{"paper_id":"09e8f423-4ac7-4147-8911-3354760b47ee","body_text":"1\nTransferrin participates in the pathogenesis of endometriosis by influencing the \nproliferation, migration and apoptosis of endometrial cells \n \nFang Jie1,3, Chaochao Xu1,3, Y unqin Ni2, Na Ding2, Xinyue Zhang2, Haitao Pan2,3* \n1Department of Gynecology, Shaoxing Maternity and Child Health Care Hospital, Shaoxing, Zhejiang , \nChina.  \n2Medical Research and Translation Center (MRTC), Shaoxing Maternity and Child Health Care \nHospital, Shaoxing, Zhejiang, China \n3 Obstetrics and Gynecology Hospital of Shaoxing University, Shaoxing, Zhejiang, China \n \n*Corresponding Author \nHaitao Pan: Shaoxing Maternity and Child Health Care Hospital, No. 222 Fenglin East Road, Shaoxing, \n312000, Zhejiang, China. Email: panhaitao@sxfby.com. \n \nAbstract \nFerroptosis is linked to various diseases, but the role of transferrin (TF) in endometriosis (EM) remains \nunclear. Expression levels of ferroptosis-related proteins, including transferrin (TF), transferrin receptor \n(TFRC), and glutathione peroxidase 4 (GPX4), were analyzed by western blotting. Compared to \nnormal endometrial stromal cells, eutopic and ectopic endometrial stromal cells from EM patients \nexhibited significantly enhanced proliferative and migratory abilities, accompanied by a marked \nreduction in glutathione (GSH) levels in both eutopic and ectopic tissues. TF and TFRC expression was \nupregulated in ectopic endometrium relative to normal controls, while GPX4 expression was \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 2\ndownregulated. To evaluate the functional role of TF, siRNA-mediated knockdown was performed in \nendometrial stromal cells, with knockdown efficiency confirmed by western blotting. Functional assays \ndemonstrated that TF knockdown not only suppressed cell proliferation (CCK-8 and clonogenic assays) \nand migration (wound healing assay) but also significantly increased apoptosis rate (flow cytometry \nwith Annexin V-FITC/PI staining).These findings implicate TF in the pathogenesis and progression of \nendometriosis, likely through modulating endometrial stromal cell proliferation, migration, and \napoptosis. \nKeywords: Endometriosis; Transferrin; Proliferation; Migration; apoptosis. \n \nIntroduction \nEndometriosis (EM) is a condition in which functional endometrial tissue grows and undergoes cyclic \nbleeding outside the uterine cavity, leading to the formation of nodules, masses, and other types \nof lesions. It primarily presents as progressively worsening pelvic adhesions, pain, infertility, and other \nsymptoms, making it a common yet challenging gynecological disorder, with an incidence as high \nas 10% among women of reproductive age[1]. Although histologically benign, EM lesions are widely \ndistributed and morphologically diverse, displaying malignant tumor-like characteristics such \nas implantation, invasion, recurrence, and metastasis[2], all of which severely affect patients’ health \nand quality of life. At present, the pathogenesis of EM remains incompletely understood. Studies \nsuggest that abnormal regulation of cellular functions and modes of cell death may be involved in \nits development and progression. \nHemorrhage in ectopic endometriotic lesions and hemolysis resulting from retrograde menstruation can \nlead to the release and accumulation of substantial quantities of free iron. Subsequently, intracellular \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 3\nfree iron can catalyze the generation of lipid reactive oxygen species (ROS) via the Fenton reaction \ncascade, resulting in cellular injury. This process is widely recognized as ferroptosis, a novel form of \nregulated cell death distinct from accidental cell death.  Despite many unresolved questions in \nferroptosis research, several studies have demonstrated its crucial role in the pathogenesis of various \ndiseases, including endometriosis (EM) [3-6]. Previous investigations have elucidated the complex role \nof ferroptosis in EM, underscoring its significance in disease development and progression [7-8].On \none hand, endometriotic lesions exhibit resistance to ferroptosis, hindering the clearance of ectopic \nendometrium and facilitating its proliferation and migration [8-9]. On the other hand, ferroptotic cell \ndeath can also trigger the release of inflammatory cytokines and activate downstream regulatory \npathways, which in turn promote proliferation and angiogenesis in adjacent tissues [10]. The key \nmechanisms underlying ferroptosis are closely associated with disturbances in iron metabolism, lipid \nmetabolism, and glutathione metabolism [11–13]. \nTransferrin (Tf), which naturally binds Fe³\n/i1 , serves as the primary iron carrier in the blood and plays a \ncrucial role in iron metabolism and ferroptosis [14]. It is widely distributed across various tissues and \norgans, where it is closely associated with cell growth and differentiation, and implicated in the \npathogenesis of numerous diseases. Previous studies have indicated that abnormal Tf expression is \nclosely linked to the development of several malignancies, including ovarian, breast, liver, and prostate \ncancers [15–18]. However, the role of Tf in the pathogenesis of endometriosis remains unclear. This \nstudy aims to examine the expression of Tf in endometriosis and to explore the impact of its abnormal \nexpression on the biological behavior of endometrial stromal cells. \nMaterials and Methods \nPatients and samples \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 4\nForty-three participants were enrolled in Shaoxing Maternity and Child Health Care Hospital from \nJanuary 2022 to September 2024. Control eutopic endometrium (Ctrl) represented samples from \nnon-endometriosis patients. Eutopic endometrium (EuE), and ectopic ovarian lesions (EcO) were \ncollected from revised ASRM Stage II-IV endometriosis patients. All the patients selected for the study \nhad no history of immune disorders, acute inflammatory states, or estrogen-dependent diseases, and \nhad abstained from any hormonal medications for three months prior to enrollment. \nPrimary cells isolation and culture  \nPrimary endometrial stromal cells were isolated and cultured as previously described [19]. In brief, \ntissue specimens were washed with phosphate-buffered saline (PBS), minced into small fragments, and \ndigested with 1 mg/mL collagenase type IV (Sangon Biotech, China) for 20–40 minutes at 37°C on a \nshaker. The resulting homogenate was filtered through a 40-\nμ m cell strainer (Beyotime Biotechnology, \nChina), and the filtrate was centrifuged for 10 minutes to pellet the cells. The harvested primary cells \nwere resuspended in complete DMEM/F12 medium (Grand Island Biological Company, USA) \nsupplemented with 10% fetal bovine serum (Sangon Biotech, China) and maintained at 37°C in a \nhumidified incubator with 5% CO\n/i1 . Cells at passage 3 were used for subsequent experiments. \nWestern blotting  \nTotal protein from tissues and cells was extracted using RIPA lysis buffer supplemented with \nphosphatase inhibitors. Cytoplasmic and nuclear proteins were fractionated using a commercial \nextraction kit (Beyotime Biotechnology, China) according to the manufacturer's instructions. Protein \nconcentrations were determined by the BCA method. Equal amounts of protein samples were separated \nby SDS-polyacrylamide gel electrophoresis and subsequently transferred to PVDF membranes \n(Beyotime Biotechnology, China). After blocking with non-fat milk, the membranes were incubated \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 5\nwith primary antibodies against the target proteins overnight at 4°C on a shaker, followed by incubation \nwith an HRP-conjugated secondary antibody. Protein bands were finally visualized using an \nelectrochemiluminescence (ECL) detection system. \nGlutathione (GSH) Assay \nTissue homogenates were prepared by adding protein remover at a ratio of 1:9 (weight g: volume mL) \nas per the instructions of the GSH assay kit (Beyotime Biotechnology, China). After centrifugation at \n10,000 rpm for 15 min, the supernatants were collected for subsequent assays. For the analysis of \ncultured cells, approximately 1×10/i1  cells were resuspended and subjected to lysis on ice for 10 min \nusing 100 μ L of protein scavenger, followed by centrifugation under identical parameters. The \ncollected supernatant was incubated with the glutathione detection working solution for 5 min. \nSubsequently, 20 \nμ L of substrate was added and the mixture was vortexed thoroughly. Following a \n20-min incubation period, the absorbance at 412 nm was recorded. \nCell transfection  \nTo knockdown TF, endometrial stromal cells were infected with a specific lentivirus (RiboBio, China), \nfollowing the supplier's instructions. Cells were also transfected with the CON520-AURKA plasmid \n(RiboBio, China) and cultured in serum-containing complete medium at 37°C. After collection and \nthree PBS washes, total RNA was extracted using the TIANGEN DP431 kit. Knockdown efficiency \nwas confirmed by measuring TF mRNA levels using the one-step qRT-PCR method (TIANGEN FP303 \nkit). Finally, real-time cellular analysis (RTCA) was employed to assess the functional impact of TF \nknockdown on cell proliferation and migration. \nCell proliferation assay   \nCell proliferation was determined by the CCK-8 assay. Briefly, 96-well plates were seeded with 3,000 \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 6\ncells per well in 100 μ L of suspension. After the designated treatments, the cultures were supplemented \nwith 10 μ L of CCK-8 reagent (Zeta Life Sciences Inc, UK) at 0, 24, 48, and 72 h. After 4 hours of \nincubation at 37°C in a 5% CO /i1  atmosphere, the absorbance at 450 nm was measured with a \nmicroplate reader. \nWound healing assay  \nA standard wound healing assay was performed. Briefly, cells were cultured in 6-well plates until \n80–90% confluent. A linear wound was then introduced across the cell monolayer using a 200 μ L \npipette tip. After removing cell debris with PBS washes, the culture medium was replaced with \nserum-free medium. To assess cell migration, the wound areas were photographed at 0, 24, and 48 \nhours, and the degree of wound closure was quantified by measuring the residual area at these time \npoints. \nFlow cytometric analysis  \nFor apoptosis analysis, endometrial stromal cells (ESCs) were stained with an Annexin V-FITC/PI kit \n(Yeasen, China) in accordance with the manufacturer's protocol. The stained cells were then subjected \nto flow cytometric analysis on an LSR II instrument to determine the proportion of early (Annexin \nV\n/i1 /PI/i1 ) and late (Annexin V /i1 /PI/i1 ) apoptotic cells. Data were processed using FlowJo software \n(version 10; FlowJo, LLC). \nStatistical analysis  \nStatistical analyses were conducted with GraphPad Prism, version 6.02. Quantitative data from three \nindependent replicates are expressed as mean ± SD. Differences between groups were assessed by \nStudent's t-test or one-way ANOV A with appropriate post-hoc tests, and statistical significance was \nassigned to results with P < 0.05. \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 7\n \nResults \nCell Proliferative and Migratory Capacities of EM are enhanced \nWe performed primary cell culture of endometrium cells in the EuE group, the EcO group and the Ctrl \ngroup. CCK-8 results showed that the proliferative capacity enhanced in the EuE group and the EcO \ngroup compared to the Ctrl group (Figure1.a). Migration is a fundamental property of cells that occurs \nduring many physiological and pathological processes including repair of damaged tissue after injury \nand the spread of cancer [20]. We found that the time required for wound closure of endometrium cells \nin the EcO group was significantly shorter than the time required for the Ctrl group (Figure1.b). The \npresent results obviously demonstrated that the proliferative and Migratory capacities of endometrium \ncells are closely related to the occurrence of EM. \n----------- -------------------------- \nInsert Figure 1. Endometriotic cells exhibit enhanced proliferative and migratory capacities. \n(a) Cell proliferation was assessed by CCK-8 assay. The eutopic (EuE) and ectopic (EcO) endometrial \nstromal cells from EM patients showed significantly enhanced proliferation compared to control (Ctrl) \nendometrial stromal cells after 72 hours of culture. \n(b) Cell migration was evaluated by wound healing assay. Confluent monolayers of human endometrial \nstromal cells were wounded with a 200-μ L pipette tip and photographed at the indicated time points (0, \n6, 24, and 48 hours). The EcO group demonstrated a significantly faster wound closure rate compared \nto the Ctrl group. \n------------------------------------ --  \nGSH content is inhibited in EM \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 8\nGSH is a linear tripeptide of l-glutamine, l-cysteine, and glycine, and is one of the most abundant and \nsignificant scavengers of ROS in eukaryotic cells [21]. A feature of ferroptosis is the reduction of \nantioxidant activity (e.g., intracellular GSH depletion ) [22]. As shown in figure 2, the GSH level in the \nEuE group was much lower, by 97.18% (p<0.001), than that of the Ctrl group. And the GSH level in \nthe EcO group was lower, by 71.13%(p<0.001), than that of the Ctrl group. The present results \ndemonstrated that, GSH is inhibited in EM. \n----------- -------------------------- \nInsert Figure 2. Glutathione (GSH) levels are significantly reduced in endometriosis (EM). \nThe GSH content was substantially decreased in both eutopic (EuE) and ectopic (EcO) endometrial \ntissues from EM patients compared to the control (Ctrl) group. \nData are expressed as the mean ± SEM. *p < 0.05, **p < 0.01, ***p < 0.001; ns, not significant. \n------------------------------------ --  \nFerroptosis  is Increased  in EM \nIt is well known that GPX4 is the critical repressor of ferroptosis [23]. And TF/TFRC is an iron carrier \nprotein that induces ferroptosis [24]. Western blot were used to detect the expression of TF, TFRC,and \nGPX4 in the three gtoups from protein levels. As shown in figure 3, TF was significantly upregulated \nin the EcO group compared to the Ctrl group (p<0.05).  TFRC was significantly upregulated in the \nEuE group compared to the Ctrl group (p<0.05). GPX4 protein expression is downregulated in the EcO \ngroup compared to the Ctrl group (p<0.05). To further validate the role of TF in EM, we sought to \ndown-regulate the mRNA expression of TF in endometrium cells using siRNA techniques for the \nsubsequent experiments. \n----------- -------------------------- \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 9\nInsert Figure 3. Expression of ferroptosis-related proteins in endometriotic lesions. \n(a, c, e) Representative western blot images of TF, TFRC, GPX4 and β -actin (loading control) in \ncontrol (Ctrl), eutopic (EuE), and ectopic (EcO) endometrial tissues. \n(b, d, f) Quantitative analysis of (b) TF, (d) TFRC, and (f) GPX4 protein levels normalized to β -actin. \nQuantitative data show that TF expression was significantly higher in the EcO group compared to the \nCtrl group, while TFRC was significantly upregulated in the EuE group. GPX4 protein expression was \ndownregulated in the EcO group. \nData are expressed as the mean ± SEM. *p < 0.05, **p < 0.01, ***p < 0.001; ns, not significant. \n------------------------------------ --  \nKnockdown of TF inhibits cell proliferation, migration and apoptosis of endometrium cells after \ntransfection \nTo investigate the role of TF in endometrium cells, the TF-specific si-TF was designed and transfected \ninto endometrium cells to further determine its effect on the cell growth of endometrium cell in vitro. \nCCK-8 assay results revealed that the TF knockdown obviously suppressed the proliferation rate of \nendometrium cells (Figure 4.a). Wound healing assay was used to assess the migration ability of the \ncells, and the results revealed that, compared with the control conditions, knockdown of TF \nsignificantly decreased the wound healing rate and number of migrated cells (Figure 4.b). Flow \ncytometry was carried out for cell apoptosis examination, the results revealed that, knockdown of TF \nsignificantly  increased apoptosis rate in endometrium cells (Figure 4.c).  \n \n----------- -------------------------- \nInsert Figure 4. Knockdown of TF inhibits endometrial stromal cells proliferation and migration, \nincreases apoptosis in vitro.   \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 1 0\n(a)  The proliferative capacity of endometrial stromal cells was assessed by CCK-8 assay following TF \nknockdown. Knockdown of TF significantly suppressed cell proliferation compared to the control \ngroups. \n(b) Cell migration was evaluated by wound healing assay. Confluent monolayers of the indicated \nendometrial stromal cells groups were scratched and monitored over 96 hours. TF knockdown \nmarkedly delayed wound closure and reduced the number of migrated cells relative to controls. \n(c,d) Apoptosis was assessed by flow cytometry. TF knockdown significantly increased the apoptosis \nrate of endometrial stromal cells compared to control groups. \nData are expressed as the mean ± SEM. *p < 0.05, **p < 0.01, ***p < 0.001; ns, not significant. \n------------------------------------ --  \nDiscussion \nThe precise pathogenesis of endometriosis, though not yet fully elucidated, is recognized to involve \naberrant sex-steroid signaling and inflammatory processes. The retrograde flux of endometrial tissue \ninto the pelvic cavity during menstruation represents a well-established mechanism for the initiation of \npelvic lesions, while lymphatic or vascular metastasis has been suggested as a potential pathway for the \ndevelopment of extrapelvic lesions [24-26]. Previous research by Chinese scholar Jinghe Lang and \ncolleagues further identified fundamental abnormalities in the eutopic endometrium of women with \nendometriosis, which exhibits enhanced capacities for proliferation, implantation, and angiogenesis, \nalong with a heightened ability to survive in ectopic microenvironments [27]. In line with these \nobservations, our study demonstrated that eutopic endometrial stromal cells from EM patients display \nsignificantly increased proliferative and migratory activities compared to normal endometrial stromal \ncells from non-EM individuals, with these aberrant behavioral characteristics being even more \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 1 1\npronounced in ectopic lesions. These findings collectively indicate that functional alterations in \nendometrial stromal cells are closely associated with the pathogenesis of endometriosis. \nHemorrhage in ectopic endometriotic lesions and hemolysis resulting from retrograde menstruation \nlead to the release and accumulation of substantial amounts of insoluble Fe³/i1 . Subsequent biochemical \nreactions, notably the Fenton reaction, drive the generation of reactive oxygen species (ROS), which \ninduce lipid peroxidation. Consistent with this mechanism, studies have reported that patients with \nendometriosis exhibit decreased antioxidant system activity alongside significantly elevated levels of \nROS and lipid peroxidation markers in both serum and peritoneal fluid compared to healthy \nwomen [28]. The persistent production and accumulation of ROS inflict considerable damage on \ncellular structures and functions, promoting somatic mutations, tumorigenic transformation, and \nproliferative responses. Moreover, ROS are intimately involved in metabolic and proliferative signaling, \nwith dysregulated ROS pathways being implicated in cancer progression and chronic inflammatory \ndiseases [29–31]. To maintain redox homeostasis and mitigate oxidative damage, the body employs a \nsophisticated antioxidant system. Among its components, glutathione (GSH) serves a critical role in \nantioxidative defense, protecting cells from oxidative stress in the context of endometriosis [32]. This \nsystem is critically coordinated by glutathione peroxidase 4 (GPX4) [23], which utilizes GSH to \nspecifically reduce lipid hydroperoxides, thereby preventing the iron-dependent peroxidative chain \nreactions that drive ferroptosis. In our study, we observed a significant reduction in GSH content in \nboth eutopic and ectopic endometrial tissues from EM patients relative to normal endometrium. \nConsistently, GPX4 protein expression was also significantly downregulated in ectopic lesions. The \nconcurrent reduction in both GSH and GPX4 suggests a weakened anti-ferroptotic capacity, potentially \nincreasing the susceptibility of endometriotic cells to iron-dependent oxidative damage and ferroptosis. \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 1 2\nThe primary mechanism for cellular iron uptake is mediated by transferrin (TF), a liver-synthesized \nglycoprotein that functions as a natural chelator with two high-affinity binding sites for ferric iron \n(Fe³/i1 ) [33–34]. In the context of endometriosis, the release and accumulation of substantial Fe³/i1  from \nectopic lesions allow TF to bind these ions. The resulting transferrin-bound iron is internalized via \nbinding to transferrin receptor (TFRC) and clathrin-mediated endocytosis. During this process, Fe³/i1  is \nreleased, reduced to Fe² /i1 , and transported into the cytoplasm through divalent metal transporter 1 \n(DMT1), contributing to the intracellular labile iron pool [35–36]. Subsequently, cytosolic Fe² /i1  \ncatalyzes the Fenton reaction, thereby driving lipid peroxidation of cellular membranes and generating \nlipid-derived ROS. This oxidative stress is implicated in diverse pathological processes, including \nchronic inflammation and cancer [37–38]; furthermore, ROS play an established role in promoting \ntumor angiogenesis, migration, invasion, and metastasis [39–41].In this study, our observation of \nelevated TF and TFRC expression in ectopic endometrium from EM patients, relative to normal \nendometrium, suggests a model in which increased TF-mediated iron import enhances intracellular \nlabile iron availability, thereby stimulating ROS production and influencing cellular behavior. To \nfurther investigate the functional role of TF, we performed TF knockdown and observed a \ncorresponding decrease in proliferative and migratory capacities, along with a significant increase in \nthe apoptosis rate. These results imply that aberrant TF expression may contribute to the pathogenesis \nand progression of endometriosis by modulating key cellular behaviors such as proliferation, migration \nand apoptosis. \n \nConclusion \nIn summary, this study demonstrates that TF is dysregulated and highly expressed in endometriosis. \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 1 3\nKnockdown of TF inhibits disease progression, likely by modulating ferroptosis and apoptosis \npathways, which provides new evidence for TF as a potential therapeutic target. However, further \nvalidation in animal models and clinical studies is required. \nEthics approval and consent to participate \nThis study was approved by the Medical Ethics Committee of Shaoxing Maternity and Child Health \nCare Hospital (Approval No. 2022-001). \nConsent for publication \nWritten informed consent was obtained from all individual participants involved in the study. \nParticipants consented to the publication of anonymized data derived from their samples and clinical \ninformation. This study was conducted in accordance with the ethical standards of the institutional \nresearch committee . \nAvailability of data and materials \nThe datasets generated and/or analysed during the current study are not publicly available due to the \nsensitive nature of the clinical data involved and to protect the privacy of the participants, but are \navailable from the corresponding author (Haitao Pan) on reasonable request. \nCompeting interests \nThe authors declare that they have no competing interests. \nFunding \nThis study was funded by Foundation of Zhejiang Province medical health (2022KY1306） . \nAuthors' contributions \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 1 4\nFJ designed the study, mainly completed the experiment, and wrote the manuscript under the direction \nof HTP. CCX participated in study design and advised the paper. YQN, ND and XYZ performed the \nexperiments and analyzed data. HTP contributed to experimental design, interpretation of results, and \narticle revision. \nAcknowledgments \nWe sincerely thank all the personnel involved in this study for their valuable contributions. \n \nReferences \n \n1.  As- Sanie ,  S., e t  a l.,  End ome trios is : A  R ev i ew .  J AM A, 20 2 5.  334 ( 1): p.  64-7 8.D OI : \n10 .1 00 1 /ja m a . 20 2 5 . 2975 .  \n2.  As g ha ri,  S., e t  a l. , End o metri osi s:  P e rs p e ct ive ,  light s,  and s had o w s of  e tiolo gy .  B i o m e d  \nPh a rmac o th e r , 201 8 .  106:  p.  1 63- 1 7 4. 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D OI :  10 .1 03 8 /s41 4 22 - 020 -0 044 1 -1 . \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n 1 5\n14 .  G a o ,  M . ,  e t  a l . ,  G lut aminol ys i s  a nd T r a nsf err i n R egulat e Ferr o p t o s i s .  M o l  C e l l ,  2 0 1 5 .  59(2 ) :  p .  \n2 98-3 0 8 . DOI:  1 0. 1 01 6 / j.m olcel . 2 0 15. 06. 011.  \n15 .  De s hp a nd e , P ., et  al., T r ansf e r rin a n d  oct aa r ginine  mo di fi e d  dua l-f u n c ti o n al  li po s om es  w it h \nimpro v ed  ca ncer  c ell t arg et i n g  and  e nhanc e d  in tr ac el lula r  d eliv er y f or  t he  trea t men t  of  o vari an \ncanc er .  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R. , e t  al ., Ferr op t os is :  A R egul at e d Cell De ath  N e x us Lin k i ng M e t a bo l is m,  R e d o x  \nB io l og y , an d  Di s eas e .  Ce l l,  2 0 1 7. 171 (2 ):  p .  273 -28 5 .D O I:  1 0 .1 016 / j. c e l l . 2017 .09 .021 . \n23 .  Ch e n , X., et al ., C ellul ar d e gr ad atio n s ys t e m s  in f e rr opt osi s. C el l D e a t h Dif f e r , 20 2 1 . 28 (4 ) :  p .  \n1 135- 1 14 8 DO I: 1 0 .1 0 38 / s 41 41 8-0 2 0- 00 7 28- 1.  \n24 .  H o r n e ,  A . W .  a n d  S . A .  M i s s m e r ,  P at hoph ys iol ogy ,  di ag n os is, and  m anag emen t  o f e n dom etri o s i s .  \nBMJ ,  20 22. 379 : p .  e 0 7 0 750 .D O I : 1 0 .11 36 /b m j-2 022 -0 7 0 7 50 .  \n25 .  Sau nder s, P . T . K. a n d A. W . H orn e,  E n d o metri os is: Et iolog y , p at hobiolo gy ,  an d  t he r ape ut i c  pr ospec ts.  \nCel l,  2 0 2 1 . 184 ( 1 1 ):  p.  28 0 7- 2 82 4.D OI: 1 0. 10 16 / j.cell.2 0 21. 0 4 . 0 41 .  \n26 .  Z on derv a n , K. T . , C.M . 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DOI:  10. 11 7 2 /jci.i n s i gh t. 13 91 63.  \n \n \n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. 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It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint \n\n.CC-BY-NC-ND 4.0 International licenseavailable under a \n(which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made \nThe copyright holder for this preprintthis version posted March 16, 2026. ; https://doi.org/10.64898/2026.03.13.711522doi: bioRxiv preprint","source_license":"CC0","license_restricted":false}