Metformin sensitizes endometriosis to medroxyprogesterone acetate treatment through MIG-6 mediated signaling

This study evaluates the synergistic therapeutic effect of metformin (MET) combined with medroxyprogesterone acetate (MPA) on endometriosis (EM) and investigates the involvement of the steroid receptor coactivator-1 (SRC-1) and mitogen-inducible gene 6 (MIG-6). Immunohistochemical analysis revealed significantly decreased SRC-1, progesterone receptor (PGR), and MIG-6 protein expression in human ectopic EM lesions compared to normal eutopic endometrium. In an EM mouse model, the combination of metformin (MET) and MPA resulted in the greatest reduction of ectopic lesion size and weight compared to either treatment alone. This combination therapy also uniquely increased serum Eotaxin and decreased interleukin-12p40 levels. Transcriptome analysis demonstrated specific enrichment of immune activation pathways only in the combination treatment group. In vitro, using the human endometriosis epithelial cell line 12Z, the MET and MPA combination significantly suppressed cell proliferation and migration, concomitant with an upregulation of SRC-1, PGR, and MIG-6 messenger RNA expression. We conclude that MET enhances the therapeutic efficacy of MPA against EM. This effect may be mediated through MIG-6 signaling and involves the upregulation of SRC-1, inhibiting ectopic cell proliferation and migration, and inhibiting endometriotic lesion progression, representing a novel strategy to overcome progesterone resistance. Key messages - SRC-1, MIG-6, and PGR are downregulated in human endometriotic lesions. - MET and MPA act cooperatively to suppress lesion growth in a murine model. - Combination therapy increases Eotaxin levels while decreasing IL-12p40 in mice. - MET and MPA activate immune surveillance pathways within lesions. - MET and MPA synergistically inhibit endometriotic cell growth and migration. Similar content being viewed by others Data availability The raw sequence data reported in this paper have been deposited in the Genome Sequence Archive (Genomics, Proteomics & Bioinformatics 2025) in National Genomics Data Center (Nucleic Acids Res 2025), China National Center for Bioinformation/Beijing Institute of Genomics, Chinese Academy of Sciences (GSA: CRA034922) that are publicly accessible at https://ngdc.cncb.ac.cn/gsa.

As-Sanie S, Mackenzie SC, Morrison L, Schrepf A, Zondervan KT, Horne AW, Missmer SA (2025) Endometriosis: a review. JAMA 334:64–78 Zondervan KT, Becker CM, Missmer SA (2020) Endometriosis. N Engl J Med 382:1244–1256 Vercellini P, Buggio L, Berlanda N, Barbara G, Somigliana E, Bosari S (2016) Estrogen-progestins and progestins for the management of endometriosis. Fertil Steril 106:1552-1571 e1552. https://doi.org/10.1016/j.fertnstert.2016.10.022 Teasley HE, Jeong MP, Kim TH (2019) A calcium-dependent phospholipase A2 (cPLA2) expression is regulated by MIG-6 during endometrial tumorigenesis. Biochem Biophys Res Commun 511:129–134 Kim TH, Lee DK, Cho SN, Orvis GD, Behringer RR, Lydon JP, Ku BJ, McCampbell AS, Broaddus RR, Jeong JW (2013) Critical tumor suppressor function mediated by epithelial Mig-6 in endometrial cancer. Cancer Res 73:5090–5099 Yoo JY, Kim TH, Shin JH, Marquardt RM, Muller U, Fazleabas AT, Young SL, Lessey BA, Yoon HG, Jeong JW (2022) Loss of MIG-6 results in endometrial progesterone resistance via ERBB2. Nat Commun 13:1101. https://doi.org/10.1038/s41467-022-28608-x Jeong JW, Lee HS, Lee KY, White LD, Broaddus RR, Zhang YW, Vande Woude GF, Giudice LC, Young SL, Lessey BA, Tsai SY, Lydon JP, DeMayo FJ (2009) Mig-6 modulates uterine steroid hormone responsiveness and exhibits altered expression in endometrial disease. Proc Natl Acad Sci U S A 106:8677–8682 Kumagami A, Ito A, Yoshida-Komiya H, Fujimori K, Sato A (2011) Expression patterns of the steroid receptor coactivator family in human ovarian endometriosis. J Obstet Gynaecol Res 37:1269–1276 Szwarc MM, Lydon JP, O’Malley BW (2015) Reprint of “Steroid receptor coactivators as therapeutic targets in the female reproductive system.” J Steroid Biochem Mol Biol 153:144–150. https://doi.org/10.1016/j.jsbmb.2015.08.012 Glintborg D, Altinok ML, Mumm H, Hermann AP, Ravn P, Andersen M (2014) Body composition is improved during 12 months’ treatment with metformin alone or combined with oral contraceptives compared with treatment with oral contraceptives in polycystic ovary syndrome. J Clin Endocrinol Metab 99:2584–2591. https://doi.org/10.1210/jc.2014-1135 Mitsuhashi A, Sato Y, Kiyokawa T, Koshizaka M, Hanaoka H, Shozu M (2016) Phase II study of medroxyprogesterone acetate plus metformin as a fertility-sparing treatment for atypical endometrial hyperplasia and endometrial cancer. Ann Oncol 27:262–266 Xu JN, Zeng C, Zhou Y, Peng C, Zhou YF, Xue Q (2014) Metformin inhibits StAR expression in human endometriotic stromal cells via AMPK-mediated disruption of CREB-CRTC2 complex formation. J Clin Endocrinol Metab 99:2795–2803 Yari S, Khoei HH, Saber M, Esfandiari F, Moini A, Shahhoseini M (2021) Metformin attenuates expression of angiogenic and inflammatory genes in human endometriotic stromal cells. Exp Cell Res 404:112659 Neto AC, Botelho M, Rodrigues AR, Lamas S, Araujo B, Guimaraes JT, Gouveia AM, Almeida H, Neves D (2025) Metformin reverses infertility in a mouse model of endometriosis: unveiling disease pathways and implications for future clinical approaches. Reprod Biomed Online 50:104474. https://doi.org/10.1016/j.rbmo.2024.104474 Xue J, Zhang H, Liu W, Liu M, Shi M, Wen Z, Li C (2013) Metformin inhibits growth of eutopic stromal cells from adenomyotic endometrium via AMPK activation and subsequent inhibition of AKT phosphorylation: a possible role in the treatment of adenomyosis. Reproduction 146:397–406 Zhang H, Xue J, Li M, Zhao X, Wei D, Li C (2015) Metformin regulates stromal-epithelial cells communication via Wnt2/β-catenin signaling in endometriosis. Mol Cell Endocrinol 413:61–65 Varghese F, Bukhari AB, Malhotra R, De A (2014) IHC profiler: an open source plugin for the quantitative evaluation and automated scoring of immunohistochemistry images of human tissue samples. PLoS One 9:e96801 Jeljeli M, Riccio LGC, Chouzenoux S, Moresi F, Toullec L, Doridot L, Nicco C, Bourdon M, Marcellin L, Santulli P, Abrao MS, Chapron C, Batteux F (2020) Macrophage immune memory controls endometriosis in mice and humans. Cell Rep 33:108325 Shree N, Bhonde RR (2016) Metformin preconditioned adipose derived mesenchymal stem cells is a better option for the reversal of diabetes upon transplantation. Biomed Pharmacother 84:1662–1667 Jeffrey M, Lang M, Gane J, Chow E, Wu C, Zhang L (2014) Novel anticonvulsive effects of progesterone in a mouse model of hippocampal electrical kindling. Neuroscience 257:65–75 Ando H, Miyamoto T, Kashima H, Higuchi S, Ida K, Mvunta DH, Shiozawa T (2017) Panobinostat enhances growth suppressive effects of progestin on endometrial carcinoma by increasing progesterone receptor and mitogen-inducible gene-6. Horm Cancer 8:257–267 Yao L, Wang L, Zhang R, Soukas AA, Wu L (2025) The direct targets of metformin in diabetes and beyond. Trends Endocrinol Metab 36:364–372 LaMoia TE, Shulman GI (2021) Cellular and molecular mechanisms of metformin action. Endocr Rev 42:77–96 Gribble FM, Reimann F (2021) Metabolic messengers: glucagon-like peptide 1. Nat Metab 3:142–148 Bahar ME, Kim HJ, Kim DR (2023) Targeting the RAS/RAF/MAPK pathway for cancer therapy: from mechanism to clinical studies. Signal Transduct Target Ther 8:455. https://doi.org/10.1038/s41392-023-01705-z Liu J, Li X, Li Y, Gong Q, Luo K (2025) Metformin-based nanomedicines for reprogramming tumor immune microenvironment. Theranostics 15:993–1016 Xie Y, Wang YL, Yu L, Hu Q, Ji L, Zhang Y, Liao QP (2011) Metformin promotes progesterone receptor expression via inhibition of mammalian target of rapamycin (mTOR) in endometrial cancer cells. J Steroid Biochem Mol Biol 126:113–120 Dai Y, Ye Z, Lin X, Zhang S (2025) Immunopathological insights into endometriosis: from research advances to future treatments. Semin Immunopathol 47:31. https://doi.org/10.1007/s00281-025-01058-5 Jeung I, Cheon K, Kim MR (2016) Decreased cytotoxicity of peripheral and peritoneal natural killer cell in endometriosis. Biomed Res Int 2016:2916070 Măluțan AM, Drugan T, Ciortea R, Bucuri C, Rada MP, Mihu D (2017) Endometriosis-associated changes in serum levels of interferons and chemokines. Turk J Med Sci 47:115–122 Bailey AP, Hill AS, Beste MT, Cook CD, Sarda V, Laufer MR, Isaacson KB, Griffith LG, Missmer SA (2021) Comparison of cytokines in the peritoneal fluid and conditioned medium of adolescents and adults with and without endometriosis. Am J Reprod Immunol 85:e13347 Zhao W, Kang S, Zhao J, Wang L, Cao S, Li Y (2019) Aberrant methylation of the IL-12B promotor region contributes to the risk of developing ovarian endometriosis. Mol Reprod Dev 86:632–638 Chauhan S, More A, Chauhan V, Kathane A (2022) Endometriosis: a review of clinical diagnosis, treatment, and pathogenesis. Cureus 14:e28864 Berlanda N, Somigliana E, Vigano P, Vercellini P (2016) Safety of medical treatments for endometriosis. Expert Opin Drug Saf 15:21–30 de Souza Gaio G, Kemczenski F, Fernandes Oliveira Amador W, Farias CF, Chagas J (2025) Clinical effectiveness of progestogens compared to combined oral contraceptive pills in the treatment of endometriosis: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 306:219–225. https://doi.org/10.1016/j.ejogrb.2025.01.033 Marquardt RM, Kim TH, Shin JH, Jeong JW (2019) Progesterone and estrogen signaling in the endometrium: what goes wrong in endometriosis? Int J Mol Sci. https://doi.org/10.3390/ijms20153822 Yilmaz BD, Bulun SE (2019) Endometriosis and nuclear receptors. Hum Reprod Update 25:473–485 Flores VA, Vanhie A, Dang T, Taylor HS (2018) Progesterone receptor status predicts response to progestin therapy in endometriosis. J Clin Endocrinol Metab 103:4561–4568 Bulun SE, Yilmaz BD, Sison C, Miyazaki K, Bernardi L, Liu S, Kohlmeier A, Yin P, Milad M, Wei J (2019) Endometriosis. Endocr Rev 40:1048–1079 Koubovec D, Ronacher K, Stubsrud E, Louw A, Hapgood JP (2005) Synthetic progestins used in HRT have different glucocorticoid agonist properties. Mol Cell Endocrinol 242:23–32 Pridjian G, Schmit V, Schreiber J (1987) Medroxyprogesterone acetate: receptor binding and correlated effects on steroidogenesis in rat granulosa cells. J Steroid Biochem 26:313–319. https://doi.org/10.1016/0022-4731(87)90095-1

Thank the resources from Biorender (https://app.biorender.com) for helping us construct Fig. 5. Funding This work was supported by the Shenzhen Science and Technology Program (No. JCYJ20220531094012027), Shenzhen Key Laboratory on Technology for Early Diagnosis of Major Gynecologic Diseases (SYSPG20241211173501001), the Shenzhen Key Medical Discipline Construction Fund (No. SZXK027), the Shenzhen Science and Technology Program (JCYJ20220818102811025), the Shenzhen High-level Hospital Construction Fund and Peking University Shenzhen Hospital Scientific Research Fund (KYQD2024433), the Scientific Research Foundation of Peking University Shenzhen Hospital (KYQD2023289), the Beijing Science and Technology Innovation Medical Development Foundation (KC2023-JX-0186-RZ105) and the Shenzhen Science and Technology Program (No. RCBS20231211090710015). Author information Authors and Affiliations Contributions Guanwen Gao: writing—original draft, writing—review and editing, methodology, formal analysis; Lvfang Duan: resources, investigation, methodology; Fanfan Zhu: resources, validation; Wenkui Dai: software, formal analysis; Lina Geng: resources; Degao Liu: resources; Jinju Lin: resources; Huashan Zhao: supervision, project administration, writing—review and editing; Yunfei Wang: project administration, writing—review and editing; Changzhong Li: visualization, validation, methodology, funding acquisition, data curation, supervision, writing—review and editing; all authors read and approved the final manuscript. Corresponding author Ethics declarations Ethics approval The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committees of Peking University Shenzhen Hospital (number: 2023–094). All experimental processes involving animal handling comply with the ethical review requirements for laboratory animals of Peking University—Hong Kong University of Science and Technology Medical Center, Shenzhen, China (number: 2024–158; 2022–571). Consent to participate Informed consent was obtained from all individual participants included in the study. Consent for publication Not applicable. Competing Interests The authors declare no competing interests. Clinical trial number Not applicable. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary Information Below is the link to the electronic supplementary material. ESM1 (download PNG ) (PNG 2.32 MB) ESM2 (download PNG ) (PNG 3.72 MB) ESM3 (download PNG ) (PNG 1.92 MB) ESM4 (download PNG ) (PNG 530 KB) ESM5 (download PNG ) (PNG 282 KB) ESM6 (download XLSX ) (XLSX 9.41 KB) ESM7 (download XLSX ) (XLSX 12.4 KB) ESM8 (download XLS ) (XLS 479 KB) ESM9 (download XLSX ) (XLSX 12.9 KB) ESM10 (download XLSX ) (XLSX 7.16 MB) ESM11 (download DOCX ) (DOCX 12.1 MB) Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. About this article Cite this article Gao, G., Duan, L., Zhu, F. et al. Metformin sensitizes endometriosis to medroxyprogesterone acetate treatment through MIG-6 mediated signaling. J Mol Med 104, 49 (2026). https://doi.org/10.1007/s00109-026-02655-z Received: Revised: Accepted: Published: Version of record: DOI: https://doi.org/10.1007/s00109-026-02655-z