. SERCA) e.g.
by thapsigargin or by signal-mediated store Ca release, such as following agonist stimulation (17). A
number of downstream signal effectors resulting from GPCR activation, including IP3 and DAG, are
known to contribute to store-operated Ca entry, both of which are activated in the myometrium in
response to oxytocin. Evidence for SOCE in myometrium comes from a number of studies showing
that the rise in [Ca]i following agonist stimulation was greater in the presence of extracellular Ca
compared to zero-Ca conditions (suggestive of Ca influx). This Ca influx was also insensitive to
nifedipine and therefore was independent of VOCCs. It was blocked by PLC inhibition (18) and by
SKF96365, a Ca channel inhibitor previously used in studies of SOCE (19) and was stimulated by
depletion of the Ca store following inhibition of SERCA (15). Furthermore, the expression of the
transient receptor potential (Trp) superfamily of proteins, notably TRPC subfamily, which are known
to mediate non-selective cation and Ca entry in response to a variety of stimuli in a number of cell
types (20, 21), have been detected in myometrium (22, 23), which further suggests that pathways
for SOCE exist in the myometrium and that they contribute to the mechanism of Ca influx during
oxytocin stimulation.

SR Ca release
Accepted Article
Release of intracellular Ca from stores during oxytocin-induced contractions was suggested from
studies of human myometrium (10). It is difficult however to directly demonstrate SR Ca release in
any tissue (24). In freshly dispersed uterine myocytes however, our group has succeeded in loading
the SR with the low affinity Ca sensitive indicative mag-Fluo-4, and studying the effect of agonists on
luminal SR Ca (25). Combining this with cytosolic loading with the high affinity Ca indicator, fura-2,
allows the simultaneous investigation of changes in both lumenal store and cytosolic Ca
concentrations. Using these methods in rat myometrial cells, both a decrease in luminal SR [Ca] and
a transient rise in cytosolic [Ca] was observed following oxytocin application in zero Ca conditions (9,
25, 26). Thus oxytocin can cause release of SR Ca and a lowering of SR Ca content, which, as
indicated above, will trigger capacitative Ca entry. The dynamics of Ca signalling however will be
different under normal physiological conditions (i.e. presence of external Ca), with a more sustained
rise in cytosolic [Ca] being reported (9), which is indicative of Ca release and entry, followed by L-
type Ca channel entry.
Ca efflux
Another mechanism whereby agonists can affect Ca signals and hence contraction, is by modulating
the efflux of Ca across the plasma membrane. In myometrium this occurs via Na-Ca exchange and
the plasmalemmal Ca-ATPase (27). There is limited evidence to suggest that oxytocin has effects on
Ca extrusion mechanisms via inhibition of Ca-ATPases and Ca efflux from cells, prolonging the
elevation of [Ca]i (28, 29). Given the potential importance of these mechanisms to the ability of
oxytocin to modulate uterine Ca signals and contractility, further studies of these aspects of oxytocin
action are called for. Cytoplasmic calcium will also be lowered after oxytocin stimulation by the SR
Ca-ATPase (SERCA) (25). The effect of oxytocin on SERCA activity appears not be have studied but
inhibition of SERCA leads to increased ca signalling and force in human myometrium (30).

Ca sensitisation
Accepted Article
In uterine smooth muscle cells, the force of contraction depends on the balance between the
activities of MLCK and myosin light chain phosphatase (MLCP) as these dictate the extent of myosin
phosphorylation and hence contraction: Phosphorylation of the regulatory light chains by MLCK is
responsible for bringing about contraction whilst dephosphorylation by MLCP brings about
relaxation (see figure). Oxytocin binding to its receptor also triggers the activation of Rho proteins (a
family of Ras homology proteins) which regulate acto-myosin interactions and Ca sensitivity of the
contractile proteins in smooth muscle. In the myometrium, RhoA is activated primarily via activation
of Gα12/13 proteins, which in turn triggers the activation of Rho kinase (ROCK). ROCK then inhibits
MLCP by phosphorylation of its myosin-binding subunit (MYPT1) (31, 32) thereby also inhibiting the
dephosphorylation of myosin light chains (see figure and (33)). This produces a greater level of light
chain phosphorylation and tension at a given level of Ca. Phosphorylation of myosin to augment
contraction in this Ca-independent manner is known as Ca sensitisation (34). In addition to ROCK,
PKC activated by DAG following oxytocin receptor activation, can also affect MLCP activity either by
phosphorylation of the phosphatase directly, or via CPI-17, a smooth muscle specific inhibitor of
MLCP (35). However to what extent sensitisation is a mechanism of oxytocin stimulation of uterine
smooth muscle cells is debatable. While some data exists to support it, including data from human
studies, (9, 36, 37), these have either not measured [Ca]i or not done so under steady state
conditions. When examined directly, inhibition of Rho-ROCK pathway in the uterus produced only
moderate effects on [Ca]i and force (38), suggesting that unlike vascular smooth muscles, Ca
sensitisation, at least via the ROCK pathway, is little used in myometrium and is unlikely therefore to
play a major role in oxytocin’s action.
In addition to oxytocin's direct influences on the force-calcium relationship in the myometrium,
oxytocin may have other roles which modulate myometrial contraction that are independent of the
contractile apparatus. For example, in baboon corpus lutea, oxytocin was shown to increase

expression of the major gap junction protein Connexin 43 (39). In the myometrium, expression of
Accepted Article these gap junctions facilitates the co-ordination and synchronicity of myometrial contractions which
are needed labour (40). More recently, oxytocin was shown to be associated with nuclear
translocation of the transcription factor, NFAT (nuclear factor of activated T cells). NFAT is activated
following a rise in [Ca]i whereby calcinuerin mediates its dephosphorylation and unmasking of a
nuclear localisation signal. In myometrial cells, oxytocin induced a concentration-dependent
translocation of the transcription factor to the nucleus which was inhibited by oxytocin and
calcineurin inhibitors (41), thus highlighting oxytocin's other potential role as a signal for
transcription.
Oxytocin and other tissues
In tissues such as amnion and decidua (uterine epithelium), evidence for OTR signalling has also
been documented: For example, in the amnion, up-regulation of OTR was reported in rabbits at the
end of pregnancy and oxytocin binding to its receptor was significantly increased in human fetal
membranes with labour onset (42, 43). More recently, Terzidou et al., 2011 showed an increase in
OTR mRNA and protein concentrations in human amnion epithelial cells with the onset of labour,
and incubation of these cells with oxytocin simulated an up-regulation of cyclo-oxygenase 2 and
synthesis of prostaglandin E2, via the extracellular signal-regulated protein kinase signal transduction
pathway (44). Oxytocin gene and receptor expression have also been shown in chorion and decidua
in humans (45). Treatment of human decidua with oxytocin resulted in stimulation of Prostaglandin
F2α production (46, 47). The mechanism for this may involve the mitogen-activated protein kinase
(MAPK) system, possibly attributed to the activities of PKC (48). Prostaglandins themselves are key
modulators of myometrial contraction therefore, it suggests a complimentary role for oxytocin/OTR
signalling in uterine tissues exists whereby oxytocin can interact both directly with the myometrium
in stimulating uterine contractions, but also indirectly, via the formation of prostaglandins in other
tissues.

Regulation of myometrial oxytocin and oxytocin receptors
Accepted Article
The regulation of oxytocin’s uterotonic activity can be considered from two aspects; 1) changes in
the concentration of oxytocin in the circulation and 2) changes in OTR expression or its sensitivity.
We will discuss each in turn next.
Oxytocin concentration
A raised plasma oxytocin concentration at some stage during parturition has been detected for most
placental mammals including humans (49, 50). For many animals, immediately prior to labour onset,
oxytocin is released from the pituitary into the maternal circulation. However, there is no good,
consistent evidence to support a significant increase in maternal oxytocin concentration prior to
labour onset in humans (51-53). Thornton et al., (1992) reported that the progress of labour is not
related to an increase in oxytocin concentration and that uterine contractions are not associated
with changes in its plasma concentration (54). A surge in oxytocin towards the second and third
stage of labour has however been reported, but only in a few women (54, 55). In animals it has been
shown that release of oxytocin from the pituitary is pulsatile, most of which occurs during fetal
expulsion (56, 57). Discrete fluctuations (pulses) in oxytocin concentration have been detected in
humans by some but not others (52, 54). The precise measurement of oxytocin concentration in
labour however, has been fraught with technical difficulties, including the accuracy of the methods
of sampling used, particularly when trying to measure short bursts of peptide release, oxytocin
having a short half life and that it undergoes rapid metabolism and clearance (58). All of which are
likely to have given rise to the wide variation and inconsistencies in oxytocin concentrations being
reported. In addition as noted earlier, oxytocin is also produced locally by intrauterine tissues (45).
Thus the close proximity of these tissues to myometrium (and decidua) suggests that a paracrine OT
signalling system within intrauterine tissues may also contribute to labour onset and/or progression.
This would therefore alleviate the need for a significant change in the maternal circulation (59) and

would provide one explanation for the lack of change in maternal circulation concentration
Accepted Article observed.
Interestingly, circulating oxytocin does not appear to be essential for labour since human labour
occurs normally in cases of maternal pituitary gland dysfunction or in the absence of oxytocin arising
from the fetal circulation such as in fetal anencephaly (60). Oxytocin deficient mice (OT -/-) also
deliver normally (61, 62), suggesting additional pathways to parturition exist (e.g. prostaglandin
signalling, increased coordination of excitability of myocyte through gap junction proteins) and may
be compensating for the functional loss of oxytocin. Interestingly, in the rat, giving low doses of
oxytocin actually produces a delay to subsequent fetal expulsion, and does so more effectively than
administration of high doses of an oxytocin antagonist (63). As noted by Russell & Leng (50) this may
be due to desensitisation of uterine oxytocin receptors, and reduced OTR gene expression (see (64)
and later).
Oxytocin Receptor expression
In the myometrial tissues of humans, OTR mRNA levels and OTR density increase at labour onset
(possible mechanisms for this are discussed later) which is thought to mediate an increase in
sensitivity of the myometrium to oxytocin at term (65-67). OTRs were shown to be low in expression
in early gestation but rise to twelve-fold by 37-41 weeks and to be maximally expressed after labour
onset. Furthermore, OTR numbers in the myometrium are increased in preterm as well as term
labour (65). In rats, OTR expression is significantly lower mid-gestation compared to non-pregnant
levels but increases significantly alongside other uterine stimulant systems at parturition (68).
Similarly to oxytocin production, expression of OTRs is not confined to the myometrium. Chorio-
decidual tissue OTR expression also increases during parturition (69) and spatial differences exist
between OTR expression within uterine tissues. For example in the myometrium, OTR expression
was found to be higher in the fundus compared to the lower segment (65, 70). It is suggested that

this spatial distribution would allow for an increase in contractile force arising from the fundal region
Accepted Article whilst the lower segment remains relaxed and therefore would aid fetal decent and passage during
labour. Thus, it is now thought that a change in the receptor expression (amount and location)
rather than concentration of the peptide, is important for labour onset and progression (59).
Post partum, OTR levels decline rapidly in both the chorio-deciual tissues and uterus in rats (71). In
contrast, OT binding sites in the mammary glands remain up-regulated postpartum during the
ensuing lactation period (72) It is suggested that this down regulation of receptors in the uterus may
be needed to prevent unwanted uterine contractile activity in response to oxytocin production
during lactation.
In addition, there is also a central role for oxytocin in the timing of parturition in rats. Neurons within
the CNS also express OTRs and there is dynamic change in OTR mRNA in the brain perinatally, with a
marked increase in specific brain regions such as the supra-optic nucleus, prior to labour (73).
Oxytocin is able to facilitate its own release and can act centrally as a neuromodulator or
neurotransmitter For example, it has recently been shown to cause a shift in neuronal GABA
signalling that might be relevant to the aetiology of autism (74). It can also control the pathways
mediating sensory input from the uterus e.g. cervical stretch, and uterine afferents that terminate
within the brainstem are thought to aid a positive feedback loop (also known as the Ferguson reflex)
to further stimulate oxytocin release (75). That OTRs are expressed in the brain also provides further
evidence for a central role of oxytocin in maternal behaviour such as mother-child bonding.
Regulation of receptor expression
Despite the marked increase in both OTR mRNA and protein with parturition being one of the most
consistent findings in all models examined, the mechanisms regulating myometrial OTR expression
in the human still remain largely undefined, but are likely to be multifactorial.

Steroids: It is suggested that the receptor mRNA concentration is hormonally regulated as in
Accepted Article rodents, there is a good correlation between circulating steroid concentrations and OTR expression.
The general consensus is that oestrogens increase the amount of uterine OTR mRNA and the
number of OTR binding sites whilst conversely, progesterone suppresses OTR expression: Use of the
oestrogen receptor antagonist tamoxifen, was shown to delay parturition by 24 hours and was
associated with a delay in the normal increase in OTR levels in rats (76), whilst administration of the
progesterone receptor antagonist RU486 caused a rapid and marked increase in OTR expression (77,
78). In humans and ruminants however, the mechanism of steroid regulation of OTR expression is
not fully understood and its importance is contested by some particularly because there is no
evidence to support a significant change in circulating oestrogen or progesterone concentration, or
a change in the oestrogen:progesterone ratio, such as seen in rodents (80). Instead, it is thought that
humans undergo a 'functional progesterone withdrawal' which is likely to result from local
progesterone metabolism (81) a shift in the ratio of the expression of progesterone receptor
isoforms (PR-A/PR-B) (82) and altered progesterone receptor co-factor expression (83).
Cholesterol is one of the most abundant lipids within the membrane and has a major role in
determining membrane fluidity and thus the function and organisation of membrane proteins,
including GPCRs (84). There is now a body of evidence to show that the plasma membrane
cholesterol content can regulate the ligand binding affinities and stability of the OTR and therefore
affect receptor signalling (85, 86). Oxytocin receptors preferably localise to cholesterol-rich domains
(also known as lipid rafts) which are often enriched with the protein caveolin, forming the plasma
membrane invaginations known as caveolae (87). It is when localised to within these cholesterol-
rich domains that OTRs show a higher affinity for oxytocin binding (88).
In the myometrium, modulation of membrane cholesterol which subsequently disrupts raft and
caveolae formation causes profound changes in myometrial contractility, including contractions

stimulated by oxytocin (89-91). That the oxytocin receptor is regulated by the biophysical properties
Accepted Article of the membrane therefore suggests that any perturbations to this may have important implications
for parturition, for example labours in obese women where serum cholesterol is predicted to be
high.
Interestingly, progesterone has been shown to inhibit cholesterol esterification and transport to and
from the plasma membrane, which would lead to a reduced cholesterol content within caveolae.
Thus a continuous presence of high progesterone concentration, such as during gestation, would
maintain the OTRs in a low affinity state. However, a subsequent progesterone withdrawal (such as
observed in rodents) would restore cholesterol transport and thereby also increase cholesterol
within caveolae. The responsiveness of the receptors to oxytocin would then increase as they would
switch to their high affinity state (8). This may aid the explanation of the increase in OTR
responsiveness towards labour onset in rodents. However, given that humans undergo a functional
progesterone withdrawal, progesterone-regulation of cholesterol and its relationship to activities of
the OTR in humans warrants further attention.
Stretch: As well as steroidal regulation of receptor expression, stretch of the myometrium is also
considered to be a major stimulus for increased OTR expression and is therefore thought to be a
further level in the control of uterine activity. Studies of animals with bicornuate uterus (e.g.
rodents) (78, 92) or double uterus (e.g. wallabies) (93) have shown that only in pregnant horns or
uterus (subjected to stretch from the growing fetus), was there an increase in the OTR. No increase
was observed in the non-pregnant horn demonstrating that endocrinological changes alone were
not sufficient to stimulate OTR expression and that mechanical stretch is needed. In studies of
primary cultures of human uterine myocyte cells obtained from non-labouring women at late
gestation, stretch also caused an increase in OTR expression. However this was not observed from
cells obtained during labour or from non-pregnant women (94) and may therefore indicate a

gestational dependent effect of stretch on induction of OTR expression or reflect the beginning of
Accepted Article down regulation of receptor expression that occurs post labour.
Increased or aberrant uterine distension may also help explain the high rates of preterm labour
often associated with cases of polyhydramnios (95) and multiple pregnancy (96-98), particularly, if
the uterus is subjected to higher degree of stretch at an earlier time point in gestation. Interestingly,
our recent in vitro studies of myometrial contraction from twin pregnancies showed an increased
response to oxytocin compared to singleton pregnancies (97) although oxytocin expression was not
examined. The stimulus for increased OT expression in found in preterm labours where they are not
confounded by a large fetus or multiple pregnancy (i.e. a relatively unstretched uterus) however is
not known.
Given the relationship between increased stretch and OTR expression, one may expect that
myometrium from prolonged pregnancies (given their extended gestation and associated higher
birth weight babies, hence greater stretch), would have a greater OTR expression and therefore
higher sensitivity to oxytocin. However, the expression of OTRs in cases of failed induction of labour
and postterm pregnancies (43-46 weeks) was shown to be significantly lower than in spontaneous
labour at term (65). In vitro, we also showed that the oxytocin response of the myometrium from
women with postdates pregnancy (<41weeks +3 days) in labour was significantly lower compared to
myometrium from women at term in labour (99) which may be as a consequence of reduced OTR
expression in these tissues.
Desensitisation
Repeated or prolonged stimulation of some GPCRs results in the loss of hormonal responsiveness,
known as desensitisation. The molecular mechanism responsible for desensitisation is mediated via
the recruitment of β-arrestin to the receptor following agonist stimulation. Following agonist

binding, GPCR kinases (or other kinases such as PKC) phosphorylate the C-terminal tail of the
Accepted Article receptor causing β-arrestin recruitment, which then sterically hinders any additional G protein
coupling and thus diminishes further second messenger signalling (100). Often, receptors then
become internalised via the classical clathrin-mediated pathway where they are then either targeted
for recycling to the cell membrane or degradation by lysosomes. Continuous and prolonged
exposure of myometrial cells to oxytocin in vitro leads to a reduced response (64, 101) which is
associated with a loss of OT binding sites, decreased receptor mRNA as well as receptor
internalisation (102). A loss of oxytocin receptors has also been demonstrated during oxytocin-
induced and oxytocin-augmented labours (103) suggesting that receptor downregulation also occurs
in vivo which may have important clinical consequences (discussed later).
Cross- talk between oxytocin and arginine vasopressin receptors
Arginine vasopressin (AVP, also known as antidiuretic hormone and simply, vasopressin) is another
cyclic neurohypophysial peptide. As its name suggests, its major functions are to retain water and
constrict blood vessels. It is produced within magnocellular neurons of the hypothalamus which are
situated adjacent to the neurons that produce oxytocin. AVP is also released from the posterior
pituitary. In humans, the oxytocin and vasopressin peptides are structurally very similar, each
having nine amino acids and a disulfide bond, and differing by only two amino acids (in positions 3
and 8). It also has a short half life (~20 minutes) (104, 105) and is derived from a preprohormone
(106). Like oxytocin, AVP also signals through GPCRs (V1aR, V1bR and V2R) which have a relatively high
homology to OTRs. V1aRs couple to Gαq/11 proteins and mediate effects via activation of PLC-β whilst
V2Rs selectively couple to Gαs proteins which activate cyclic AMP (cAMP) signalling. V1bR (also known
as V3Rs) can activate several signalling pathways via different G-proteins, according to the level of
receptor expression and concentration of vasopressin e.g. PKC via Gαq/11 and cAMP via Gαs (107). The
structural similarity of the two peptides (~80% homology) as well as high sequence homology of the

receptors, specifically around the extracellular binding domain, cause some cross reactivity between
Accepted Article peptides and receptors. That is, studies of receptor binding show that AVP binds to its own receptor
and to the OTR, and in a similar fashion, oxytocin binds mainly to the OTR but can also, to some
extent activate vasopressin receptors (108, 109). Oxytocin and vasopressin receptors can also form
functional homo- or heterodimers (110) adding further complexity into this system.
That AVP has been shown to induce contraction of the uterus in a number of animals including
human (111-114), suggests a physiological role for this peptide in the myometrium exists; the nature
of which however is unclear. Human myometrium is more sensitive to AVP than to oxytocin, which
has been demonstrated in both in vitro (114) and in vivo studies (111, 115, 116). The effect is
thought to be mediated via the V1aR which, as well as the uterus, is also expressed in smooth muscle
cells of blood vessels, liver, adrenal cortex, brain and platelets. The V1bR is expressed within the
adrenal medulla, anterior pituitary and other parts of the brain whilst the V2R is mainly located to
the kidneys where it mediates AVP's antidiuretic effects. As with the OTR, there is some evidence to
suggest that the density of V1aR is moderately increased at latter weeks of gestation (117) and
expression of V1aR has also been reported in preterm labour tissues (114, 115, 118), however a
change in receptor expression has not been reported by all (119).
What is consistent between studies however is that the V1aR expression remains high in the
myometrium throughout gestation, which suggests that a biologically active role for AVP in the
pregnant myometrium does exist. This is further supported by the clinical observations that infusion
of AVP is able to induce labour whilst a 24 hour water fast was also able to increase delivery rates
(120). That both OTR and V1aRs are highly expressed in the myometrium however, has also posed
the question of which peptide and or receptor is (most) responsible for contraction and/or
parturition? (58).

Similarly to oxytocin, there appears to be no increase in AVP concentration in the maternal
Accepted Article circulation prior to labour onset. However this does not rule out a role for local peptide synthesis
and paracrine signalling, such as AVP arising from the fetus. Amniotic fluid AVP concentration has
been reported to increase which is likely to be from fetal origin. Moreover, fetal AVP is also known
to be produced during progression of established labour (121) and in response to fetal stress such as
fetal hypoxia (122). This increase in local formation however, occurs well after the onset of labour,
thus the role of AVP in initiation of parturition is still questioned.
The cross reactivity of receptors and peptides also has important consequences for pharmacologic
therapies employing OTR receptor antagonists (discussed later). That the uterus expresses both OTR
and V1a R and that they are functionally coupled to myometrial contraction, also poses the question
of whether antagonism of both receptors is required for effective tocolysis, such as for preterm
labour (discussed later). The relative importance of the two receptors for labour can probably not be
fully understood until more specific receptor-subtype ligands have been developed and tested in
humans.
Clinical uses of oxytocin receptor agonists and antagonists
Since oxytocin induces contraction in the myometrium, both the activation and the inhibition of its
receptor have long been targets in the management of dysfunctional and preterm labours
respectively. Clinically, synthetic oxytocins (Syntocin and Pitocin) have been developed for use in
labour induction and augmentation whilst a synthetic analogue of oxytocin (Carbetocin) is used to
prevent uterine atony and haemorrhage following caesarean section.

Oxytocin agonists, labour induction and augmentation
Accepted Article
The goal of labour induction is to achieve vaginal delivery by stimulating uterine contractions prior to
spontaneous labour onset and is indicated when the benefits of early delivery outweigh the harms
associated with continuation of pregnancy. The role of oxytocin as an inducing agent is not to be
confused with its role in the augmentation of labour (discussed later). It is estimated that 20% to
30% of women will receive labour induction. Of these, less than two thirds will give birth without
further intervention and 22% will require caesarean section delivery (123). Oxytocin has been used
alone, in combination with amniotomy (breaking of the amniotic membranes), or following cervical
ripening with other pharmacological (e.g., Prostaglandin treatment) or non-pharmacological
methods. However studies suggest that intravenous oxytocin alone should not be used for induction
of labour, since when compared with vaginal PGE2 as an inducing agent, oxytocin alone results in
fewer vaginal deliveries within 24 hours, a lower Bishop score (assessment of cervical favourability,
(124)) at 24 hours and more caesarean section deliveries (125). The current use of oxytocin infusion
is secondary to prostaglandin treatment, after sufficient effacement/ripening of the cervix has been
achieved (123).
Dystocia is a perturbation in the normal progression of labour and has complex causes but inefficient
uterine action is the end result. There is natural variation in the length of labour, thus there is no
‘normal length’ per se. First labours last, on average around 8 hours (unlikely to last >18hours) and
second labours last around 5 hours (unlikely to last >12 hours) (126). Assessment of labour
progression is multifactorial including degree of dilation, fetal rotation, head decent and strength,
duration and frequency of uterine contractions. It is suggested that up to one third of women can
experience delay in labour (127).
Poor progress in labour can be managed medically with uterotonic agents, assisted fetal extraction
or failing this, caesarean section. Currently oxytocin is the only pharmacologic treatment available

for dysfunctional labour and unfortunately this only works in around 50 % of cases (128). Moreover
Accepted Article the prediction of success is complex, requiring assessment of a number of fetal and maternal factors
including obstetric history, gestational age of fetus, fetal presentation and cervical status. Labour
augmentation may be necessary when there is a failure of cervical dilatation or fetal descent with
spontaneous uterine contractions. The goal of labour augmentation with oxytocin is therefore to
enhance inadequate uterine contractions to achieve vaginal delivery. The National Institute of
Clinical Excellence guidelines state that oxytocin should be delivered as a continuous infusion with
incremental doses (given at intervals no more frequent than 30mins) until adequate contractions are
achieved, typically 4-5 contractions in 10 minutes (126).
Although oxytocin is widely used in obstetric care, there is a lack of consensus with respect to its
optimal dosage, timing (early or delayed administration) safety and efficacy. Early
radioimmunoassay studies suggested the half life of oxytocin to be around 3-6 minutes (129) which
gave recommendations for increases of infusion rates to be every 15-20 minutes. More recent in
vivo studies however, found that steady-state plasma oxytocin concentration and maximal uterine
contractile response was achieved after 40 minutes infusion, suggesting that oxytocin's half-life is
more likely to be between 10 and 15minutes (130), and intervals of 30-40 minutes are more superior
in terms of efficacy and safety (131).
Howclinicians should administer oxytocin to women for labour induction and augmentation, and the
monitoring of its effects is therefore an important obstetrical issue (132). A number of studies have
shown that vaginal birth can be achieved with a cervical dilatation rate of 0.5-1cm per hour.
However, for some women, progress may be slower but still remain within normal limits. Some
therefore believe patience with ongoing fetal assessment may also be beneficial and would avoid
unnecessary augmentation for longer periods than necessary (133). As discussed above,
desensitisation of the OTR can arise after prolonged exposure to oxytocin. Clinical studies have
demonstrated a loss of uterine activity, measured via intrauterine pressure catheter recordings in

women undergoing labour augmentation (134), which may account for reduced efficacy of oxytocin.
Accepted Article That the OTRs become desensitised, such as following prolonged labour augmentation, also poses a
risk for uterine atony and haemorrhage in the peripartum period (135), discussed later.
Each contraction-relaxation cycle of the uterus causes an intermittent decrease or interruption in
blood flow which decreases oxygen exchange between the mother and the fetus (136). Under
normal physiological conditions, the feto-placental unit can tolerate these changes, and the greater
the interval between contractions, the greater the time to perfuse the placenta and deliver oxygen
to the fetus (137). Oxytocin infusion however can lead to uterine hyperstimulation. If uterine activity
is excessive and the effects exceed the ability of the feto-placental unit to compensate, blood
flowing to the placenta and oxygen delivery to the fetus is reduced which can lead to intrapartum
fetal hypoxemia or distress. Oxytocin is also capable of causing tetanic contractions, which can result
in fetal death (138-140).
There is much variation in the responsiveness of women to oxytocin, as evident from studies
showing that one dose for one may not have the same outcomes for another. Kimura et al.,
demonstrated that the reaction to the uterus to oxytocin even within the same patient could vary
from one day to the next (141). Some have suggested that the uterus should perhaps be rested in
labour, rather than continuous infusion that results in little progress (142). Moreover, the nature of
oxytocin release from the pituitary is pulsatile and therefore, a more physiological approach to
oxytocin administration ( such as a pulsatile infusion) has also been suggested and trialled (143-145).
Postpartum haemorrhage
Post delivery of the fetus and placenta, forceful uterine contractions are required to clamp uterine
blood vessels and stem bleeding. Thus oxytocin’s endogenous role in labour is also extended to

reinforcing contractions after delivery. Postpartum haemorrhage (PPH) occurs in up to 15% of
Accepted Article vaginal deliveries (146) and represents the most important cause of maternal morbidity and
mortality worldwide. Excessive bleeding during or postpartum in most cases is a result of uterine
atony, therefore the prophylactic use of uterine contractants to enhance myometrial contraction
and uterine retraction have long been used in the prevention of PPH. Oxytocin has been most
widely used but it's relatively short half-life requires continual intravenous infusion, as is the case for
labour augmentation. Syntometrine is an oxytocin/ergot alkaloid combination drug which is
frequently used in vaginal deliveries. It has the rapid uterotonic activity of oxytocin combined with
the prolonged effects of ergometrine, however it is associated with more side effects due to the
activity of ergometrine on other smooth muscles (147).
More recently, Carbetocin, a synthetic analogue of oxytocin with a suggested half life approximately
4-10 times longer than that reported for oxytocin (148), has been developed for prevention of PPH.
It has been shown to have a greater safety and tolerability profile compared to oxytocin with the
added benefit that it can be administered as a single dose injection rather than long term infusion as
required for oxytocin. Today, carbetocin is often the primary treatment administered after delivery
to prevent PPH. It has been shown to be associated with less blood loss compared to syntometrine
in women who have vaginal deliveries, and has significantly fewer adverse effects (148, 149). It is
also routinely administered prophylactically following caesarean section delivery to prevent severe
blood loss and therefore reduce maternal morbidity and mortality.
Novel receptor agonists
In 1909, shortly after its discovery, oxytocin (pituary extract) was used for uteronic action in the
treatment of postpartum haemorrhage (150). Fifty years later it was then used for labour induction
(151). Since then however, little has changed, with only the synthetic oxytocins and oxytocin

analogues being developed and making it into clinical practice. This has prompted a shift in the
Accepted Article focus of uterine stimulants from other sources (152). Natural cyclotides, as well natural plant
extracts have shown some oxytocic activity and may therefore provide a novel source of uterine
stimulants (see (153, 154)). In a study of pomegranate seed extract, for example, a large stimulation
of rat uterine contractility was found (155). These authors went on to show that this effect was due
to β-sitosterol and inhibition of SERCA (and K channels) which is one of the potential mechanisms of
oxytocin’s action. In a review of uterotonic plant preparations in sub-Saharan Africa, Tripathi et al.,
(2013) identified 208 plant species (156). Thus the possibility of some of these being novel oxytocics
is strong. The development of OTR ligands that prevent receptor desensitisation may also be a novel
approach in the treatment of adverse clinical events such as post partum haemorrhage following
prolonged oxytocin therapy.
Oxytocin antagonists and preterm birth
Preterm birth (birth before 37 weeks gestation) is the most important cause of perinatal morbidity
and mortality. Early uterine contractions are one of the most recognised signs of spontaneous
preterm labour. The main method for delay of preterm birth therefore often involves
pharmacological inhibition of myometrial contractions (tocolysis). The aim of tocolytic treatment is
to delay labour sufficiently (24-48 hours) such that the mother can be safely transferred to a
specialist unit with appropriate neonatal care facilities and for the giving of antenatal corticosteroids
to aid fetal lung maturation and increase survival. There are several classes of tocolytic available.
Each has a different mechanism of action and have been reviewed elsewhere (157, 158).
There is some evidence for a premature activation of oxytocin secretion in preterm birth, suggesting
a pathogenic role for it in preterm labour. In this regard, OTR antagonists are one class of treatments
that have been developed as tocolytic agents for women in preterm labour. Oxytocin-receptor

antagonists are also useful for obtaining acute tocolysis in term labour, in situations when there is a
Accepted Article need to stop labour e.g. fetal distress (discussed elsewhere, (159)). Atosiban (Tractocile) is a mixed
oxytocin/vasopressin receptor competitive antagonist. That is, it has actions on both the OTR and
vasopressin (V1a) receptor. Its structure is based upon the amino acid structure of oxytocin except
with modifications at position 1, 2, 4 and 8 and it competes and thus, blocks oxytocin binding.
However, given its lack of receptor specificity, it is not known whether (or how much) the
antagonistic activity of atosiban on the V1aR also contributes to its tocolytic properties. In clinical
studies, atosiban has been shown to be as efficacious as other tocolytics in the treatment of
spontaneous preterm labour (160-162) and in the case of β2-adrenergic agonists, atosiban is thought
to have less unwanted side effects (160). Despite this, a systematic review of the evidence did not
find atosiban to be any more superior to other tocolytics towards neonatal outcomes (163, 164).
Furthermore, atosiban has limited bioavailability and requires parenteral administration and
hospitalisation. Its low affinity for the OTR and antagonistic activities at the V1aR, has ignited
interest in the development of other peptide and non-peptide antagonists with greater specificity
for the OTR.
One of the more OTR-selective competitive antagonists barusiban (Ferring), when tested, showed a
greater specificity for the human OTR than either the V1aR or V2R respectively (165) with greater
potency and longer duration of activity than atosiban. In in vitro experiments using isolated
myometrium from term and preterm women, barusiban was shown to be as effective as atosiban in
inhibiting oxytocin- induced myometrial contractions (166). Non-human primate studies also
showed that barusiban was successful in suppressing oxytocin-induced uterine activity (167, 168).
However, in a proof of concept clinical trial vs. placebo, barusiban was not found to be any more
effective in stopping preterm labour in pregnant women at late gestational age and no reduction in
uterine contractility was observed (169). At present barusiban is being trialled for reducing
implantation failure (due to uterine contraction) during embryo transfer for women undergoing

fertility treatment (In vitro fertilisation or intra-cytoplasmic sperm injection) (170). Results have not
Accepted Article yet been published.
Interestingly, whilst barusiban has not been proven to be effective in inhibiting labour at late
gestation, the more V1aR specific antagonist, relcovaptan has been reported to inhibit contractions in
women with preterm labour (171). However, women also received rescue tocolysis after 2 hours,
and delay to delivery was not measured in this group. This drug may have better clinical uses in the
treatment of dysmenorrhoea (172).
There is clearly need for more efficacious oxytocin (and perhaps vasopressin) receptor agonists with
more specific pharmacological profiles and greater bio availabilities. With this in mind
pharmaceutical companies and researchers have now expanded their searches towards
development of non-peptide oxytocin antagonists, having anticipated them having a greater bio
availability orally than former peptide forms (see Manning et al., 2012 (173)). The 4 most described
are GSK 221149A also known as Retosiban, L368899 (Merck), SSR126768 (Sanofi-Aventis) and
WAY1627720 (Pfizer). Disappointingly both L368899 and WAY162770 failed in clinical and pre-
clinical development for treatment of preterm labour respectively. L368899 showed poor oral
bioavailability and pharmacokinetic profile as well as unwanted behavioural side effects when tested
in rhesus monkeys (174). However, whilst WAY 1627720 failed in preclinical development, it may
have potential as a research tool, particularly in the study of oxytocin activity in the CNS, as
described for other OTR antagonists (173). SSR126768 showed uterine-relaxing properties in vitro
and in vivo in various rat and human models (175). As of January 2008, SSR126768 was still under
active development (phase 1 trials) (176).
The most promising non-peptide OT antagonist for use in treatment of preterm labour is Retosiban.
Preliminary studies in rats showed it had a higher affinity for OTR than V1aR or V2R and in in vivo
studies also in the rat, it was effective in reducing oxytocin-induced contractions and spontaneous

contractions when tested in late gestation (d19-d21) (177). More recently, the efficacy and safety of
Accepted Article retosiban has been tested in a multicentre, randomised control phase 2 clinical trial in women with
spontaneous preterm labour (between 30 and 36 weeks). Women received either IV infusion of
retosiban for 48 hours or placebo. Results indicated that retosiban was associated with a significant
increase in time to delivery (mean increase of 8.2 days) and decrease in preterm birth rate. The
incidence of preterm birth in the retosiban group being 18.7% compared to 47.2% in the placebo
group with an associated relative risk of 0.38 (95% CIs 0.15, 0.81) for preterm birth in the retosiban
group (178). Furthermore, the safety profile of retosiban was favourable and recommendation by
the researchers for progression into phase 3 studies was given. Thus it remains to be seen how
effective this compound will be and how valuable in clinical practice.
Future
It is suggested that up to one third of women will require augmentation of labour, which is likely to
take the form of an oxytocin agonist. However oxytocin is reported to only be effective in around
50% of cases (128). When compared to other medical situations such as cardiac disease where there
is a plethora of treatments available, one treatment which at best works 50 % of the time for women
in labour is lamentable. Likewise for preterm labour, atosiban is the only oxytocin receptor
antagonist available clinically as a tocolytic in Europe, but it is without Food and Drug agency
approval in the US due to its lack of efficacy over other treatments and no evidence of improvement
in neonatal outcomes. As a result, there is increasing interest in neurohypophysial peptide research,
particularly towards the design of more selective OTR and AVPR agonists and antagonists in both
peptide and nonpeptide forms (see Manning et al., 2012 (173)). In addition, oxytocin analogues with
greater bio-availabilities and stability ex vivo also offer the potential for improved treatment
strategies in lower resource settings. However, questions over the role and contribution of the
peptides oxytocin and vasopressin and their receptors in preterm and term labour still remain.

Answers require pharmacological input coupled with basic science research to unravel the complex
Accepted Article roles of these neurohypophysial peptides in parturition.
Figure 1. Oxytocin receptor signalling in the myometrium leading to contraction. Binding of
oxytocin to its receptor activates Gαq/11 which activates PLC-β, which in turn hydrolyses PIP2 to IP3
and DAG. IP3 causes release of Ca from the sarcoplasmic reticulum (SR) and DAG activates PKC.
Activation of Gαq/11 is also suggested to cause the opening of voltage-operated Ca channels and Ca2+
entry, the mechanism of which is not clear and may be as a result of direct activation or indirect
activation of channel opening. Inhibition of the Ca-ATPase pump inhibits Ca exit from the cell, thus
promoting elevated [Ca]i. The reduction in lumenal SR [Ca] is thought to trigger capacitative or store-
operated Ca entry. The combined elevation in [Ca]i leads to formation of the Ca-calmodulin complex
which then activates MLC kinase, resulting in acto-myosin crossbridge cycling and myometrial
contraction.
In addition, DAG activation of PKC activates the MAPK cascade resulting in increased PLA2 activity
and prostaglandin production, which also contributes to contraction (mechanism not shown). DAG-
activated PKC also signals for phosphorylation of CPI-17 whilst oxytocin binding to OTR also activates
Rho-A which in turn activates ROCK. Both phosphorylated CPI-17 and ROCK inhibit MLCP leading to
increased MLC phosphorylation and is the proposed mechanism of Ca sensitisation in the
myometrium. Oxytocin receptor signalling in other uterine tissues (e.g. decidua and amnion) also
signals for prostaglandin production which may mediate local paracrine signalling with the
myometrium.
OTR: oxytocin receptor, ROC: Receptor operated channel, VOCC: voltage operated Ca channel, LTCC:
L-type Ca channel, TRP: Transient receptor potential channel: PLC-β: phospholipase C-β, PIP2:
phosphatidylinositol 4,5-bisphosphate, IP3: inositol 1,4,5- triphosphate, DAG: diacylglycerol, PKC:

protein kinases type C, CPI-17: C-kinase-activated protein phosphatase-1 (PP1) inhibitor 17kDa, Ca-
Accepted Article CAM: Ca-calmodulin complex, MLCK: myosin light-chain kinase, MLCP: myosin light chain
phosphatase, MAPK: mitogen-activated protein kinase, ERK: extracellular signal-regulated protein
kinase, PLA2: phospholipase A2, ROCK: RhoA-associated protein kinase, SOCE: store-operated Ca
entry.
Red pathways indicate signalling pathways with direct influences on [Ca]i whilst purple and turquoise
lines indicate Ca-independent pathways to contraction including Ca sensitisation (purple lines) and
production of prostaglandins (turquoise pathways). Dotted lines indicate where mechanisms are not
yet fully elucidated.
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Accepted Article

Oxytocin: Its Mechanism of Action and Receptor Signalling in The Myometrium

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Oxytocin: Its Mechanism of Action and Receptor Signalling in The Myometrium

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Received Date : 04-Feb-2014

Accepted Article Revised Date : 14-Mar-2014

Accepted Date : 28-Mar-2014

Article type : Review Article

Oxytocin: its mechanism of action and receptor signalling in the myometrium

Medicine, University of Liverpool, Liverpool, UK

Medicine, University of Liverpool, Liverpool, UK

Corresponding author Dr Sarah Arrowsmith

Department of Cellular and Molecular Physiology

Institute of Translational Medicine

Telephone: +44 (0)151 794 5341

Fax: +44 (0)151 794 5321

number of signalling events to stimulate contraction, primarily by elevating intracellular calcium

(Ca). This includes; inositol-tris-phosphate-mediated store calcium release, store-operated Ca entry

Short running title: Oxytocin receptor signalling in the myometrium

Key words: Oxytocin, vasopressin, myometrium, labour, tocolysis

sequenced and synthesised by du Vigneaud in 1953 (2).

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hypophysial neuropeptide hormone, synthesised by the magnocellular neurons of the supraoptic

the pituitary gland. It is produced as a pre-propeptide which is subjected to a number of

placenta, as well as by the testes.

Oxytocin’s effects on myometrium

hydrolysis of phosphoinositide-bis-phoshate (PIP2) into inositol-tris-phosphate (IP3) and

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complex (8, 9).

number of Ca influx mechanisms could be responsible for this.

oxytocin-stimulated calcium influx is independent of VOCCs, as inhibition of these channels using

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depolarisation and subsequent VOCC opening.

by thapsigargin or by signal-mediated store Ca release, such as following agonist stimulation (17). A

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studies of human myometrium (10). It is difficult however to directly demonstrate SR Ca release in

type Ca channel entry.

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contraction in this Ca-independent manner is known as Ca sensitisation (34). In addition to ROCK,

play a major role in oxytocin’s action.

In addition to oxytocin's direct influences on the force-calcium relationship in the myometrium,

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nuclear localisation signal. In myometrial cells, oxytocin induced a concentration-dependent

Oxytocin and other tissues

modulators of myometrial contraction therefore, it suggests a complimentary role for oxytocin/OTR

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We will discuss each in turn next.

consistent evidence to support a significant increase in maternal oxytocin concentration prior to

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Oxytocin Receptor expression

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be needed to prevent unwanted uterine contractile activity in response to oxytocin production

Regulation of receptor expression

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evidence to support a significant change in circulating oestrogen or progesterone concentration, or

caveolae formation causes profound changes in myometrial contractility, including contractions

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progesterone withdrawal, progesterone-regulation of cholesterol and its relationship to activities of

the OTR in humans warrants further attention.

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expression in these tissues.

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in vivo which may have important clinical consequences (discussed later).

Cross- talk between oxytocin and arginine vasopressin receptors

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change in receptor expression has not been reported by all (119).

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