Nanotechnology strategies for endometrium health: Are we on the right track?

Even though local delivery towards endometrial conditions may appear feasible physically, endometrial delivery is very challenging due to its dynamic nature, which makes its physical barrier more complicated for adhesion along with localized binding limiting the drugs’ bioavailability and sustained release [ 10 , 134 ]. The endometrial thickness changes depending upon the menstrual cycle day and its shedding may completely prevent drug bioavailability. In addition, the mucus layer can entrap or completely repel drugs, and the mucociliary clearance that contains a natural mechanism for clearing foreign substances has become the major challenges for targeting the endometrium. In some cases, fibrosis and scarring can also block drug diffusion. Besides this, it may also be noted that the regenerative potential of the endometrium is particularly limited, which calls for better drug delivery systems and prolonged release of drugs. Nanotechnology offers means for localized delivery not only through physical barriers but also through systemic and cell entering mechanisms. Key examples in this review show that inorganic/organic nanoparticles, lipid nanoparticles, along with functionalized nanomaterials targeting inflammation, cellular pathways and disease characteristics particularly lighten the disease burden. Hence, it is important to follow nanotechnology approaches over conventional methods. In this review, we have specifically highlighted the pathway targeting approach which has a higher anticipated translation over other chemical and charge-based approaches used in other drug delivery systems. In Fig. 1 -12, we have summarized the most-promising nanotechnology strategies for endometrial disorders in our view. Emerging market trends for nanotechnology-based drug delivery systems can also be anticipated. Paclitaxel is a particularly important drug used for treatment of endometrial disorders and has been previously mentioned in this report. Abraxane™ (albumin-bound nanoparticle form of paclitaxel) and Pazenir™, which are already approved for cancer therapy, have a high potential to be used for endometrial applications [ 135 ]. Furthermore, another important drug is progestogen, when used by itself and in combination can help in addressing endometrial disorders. From a translational perspective, several recent clinical efforts have explored the application of nanotherapeutics for endometrial and other gynecologic malignancies. Notably, a clinical trial ( NCT02646319 ) investigated nanoalbumin-bound rapamycin (nab-rapamycin or ABI-009) delivered via intravenous infusion for endometrial carcinoma, particularly in the context of tumors harboring mTOR mutations. Another trial is evaluating ELU001, a folate receptor alpha (FRα)-targeted conjugate, in patients with FRα-overexpressing solid tumors. In a separate clinical study ( NCT00466960 ), the combination of GM-CSF (Sargramostim) with nab-paclitaxel has shown potential efficacy in patients with platinum-refractory gynecologic cancers. Furthermore, nab-paclitaxel combined with Bevacizumab is under investigation in clinical trials ( NCT02020707 ) for stage IV unresectable melanoma and advanced gynecologic cancers, including those of the cervix, endometrium, ovary, fallopian tube, and peritoneal cavity. In the domain of nanodiagnostics, the nanoparticle-based MRI contrast agent SN132D (SPAGOPIX-02) is being evaluated in a clinical trial ( NCT05664828 ) for suspected endometriosis. Additionally, sentinel lymph node mapping using carbon nanoparticles (CNP), either alone or in combination with indocyanine green (ICG), is under investigation in endometrial cancer ( NCT03778255 ). Collectively, these ongoing clinical trials underscore the growing emphasis on translating nanotechnology-based approaches for the diagnosis and treatment of endometrial and related gynecologic disorders. Formulations comprising LNPs and PLGA as the drug carrier has high translational potential, with model examples mentioned in this review. Additionally, it is important to take inspiration and combinatorial approaches from other disease models, specifically inflammatory diseases. In this context, Mitragotri lab's innovation of immune cellular backpacks is a promising tool for localized drug delivery from the same patient and high immunotolerance devised for infiltration of drug laden immune cells to reduce the inflammatory disease burden [ [136] , [137] , [138] ]. These inventions involve using the individual's own immune cells, loading them with immunomodulatory and/or drugs of interest and introducing them back to the patient where the drug loaded immune cell gets recruited to the site of inflammation and releases the drug.

A comprehensive literature search was conducted using PubMed database to identify relevant studies on nanomedicine-based approaches for endometrial health. The search terms included endometrial diseases, such as “endometriosis”, “endometrial cancer”, “adenomyosis”, “endometritis”, “endometrial hyperplasia”, “uterine bleeding”, and “asherman syndrome”. The search was conducted these endometrial diseases, with a combination of the term “nanoparticles”. Boolean operators (AND, OR) were used to refine the search strategy. The restriction that was applied concerning these key words must be presented either in the title of the manuscript or in the abstract. However, there was no restriction related to language or publication date to ensure a broad collection of studies. The last search update was performed on Dec 15, 2024. The initial search results were compiled and managed using Windows Excel and EndNote X20 for reference documentation, organization, and duplicate removal. The search yielded articles presented in Fig. 2 . The bibliometric analysis of these studies indicates a significant rise in research interest in cumulative endometrial health related studies since 1990 ( Fig. 2 A). Among the seven commonly experienced endometrium diseases, most studies were focused on endometriosis (47.9 %) and endometrial cancer (33.5 %), followed by research on adenomyosis (6.58 %), endometritis (5.41 %), endometrial hyperplasia (4.65 %), uterine bleeding (1.46 %), and asherman syndrome (0.44 %) ( Fig. 2 B). Nanomedicine based investigations in endometrium diseases are limited ( Fig. 2 C). Overall, studies focused on the therapeutic role of nanomedicine in endometriosis and endometrial cancer, underscoring its potential as an emerging precision medicine strategy. Further breakdown of these studies revealed a predominance of research on polymeric nanoparticles, metal-based nanocarriers, carbon nanoparticles, lipid-based carriers, and hybrid nanoplatforms. In detail, we have included in detail about articles from reference 25 to 156. These articles are highly relevant for this review topic that investigates the use of nanoparticles, drug delivery vehicles, diagnostic, imaging, immunotherapy, and surgical procedures related to endometrium diseases. Fig. 2 Peer-reviewed literature related to endometrial disorders and the role of nanomedicine. A. Progressive trends in endometrial disorder-related publications, highlighting a broader implication in endometriosis and endometrial cancer. B. Representation of proportional distributions of various endometrium diseases-associated studies prevalent in the United States (US). C. Bar graph demonstrating nanomedicine research focused on various endometrial diseases. The search was conducted on December 15, 2024, using PubMed server. There was no exclusion criteria applied, to ensure a comprehensive analysis. Fig. 2 Peer-reviewed literature related to endometrial disorders and the role of nanomedicine. A. Progressive trends in endometrial disorder-related publications, highlighting a broader implication in endometriosis and endometrial cancer. B. Representation of proportional distributions of various endometrium diseases-associated studies prevalent in the United States (US). C. Bar graph demonstrating nanomedicine research focused on various endometrial diseases. The search was conducted on December 15, 2024, using PubMed server. There was no exclusion criteria applied, to ensure a comprehensive analysis. Table 1 documents recent and valuable review articles that comprehensively discuss the application of nanomedicine in biomedical research, particularly in various endometrial diseases. It highlights studies that explore the therapeutic potential of nanotechnology-based interventions in any one of the endometrial disorders or devoted to any one type of research on diverse nanoplatforms. Table 1 Recent and valuable review articles on nanomedicine related studies in endometrial diseases. Table 1 Title of review article Primary author, year, and citation Scope, significance, and key conclusions Rethinking the application of nanoparticles in women's reproductive health and assisted reproduction Davis E.H et al., 2024 [ 7 ] This article explores nanoparticles' potential in reproductive health, including managing conditions, like PCOS, endometriosis, uterine fibroids, and STIs, along with advancement in assisted reproductive technologies. It highlights therapeutic innovations and preservation methods while addressing clinical challenges. The Role of Nanomedicine in Benign Gynecologic Disorders Lulseged B.A et al., 2024 [ 8 ] This subsequent review accounts for nanoparticles' potential in treating gynecological conditions like leiomyoma, endometriosis, PCOS, and menopause, emphasizing their role in targeted drug delivery and hormone therapy. The Application of Nanoparticle-Based Imaging and Phototherapy for Female Reproductive Organs Diseases Luo L et al., 2024 [ 9 ] Presents nanoparticle-based imaging and phototherapies for endometriosis, gynecological cancers, infections, and chronic pain. This work highlights minimally invasive diagnostics and targeted treatments, with transformative implications for women's health. Recent Advances in Nanotechnology-Based Drug Delivery Systems for the Diagnosis and Treatment of Reproductive Disorders Acharya B et al., 2024 [ 10 ] This work covers nanotechnology-based solutions for early detection, targeted delivery, and imaging capabilities for disorders such as endometriosis, infertility, pregnancy, and reproductive cancers. In Situ Photo Responsive Biodegradable Nanoparticle Forming Intrauterine Implant for Drug Delivery to Treat Ovarian Diseases: A Rationale-based Review Corrie L et al., 2024 [ 11 ] In this review, novel drug delivery strategies (photo-sensitive and biodegradable intrauterine implants) were presented for endocrine disorders, offering sustained release and improved targeting with reduced side effects. Therapeutic potential of nanotechnology in reproduction disorders and possible limitations Barroso P.A.R et al., 2023 [ 5 ] This work reports the therapeutic potential of NPs in treating reproductive disorders, such as ovarian failure and endometriosis, focusing on lipid-based NPs. It also addresses the challenges and limitations of NPs in clinical translation for reproductive health. Nanoparticles in pregnancy: the next frontier in reproductive therapeutics Pritchard N et al., 2021 [ 12 ] This article considers the potential of NP-based therapies in reproductive medicine, including fertility-sparing treatments, gene delivery, and targeted therapies for ectopic pregnancies. It emphasizes nanotechnology's promise in managing pregnancy-related conditions and minimizing risks to both mother and fetus. Drug discovery by formulation design and innovative drug delivery systems (DDS) Okada H 2011 [ 13 ] Essays innovations in microcapsules and cell-penetrating peptide (CPP)-based systems, showcasing their ability to enhance therapeutic efficacy, improve patient quality of life, and drive a paradigm shift in drug discovery and delivery. This work includes their application in hormone-dependent diseases, endometriosis, cancers, and immune disorders. A Comprehensive Review of Advanced Diagnostic Techniques for Endometriosis: New Approaches to Improving Women's Well-Being Kaspute G et al., 2024 [ 14 ] This article explores innovative diagnostic approaches for endometriosis, emphasizing AI and nanotechnology. It highlights saliva miRNA signatures, epigenetic markers, and advanced sensors as promising tools for precise, non-invasive detection. Targeted nanoparticles for imaging and therapy of endometriosis Slayden O et al., 2024 [ 4 ] This review showcases nanoplatforms for imaging and treating endometriosis, highlighting their use. It presents their precise lesion targeting, imaging, and thermal ablation, advancing diagnostic and therapeutic solutions. Nanomedicines for Endometriosis: Lessons Learned from Cancer Research Moses A.S et al., 2021 [ 15 ] It offers potential use and translation of nanomedicines in endometriosis treatment, focusing on their role in improving diagnosis and therapy, along with future directions. Drug delivery for the treatment of endometriosis and uterine fibroids Friend D.R 2017 [ 16 ] This article examines drug delivery strategies for endometriosis and fibroids, emphasizing hormonal systems and emerging nanotechnology. It also discusses existing long-acting implantable contraceptive-based depots to target biochemical changes and improve treatment outcomes. Folate-engineered chitosan nanoparticles: next-generation anticancer nanocarriers Kesharwani et al., 2024 [ 17 ] Discusses a promising drug delivery system conjugated with folic acid promoted for cancer therapy due to the enhancement in the solubility, permeability, and bioavailability of hydrophobic anticancer agents while enabling sustained drug release. Chitosan NPs selectively target FR-overexpressing tumors, such as ovarian and endometrial cancers, overcoming drug resistance and improving therapeutic efficacy. Placenta-targeted Treatment Strategies for Preeclampsia and Fetal Growth Restriction: An Opportunity and Major Challenge Cui J et al., 2024 [ 18 ] This review explores placenta-targeted treatment strategies, their potential applications, and future directions for improving therapeutic outcomes in pre-eclampsia (PE) and fetal growth restriction (FGR). Particles and Prejudice: Nanomedicine Approaches to Reducing Health Disparities in Endometrial Cancer Rowlands CE et al., 2024 [ 19 ] It documents information of the intersection of nanomedicine, precision oncology, and racial health inequities, highlighting innovative strategies to reduce endometrial cancer mortality. Benefit of Silver and Gold Nanoparticles in Wound Healing Process after Endometrial Cancer Protocol Toczek et al., 2022 [ 20 ] The silver and gold nanoparticles help address key barriers to healing, such as bacterial biofilms, which resist traditional treatments. However, their use is inconsistent, highlighting the need for standardized treatment guidelines in clinical practice. Sentinel lymph node mapping in endometrial cancer after 2020 ESGO-ESTRO-ESP consensus update: what will happen in the next few years? Barczynski et al., 2022 [ 21 ] This review emphasizes advancements in non-invasive methods, such as radiomics, and the growing research on optimizing sentinel lymph node mapping in various endometrial cancer populations. Endometrial Cancer: Genetic, Metabolic Characteristics, Therapeutic Strategies and Nanomedicine Cai Y et al., 2021 [ 6 ] Focuses on genetic alterations, including X chromosome inactivation and the impact of metabolic disorders in cancer. Discusses nanotechnology is emerging as a promising tool for early diagnosis, metastasis detection, and treatment, though further research is needed to fully explore its potential in endometrial cancer therapy. Comparison of different tracers in sentinel lymph node detection for endometrial cancer: A systematic review and network meta-analysis Feng et al., 2024 [ 22 ] The systemic meta-analysis confirms the combination of radioactive isotopes and indocyanine green was the most effective method, demonstrating high detection rates for both total and bilateral nodes. Oral nano-formulations for endocrine therapy of endometrioid adenocarcinomas Cui et al., 2024 [ 23 ] This review discusses the use of oral endocrine therapies, such as progestins and aromatase inhibitors, and addresses their limitations due to low solubility and bioavailability. Additionally, it also emphasizes the potential of nanotechnology in enhancing these therapies through oral nano-formulations, improving drug delivery and targeting in endometrial cancer treatment. Recent and valuable review articles on nanomedicine related studies in endometrial diseases. Despite many advancements in nanomedicine, there is currently no comprehensive review article that systematically evaluates the role of nanomedicine in endometrial diseases, nor one that emphasizes the optimization of nanoparticle-based drug delivery systems to improve therapeutic efficacy. Existing studies primarily focus on oncology-related applications, yet the integration of nanomedicine into non-malignant endometrial disorder remains underexplored. Furthermore, there is a lack of extensive research on how nanotechnology can enhance drug bioavailability, enable site-specific targeting, and mitigate systemic toxicity in the treatment of endometrial diseases. Therefore, the primary objective of this review is to highlight the molecular mechanisms underlying nanoparticle-based therapies, their role in enhancing drug delivery, and their potential for clinical translation in endometrial health. By addressing these knowledge gaps, this review aims to provide a critical framework for future research, paving the way for more effective and targeted therapeutic strategies using nanomedicine in endometrial disease management.

Victoria Herrara: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Formal analysis, Data curation. Dana Tarab-Ravski: Writing – review & editing, Writing – original draft, Visualization, Validation, Software, Methodology, Investigation, Formal analysis. Subhash C. Chauhan: Writing – review & editing, Writing – original draft, Visualization, Validation, Software, Resources, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Nikesh Narang: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Formal analysis. Mohammad Mirazul Islam: Writing – review & editing, Writing – original draft, Visualization, Validation, Software, Resources, Methodology, Investigation, Formal analysis, Data curation. Dan Peer: Writing – review & editing, Writing – original draft, Visualization, Validation, Software, Resources, Investigation, Formal analysis, Conceptualization. Rajendra Prasad: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Murali M. Yallapu: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization.

Not applicable as this work do not involve use of animals or human studies.

Future research directions should prioritize the development of next-generation multifunctional nanoparticles capable of co-delivering multiple therapeutic agents, encompassing chemotherapeutic compounds and gene-silencing molecules such as miRNA and siRNA. These RNA-based nanoformulations represent a novel strategy for modulating key molecular pathways implicated in endometriosis and other gynecological disorders. For this purpose, LNPs hold the highest translational promise. In a foreseeable future perspective of efficient drug delivery, LNPs are the promising tools to be used for drug delivery for female reproductive health problems including endometrium, placenta and ovarian cancer, briefly explained here. LNPs, as mentioned earlier in this review, are a favorable delivery strategy for RNA due to their high encapsulation efficiencies, low immunotoxicity, and protection of the RNA cargo. Moreover, they facilitate cellular internalization and can improve tissue-specific accumulation of therapeutic RNA molecules [ 139 , 140 ]. They are commonly comprised of a mixture of four lipids: a phospholipid, a polyethylene glycol-conjugated lipid (PEGylated lipid), cholesterol, and an ionizable cationic lipid. These lipids are later combined with the RNA payload commonly by a microfluidic mixing technique. The head group of the ionizable cationic lipid forms electrostatic interactions with the nucleic acids due to its positively charged nature in low pH, while maintaining a neutral charge in physiological pH levels in the circulation. Their production process results in the formation of scalable, uniform, small LNPs, which can be used to deliver siRNA, miRNA, messenger RNA (mRNA), and components of the CRISPR/Cas9 system for gene editing. By harnessing RNA-LNPs to manipulate gene expression, these new therapeutic modalities hold great potential for addressing many reproductive health conditions. While the clinical application of RNA-LNPs has paved the way for further approvals, challenges remain in avoiding liver accumulation and improving their safety and specificity upon systemic administration. 93-95 To our knowledge, while there are currently no RNA-LNPs under evaluation for the treatment of endometrium diseases, some attempts have been made to examine the accumulation of RNA-LNPs in the female reproductive system and test the therapeutic effects of RNA-LNPs for placenta-related conditions and ovarian cancer ( Fig. 13 ). Fig. 13 Lipid nanoparticles (LNPs) used for female reproductive health conditions. This image was constructed using BioRender. Fig. 13 Lipid nanoparticles (LNPs) used for female reproductive health conditions. This image was constructed using BioRender. Several studies have investigated the accumulation of RNA-LNPs in the reproductive system. Poley M. and Mora-Raimundo P. et al., previously evaluated how the cyclic physiological changes timed with the monthly menstrual cycle change accumulation in the female reproductive system of different types of nanoparticles and LNPs encapsulating mRNA [ 141 ]. Their study showed a significant ovary and uterus accumulation of LNPs during the estrus stage, in which there is an increased blood supply to the ovaries, therefore highlighting the importance of studying the effects of the menstrual cycle on nanomedicine activity. Therefore, to explore the potential of mRNA therapy for extrahepatic tissues, Ferraresso F. et al., evaluated the expression of exogenous protein upon an intravenous injection of a clinically relevant mRNA-LNP formulation in a swine model [ 142 ]. Along with other major organs, the uterus demonstrated significant expression levels of the exogenous protein, as compared to swine treated with PBS or LNPs containing scrambled mRNA. Together, this research shows the feasibility and potential of harnessing RNA-LNPs for reproductive health applications. The LNPs’ scope is further employable to placenta. The placenta is a fetal organ that develops during gestation and throughout pregnancy inside the uterus, used to supply the fetus with nutrients and oxygen. Insufficient vasodilation in the placenta can result in placental disorders, among them pre-eclampsia, which can lead to fetal growth restriction (FGR). LNPs offer the opportunity to reach organs with extensive blood flow upon systemic administration and, therefore, can potentially target the placenta. In a recent study, Swingle K. L. et al. screened LNP formulations composed of various ionizable cationic lipids in delivering mRNA to the placenta [ 143 ]. They tested the mRNA-LNPs on placental cells in vitro and compared their accumulation in non-pregnant and pregnant mice in vivo . Furthermore, to evaluate the functional delivery of a clinically relevant mRNA for placental disorders, vascular endothelial growth factor (VEGF) was chosen as a therapeutic target due to its current evaluation in recombinant and viral gene therapy approaches. Using their new mRNA-LNP formulation, they achieved high expression levels of VEGF in the placenta. After performing further high-throughput screening of 98 LNPs, they explored the therapeutic effects of VEGF mRNA using their placenta-tropic LNP formulation for pre-eclampsia [ 144 ]. Using an inflammation-induced pre-eclampsia mouse model, they showed that pre-eclamptic mice treated with VEGF mRNA using their lead formulation demonstrated a greater daily change in weight, significantly increased litter size and maternal hypertension was permanently alleviated. The same group also used an orthogonal design of experiments (DOE) to identify optimized LNP formulations and improve mRNA delivery to the placenta [ 145 ]. By modifying the molar ratios of the four lipid components of LNPs and using the same lead ionizable lipid as Swingle K. L. et al., their optimized LNP formulation significantly improved mRNA expression in the placenta while reducing liver accumulation. Furthermore, Safford H. C. et al. also evaluated the effects of mRNA-LNP rigidness on placenta uptake. They showed that LNPs with enhanced stiffness exhibit improved mRNA delivery to the placenta [ 146 ]. Geisler H. C. et al. from the same group also generated targeted LNPs (tLNPs) to enhance mRNA delivery to the placenta in vivo [ 147 ]. LNPs were coated with an antibody that targets endothelial growth factor receptor (EGFR), which is an abundantly expressed target on human and murine placentas and especially during placental dysfunction. As compared to non-targeted LNPs, anti-EGFR tLNPs resulted in a two-fold increase in the mRNA expression in the placenta of pregnant mice. These results underscore the potential of targeted LNPs to improve the therapeutic effects of mRNA therapy for placental-related diseases. Nevertheless, a comprehensive evaluation of this anti-EGFR delivery platform with therapeutic mRNA cargo in relevant mouse models is necessary. Ovarian cancer is a leading cause of cancer-related mortality across women. While most patients will respond to first-care treatment, including surgical resections and neoadjuvant chemotherapy, 80–85 % will relapse with an aggressive and chemo-resistant disease. Therefore, there is a constant need for the development of new therapeutic options to treat ovarian cancer. Singh M. S. et al. generated LNPs which encapsulate a combination of two siRNAs, one targeting polo-like kinase 1 (PLK1) and the other targeting eukaryotic translation-initiation factor 3c (eIF3c), to simultaneously inhibit different cellular pathways that are crucial for ovarian cancer proliferation [ 148 ]. To enhance the specificity of the LNPs upon intraperitoneal injections, they coated the LNPs with hyaluronan (HA) to target CD44, an overexpressed glycoprotein in ovarian cancer cells. Evaluating the therapeutic effects of the siRNA-HA-LNPs in an ovarian cancer mouse model revealed a significantly higher, overall survival of 60 %, for mice treated with the combination siRNA, as compared to 10 % and 20 % overall survival in mice treated with only siRNA-eIF3c- and siRNA-PLK1- HA-LNPs, respectively. This work was the first to demonstrate the potential and feasibility of ovarian cancer treatment with siRNA-LNPs. Chatterjee S. et al., have also harnessed siRNA-LNPs for the treatment of ovarian cancer and explores cytoskeleton associated-protein 5 (CKAP5) as a new therapeutic target [ 149 ]. They showed that ovarian cancer cell lines with high genomic instability effectively responded to the silencing of CKAP5 due to a resulting cell cycle arrest and spindle defect. Furthermore, ovarian cancer-bearing mice treated with siRNA-CKAP5-LNPs demonstrated an overall survival of 80 %. Finally, Rosenblum D. and Gutkin A. et al. harnessed CRISPR/Cas9 technology to induce gene editing for the treatment of ovarian cancer using targeted LNPs [ 150 ]. They co-encapsulated mRNA to express the Cas9 protein and sgRNA to guide the Cas9 to a specific chromosomal DNA sequence. The CRISPR/Cas9 LNPs (cLNPs) were coated with an anti-EGFR antibody to enhance their specificity to ovarian cells, which overexpress EGFR. To test therapeutic effects, they chose to induce gene editing of PLK1. In ovarian cancer-bearing mice, EGFR-targeted sgPLK1-cLNPs enabled up to 80 % gene editing, inhibited tumor growth and increased overall survival by 80 %.

Nanomedicine has emerged as a promising approach for the diagnosis and treatment of endometrial diseases, enabling precise, targeted, and efficient therapeutic delivery. The application of nanoparticle-based drug carriers has demonstrated significant potential in enhancing bioavailability, prolonging systemic circulation, and facilitating site-specific delivery, thereby improving therapeutic outcomes. This review systematically explores the development of nanotechnology-driven strategies involving anti-inflammatory agents, hormonal modulators, and chemotherapeutic drugs aimed at enhancing treatment efficacy while minimizing systemic toxicity. Furthermore, advancements in biomaterials have enabled the fabrication of biodegradable and biocompatible nanocarriers with controlled drug release kinetics, improving therapeutic precision. From this review, model examples are illustrated in Fig. 14 that exhibits chitosan oligosaccharide-g-steric acid mediated delivery of A-317491 for treatment of endometriosis associated pain, CIP2b nanoparticles induced enhanced internalization, reduction of proliferation, and inhibition of vascularization, PDK1 inhibitor JX06 nanoparticles significantly persuade anticancer activity in patient derived cells and mouse models, magnetic nanoparticles for local drug delivery to the endometrium tissue and SPARC-mediated active endometrial tissue targeting and improving immunotherapy to treat endometriosis. About the drug delivery routes from the given examples, the intravenous route can be considered a consensually adopted route due to the highly dynamic nature of the endometrium, which makes the drug localization difficult to achieve. Nonetheless, magnetic nanoparticles and intrauterine devices can be a preferred route for local delivery. However, long-term use of intrauterine devices may cause fibrosis and aggravate pro-inflammatory responses depending upon the nature of material [ 151 ]. As for efficient methods of drug loading (in general), Table 2 summarizes the generalized comparisons of nanoparticles type and their biocompatibility, degradation and drug loading efficiencies [ [152] , [153] , [154] , [155] , [156] ]. Fig. 14 Model examples of drug delivery/targeting strategies for endometrial conditions. A. Chitosan oligosaccharide-g-steric acid (CSOSA/NLC) mediated delivery of A-317491 facilitates reduced endometriosis associated pain, B. CIP2b nanoparticles enhances internalization, reduction of proliferation, and inhibition of vascularization, C. PDK1 inhibitor JX06 nanoparticles significantly persuade anticancer activity in patient derived cells and mouse models, D. Applied magnetic fields induce higher temperature at the endometrium tissue and release, which introduces anti-inflammatory properties from the injected hydrogel, E. SPARC-mediated active endometrial tissue targeting and improving immunotherapy to treat endometriosis. This figure was constructed using BioRender taking concept from References 41, 76, 78, 50, and 54, respectively. Fig. 14 Table 2 Comparisons of nanoplatforms and their respective biocompatibility, degradation rate, and drug loading efficiency. Table 2 Nanoparticle Type Specification Biocompatibility Degradation Rate Drug Loading Efficiency Inorganic NP Mesoporous Silica NPs (MSNs) Good; easily functionalized to improve compatibility Slow to moderate; pH-dependent, enzymatic enhancement possible Very high, tunable via pore size and surface chemistry Gold NPs (AuNPs) High (especially with PEG or protein coatings) Non-biodegradable Moderate; surface-modified AuNPs improve loading and targeting Iron Oxide NPs (Fe 3 O 4 ) FDA-approved for imaging; biocompatible when coated Slow; enzymatic or acidic environment helps clearance Moderate; often used with drug conjugates or coatings Polymeric PLGA-based Nanoparticles Excellent; FDA-approved; minimal immune response Controlled (days to months); tunable via LA/GA ratio Moderate–High; better for hydrophobic drugs PEGylated Polymer NPs Very high; stealth behavior reduces opsonization Very slow or non-degradable (unless using cleavable PEG) Low–Moderate; improves circulation but can reduce cargo loading Lipid-Based Liposomes High; mimic natural membranes; low immunogenicity Fast (hours to days); phospholipid bilayers degrade easily High (hydrophilic drugs in core, hydrophobic in bilayer) Solid Lipid Nanoparticles (SLNs) High; stable and safe; more stable than liposomes Moderate; slower than liposomes but biodegradable Moderate–High; suitable for lipophilic drugs Hybrid Systems Lipid–Polymer Hybrid NPs Excellent; combines biocompatibility of lipids + mechanical strength of polymers Tunable via core–shell design (lipid shell, polymer core) Very high; dual loading (hydrophobic core, hydrophilic shell or vice versa) PEG–PLGA Lipid Hybrids Stealth profile, reduced clearance, biocompatible Degradation of PLGA core; lipid shell adds stability High encapsulation efficiency and sustained release Model examples of drug delivery/targeting strategies for endometrial conditions. A. Chitosan oligosaccharide-g-steric acid (CSOSA/NLC) mediated delivery of A-317491 facilitates reduced endometriosis associated pain, B. CIP2b nanoparticles enhances internalization, reduction of proliferation, and inhibition of vascularization, C. PDK1 inhibitor JX06 nanoparticles significantly persuade anticancer activity in patient derived cells and mouse models, D. Applied magnetic fields induce higher temperature at the endometrium tissue and release, which introduces anti-inflammatory properties from the injected hydrogel, E. SPARC-mediated active endometrial tissue targeting and improving immunotherapy to treat endometriosis. This figure was constructed using BioRender taking concept from References 41, 76, 78, 50, and 54, respectively. Comparisons of nanoplatforms and their respective biocompatibility, degradation rate, and drug loading efficiency. Various nanotechnology-based approaches and medicines have gained tremendous attention in human healthcare. However, these approaches still face various challenges, particularly regulatory approval and consideration. The promising outcomes of utilizing RNA-LNPs for gene silencing and gene editing pave the way for new therapeutic modalities in the challenge of addressing aggressive ovarian malignancies. Overall, RNA-LNPs show significant potential for overcoming current treatment limitations of reproductive health conditions. As future research and clinical trials continue to explore LNP formulations and RNA technologies, these innovations will likely advance, ultimately improving therapeutic efficacy and patient outcomes. Further integration of nanomedicine with personalized medicine approaches, leveraging patient-specific molecular and genetic profiles, holds realizable hopes for optimizing treatment regimens and improving patient outcomes. Considering all these advantages, the point to be addressed is the deeper understanding of pharmacokinetics and dosage decision in clinical trials by addressing hormonal changes in sex-based differences. The studies should emphasize on the menstrual cycle state, menopausal state, history of hormonal therapies etc. Furthermore, the drugs used in the clinical trials mentioned in this review, e.g., paclitaxel, bevacizumab, and rapamycin, have been previously studied for other conditions with or without some adverse effects [ [157] , [158] , [159] ], but deeper understanding of them is needed for reconsidering them for female reproductive/endometrial disorders. In addition to therapeutic applications, nanotechnology-driven point-of-care diagnostics can significantly advance the early detection and management of endometrial/reproductive health diseases, particularly in resource-constrained settings. However, critical challenges such as nanotoxicology, material degradation, and clearance must be systematically evaluated to ensure the safety and biocompatibility of nanomedicine-based interventions. Furthermore, despite the substantial potential of nanomedicine in gynecological healthcare, clinical translation remains hindered by regulatory complexities, scalability limitations, and long-term safety concerns. Addressing these challenges through rigorous preclinical and clinical investigations will be essential to facilitate the widespread adoption of nanomedicine for endometrial disease management, ultimately paving the way for more effective, targeted, and patient-centric therapeutic solutions.

The endometrium is the highly dynamic, innermost lining of the uterus, which is a critical component of female reproductive health. This tissue lining undergoes continuous regeneration and adaptation throughout the menstrual cycle, driven by a complex and finely tuned interplay of hormonal, cellular, and molecular processes. Such adaptability is not only essential for effective implantation and pregnancy, but a key indicator of overall gynecological well-being. The healthy endometrium relies on multiple processes, including proliferation and differentiation, vascularization and angiogenesis, and decidualization. However, disorder in the structure and functions of the endometrium or hormonal imbalance can lead to a spectrum of conditions with profound implications for women's health [ [1] , [2] , [3] ]. The common factors influencing endometrial health include but are not limited to hormonal imbalance, persistent inflammation or infection, poor nutrition, microbiota, and immune modulation. Commonly observed endometrium diseases include endometriosis, endometrial carcinoma, endometritis, adenomyosis, endometrial hyperplasia, asherman syndrome, and uterine bleeding ( Fig. 1 , left side representation). Amongst endometrial diseases, nanotechnology-based strategies have been under investigation for reducing disease burden in endometriosis, endometrial cancer, adenomyosis, endometritis, endometrial hyperplasia, etc. Endometriosis is a complex gynecological condition affecting up to 15 % of women of reproductive age. It is characterized by ectopic implantation of endometrial-like tissue, resulting in chronic pelvic pain, infertility, dysmenorrhea, and systemic inflammation. Endometritis is an inflammatory condition of the endometrial lining, primarily triggered by microbial infections or immune dysregulation, with significant implications for reproductive health. It manifests in acute and chronic forms, each characterized by unique pathological and clinical features. Adenomyosis is a gynecological disorder characterized by the ectopic presence of endometrial glands and stroma within the myometrium. This condition often results in clinical manifestations such as chronic pelvic pain, abnormal uterine bleeding, and infertility. Endometrial hyperplasia (EH), marked by an increased gland-to-stroma ratio, is a precursor to endometrioid endometrial carcinoma. Fig. 1 Graphical representation of endometrial disorders and nanotechnology based solutions for therapeutics and theranostics addressed in this review. The image content is a representation and not accurate of endometrium pathology. Endometrium disorders due to hormonal imbalance and changes in its structure and function leading to a spectrum of conditions, including endometriosis, endometrial carcinoma, endometritis, adenomyosis, endometrial hyperplasia, asherman syndrome, and uterine bleeding (left side schematic representation). Various types of nanoparticles and biomaterials used to tackle endometrium health (right side schematic representation). This image was constructed using BioRender. Fig. 1 Graphical representation of endometrial disorders and nanotechnology based solutions for therapeutics and theranostics addressed in this review. The image content is a representation and not accurate of endometrium pathology. Endometrium disorders due to hormonal imbalance and changes in its structure and function leading to a spectrum of conditions, including endometriosis, endometrial carcinoma, endometritis, adenomyosis, endometrial hyperplasia, asherman syndrome, and uterine bleeding (left side schematic representation). Various types of nanoparticles and biomaterials used to tackle endometrium health (right side schematic representation). This image was constructed using BioRender. Traditional treatment approaches for endometrium diseases are hindered by significant limitations including: (a) inefficient drug distribution resulting in inadequate drug concentrations at the disease site; (b) systemic toxicity due to non-specific delivery, causing damage to healthy tissues and leading to side effects such as immune suppression, gastrointestinal disturbances, and fatigue; (c) the development of drug resistance from repeated exposure to chemotherapeutic agents; (d) limited penetration into endometrial lesions, reducing therapeutic efficacy; (e) high recurrence rates, which pose ongoing challenges to long-term disease management; and (f) severe impacts on patients' physical and emotional well-being, compromising their overall quality of life. These challenges underscore the need for innovative nanotechnology-based approaches, which provide targeted, efficient, and minimally toxic theranostic solutions. Nanoparticle-based technologies have transformed the treatment of endometrial disorders by addressing the limitations of conventional therapies [ [4] , [5] , [6] ] ( Fig. 1 , right side representation). These innovations enable precise drug delivery, enhanced imaging, and ensure controlled drug release, significantly improving therapeutic efficacy and patients’ quality of life. Nanoparticles enhance the solubility and stability of therapeutic agents, improving bioavailability and allowing for controlled, sustained drug release. They selectively target molecular biomarkers on endometrial cells, ensuring drug accumulation at disease sites while minimizing off-target effects. This reduces dosing frequency, improves compliance, and circumvents drug resistance mechanisms, particularly in endometrial carcinoma, amplifying chemotherapeutic efficacy, and offering a safer treatment profile. Multifunctional nanoparticles incorporating diagnostic imaging agents enable real-time monitoring of disease progression and treatment response, while nano-antioxidants like curcumin and resveratrol mitigate oxidative stress, a key factor in disease pathophysiology.

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Rajendra Prasad often refered as Rajendra Prasad Meena.

The applications of nanoparticles in endometrial disease management include encapsulating chemotherapeutics or hormonal agents for localized and sustained release, integrating imaging agents for early detection and monitoring, enabling combination therapies with synergistic agents, and supporting gene therapy by delivering tools like CRISPR-Cas9 or siRNA to address genetic abnormalities. By addressing critical challenges of traditional treatments, nanoparticle-mediated delivery systems represent a paradigm shift in endometrial disorder management. Ongoing advancements in nanotechnology promise safer, more effective, and highly personalized therapies, with the potential to establish nanoparticle-based approaches as the clinical standard, transforming patient care and outcomes [ 24 ]. Recent interest in nanoparticle-based technologies for endometrial disorders has been strengthened with approaches using metal, polymer, magnetic, and lipid nanoparticles, along with intrauterine implants, and targeted drug delivery strategies. Endometriosis, a complex gynecological condition affecting up to 15 % of women of reproductive age. It is characterized by ectopic implantation of endometrial-like tissue, resulting in chronic pelvic pain, infertility, dysmenorrhea, and systemic inflammation. Despite advancements in understanding its pathogenesis, which involves oxidative stress, dysregulated immune responses, and enhanced proliferation of endometriotic cells, the precise mechanisms underlying the disease remain incompletely elucidated. Current therapeutic options, including estrogen suppression and surgical excision, are associated with significant limitations such as adverse effects, high recurrence rates, and procedural complications. Innovative approaches, including targeted therapies, advanced gene delivery systems, and novel pharmacological formulations, present promising opportunities for developing safer and more effective treatments, underscoring the critical need for transformative strategies to improve clinical outcomes. Mesoporous silica nanoparticles are first generation formulations implemented for endometriosis therapy. These nanoparticles were demonstrated to be the most suitable vehicle for delivery of muramyl dipeptide analogue to peritoneal macrophages, offering a promising platform for immunomodulatory therapies for the endometrium [ 25 ]. These non-toxic mesoporous silica topical nanoparticles efficiently suppressed the stimulatory role of macrophages associated with molecular pathways, including reduced membrane expression of scavenger receptors SR-AI and SR-B, downregulation of mRNA expression of innate immune markers Nucleotide-binding oligomerization domain 2 and receptor for advanced glycation end products , along with diminished synthesis of the proteolytic enzyme matrix metalloproteinase-9 (MMP-9) alongside its inhibitor, tissue inhibitor of metalloproteinase-1. Furthermore, cerium oxide (nanoceria) nanoparticles exhibit a superior free radical scavenging nature. Due to this inherent property, they were efficient in mitigating endometrial lesions induced in mice models [ 26 ]. This behavior was confirmed by evaluating total reactive oxidative species (ROS), lipid peroxidation, antioxidant capacity, adrenomedullin, vascular endothelial growth factor (VEGF), and blood vessel density levels. Together, the data demonstrated that cerium nanoparticles are efficient in inhibiting pathogenesis of abnormal proliferation, oxidative stress, and angiogenesis in endometriosis. A recent investigation also suggests nanoceria acts as a non-steroidal anti-inflammatory, and theranostic agent for endometriosis [ 27 ]. Nanoceria significantly inhibited ectopic lesion size, inflammation, and expression of phosphorylated Signal Transducer and Activator of Transcription 3 (STAT3) in the ectopic lesions and eutopic uterus of a genetically engineered Pgrcre/+Rosa26mTmG/+ mouse model. This was achieved due to a 3-fold higher target accumulation in ectopic lesions as compared to nonspecific uptake in the uterus. In addition, this treatment does not affect fertility or early pregnancy processes (implantation and decidualization). It is well known that Poly(lactic- co -glycolic acid) (PLGA) nanoparticle-assisted drug delivery overcomes the limitations of native drugs or oligonucleotides and offers enhanced bioavailability, controlled release, and minimal toxicity. Such formulations are also promising in the treatment of endometriosis and associated fertility restoration. Singh et al., [ 28 ] reported about a PLGA-based dual drug (epigallocatechin gallate and doxycycline) nanoparticle for advancement in the therapeutic management of endometriosis. This combinatorial treatment demonstrated efficacy in reducing oxidative stress, inhibiting MMP activity, and suppressing angiogenesis suggesting its potential to mitigate endometriosis progression. Additionally, the observed improvements in oocyte quality and reproductive outcomes underscore their broader clinical relevance. Another study aimed at the development of PLGA nanoparticles loaded with copaiba oleoresin for endometriosis therapeutic application [ 29 ], which confirmed a significant reduction in the viability of endometrial stromal cells derived from ectopic endometriotic tissues and eutopic lesions of endometriosis patients. Another PLGA nanoparticle mediated miRNA delivery method was developed via complexation of polyethyleneimine (PEI) coated nanoparticles with miRNA 503 [ 30 ]. This approach revealed a significant, time- and dose-dependent reduction in stromal cell viability upon treatment with PLGA-PEI-miR503 formulation (100 μM) over 12, 24, 48, and 72 h. Apoptosis rates were substantially higher in cells treated with PLGA-PEI-miR503 formulation (35.66 ± 4.6 %) as compared to respective control groups. Additionally, the in vivo test demonstrated that the miR503 formulation treated endometriotic lesions, exhibited reduced tumor volumes and distinctive cystic morphology. Using the electrospray method, microfluidics derived microparticles of bovine serum, albumin hydrogel particles containing dienogest in PLGA nanoparticles [ 31 ]. These microparticles efficiently reduced lesion volume and exhibited superior anti-inflammatory and therapeutic effects in an endometriosis mouse model. Its treatment decreased tumor necrosis factor α (TNF-α), interleukin-1 beta (IL-1β), estrogen receptor beta (ER-β), nerve growth factor (NGF), and alpha smooth muscle actin (α-SMA) levels while increasing ER-α expression, indicating reduced inflammation, pain, and angiogenesis. Upon oral administration, mice were observed to be well-tolerated and displayed no systemic toxicity. A novel composite drug delivery system based on 2-hydroxyethyl methacrylate (HEMA) and graft copolymer of acrylamide and low-density polyethylene (AAm-g-LDPE), i.e., pHEMA/AAm-g-LDPE was employed for encapsulation of letrozole [ 32 ]. This graft cross-linked polymer nanoparticles 72 % of letrozole released in 3 days. This system exhibited superior biocompatibility of the cellular models and advocates for in vivo therapeutic applications. miR-200c is downregulated in human endometriosis tissues and has a profound inhibitory activity on the proliferation and migration characteristics of human endometrial stromal cells, mediated by its regulatory influence on metastasis-associated lung adenocarcinoma transcript 1 [ 33 ]. Liang et al., [ 33 ] proved that efficient, localized and targeted delivery of miR-200c can decrease ectopic endometrial cysts in rat model. Such delivery was feasible using polymer nanoparticles constructed with arginine-glycine-aspartic acid peptide conjugated to branched PEI. Research studies have identified the overexpression of low-density lipoprotein receptors in endometriotic lesions and neoplastic cells [ [34] , [35] , [36] ]. Such phenomenon facilitates lipid-core nanoparticles selectively accumulate in these tissues and inflammatory sites due to receptor-mediated uptake. An initial study was aimed at determining low density lipoprotein like nanoemulsion (LDE) containing lipid nanoparticles [ 36 ] and its specific uptake in ovarian and deep endometriotic tissues, adjacent healthy peritoneum, and the endometrium. This study confirms that endometriotic lesions exhibit a significantly increased uptake of 14 C-labeled LDE, indicative of heightened LDL consumption, paralleling patterns observed in cancer and inflammatory conditions. A follow-up prospective study in eleven volunteers with endometriosis was conducted to evaluate methotrexate containing lipid nanoparticles [ 37 ]. The results of this study suggest that methotrexate containing lipid nanoparticles improved deep dyspareunia, chronic pelvic pain, and dyschezia, and no systemic toxicities were observed. In addition, this type of treatment modality maintains hormonal levels within normal ranges, and no significant differences between dose levels in therapeutic outcomes were detected. β-caryophyllene (BCP) is a hydrophobic sesquiterpene that acts as a non-cannabis-derived phytocannabinoid receptor antagonist that exhibits anti-proliferative, anti-inflammatory, and analgesic properties in both cellular studies and animal models of pain. In addition, BCP is reported to influence endometrial implants in adult female rats (52.5 % with observed reduction in lesion growth after 21 days) [ 38 ]. To facilitate efficient delivery of BCP, copaiba oil (mainly contains BCP) was formulated utilizing tween 80, pluronic F68, span 20, and cremophor RH40 surfactants to yield various cannabinoid nanoemultions (30.12 ± 6.31 nm) [ 39 ]. This formulation (150 μg/mL) demonstrated a significant reduction in cell viability and notable morphological changes in ectopic endometrium derived cells, indicating this bioeconomic approach for uterus-targeting endometriosis therapy. Zhao et al., [ 40 ] constructed a glycolipid-like polymeric micelle system based on lipid grafted on to chitosan (CS) oligosaccharide-steric acid micelles for targeted gene therapy in endometriosis. This polymeric micelle system is effectively compacted and delivered pigment epithelium derived factor gene to endometriotic lesions in rat model. Its superior activity was noticed by significant reductions in lesion size, increased apoptosis, and decreased microvessel density, without causing toxicity to reproductive organs. Such direction was also implemented toward delivering A-317491 (antagonist of an adenosine triphosphate (ATP)-gated ion channel, purinergic P2X3 receptor) to reduce endometriosis pain [ 41 ]. The selection of this molecule is based on pathological pain conditions that are associated with the inflammatory mediators that promote the release of endogenous ATP, which activates P2X3 receptors, triggering Ca 2+ influx and membrane depolarization, ultimately transmitting pain signals to the central nervous system. In in vitro analysis, this engineered nanoparticle formulation effectively inhibited ATP-induced, Ca 2+ influx in PC12 cells, confirming efficient receptor blockade. Additionally, these nanoparticles exhibited notable accumulation at ectopic endometrial lesions in both nude mice and rat models of endometriosis after intravenous administration. The in vivo study confirms that formulation treatment led to sustained relief of mechanical and thermal hyperalgesia in endometriotic rats, outperforming the efficacy of A-317491 in its free salt form. Fig. 3 Schematic presentation of synthesis and magnetic hyperthermia effects of injectable magnetic hydrogel for treating endometriosis. A. Diagram showcasing the preparation of iron oxide and its incorporation into DMAP-27 antimicrobial peptide. B. Graphic representation of applied magnetic fields, which induces higher temperature at the endometrium tissue and triggers release for introducing anti-inflammatory activity. C-D. BMAP-27/Fe3O4@Gel + AMF (G5) treatment in significant reduction of endometriotic legions compared to other groups (G1-G4: PBS, AMF, BMAP-27/Fe3O4@Gel, and Fe3O4@Gel + AMF) in rat model. E-F. G5 treatment reduced volumetric alterations and TNF-α expression in H&E and immunohistochemistry assays. Reprinted with permission under the terms of the Creative Commons CC BY license from Ref.[ 50 ]. Copyright © 2024, The Author(s), Advanced Science published by Wiley-VCH GmbH. Fig. 3 Schematic presentation of synthesis and magnetic hyperthermia effects of injectable magnetic hydrogel for treating endometriosis. A. Diagram showcasing the preparation of iron oxide and its incorporation into DMAP-27 antimicrobial peptide. B. Graphic representation of applied magnetic fields, which induces higher temperature at the endometrium tissue and triggers release for introducing anti-inflammatory activity. C-D. BMAP-27/Fe3O4@Gel + AMF (G5) treatment in significant reduction of endometriotic legions compared to other groups (G1-G4: PBS, AMF, BMAP-27/Fe3O4@Gel, and Fe3O4@Gel + AMF) in rat model. E-F. G5 treatment reduced volumetric alterations and TNF-α expression in H&E and immunohistochemistry assays. Reprinted with permission under the terms of the Creative Commons CC BY license from Ref.[ 50 ]. Copyright © 2024, The Author(s), Advanced Science published by Wiley-VCH GmbH. Lipoxin A4 (LXA4), an essential endogenous specialized pro-resolving lipid mediator, resolves inflammation via the inhibition of immune cell recruitment and activation of macrophage efferocytosis of apoptotic cells. These actions regulate to terminate inflammatory responses. Chen team [ 42 , 43 ] had confirmed evidence of reduced LXA4 levels in endometriotic tissues disease, endometriosis progression and endogenous delivery of LXA4 shrinkage in endometriotic lesions in mice. BML-111 (LXA4 agonist) was tested to have similar effects in animal models [ 44 ]. To improve BML-111 therapeutic activity, a calcium carbonate nanoparticle system encapsulating BML-111 was developed to support an acid-sensitive release of therapeutic payload [ 45 ]. This formulation serves multifunctional purposes, acting as a calcium ion modulator, promoting efferocytosis (the macrophage-mediated clearance of apoptotic cells), inducing apoptosis in endometriotic stromal cells, enhancing macrophage efferocytosis, and delivering BML-111 directly to ectopic lesions to resolve inflammation (reduced inflammatory cytokine levels). Another multifunctional formulation comprised of cell-penetrating peptides including PepFect6 and NickFect70, work to deliver siRNAs for specific knockdown of key therapeutic targets (ribonucleotide reductase subunit M2, RRM2 and VEGF). This formulation led to reduced cellular proliferation, migration, and invasion of endometriotic cells [ 46 ]. In addition, these effects are synergistic when combined with the endometriosis drug danazol. Intraoperative adjuvant therapies (magnetic and photothermal therapy) applied during resection are proposed to improve surgical outcomes by eliminating residual, actively proliferating cells of endometriosis. These therapies stand out as a highly effective option due to their ability to selectively destroy endometrial cancer cells with heat generated by magnetic nanoparticles under an alternating magnetic field or photoactive agents activated by targeted light. These approaches offer significant potential to minimize post-surgical recurrence of endometriosis. For successful implementation of photothermal therapy in preclinical settings, Taratula team [ 47 , 48 ] had integrated imaging and therapeutic functions of nanoformulations to eradicate endometriosis after a single treatment. Their initial study introduced an activatable nanoplatform comprised of silicon 2,3-naphthalocyanine bis (trihexylsilyloxide) in poly(ethylene glycol)- b -poly(ε-caprolactone) (PEG–PCL) nanoparticles that remain non-fluorescent until internalized by endometriotic cells. Once internalized, they emit a strong NIR fluorescence signal, enabling accurate visualization of lesions. In addition, upon exposure to targeted NIR light, the nanoparticles generate heat, effectively ablating the lesions in in vitro and in vivo models [ 47 ]. The ability of formulation confirmed a successful accumulation in endometriotic tissue, provided a clear distinction from normal tissue during imaging, and achieved complete eradication of lesions through photothermal therapy. Upon treatment with this formulation in an endometriosis primate model (rhesus macaques), the demonstrated loss of estrogen and progesterone receptors in the remaining endometrium tissue suggests its superior actions. Similarly, an innovative injectable hydrogel formulation was composed of polydopamine (photothermal agent), letrozole (drug), and agarose (matrix) for the synergistic treatment of endometriosis through photothermal-enhanced endocrine therapy [ 49 ]. This hydrogel demonstrates a rapid gelation property (3 min) and exhibits robust near-infrared (NIR)-responsive behavior (treatment site increased local temperature sharply to 63.7 °C). The temperature-induced release of letrozole from the hydrogel system was nearly double. Notably, lesion volume significantly decreased in the AG-LTZ-PDA + NIR group (∼16 mm 3 ) compared to other groups (∼25 mm 3 ), underscoring the enhanced therapeutic efficacy achieved with NIR-mediated drug release. The hexagonal magnetic nanoparticle formulation embedded into PEG-PCL nanocarriers to target VEGFR-2 domains introduce high heating efficacy at endometriosis tissues [ 48 ]. The systemic delivery of these nanoparticles can produce therapeutic temperatures exceeding 50 °C, effectively ablating lesions. This study results demonstrated precise eradication of targeted endometriotic grafts while leaving adjacent grafts, located just 7 mm away, unaffected within the same mouse. Another therapeutic approach was developed by Liu et al., [50] based on an injectable magnetic (Fe 3 O 4 nanoparticles) hydrogel system integrating magnetothermal effects and anti-inflammatory therapy (antimicrobial peptide, BMAP-27) ( Fig. 3 ). This hydrogel formulation effectively targets endometriotic lesions and achieves localized hyperthermia, raising lesion temperatures to 63.3 °C, resulting in the ablation of ectopic endometrial cells. Simultaneously, due to the thermoresponsive property of the hydrogel, it ensures controlled release of BMAP-27, significantly reducing inflammatory markers such as TNF-α and modulating the inflammatory microenvironment. This approach can reduce 90 % of lesions due to precise lesion ablation with inflammation modulation, a highly promising, minimally invasive treatment strategy for endometriosis. Endometriosis involves abnormal immunological and inflammatory responses in the peritoneal environment, which promotes ectopic endometrial implantation. Elevated levels of CD4 + CD25 + Treg cells in peritoneal fluid are observed in women with endometriosis, where these cells maintain immune tolerance [ 51 ]. Immune checkpoint inhibitors (CPIs) like anti-Cytotoxic T-Lymphocyte-Associated Protein 4 (CTLA-4) target T cell regulation by blocking CTLA-4, a molecule expressed on activated T cells and Tregs. Anti-CTLA-4 antibodies have shown promise in limiting Treg activation and suppressor functions, as demonstrated preclinical tumor models, highlighting their potential for immune modulation in diseases like endometriosis. A study was carried out on PLGA/anti-CTLA-4 system that promotes the localization of anti-CTLA-4 to CD4 + CD25 + Treg cells, improving their bioavailability and immune regulation within the peritoneal fluid [ 52 ]. In an endometriosis mouse model, it significantly reduced Treg cell populations, suppressed ectopic endometrial cell proliferation and invasion, and downregulated IL-10 and TGF-β cytokines compared to a single anti-CTLA-4 treatment. Sustained delivery of anti-CTLA-4 from PLGA nanoparticles ensured prolonged efficacy, with greater suppression observed over time. A subsequent study explores the use of PLGA NPs to deliver CC chemokine receptor 5 antibody (anti-CCR5) to enhance its suppressive effect on macrophages in a mouse endometriosis model [ 53 ]. This nanoparticle system shows sustained release of anti-CCR5 over 24 days. Compared to free anti-CCR5, the nanoparticle system significantly reduced macrophage proportions, as well as the secretion of interleukin-10 (IL-10) and transforming growth factor-beta (TGF-β), which led to decreased proliferation and invasion of ectopic endometrial cells. Endometriosis shares malignant tumor-like features, and its microenvironment comprises epithelial, stromal, and immune cells, that are heavily influenced by macrophages. In this condition, the peritoneal fluid and lesion sites are abnormally elevated macrophages, predominantly exhibiting the dysfunctional M2 phenotype. This phenomenon promotes cell proliferation and invasion. These macrophages also secrete IL-10 and TGF-β, impairing NK cell function and inducing regulatory T cells (Tregs), thereby enabling immune escape. A study evaluated therapeutic potential of mifepristone loaded BSA nanoparticles in treating endometriosis [ 54 ] ( Fig. 4 ). This is a novel concept that targets endometrium compared to uterus tissue due to SPARC-mediated active recruitment ( Fig. 4 A–C). In vitro , it showed antiproliferative and pro-apoptotic effects on ectopic endometrial cells compared to free mifepristone, and induced immunogenic cell death (ICD) markers, such as calreticulin and High Mobility Group Box 1 (HMGB1), and effectively repolarized M2 macrophages to the pro-inflammatory M1 phenotype. In addition, it reduced endometriotic tissue volume and weight while presenting enhanced immune response by increasing the M1 macrophage population and promoting a Th1 immune shift with a higher CD8+/CD4+ T cell ratio ( Fig. 4 D–F). This treatment decreased regulatory T cells (Tregs) and improved the CTL/Treg ratio while reducing PD-L1+ cells in endometriotic tissues, alleviating the immunosuppressive microenvironment ( Fig. 4 F). Fig. 4 A novel concept of SPARC-mediated active endometrial tissue targeting and improving immunotherapy to treat endometriosis. A. Schematic representation of BSA@Mif NPs specific recruitment into endometriosis tissue not in the uterus due to SPARC-mediated targeting. B-C. Ex vivo confirmation in endometrium and uterus tissues after treating subcutaneous endometriosis-bearing mice with free DiR dye or BSA@DiR (B) and Mif or BSA@Mif (C). D. Superior therapeutic outcome of BSA@Mif over free Mif in endometriosis mouse model. E. BSA@Mif efficiently regulates the immune microenvironment of endometriosis. F. Immune associated markers such as macrophages, T cell regulation, and PD-L1 presentation of treatment groups. Reproduced with permission from Ref. [ 54 ]. Copyright 2024 Elsevier. Fig. 4 A novel concept of SPARC-mediated active endometrial tissue targeting and improving immunotherapy to treat endometriosis. A. Schematic representation of BSA@Mif NPs specific recruitment into endometriosis tissue not in the uterus due to SPARC-mediated targeting. B-C. Ex vivo confirmation in endometrium and uterus tissues after treating subcutaneous endometriosis-bearing mice with free DiR dye or BSA@DiR (B) and Mif or BSA@Mif (C). D. Superior therapeutic outcome of BSA@Mif over free Mif in endometriosis mouse model. E. BSA@Mif efficiently regulates the immune microenvironment of endometriosis. F. Immune associated markers such as macrophages, T cell regulation, and PD-L1 presentation of treatment groups. Reproduced with permission from Ref. [ 54 ]. Copyright 2024 Elsevier. Anti-angiogenic therapy is a promising approach for treating endometriosis. This therapy targets angiogenesis, a process crucial for the growth and maintenance of endometrial lesions. It inhibits VEGF-A, which is overexpressed in endometriotic lesions and promotes blood vessel formation to sustain lesion growth. Anti-angiogenic compounds (anti-VEGFA antibody, TNP-470, endostatin, and anginex) have shown efficacy in reducing lesion growth in EM. A non-viral carrier of RGD1-R6 peptide (targets αvβ3-expressing cells known overexpression on endothelial cells of ectopic endometrial lesions) complexed with anti-VEGFA siRNA for enhanced gene silencing efficiency (two-fold) and reduced endothelial cell migration (three-fold) [ 55 ]. This RGD1-R6 carrier facilitated effective siRNA delivery and penetration into endometriotic tissues in rat model. This treatment demonstrates potent anti-angiogenic effects that reduced lesion size and angiogenesis compared to dienogest (a commonly used drug for EM treatment). Similarly, hyaluronic acid modified nanovectors were employed to deliver beclin-1 [ 56 ] which is a regulator of autophagy. The role of beclin-1 includes regulating apoptosis and autophagy. This study suggests time dependent endocytose of these nanoparticles in endometrial stromal cells. Such construction enabled targeted delivery and accumulation at the site of ectopic cysts due to high CD44 expression in cystic tissues. Beclin-1 delivery through these nanoparticles significantly reduced the size, weight, and number of ectopic lesions. Furthermore, enhanced autophagy activity due to Beclin-1 delivery was confirmed by excessive autophagic vesicles observed under transmission electron microscopy. Another subsequent investigation delineated the specific delivery of silver nanoparticles with the help of PL1 peptide [ 57 ]. This specific peptide binds to tenascin C domain C (TNC-C) and fibronectin Extra Domain-B (Fn-EDB) that are expressed by endometriotic epithelial (12Z) and endometrial stromal cells (HESC). This carrier delivers potent antimitotic drug, monomethyl auristatin E, efficiently to 12Z and HESC, with even 30 nM inducing severe toxicity profiles both two- and three-dimensional (2D and 3D) culture models. This unique nanoplatform can be receptor targeting and theranostic potential in clinical samples. Neutrophils are considered a key component of the innate immune system and infiltrate in the systemic circulation and peritoneal fluid of endometriosis patients compared to healthy controls [ 58 , 59 ]. Considering this phenomenon, Zhu et al., [ 60 ] investigated the role of neutrophils carrying bovine serum albumin nanoparticles and selective enrichment in endometriotic lesions ( Fig. 5 ). Glucose oxidase (GOx)-loaded BSA nanoparticles for targeted glucose depletion in endometriotic lesions by preserving its enzymatic activity and glucose catalysis, enhanced stability compared to free GOx. This approach not only depletes glucose but generates hydrogen peroxide selectively in endometriotic lesions, while minimizing cytotoxicity. Fig. 5 Overview of serum based Gox nanoparticle approach for endometriosis treatment. A Representation of BSA self-assembly with GOx leading to BSA-Gox nanoparticles in the presence of a crosslinker. B. Schematic presentation of neutrophil enrichment in human and in mouse endometriosis lesions upon intraperitoneal administration. This treatment introduced glucose depletion that induces apoptosis of eutopic stromal cells. Reprinted with permission under the terms of the Creative Commons CC BY license from Ref. [ 60 ]. Copyright © 2023, The Author(s), published by Springer Nature. Fig. 5 Overview of serum based Gox nanoparticle approach for endometriosis treatment. A Representation of BSA self-assembly with GOx leading to BSA-Gox nanoparticles in the presence of a crosslinker. B. Schematic presentation of neutrophil enrichment in human and in mouse endometriosis lesions upon intraperitoneal administration. This treatment introduced glucose depletion that induces apoptosis of eutopic stromal cells. Reprinted with permission under the terms of the Creative Commons CC BY license from Ref. [ 60 ]. Copyright © 2023, The Author(s), published by Springer Nature. Endometriosis is a condition characterized by infiltrative growth without clear boundaries, which complicates surgical planning. In general, the use of optical systems based on reporter systems (encoded fluorescence or bioluminescence reporters) and adenoviral vector-mediated fluorescent labeling in vivo imaging have been implemented to image endometriosis. The conventional optical imaging is limited by low imaging depth and restricts its implementation. Magnetic resonance imaging (MRI) is a widely used non-surgical method for diagnosing endometriosis. Gadolinium (Gd) and magnetic nanoparticle-based contrast agents are commonly employed in MRI to improve the visibility of tissues. However, conventional Gd and MNPs based agents are non-targeting in nature in specific identification of endometriosis lesions. Therefore, Zhang et al., [ 61 ] designed a gadolinium based nanoformulation containing bevacizumab and fluorescence dye (NaGdF4@PEG@bevacizumab–Cy5.5, NPBCNs) to target VEGF, which is enriched in endometriosis lesions. These nanoparticles showed low cytotoxicity, high affinity for VEGF, and strong signal enhancement in MRI images of endometriosis lesions in rats. Histopathological and fluorescence imaging analyses further provide evidence and presence of these nanoparticles in endometriosis tissues. Iron-oxide-based dextran-coated magnetic nanoparticles conjugated with cRGD-peptide and NIR dye have been proposed for use in imaging of endometriotic lesions [ 62 ]. The selection of cRGD peptides (arginine-glycine-aspartic acid sequence) are targeting angiogenesis and cell adhesion by preferentially binding to the alpha(v)beta3 and alpha5beta1 integrins on endometriotic cells and endometriotic vasculature. In recent years, the application of photoacoustic imaging for detecting and monitoring endometriosis lesions has shown promising potential. This imaging technology leverages either endogenous or exogenous contrast agents to absorb light, generate thermal expansion, and emit sound waves, enabling high-contrast imaging based on differences in light absorption and thermoelastic properties. Such contrast imaging offers high sensitivity (93 %) and specificity (∼100 %) in subcutaneous endometriosis models. However, the hybrid nature of photoacoustic imaging, combining deep tissue penetration and high resolution, makes for a valuable noninvasive imaging tool for endometriosis detection and tracking. Toward this, a development of polydopamine embedded hyaluronic acid nanoparticles as the contrast agent for imaging and characterizing endometriosis lesions has been studied [ 63 ]. The photoacoustic signals were detected in the upper boundaries of lesions at various time points (2, 4, 8, 12, and 24 h post-injection) but peaked at 8 h. In addition, another approach combines photoacoustic and fluorescence imaging using gold-FITC nanoparticles for labeling syngeneic uterine tissue fragments in a mouse model of endometriosis [ 64 ]. This study results indicated that gold-FITC nanoparticles incubated with tissue fragments at various times (1–3 h) showed increased fluorescence intensity. Photoacoustic imaging revealed distinct regions of gold nanoparticle-labeled tissue of endometriosis lesions. In addition, FITC-positive lesions were visible in the peritoneal cavity of treated mice but absent in controls. Another novel technology was introduced based on an activatable nanoplatform featuring silicon 2,3-naphthalocyanine bis (trihexylsilyloxide) encapsulated within PEG–PCL nanoparticles for accurate visualization of endometriotic lesions [ 47 ]. Serum cancer antigen 125 (CA125) assay is considered the standard for diagnosing and monitoring epithelial ovarian cancer. Elevated CA125 levels are also observed in benign conditions like endometriosis, pelvic inflammatory disease, menstruation, and pregnancy. Toward this, Gidwani et al., constructed a nanoparticle-based lectin immunoassay [ 65 ] and europium nanoparticle-based sialyl-Tn monoclonal antibody assay [ 66 ] to distinguish cancer vs endometriosis conditions. An advanced label-free immunosensor was also developed by using electrochemical detection of CA125 [ 67 ]. The sensor was fabricated using a one-step electrochemical deposition of a gold nanoparticle and reduced graphene oxide nanocomposite. This sensor demonstrates a dynamic detection range of 0.0001–300 U/mL and an impressively low detection limit of 0.000042 U/mL. This method demonstrated results of CA125 levels of 20 U/mL in healthy patients while Stage I to IV patients with levels of 43, 55, 70, and 90 U/mL, respectively, consistent with ELISA. This immunosensor measuring interactions between immobilized antibodies and antigens not only exhibited high selectivity, stability, and reproducibility, but made it a reliable tool for clinical diagnostics. Endometrial cancer, the most common gynecologic malignancy in the US, is projected to affect 69,120 individuals in 2025, with 13,860 fatalities. Diagnosis typically involves transvaginal ultrasonography and endometrial biopsy, with hysteroscopy or dilation and curettage used for inconclusive cases. Standard treatment includes total hysterectomy with bilateral salpingo-oophorectomy, complemented by radiation or chemotherapy based on staging and histology. Emerging therapies, such as immunotherapy and targeted agents, offer promising options for advanced disease. Early detection and personalized treatment strategies remain key to improving outcomes, with ongoing research focusing on molecular characterization and precision medicine. This section is devoted to discussing various technical advances in the treatment and diagnosis of endometrial cancer. Metal and metal oxide-based nanoparticles have been previously implemented for therapeutic applications. To begin with Chinnathambi et al., [ 68 ] proposed the potent anti-human endometrial cancer properties of copper nanoparticles (Cu NPs) synthesized using Allium noeanum leaf extract. Its activity arises due to strong antioxidant activity. These NPs offered significant cytotoxicity against various human endometrial cancer cell lines, including Ishikawa, HEC-1-A, HEC-1-B, and KLE cell lines. However, the highest efficacy of NPs was observed in HEC-1-B cells (IC50 = 331 μg/mL). Additional studies highlight the promising role of nanomaterials combined with drug molecules in endometrial cancer therapy [ [69] , [70] , [71] ]. Thymoquinone-encapsulated selenium NPs exhibited a dose-dependent cytotoxic effect on HEC1B endometrial carcinoma cells by modulating the Mitogen-activated protein kinase (MAPK) signaling pathway, though further refinement is required to enhance their therapeutic potential [ 69 ]. Iron-based nMIL-100 NPs composited of metal-organic frameworks functioned as potent Fenton catalysts, generating ROS and depleting intracellular glutathione, thereby inducing oxidative stress in endometrial cancer cells [ 70 ]. However, the concurrent activation of mitophagy mitigated apoptosis, indicating that suppression of mitophagy could potentiate therapeutic efficacy. Furthermore, the combinatorial use of disulfiram and copper-cysteamine exhibited significant synergistic anti-tumor activity by inhibiting tumor progression, angiogenesis, and mitochondrial function both in vitro and in vivo [ 71 ]. An iron oxide-based NPs identified to deliver miR-326 to human endometrial carcinoma stem cells (HuECSC) [ 72 ]. This miR-contained NPs formulation significantly inhibited the in vitro proliferation, cell cycle progression, invasion, and angiogenesis of HuECSC. In vivo , this formulation further reduced tumorigenicity and neovascularization of HuECSCs xenograft in nude mice. Mechanistically, miR-326 targets the G protein-coupled receptor 91 (GPR91) gene, leading to the suppression of the GPR91/STAT3/VEGF signaling pathway, which is crucial for cancer stem cell maintenance. An initial report [ 73 ] promoted the potential use of synthetic polymeric nanoparticles to enhance paclitaxel (PTX) efficacy and induce lethality in uterine serous carcinoma. This carcinoma presents with loss-of-function p53 mutations. Polymer carriers are not only utilized for single drug molecule delivery but also for combination of dual drug delivery. The combination of PTX-loaded NPs and the antiangiogenic molecular inhibitor (BIBF 1120) effectively inhibited tumor progression and improved survival in a xenograft model, indicating this combination approach suitable for the treatment of p53-driven cancers. Metadherin (MTDH) acts as a key regulator of chemotherapy resistance through its RNA binding function, and its role in controlling Fanconi anemia complementation group DNA repair proteins [ 74 ]. This investigation further delineated the feasibility of inhibition of MTDH expression by treatment with pristimerin-loaded nanoparticles that effectively reduce FANCD2 and FANCI levels, in turn, restoring sensitivity to platinum-based therapy. In addition, a synergistic combination of crizotinib (CRZ) and gemcitabine (GEM) drug delivery was successful using a self-assembled tri-block copolymer PCL-b-PEG-b-PCL based nanoparticle [ 75 ]. Compared to free CRZ and GEM, the NPs formulation exhibited significantly higher cytotoxicity on Ishikawa and KLE cell lines (IC50: 11.16 μg/mL and 6.05 μg/mL, respectively). This behavior is attributed to improved cellular penetration and controlled drug release. Moreover, mitochondrial membrane potential disruption is a key mechanism for induction of apoptosis in cancer cells. Another example is a ciprofloxacin derivative nanoparticle formulation that exhibits a potent synergy in combination with paclitaxel against endometrial cancer [ 76 ] ( Fig. 6 A). The reason for such activity is enhanced tumor accumulation of drugs, reduced IC50, and increased G2/M cell cycle arrest in Hec50co cells. This combination therapy effectively slows down tumor progression and inhibits vascularization ( Fig. 6 B) without introducing additional systemic toxicity. Fig. 6 Superior pre-clinical performance of paclitaxel and CIP2b nanoparticles combination. A. Schematic portraits of CIP2b nanoparticles enhanced internalization, reduction of proliferation, and inhibition of vascularization. B. Enhanced action of paclitaxel with CIP2b nanoparticles confirmed by immunohistochemistry analysis. Mice treated with PTX + CIP2b NPs exhibited reduction in proliferating cells (confirmed by Ki67 staining, yellow arrows) and vascularization (determined by CD31 staining). Reprinted with permission under the terms of the Creative Commons CC BY license from Ref. [ 76 ], Copyright © 2023, The Author(s), Small published by Wiley-VCH GmbH. Fig. 6 Superior pre-clinical performance of paclitaxel and CIP2b nanoparticles combination. A. Schematic portraits of CIP2b nanoparticles enhanced internalization, reduction of proliferation, and inhibition of vascularization. B. Enhanced action of paclitaxel with CIP2b nanoparticles confirmed by immunohistochemistry analysis. Mice treated with PTX + CIP2b NPs exhibited reduction in proliferating cells (confirmed by Ki67 staining, yellow arrows) and vascularization (determined by CD31 staining). Reprinted with permission under the terms of the Creative Commons CC BY license from Ref. [ 76 ], Copyright © 2023, The Author(s), Small published by Wiley-VCH GmbH. A few other formulations that were formulated with MEK 1/2 inhibitor and paclitaxel [ 77 ] and pyruvate dehydrogenase kinase 1 (PDK1) inhibitor and metformin [ 78 ] offered synergistic anti-endometrial cancer activity both in vitro and in vivo . It was confirmed that metabolic reprogramming in hyperglycemic endometrial cancer cells, which was characterized by enhanced glycolysis and diminished oxidative phosphorylation. Proteomic analysis identifies PDK1 as a key driver of this shift. A nanoparticle formulation containing PDK1 inhibitor, JX06, combined with metformin (Met) was tested against human derived endometrial cancer cells ( Fig. 7 A). It was found that JX06-NPs + Met effectively suppresses proliferation. Additionally, JX06-NPs accumulate in tumors of diabetic EC-bearing mice and, in combination with Met, significantly inhibit tumor growth ( Fig. 7 B–C). The tumor regression is observed by the significant apoptosis confirmed in immunofluorescence analysis ( Fig. 7 D). These findings establish JX06-NPs and Met as a promising metabolic-targeted therapy for diabetic EC patients. Fig. 7 PDK1 inhibitor JX06 nanoparticles significantly persuade anticancer activity in patient derived cells and mouse models. A. Diagram of patients diagnosed with endometrial cancer at stage IA grade 2. Enlarged view of tumor tissues. B. Fluorescence based semiquantitative visualization of JX06 NPs accumulate in various organs. Both tumor and liver tissues are home for these nanoparticles. C . JX06 NPs combined with metformin (JX06-NPs + Met) exhibited considerable tumor size reduction in mice compared to free metformin, JX06-NPs, and JX06+Met alone groups. D. Representative H&E (cellular structure) and TUNEL (apoptosis symbol) in tumor tissues. A pronounced apoptosis potential is viewed by large number of green staining. Reprinted with permission under the terms of the Creative Commons CC BY license from Ref. [ 78 ]. Copyright © 2024, The Author(s), Advanced Science published by Wiley-VCH GmbH. Fig. 7 PDK1 inhibitor JX06 nanoparticles significantly persuade anticancer activity in patient derived cells and mouse models. A. Diagram of patients diagnosed with endometrial cancer at stage IA grade 2. Enlarged view of tumor tissues. B. Fluorescence based semiquantitative visualization of JX06 NPs accumulate in various organs. Both tumor and liver tissues are home for these nanoparticles. C . JX06 NPs combined with metformin (JX06-NPs + Met) exhibited considerable tumor size reduction in mice compared to free metformin, JX06-NPs, and JX06+Met alone groups. D. Representative H&E (cellular structure) and TUNEL (apoptosis symbol) in tumor tissues. A pronounced apoptosis potential is viewed by large number of green staining. Reprinted with permission under the terms of the Creative Commons CC BY license from Ref. [ 78 ]. Copyright © 2024, The Author(s), Advanced Science published by Wiley-VCH GmbH. Continuing, the clinical and biological significance of EZH2 overexpression in endometrial cancer is linked to poor patient outcomes [ 79 ]. Researchers observed that silencing EZH2 led to reduced tumor cell viability, invasiveness, and growth, along with enhanced sensitivity to chemotherapy drugs such as taxanes and cisplatin. These effects were observed by utilizing siRNA-loaded chitosan nanoparticles. All these findings suggest the promise of nanoparticle-based and combination treatment approaches in overcoming endometrial cancer resistance, paving the way for advanced therapeutic strategies with potential clinical applications. The use of lipid nanoparticles (LNPs) represents a promising alternative for delivery of therapeutics in endometrial cancer. Among these, RNA interference (RNAi)-based therapies utilizing LNPs, such as ALN-VSP, have demonstrated significant potential in silent oncogenic genes like VEGF and kinesin spindle protein, leading to tumor regression in endometrial cancer patients [ 80 ]. This reports the feasibility of RNAi therapeutics for clinical applications. Additionally, the encapsulation of tamoxifen within solid lipid nanoparticles (SLNs) has demonstrated a capacity to attenuate its estrogen agonist effects by downregulating the expression of ERα and VEGF-A genes in the endometrial tissue of ovariectomized female Sprague-Dawley rats. This targeted modulation effectively reduces oxidative stress and may lower the risk of endometrial carcinogenesis, indicating that SLN-based tamoxifen delivery offers a safer and more efficacious alternative as compared to conventional administration [ 81 ]. However, pharmacokinetic studies indicate that obesity influences mononuclear phagocyte system (MPS) function, which in turn affects the bioavailability and efficacy of nanoparticle-based therapeutics, such as PEGylated liposomal doxorubicin (PLD) [ 82 ]. Higher MPS activity in obese patients leads to reduced PLD exposure, necessitating dose adjustments to achieve optimal therapeutic outcomes. Another study investigates the use of lipid bubbles with ultrasound exposure to enhance delivery of chemotherapy in gynecological cancers, specifically endometrial cancer [ 83 ]. The bubble ultrasound-mediated drug delivery system was tested with cisplatin, pegylated liposomal doxorubicin, and bevacizumab. Both chemotherapy drugs showed significant tumor reduction when delivered via this lipid bubble formulation, with minimal side effects, whereas bevacizumab showed limited efficacy, offering a promising strategy for enhancing chemotherapy outcomes in endometrial cancer. New self-nanoemulsifying drug delivery systems were projected to preconcentrate raloxifene hydrochloride at the tumor site for modulating estrogen receptor for endometrial cancer prevention [ 84 ]. The drug formulation demonstrated the ability to carry and locally deliver the drug to the uterus, with prolonged retention facilitated by the first uterine pass effect. Ultrasound imaging before and after treatment showed significant regression of the EC tumor mass in the rabbit model. Localized delivery of lipids and liposome formulations have been implemented, including ultra deformable vesicles via the intravaginal route as a targeted drug delivery method for EC management [ 85 ]. Through this approach, carboplatin containing nanovesicles demonstrated the ability to carry and locally deliver the drug to the uterus, with prolonged retention facilitated by the first uterine pass effect. Ultrasound imaging before and after treatment showed significant regression of the EC tumor mass in the rabbit model. Another novel approach aimed at combining both an emulsifying drug delivery system and a polymeric microneedle system [ 86 ]. Such an advanced system was proposed to improve the delivery of progesterone through the skin in a controlled way. Progesterone is often used in hormone therapy to reduce the risk of endometrial cancer but often faces issues such as breaking down too quickly when taken orally and not dissolving properly enough for skin delivery. Such dual layered construct was able to penetrate the skin of pigs and release progesterone in a controlled manner over 82 h, which was much more effective than using just PG suspension or PG-emulsions. The release continued steadily for up to 15 days. Targeted delivery of therapeutic agents by nanoparticles evolved as a new way to treat endometrial cancer. A study by Chen et al., [ 87 ] facilitates targeted delivery of brusatol in lipid polymer nanoparticles utilizing glycosaminoglycan-placental chondroitin sulfate A binding peptide. This treatment effectively inhibited tumor cell proliferation, invasion, and migration by modulating key apoptotic and metastatic pathways, including BCL2, BAX, cleaved caspase-3, MMP-2, and MMP-9. Another study explored the use of AS1411 as a targeting moiety on AuNPs to deliver acridine orange derivative or imiquimod [ 88 ]. Such constructed NPs improved cellular uptake and cytotoxicity. Moreover, incorporating these nanoparticles into a PEG-based gel formulation for topical application in the female genital tract demonstrated promising retention in porcine vaginal epithelia. Folic acid decorated NPs were also found to be efficient in targeted delivery of PTX in endometrial carcinoma [ 89 ]. The FOL-targeted PTX NPs displayed superior cytotoxicity against HEC-1A cancer cells, likely through apoptosis induction, with in vivo studies confirming their efficacy. Histological analysis revealed no significant toxicity to the liver or kidneys. In another approach, hyaluronic acid was employed to target CD44-expressing endometrial cancer cells [ 90 ]. It offers specific delivery in 3D of tumor cells and showed enhanced cytotoxicity, improved nanoparticle internalization, deeper tumor penetration, and suppression of cell growth, cell cycle arrest, and EMT. CXCR-4 is a receptor that is often overexpressed in endometrial cancer, contributing to tumor growth, spread, and blood vessel formation. Targeting CXCR-4 has shown promise in improving treatment outcomes by blocking tumor cell movement and reducing the spread of cancer. Developing therapies that target CXCR-4, like small molecules or nanoparticles, could provide a more effective and precise way to treat endometrial cancer [ 91 , 92 ]. Medina-Gutiérrez confirmed a superior targeting of in vitro and in vivo subcutaneous endometrial cancer models utilizing CXCR4-targeted T22-GFP-H6 nanocarrier [ 91 ]. This team also demonstrated two variants of CXCR4-targeted nanoparticles, i.e., C. diphtheriae (T22-DITOX-H6) or P. aeruginosa (T22-PE24-H6) toxins capable of inducing apoptosis and significantly reducing tumor burden [ 92 ]. The T22-DITOX-H6 nanoparticle, particularly, showed strong efficacy in a highly metastatic EC orthotopic model, reducing metastasis in the peritoneum, lungs, and liver without causing off-target toxicity. Furthermore, dual-targeting and multivalent aptamers are promising strategies for improving drug delivery in endometrial cancer [ 93 ]. These aptamers, short single-stranded oligonucleotides, specifically bind to cancer cell markers, enabling targeted therapeutic delivery while reducing off-target effects, thereby enhancing treatment precision and efficacy. The platform effectively increased EC cell sensitivity to DOX by targeting the genetic regulation of drug responsiveness. Sentinel Lymph Node (SLN) mapping is a promising alternative to systemic lymphadenectomy for staging early-stage endometrial cancer, especially in low-risk patients. Detection rates vary by stage, histology, and technique, with various tracers such as technetium-99m, colloid and dyes, carbon nanoparticles and radiomics improving precision [ 21 ]. Further research is needed to optimize clinical applications. Collective clinical analysis encourages the use of carbon nanoparticles (CNPs) and carbon dyes as effective agents for SLN mapping in endometrial cancer [ [94] , [95] , [96] , [97] ]. CNPs, either alone or in combination with indocyanine green (ICG), achieve high detection rates and diagnostic accuracy, with cervical injections offering superior sensitivity over fundal injections [ 94 , 95 ]. The addition of ICG enhances SLN detection, particularly in laparoscopic and high-risk cases, while carbon dye presents a cost-effective, non-allergenic alternative suitable for low-resource settings [ 95 ] ( Fig. 8 A–B). SLN mapping with CNPs provides reliable lymphatic pathway visualization and high negative predictive values, making it a viable technique for endometrial cancer staging, particularly in early-stage patients [ 96 , 97 ]. Another study also reports that the overall detection rate of CNPs was 95 %, with no significant difference between the two cancer types [ 98 ]. The combined technique significantly improved bilateral detection rates compared to single tracers. Sensitivity and negative predictive values were highest when SLNs were bilaterally mapped, demonstrating the reliability of this approach for accurate lymph node assessment. Similarly, these CNPs can also exhibit increased SLN detection in the common iliac and para-aortic or precaval regions, whereas low-risk patients show higher SLN detection in the internal iliac areas [ 99 ]. These findings highlight the potential of carbon-based nanoparticles for improving lymph node assessment and guiding personalized treatment strategies in endometrial cancer. Fig. 8 Sentinel Lymph Node utilizing nanomaterials. Depiction of facilitation of lymph nodes and their vessels A. under natural light and B. using carbon nanoparticles in combination with indocyanine green. Reproduced with permission from Ref. [ 95 ], Copyright 2021 John Wiley and Sons. Fig. 8 Sentinel Lymph Node utilizing nanomaterials. Depiction of facilitation of lymph nodes and their vessels A. under natural light and B. using carbon nanoparticles in combination with indocyanine green. Reproduced with permission from Ref. [ 95 ], Copyright 2021 John Wiley and Sons. SLN mapping and emerging nanotechnology-based detection methods are revolutionizing the early diagnosis and staging of endometrial cancer [ [100] , [101] , [102] ]. Traditional biomarkers like squamous cell carcinoma antigens have been leveraged for enhanced biosensing using gold nanoparticles, significantly improving detection sensitivity [ 100 ] ( Fig. 9 A–C). Similarly, surface-enhanced Raman scattering (SERS) with silver nanoparticle-based plasmonic scaffolds has demonstrated high specificity in detecting extracellular vesicles (EVs), offering a rapid, label-free diagnostic platform [ 101 ]. Furthermore, SERS-based detection of epithelial-mesenchymal transition (EMT) markers, such as microRNA-200a-3p and ZEB1, utilizing silver nanoparticles modified with iodine and calcium ions, enables highly sensitive and stable molecular profiling [ 102 ] ( Fig. 9 D–F). These advancements highlight the growing potential of nanotechnology-driven approaches for precise and minimally invasive endometrial cancer detection, paving the way for improved diagnostic accuracy and targeted therapeutic interventions. Fig. 9 Serum and exosome-based detection assays are used to detect endometrial cancer. A-B. Ultrasensitive detection levels of SCC-Ag and SCC-Ag-gold nanoparticles in the range of 62.5 fm to 1pM antibody of 1 pM SCC-Ag by the methods. C. Depiction of comparison of two methods of detection. Reprinted with permission under the terms of the Creative Commons CC BY license from Ref. [100]. Copyright © 2022, The Author(s), published by John Wiley & Sons, Inc. D. Schematic representation of nanoparticle mediated detection enhancement of ZEB1 and miR-200a-3p. Differentiation of E. total RNA and F. total protein in principal component analysis for accurate detection of endometrial cancer. Reproduced with permission from Ref. [ 102 ], Copyright 2021 John Wiley and Sons. Fig. 9 Serum and exosome-based detection assays are used to detect endometrial cancer. A-B. Ultrasensitive detection levels of SCC-Ag and SCC-Ag-gold nanoparticles in the range of 62.5 fm to 1pM antibody of 1 pM SCC-Ag by the methods. C. Depiction of comparison of two methods of detection. Reprinted with permission under the terms of the Creative Commons CC BY license from Ref. [100]. Copyright © 2022, The Author(s), published by John Wiley & Sons, Inc. D. Schematic representation of nanoparticle mediated detection enhancement of ZEB1 and miR-200a-3p. Differentiation of E. total RNA and F. total protein in principal component analysis for accurate detection of endometrial cancer. Reproduced with permission from Ref. [ 102 ], Copyright 2021 John Wiley and Sons. Endometritis is an inflammatory condition of the endometrial lining, primarily triggered by microbial infections or immune dysregulation, with significant implications for reproductive health. It manifests in acute and chronic forms, each characterized by unique pathological and clinical features. Acute endometritis, commonly associated with postpartum infections or invasive uterine procedures, presents with symptoms and is typified by neutrophilic infiltration and micro abscess formation. In contrast, chronic endometritis is a largely asymptomatic condition, marked by plasma cell infiltration in the endometrial stroma, and is strongly associated with infertility, recurrent pregnancy loss, and other adverse reproductive outcomes. Bacterial pathogens such as Chlamydia , Ureaplasma , and Mycoplasma are key contributors to its etiology. However, the lack of standardized diagnostic protocols and clear clinical guidelines has hindered its routine evaluation in infertility assessments. Advancing research, including well-designed multicenter studies, is essential to deepen our understanding of its pathophysiology, establish consensus diagnostic criteria, and develop effective therapeutic approaches to enhance reproductive outcomes for affected individuals. A study by Murakoshi et al., [ 103 ] proposed that chlormadinone acetate (CMA) implantation can serve as a potential drug-delivery system, leveraging its antigonadotropic and glucocorticoid-like activities while mitigating progestogenic-induced histopathological changes in the uterus of female beagle dogs. In detail, this study proved that subcutaneous implantation of CMA in female beagle dogs effectively inhibited estrus, with no significant histopathological evidence of endometritis in the uterine tissues. However, the implantation resulted in cystic glandular hyperplasia but no other remarkable uterine alterations. Ovarian analysis revealed the presence of developing ovarian follicles, but no mature follicles or corpus luteum, indicating a suppression of normal ovarian function. Moreover, no notable changes were found in other organs such as the liver, adrenal glands, and mammary glands. Extensive literature emphasizes the importance of understanding the molecular pathogenesis of endometritis, particularly in relation to the role of Gram-negative and Gram-positive bacteria and their endotoxins [ 104 ]. The activation of cellular receptors, such as toll-like receptors (TLRs) and nucleotide-binding and oligomerization domain (NOD)-like receptors (NLRs), trigger inflammatory signaling pathways, including MAPK and nuclear factor kappa B (NF-κB), which contribute to the upregulation of pro-inflammatory cytokines. Chitosan, derived from chitin, is a biocompatible, biodegradable polysaccharide with significant potential in nanotechnology, particularly for drug delivery, tissue engineering, and antimicrobial applications. Recent development of a multifractal theoretical model to explain the dynamics of drug release from chitosan-based hydrogels containing an antimicrobial aldehyde was done [ 105 ]. The model incorporates scale transitions in scale space, linking experimental data to the release mechanisms. The model demonstrates prolonged release behavior, validated by in vitro experiments, and suggests the hydrogel is a promising alternative to traditional antibiotics for treating chronic endometrial conditions, such as intrauterine adhesions (IUAs) complicated by endometritis. Furthermore, a thermosensitive injectable chitosan/β-glycerophosphate hydrogels loaded with berberine and carvacrol were proposed for the treatment of endometritis [ 106 ] ( Fig. 10 ). The antimicrobial activity of these hydrogels was effective against reproductive infection caused by E. coli and S. aureus . In vivo, the hydrogels reduced bacterial load, alleviated infection-induced damage, and improved tissue safety without causing inflammation or pathological issues in the uterine tissues. Fig. 10 Improved pathological condition with thermosensitive injectable chitosan/β-glycerophosphate hydrogels loaded with berberine and carvacrol. Treatment groups are Control (Group I), S. aureus + E. coli (Group II, MOD), MOD + BBR/CAR-CS/β-GP (Group III), MOD + CS/β-GP (Group IV), BBR/CAR-CS/β-GP (Group V), and CS/β-GP (Group VI). A. Mice evaluation for their mental status. Dove staining and microscopic visualization of tissue sections of endometritis in mice. B. Percent organ coefficients of various treatment groups determined, C. H&E staining for representative mouse uterine, and D. Superior therapeutic benefit of CS/β-GP hydrogel containing berberine and carvacrol in mice bearing endometritis. The experiment was conducted in 3 mice for each group. Reproduced with permission from Ref. [ 106 ], Copyright 2024, American Chemical Society. Fig. 10 Improved pathological condition with thermosensitive injectable chitosan/β-glycerophosphate hydrogels loaded with berberine and carvacrol. Treatment groups are Control (Group I), S. aureus + E. coli (Group II, MOD), MOD + BBR/CAR-CS/β-GP (Group III), MOD + CS/β-GP (Group IV), BBR/CAR-CS/β-GP (Group V), and CS/β-GP (Group VI). A. Mice evaluation for their mental status. Dove staining and microscopic visualization of tissue sections of endometritis in mice. B. Percent organ coefficients of various treatment groups determined, C. H&E staining for representative mouse uterine, and D. Superior therapeutic benefit of CS/β-GP hydrogel containing berberine and carvacrol in mice bearing endometritis. The experiment was conducted in 3 mice for each group. Reproduced with permission from Ref. [ 106 ], Copyright 2024, American Chemical Society. Moreover, exosomes are small nano-vesicles involved in cell communication, carrying proteins, nucleic acids, and lipid bilayers. Exosomes are increasingly used in drug delivery applications due to their ability to load and release drugs. Additionally, exosomes offer advantages such as low toxicity, prolonged circulation, and targeted delivery to specific cells, making them effective for treating various disorders. Exosomes as a carrier was employed to deliver rosmarinic acid (RA) in the lipopolysaccharide (LPS)-induced endometritis condition [ 107 ]. The study results demonstrated that the RA-loaded exosome groups (RALExo and RA + Exo) improved pathological conditions, enhanced progesterone levels, and increased implantation rates. Additionally, gene expression of leukemia inhibitory factor (LIF), and Mucin-16 (MUC-16) were elevated, and inflammatory cytokines such as IL-18 were regulated. Together, these findings suggest that RA-loaded exosomes have a significant anti-inflammatory effect, improve implantation, and could be a potential treatment for endometritis. Adenomyosis is a gynecological disorder characterized by the ectopic presence of endometrial glands and stroma within the myometrium [ 108 , 109 ]. This condition often results in clinical manifestations such as chronic pelvic pain, abnormal uterine bleeding, and infertility. The pathophysiological mechanisms of adenomyosis closely resemble those of endometriosis. Transvaginal ultrasound and magnetic resonance imaging modalities have significantly improved its diagnostic accuracy. Adenomyosis is associated with adverse reproductive outcomes, including diminished pregnancy and live birth rates, as well as an increased risk of miscarriage. Effective management necessitates individualized strategies, particularly for patients with severe phenotypes who may require specialized care in tertiary centers. Exosomes are a category of biologically derived extracellular vesicles in nanomaterials. The role of adenomyosis-derived extracellular vesicles in promoting EMT in endometrial epithelial cells, a process implicated in the progression of adenomyosis [ 110 ]. In a study, exosomes isolated from 22 samples (11 healthy subjects and 11 women with adenomyosis), revealed 10 microRNAs with significantly altered expression in adenomyosis subjects (hsa-miR-132-5p, hsa-miR-99a-5p, hsa-miR-451a, hsa-miR-337-5p, hsa-miR-590-3p, hsa-miR-29c-3p, hsa-miR-144-3p, hsa-miR-7-5p, hsa-miR-431-3p, hsa-miR-1275) during the menstrual phase compared to controls [ 111 ]. A pilot study assessed the efficacy of the FibroPlant-levonorgestrel (LNG) intrauterine drug delivery system [ 112 ]. This system releases about 14 μg of levonorgestrel drug daily that can treat primary and secondary dysmenorrhea. This follow-up study in 18 women (aged 16–52) over 3–33 months, resulted in a significant reduction of menstrual pain and blood loss in all but except one participant with significant fibroids. Improvements were observed within one month, with no major hormonal side effects. In addition, Zhang et al., [ 113 ] investigated the therapeutic potential of a danazol-loaded intrauterine contraceptive device for adenomyosis. An adenomyosis animal model was established in mice grafted with pituitary glands, and IUCDs delivering varying doses of danazol were administered over a two-month period. The treatment demonstrated a dose-dependent reduction in adenomyosis nodules, with a statistically significant effect observed at a dose of 2.0 mg per 20 g body weight (P = 0.002). Compared to oral administration, IUCD-based delivery achieved consistently lower and more stable plasma danazol concentrations. Endometrial hyperplasia (EH), marked by an increased gland-to-stroma ratio, is a precursor to endometrioid endometrial carcinoma [ 114 ]. Chronic unopposed estrogen exposure is the primary risk factor, with contributors like obesity, polycystic ovarian syndrome, and Lynch syndrome. Protective measures include oral contraceptives and progesterone-releasing IUDs. Endometrial hyperplasia is classified as benign (without atypia) and atypical endometrial hyperplasia (endometrial intraepithelial neoplasia, EIN), with EIN carrying a higher risk of malignancy. Diagnostic challenges have spurred research into biomarkers and genomic tools to improve risk assessment. Management varies by risk and patient needs, with hysterectomy for high-risk cases and progestin therapies, including levonorgestrel IUDs, for others. Emerging therapies like metformin show promise but need further validation. Rising obesity rates have increased endometrial hyperplasia and endometrial hyperplasia prevalence, highlighting the need for personalized treatments and molecular diagnostics to improve outcomes. A review of efficient delivery of 17β-estradiol (E2) using PLGA micro- and nano-carriers were presented to benefit postmenopausal women [ 115 ]. E2 hormone therapy alleviates menopausal symptoms and enhances cognitive function, with the inclusion of progestogens, thus necessary to prevent endometrial hyperplasia in women with intact uteri. The PLGA nanocarriers enhanced therapeutic efficacy of E2 at the same mitigating side effects of endometrial hyperplasia. Following similar lines, piceatannol (a natural polyphenol) delivery using self-nanoemulsifying drug delivery system efficiently prevented the EH induced by estradiol benzoate in rats [ 116 ] ( Fig. 11 ). Piceatannol contained self-nanoemulsifying drug delivery systems reduced uterine weight and histopathological damage caused by epidermolysis bullosa, while promoting apoptosis and antioxidant activity in the endometrium. It also lowered inflammatory markers and increased antioxidant protein expression. Other work explored the effects of combining conjugated estrogen cream with progesterone in a rat model of hypoestrogenism [ 117 ]. The treatment increased uterine weight and endometrial thickness, along with changes in Cyclin D1 and VEGF expression. Progesterone co-administration reversed these effects in a dose-dependent manner, suggesting its protective role against estrogen-induced endometrial changes. The findings emphasize the importance of balancing estrogen and progesterone for managing menopausal symptoms and preventing endometrial hyperplasia. Fig. 11 Overview of piceatannol nanoemulsion (self-nanoemulsifying drug delivery system) attenuated estradiol-induced endometrial hyperplasia in rats. This treatment increased uterine weight and associated indices, while influencing anti-proliferative, proapoptotic, anti-inflammatory activities. Reprinted with permission under the terms of the Creative Commons CC BY license from Ref. [ 116 ]. Copyright © 2022, The Author(s), published by MDPI, Basel, Switzerland. Fig. 11 Overview of piceatannol nanoemulsion (self-nanoemulsifying drug delivery system) attenuated estradiol-induced endometrial hyperplasia in rats. This treatment increased uterine weight and associated indices, while influencing anti-proliferative, proapoptotic, anti-inflammatory activities. Reprinted with permission under the terms of the Creative Commons CC BY license from Ref. [ 116 ]. Copyright © 2022, The Author(s), published by MDPI, Basel, Switzerland. The use of combined estrogen and progestin therapy for women in late menopause, demonstrates benefits of reducing the risk of endometrial thickening. The commonly used methods of administering progesterone include intramuscular, transvaginal, and oral routes. A novel microneedles approach presented to improve the administration of progesterone [ 118 ]. It was developed by combining hydroxypropyl-β-cyclodextrin with progesterone complex method and then optimized for high drug loading and encapsulation. The microneedles were made with gelatin as the tip material, and polyvinyl alcohol or hydroxypropyl cellulose as backing layers. The prepared microneedles exhibited good mechanical strength, effective skin penetration, and high drug loading rates. In vitro experiments showed enhanced transdermal delivery of progesterone. Asherman's syndrome or intrauterine adhesions is a condition characterized by the formation of scar tissue within the uterine cavity [ 119 ]. Primarily due to endometrial trauma from uterine curettage, surgeries, infections, hysteroscopy, and uterine artery embolization. The symptoms of this situation can be menstrual irregularities (amenorrhea, hypomenorrhea), infertility, recurrent pregnancy loss, cyclic pelvic pain, and endometriosis. Primary diagnosis of intrauterine adhesions includes contrast sonohysterography or hysterosalpingography for initial evaluation, hysteroscopy for confirmation, with MRI for severe cases [ 120 ]. Primary treatment options involve hysteroscopic surgery under ultrasound or fluoroscopic guidance Post-operative care include balloon catheters or intrauterine devices to prevent re-adhesion, along with estrogen therapy for endometrial regeneration [ 121 ]. Prevention measures include minimizing uterine trauma and utilization of post-surgical measures like intrauterine devices. Emerging research has demonstrated that various types of mesenchymal stem cells have the potential to mitigate Asherman's syndrome and enhance reproductive outcomes by increasing the likelihood of successful pregnancy [ 122 ]. Therefore, Cervelló et al., [ 123 ] initially proved the therapeutic potential of human CD133+ bone marrow-derived stem cells labeled with magnetic nanoparticles for regenerating damaged endometrium in a murine model of Asherman's syndrome. This treatment approach significantly increased cell proliferation in the epithelial glands (intrauterine injection, proliferation rose from 14 % to 23.15 % and with tail vein injection, proliferation rose from 6.92 % to 20.55 %). Furthermore, these nanoparticle-labeled cells engrafted primarily around endometrial blood vessels in both injection routes, with intrauterine (0.59 %) and via tail vein (0.65 %), respectively. No evidence of off-target cell migration to other organs was observed. In addition, this treatment influenced paracrine signaling, upregulation of thrombospondin 1 (2.065-fold) and downregulation of IGF-1 (0.651-fold). In addition, a collagen-based scaffold embedded with umbilical cord-derived mesenchymal stromal cells to treat recurrent IUA has been clinically tested in a phase I clinical trial [ 124 ]. The key findings of this study shown serious adverse events noticed with increased maximum endometrial thickness, decreased intrauterine adhesion scores, and improved expression of biological markers. A significant outcome is that ten patients achieved pregnancy. Followed by a clinical pilot study, evaluation of the capability of collagen scaffold/umbilical cord mesenchymal stem cell transplantation to treat unresponsive thin endometrium caused by AS [ 125 ] ( Fig. 12 ). This approach led to an increase in endometrial thickness (4.08 ± 0.26 mm to 5.87 ± 0.77 mm), an increase in endometrial volume (1.00 ± 0.32 to 1.12 ± 0.56 cm 3 ), and a decrease in uterine artery blood flow resistance (S/D value 8.03 ± 2.31 to 6.53 ± 1.21). Such transplantation method enhanced endometrial cell growth (upregulated molecular markers, including Ki67, ERα, and PR) and vascular reconstruction (increased micro-vessel density and gland numbers). Fig. 12 Schematic depiction of chitosan (CS)-based umbilical cord-derived mesenchymal stem cell (UC-MSC) therapy for endometrial regeneration and fertility restoration. The CS scaffold serves as a bioengineered matrix, optimizing UC-MSC viability, proliferation, and paracrine signaling. Upon transplantation, UC-MSCs mediate endometrial repair by modulating immune responses, promoting angiogenesis, and facilitating epithelial regeneration. This regenerative strategy aims to restore endometrial thickness, enhance endometrial receptivity, and improve fertility outcomes in patients with endometrial insufficiency or uterine factor infertility. Reprinted with permission under the terms of the Creative Commons CC BY license from Ref. [ 125 ]. Copyright © 2021, The Author(s), published by Springer Nature. Fig. 12 Schematic depiction of chitosan (CS)-based umbilical cord-derived mesenchymal stem cell (UC-MSC) therapy for endometrial regeneration and fertility restoration. The CS scaffold serves as a bioengineered matrix, optimizing UC-MSC viability, proliferation, and paracrine signaling. Upon transplantation, UC-MSCs mediate endometrial repair by modulating immune responses, promoting angiogenesis, and facilitating epithelial regeneration. This regenerative strategy aims to restore endometrial thickness, enhance endometrial receptivity, and improve fertility outcomes in patients with endometrial insufficiency or uterine factor infertility. Reprinted with permission under the terms of the Creative Commons CC BY license from Ref. [ 125 ]. Copyright © 2021, The Author(s), published by Springer Nature. Abnormal uterine bleeding refers to irregular bleeding in terms of volume, frequency, duration, or timing. The extent of uterine bleeding varies based on age, its underlying causes, and reproductive goals. AUB in adolescents is often due to ovulatory dysfunction. Whereas in women over 40, including postmenopausal women, prompt evaluation is needed to diagnose the issue as uterine bleeding or association with malignancy (endometrial cancer). Endometrial ablation and hysterectomy are surgical options for persistent cases while in other cases polypectomy, myomectomy, or uterine artery embolization can be considered. The preferred medical treatment for uterine bleeding is levonorgestrel-releasing intrauterine system. Often, oral contraceptives, tranexamic acid, and NSAIDs are used to regulate bleeding and alleviate pain. Pelvic artery embolization serves as a vital intervention for acute uterine hemorrhage that fails to respond to medical or surgical treatments. This minimally invasive technique effectively halts bleeding, restores hemodynamic stability, and mitigates risks of hemorrhagic shock, organ dysfunction, and disseminated intravascular coagulation. A case study demonstrated the effectiveness of using super-selective catheterization of the right uterine artery to deliver micro-particles and absorbable hemostatic gelatin, successfully stopping the hemorrhage [ 126 ]. This approach facilitated a cervical myomectomy while preserving the uterus, with vascular imaging confirming the blockage of blood flow to the myoma. Ferric carboxymaltose is an effective, well-tolerated treatment for rapidly correcting iron deficiency and anemia associated with heavy uterine bleeding [ 127 ]. A randomized controlled trial concluded that intravenous ferric carboxymaltose was significantly more effective than oral ferrous sulfate in treating iron deficiency anemia caused by heavy uterine bleeding [ 128 ]. It resulted in greater hemoglobin increase (≥2.0 g/dL: 82 % vs. 62 %, ≥3.0 g/dL: 53 % vs. 36 %), higher anemia correction rates (73 % vs. 50 %), and improved quality of life, including reduced fatigue and enhanced vitality, with no serious adverse events. This pilot clinical trial aimed to evaluate the efficacy of vaginal micronized progesterone versus oral dydrogesterone in the management of irregular dysfunctional uterine bleeding [ 129 ]. This study was conducted in a total of 69 women (vaginal progesterone, n = 34 or oral dydrogesterone, n = 35 group). A total of 54 participants completed the three-month treatment. The analysis revealed no statistically significant differences between the two groups in suggesting that vaginal progesterone may serve as a viable alternative to oral dydrogesterone. Ostad et al., [ 130 ] investigated the use of hollow nylon fibers to deliver norethisterone and levonorgestrel for the treatment of dysfunctional uterine bleeding and menopausal symptoms. The fibers released norethisterone and levonorgestrel at average rates of 0.5 and 0.6 μg/day, respectively, over a 14-day period. Both progestogens demonstrated cytotoxicity to endometrial cells at concentrations around 5 μg/ml and potential teratogenicity at 10 μg/ml. However, the hollow fibers mitigated the cytotoxic effects of norethisterone, while levonorgestrel delivery did not alleviate endometrial toxicity and exacerbated fetal cell toxicity. Another study assessed the efficacy of Sulmycin® Implant E, a gentamycin-impregnated collagen sponge, in reducing morbidity in vaginal hysterectomy patients [ 131 ]. A total of 228 patients were assigned to receive either intravenous cefuroxime or the Sulmycin® Implant E. The outcome of this study results showed no significant differences in postoperative infections, hospitalization, wound healing, or cuff adhesion between the groups. The Sulmycin® Implant E was well tolerated and equally effective as intravenous antibiotics for local chemoprophylaxis. A follow-up randomized controlled trial evaluated to assess the efficacy of polyethylene oxide-sodium carboxymethylcellulose gel (Intercoat) in preventing de novo intrauterine adhesions following hysteroscopic surgery [ 132 ]. The study results indicated that the use of Intercoat gel led to a significant decrease in the incidence of de novo intrauterine adhesions (IUAs) (6 % vs. 22 %, p < 0.05) and a reduction in the severity of adhesions, with fewer cases of moderate and severe intrauterine adhesions in the Intercoat group (33 % vs. 92 %, p < 0.05). Furthermore, 41.9 % of patients treated with Intercoat exhibited improved patency of the internal uterine ostium, compared to 18.2 % in the control group, where patency worsened. Continuing, Han et al., [ 133 ] evaluated the efficacy of electrosprayed PLGA nanocapsules containing tiaojing zhixue compared to the direct use of Tiaojing Zhixue for treating dysfunctional uterine bleeding. In an 80-women group study, it was confirmed a significantly higher positive response in the PLGA nanocapsule group (75 %) compared to the direct use group (42.5 %). However, treatment groups exhibited similar side effect profiles. These findings highlight the superior effectiveness of PLGA nanocapsules over direct application, suggesting they offer a viable alternative treatment for dysfunctional uterine bleeding with no additional adverse effects.