ID: 42061602
Title: Application of intraluminal indocyanine green in advanced endometriosis surgery.
Abstract: To demonstrate the step-by-step application of intraluminal indocyanine green (ICG) in endometriosis and adenomyosis surgery, including mucosa-sparing shaving of deep bladder and rectal nodules and excision of superficial tubal endometriosis. Description of surgical technique with narrated video footage. First case was a 36-year-old patient with chronic pelvic pain, urinary frequency, and dysuria. Preoperative magnetic resonance imaging revealed a bladder endometriosis nodule measuring 1.7 cm × 1.5 cm. The patient underwent robotic-assisted excision of endometriosis with total hysterectomy. Second case was a 34-year-old patient with chronic pelvic pain and dyschezia. Preoperative magnetic resonance imaging revealed a rectal endometriosis nodule measuring 2.7 cm × 1.8 cm, located 8 cm from the anal verge. The patient underwent robotic-assisted excision of endometriosis with total hysterectomy. Additional applications of intraluminal ICG highlighted in the video include superficial tubal endometriosis and intrauterine ICG use during adenomyosis excision. In the first case, cystoscopy was performed to exclude bladder mucosal involvement. The bladder was backfilled with diluted ICG, and mucosa-sparing shaving of the bladder nodule was performed under fluorescence guidance. In the second case, ICG was administered transrectally, and the rectal nodule was shaved using monopolar energy under fluorescence guidance. In the third case, ICG was used for real-time identification of the tubal lumen during excision of tubal endometriosis. In the fourth case, intrauterine ICG was used to guide the depth of excision during adenomyosis resection. Demonstration of robotic-assisted excision of endometriosis and adenomyosis using intraluminal ICG guidance. All procedures were completed without intraoperative or postoperative complications, and patients were discharged on the same day of surgery. Bladder mucosal integrity was preserved, allowing avoidance of prolonged catheterization. A voiding trial was successfully completed before discharge. At 6-week follow-up, patients reported no complaints. Intravenous ICG is well established for assessing bowel perfusion and anastomotic viability (1). Its use for ureteral perfusion has been described in limited reports, whereas pelvic nerve visualization has only been reported in isolated case reports (2, 3). Intraluminal injection of ICG into the ureters is commonly used to aid ureteral identification (4). In this video, we highlight intraluminal ICG as a valuable adjunct in advanced endometriosis and adenomyosis surgery. When combined with the advantages of robotic surgery, it enables precise mucosa-sparing excision of deep endometriotic lesions and may reduce surgical morbidity.

ID: 42141251
Title: Nuclear factor IX promotes endometriosis progression through transcriptional activation of tetraspanin-2.
Abstract: Endometriosis is a benign yet aggressive disease characterized by enhanced proliferation and invasion of ectopic endometrial tissue. Identifying upstream regulators that co-regulate these processes will provide novel insights into endometriosis pathogenesis and potential therapeutic targets. In this study, by integrating public single-cell RNA-seq data with our own RNA sequencing data, we identified nuclear factor IX (NFIX) as predominantly enriched in endometriotic stromal cells (ESCs), correlating with enhanced proliferative and invasive capacities. However, the underlying molecular mechanisms remain to be elucidated. Using the Venny platform, we intersected NFIX target genes from the KnockTF2.0 database with differentially expressed genes from our RNA sequencing data. Among these overlapping genes, we further identified tetraspanin-2 (TSPAN2) as a target of NFIX and validated that increased TSPAN2 expression mediated the regulatory effects of NFIX on ESCs' proliferation and invasion. Mechanistically, we found that NFIX exerts a significant stimulatory effect on TSPAN2 expression in ESCs. Luciferase reporter assays using serial deletion mutants confirmed that NFIX specifically binds to the -408 ~ -400 bp region of the TSPAN2 promoter, activating its transcription. Additionally, a chromatin immunoprecipitation (ChIP) assay revealed that the binding affinity of NFIX for the -408 ~ -400 bp region of the TSPAN2 promoter was higher in ESCs than in eutopic endometrial stromal cells (EMs). Moreover, NFIX knockdown in endometriosis mice downregulated TSPAN2 expression and inhibited ectopic lesion growth. Overall, this study demonstrated that NFIX promotes proliferation and invasion of ESCs by transcriptionally activating TSPAN2, suggesting NFIX as a potential therapeutic target. KEY MESSAGES: NFIX expression was markedly higher in ESCs than in EMs, correlating with increased proliferation and invasion capabilities. TSPAN2 was identified as a key mediator of NFIX-dependent regulation of proliferation and invasion of ESCs. NFIX transcriptionally activated TSPAN2 by binding to the -408 to -400 bp region of its promoter. In vivo knockdown of NFIX significantly inhibited the growth of endometriotic lesions in mice.

ID: 42172437
Title: Bioactive factors in endometriosis peritoneal fluid remodel human cardiomyocytes.
Abstract: Endometriosis is associated with increased cardiovascular disease (CVD) risk, yet the cellular basis for this relationship remains unclear. We examined whether peritoneal fluid (PF) from women with endometriosis alters cardiomyocyte behavior in vitro. Human-induced pluripotent stem cell-derived cardiomyocytes were exposed for 48 h to standard or hypertrophic media supplemented with peritoneal fluid from endometriosis or control patients. Beating frequency was measured using calcium transient imaging, differential gene expression was assessed with the Human CVD-PCR array, and sarcomere features were quantified using gray-level cooccurrence matrix (GLCM)-based texture analysis. Under standard conditions, PF increased beats per minute compared with media alone (control P = 0.0006; endometriosis P < 0.0001), and beating frequency was higher with endometriosis PF than with control PF (P = 0.0214). Sarcomere length increased, and organization metrics reduced following PF (endo and ctrl) exposure under baseline conditions (P < 0.0001), suggesting remodeling. CVD array showed that >40% of the genes were altered by Endo-PF vs. <10% by control-PF, compared with media-alone treatment. Network analysis showed enrichment of adrenoceptor and G protein-coupled receptor signaling pathways. An increased expression of STAT1 (2.49-fold, P = 0.016) and reduced G0S2 (-5.24-fold, P = 0.037), along with regulation of MYH6 and NPR2, was seen when Endo-PF was compared with Ctrl-PF. In hypertrophic media, PF treatment produced significant differences in sarcomere organization. Outcomes were condition-dependent rather than uniformly significant. Endometriosis-associated PF shifts in cardiomyocyte function, gene expression, and sarcomere structure. This supports a cell-intrinsic link between endometriosis and altered cardiac signaling states and carries implications concerning long-term cardiovascular morbidity and mortality in women with endometriosis.NEW & NOTEWORTHY Endometriosis is linked to cardiovascular disease, but its direct effects on the heart are not well understood, reflecting broader mechanistic gaps in the disease. This study shows that exposure to peritoneal fluid (PF) from women with endometriosis is sufficient to change human cardiomyocyte beating frequency, sarcomere organization, and cardiovascular disease-associated gene expression in vitro. These findings support a cell-intrinsic mechanism through which endometriosis-associated factors may influence cardiac signaling and structure, extending beyond or supporting epidemiologic associations.

ID: 42177906
Title: Lesion-centric reprogramming: hydrogel-enabled photothermal reset of endometriosis pain.
Abstract: Endometriosis-associated pelvic pain represents a prototypical failure of systemic therapy for a locally organized, neuroinflammatory disease. Persistent pain arises from the convergence of estrogen-driven lesion survival, chronic inflammation, fibrosis, and aberrant neuroangiogenesis, leading to sustained peripheral nociceptor sensitization and maladaptive neuroimmune remodeling that is poorly reflected by lesion burden alone. This disconnect underscores a fundamental need for therapies that directly interrogate and remodel the lesion microenvironment rather than suppress endocrine signaling globally. Recent advances in biomaterials engineering and energy-based therapies have enabled a new class of localized interventions based on hydrogel-enabled photothermal ablation. Injectable and in situ-forming hydrogels provide conformal, lesion-confined platforms capable of sustained drug delivery and dynamic responsiveness to external stimuli. When integrated with photothermal agents such as polydopamine or gold nanostructures, these systems convert near-infrared irradiation into spatially restricted thermal energy, permitting on-demand ablation of ectopic endometrial tissue with high precision. Critically, photothermal activation extends beyond cytotoxicity, enabling spatiotemporal modulation of matrix mechanics, enhancement of intralesional drug diffusion, and targeted disruption of inflammatory signaling and lesion-nerve crosstalk that sustain chronic pain states. Preclinical studies demonstrate that hydrogel-based photothermal platforms achieve robust lesion regression, attenuate local inflammatory and neurogenic signaling, and exhibit favorable biosafety profiles, outperforming monotherapies based on pharmacologic suppression or thermal ablation alone. In this Review, we integrate mechanistic insights from endometriosis pain biology with emerging hydrogel and photothermal technologies, critically evaluating material design principles, ablation dynamics, and multifunctional therapeutic architectures. We further address key translational challenges, including tissue penetration, thermal dose control, targeting specificity, and clinical implementation. Collectively, hydrogel-enabled photothermal strategies redefine localized, non-hormonal intervention for endometriosis-associated pelvic pain, establishing a precision framework for remodeling pathological pain microenvironments rather than merely suppressing symptoms.

ID: 42193961
Title: Is Recurrent Endometriosis a Reprogrammed Disease? Molecular Persistence Beyond Surgical Clearance.
Abstract: Background: Endometriosis is traditionally conceptualized as a localized gynecological disorder characterized by the presence of ectopic endometrial tissue. However, high recurrence rates following apparently complete surgical excision challenge this lesion-based paradigm and suggest the existence of underlying biological mechanisms that extend beyond residual disease. Increasing evidence indicates that endometriotic cells exhibit persistent molecular alterations, including dysregulated gene expression, epigenetic modifications, and immune dysfunction, which may contribute to disease maintenance and recurrence. Objective: This study aims to critically examine whether endometriosis can be considered a molecularly reprogrammed disease, characterized by persistent cellular and microenvironmental alterations that are not reversed by surgical removal of visible lesions. Methods: A narrative review of the literature was conducted using PubMed, Scopus, and Web of Science databases including studies published from January 2016 to March 2026. Studies investigating molecular, genetic, epigenetic, and immunological mechanisms of endometriosis persistence and recurrence were included. Particular attention was given to pathways involved in cellular survival, inflammation, hormone resistance, and epigenetic regulation. Results: Endometriotic cells demonstrate stable alterations in gene expression profiles, including pathways related to estrogen signaling, progesterone resistance, inflammation, and cellular proliferation. Epigenetic mechanisms, such as aberrant DNA methylation and histone modifications, appear to sustain these changes over time, contributing to a form of "molecular memory." In parallel, the peritoneal microenvironment is characterized by chronic inflammation, immune tolerance, and impaired clearance of ectopic cells. These factors collectively support lesion persistence and may explain recurrence even after complete surgical excision. Emerging evidence also highlights the role of systemic factors, including endocrine-immune interactions and microbiome-related pathways, reinforcing the concept of endometriosis as a systemic rather than purely localized condition. Conclusions: Endometriosis may be more accurately defined as a persistent, molecularly reprogrammed disease driven by stable alterations in cellular behavior and the surrounding microenvironment. This paradigm shift has important clinical implications, suggesting that surgical treatment alone may be insufficient and that future therapeutic strategies should target the underlying molecular and immunological mechanisms responsible for disease persistence.

ID: 42196513
Title: Deciphering the Diagnostic and Natural Therapeutic Implications of Necrosis by Sodium Overload and NK Signatures in Endometriosis Patients.
Abstract: Endometriosis (EMT) is characterized by a chronic inflammatory disorder in the female reproductive system, posing significant challenges to global women's health. Necrosis by Sodium Overload (NESCO) is a novel immunogenic programmed cell death (PCD) pattern that may potentially inhibit natural killer (NK) cell activation by increasing cytotoxicity and the inflammatory response in the EMT microenvironment. By integrating three bulk datasets to compare endometrium tissues between endometriosis patients and normal controls and the NESCO gene list from a public database, we identified NK- and NESCO (NN)-associated hub genes via integrative bioinformatic analyses utilizing Limma, WGCNA, CIBERSORT and machine learning frameworks. The diagnostic performance of NN-associated hub genes was evaluated across the three aforementioned datasets and two independent validation sets. Furthermore, their molecular and immune features were estimated at the bulk and single-cell transcriptomic levels. In addition, endometriosis patients were classified into two novel molecular subgroups based on consensus clustering of NN. Finally, the Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform (TCMSP) and molecular docking were used to identify compounds in Chinese traditional medicine (CTM) that can target NN-associated hub genes for endometriosis treatment. FABP4 and SLC2A1 can be considered NN-associated hub genes that are involved in EMT pathogenesis, and natural compounds including the CTM GuiZhiFuLingWan (GZFLW) can be considered therapeutic agents for EMT treatment as they target FABP4 and SLC2A1. Our study is the first to reveal the diagnostic and druggable roles of NESCO and NK cells, the corresponding molecular and immune features of NN-associated hub genes, and the therapeutic potential of GZFLW.

ID: 42275943
Title: Machine learning models for non-invasive endometriosis triage using a laparoscopically and histologically verified cohort.
Abstract: To develop and internally validate machine-learning models for non-invasive triage of women at risk for endometriosis using structured clinical variables in a laparoscopically and histologically verified cohort. This retrospective study included 2546 women who underwent laparoscopic surgery between 2008 and 2023 at two tertiary referral centers in São Paulo, Brazil. Endometriosis was confirmed in 1983 patients and absent in 563 controls, corresponding to an enriched tertiary-care case prevalence of 77.9%. Two feature-selection strategies were compared: clinician-guided selection and statistically optimized selection. Preprocessing, feature selection, MinMax scaling, and Synthetic Minority Oversampling Technique (SMOTE) were performed within the training workflow of stratified 10-fold cross-validation to minimize information leakage. Primary performance measures were F1-score, recall, positive predictive value (PPV), negative predictive value (NPV), and AUC-ROC; accuracy was reported only as a secondary metric. Statistically optimized feature selection produced modest but consistent improvements in discrimination and F1-score across most models. XGBoost achieved the highest F1-score in the statistically optimized analysis (0.916, 95% CI 0.909-0.922), with recall of 0.932 (95% CI 0.921-0.943), PPV of 0.900 (95% CI 0.894-0.906), NPV of 0.730 (95% CI 0.700-0.761), and AUC-ROC of 0.895 (95% CI 0.887-0.904). The ensemble model achieved the highest PPV (0.924, 95% CI 0.899-0.947). The most informative variables included infertility, dysmenorrhea, pain level, cyclic intestinal pain, abnormal vaginal examination, number of diseases reported, and menstrual-flow characteristics. Machine-learning models based on structured clinical variables may support non-invasive triage of women at risk for endometriosis. The contribution of the revised framework is the use of a clinically verified cohort, transparent feature selection, and leakage-aware internal validation rather than removal of diagnostically challenging records. Because this retrospective study was internally validated in tertiary referral centers with enriched disease prevalence, external validation, local calibration, and prospective clinical utility assessment are required before implementation.

ID: 42410715
Title: Steroid hormone profiling reveals altered adrenal androgen production in endometriosis.
Abstract: Endometriosis is a chronic, hormone-dependent condition affecting an estimated 190 million women worldwide. Our understanding of hormonal contributions to endometriosis pathophysiology is incomplete, hindering the identification of diagnostic biomarkers and novel therapeutic targets. Although the role of estrogens is well established, research on androgens in endometriosis is limited and the contribution of adrenal-derived 11-oxygenated androgens remains largely unknown. We performed steroid androgen profiling to measure androgen concentrations in serum from healthy controls and women with laparoscopically confirmed endometriosis. We found that women with endometriosis had a distinct hormone signature characterized by systemic differences in adrenal androgen concentrations and 11-ketotestosterone excess.Using metabolomic data, we generated statistical models that showed robust discrimination between healthy controls and women with endometriosis (AUC = 0.99; positive predictive power = 96.84%, negative predictive power = 92.86%) consistent with an endometriosis-specific signature. Data were partitioned into train and validation groups to assess diagnostic potential and a refined model identified >95% of endometriosis patients in a blinded sample set. Collectively, these data reframe endometriosis as an androgen-dependent disorder and highlight 11-oxygenated androgens as potential diagnostic biomarkers and future therapeutic targets.

ID: 42415771
Title: TongueNet-GYN: a multimodal deep learning framework for non-invasive gynecological disease screening in digital public health.
Abstract: Gynecological diseases, such as polycystic ovary syndrome (PCOS) and endometriosis, are prevalent global health concerns. Conventional diagnostics often rely on invasive procedures or costly imaging, limiting accessibility in resource-constrained settings. This study proposes TongueNet-GYN, a novel, non-invasive screening framework that leverages tongue image analysis integrated with modern AI. We compiled a dataset of 3,167 tongue images. To address class imbalance, a hybrid strategy combining Borderline-SMOTE and clinically constrained data augmentation was employed. The framework integrates structured clinical priors with deep semantic features extracted via an enhanced Attention-CLIP model. Additionally, quantified morphological features were incorporated to mirror clinical diagnostic logic. TongueNet-GYN was evaluated using a robust framework comprising 5-fold cross-validation on a discovery set (85%) and subsequent validation on an independent held-out test set (15%). The model achieved a high diagnostic Accuracy of 90.14% and an AUC of 89.74% on the unseen test data. Furthermore, the integration of patient age was identified as a critical factor, yielding measurable improvements in both diagnostic accuracy and framework robustness. These results demonstrate that TongueNet-GYN provides a precise, efficient, and scalable digital health solution, offering potential for improving early screening and health equity in women's chronic disease management.

ID: 42434301
Title: The hypoxia-epigenetics-ncRNA axis in endometriosis: from molecular cascades to self-sustaining pathogenic circuits.
Abstract: Endometriosis is a debilitating chronic inflammatory disorder driven by extensive molecular reprogramming. Despite significant bench research into its pathogenesis, translating these molecular discoveries into clinical practices that improve patient outcomes remains a critical challenge. This comprehensive review bridges the gap between basic life sciences and clinical application by delineating the hypoxia-epigenetics-non-coding RNA (ncRNA) axis as the primary engine of endometriosis pathogenesis. We elucidate how microenvironmental stress, specifically hypoxia via HIF-1α stabilization, initiates a coordinated cascade of aberrant DNA methylation, post-translational histone modifications, and ncRNA dysregulation. We illustrate how these isolated molecular events converge into a highly integrated, self-sustaining pathogenic circuit that drives hallmark clinical phenotypes, including progesterone resistance, chronic inflammation, and tissue invasiveness. To overcome traditional disciplinary silos, we propose a four-stage dynamic progression model that maps the transition from acute epigenetic stress to chronic disease manifestation, offering a robust framework for clinical stratification. Disrupting this specific axis offers new avenues for non-hormonal precision therapeutics and the development of non-invasive diagnostic biomarkers to address significant unmet clinical needs in endometriosis management.