Evaluation of microecological therapy in endometriosis through modulation of the gut microbiota

The current study was a retrospective analysis to evaluate the efficacy of microecological modulation as an adjunct to laparoscopic surgery in patients with endometriosis. A total of 187 female patients diagnosed with endometriosis between January 2022 and December 2023 were recruited. These patients were divided into two groups based on the treating strategies received: Control group, a surgery-only control group ( n  = 103); Combined group, a surgery plus microecological therapy group ( n  = 84). Additionally, 60 healthy women without endometriosis were included as a blank group for gut microbiota analysis. The inclusion criteria for the enrolled cases were as following: (1) women aged 18–45 years; (2) clinical and histological diagnosis of endometriosis confirmed via laparoscopy; (3) no previous treatment with probiotics or prebiotics in the past 3 months. Those who met the following criteria were excluded from the analysis: (1) History of gastrointestinal diseases; (2) presence of autoimmune diseases or significant metabolic disorders; (3) antibiotic or hormonal therapy within 3 months prior to enrollment; (4) pregnancy or lactation. The study was approved by hospital’s institutional review board, and all participants provided informed consent. All enrolled patients underwent standard laparoscopic surgery to excise endometriotic lesions followed by identical routine postoperative care, which included administration of standard analgesics (nonsteroidal anti-inflammatory drugs), a single prophylactic dose of cefuroxime (or clindamycin in penicillin-allergic patients) before surgery, early mobilization and gradual resumption of diet under nursing supervision, and wound care. No hormonal therapy or other disease-modifying drugs were prescribed during the follow-up period, to avoid potential confounding. In addition, patients in the combined intervention group received microecological therapy as described below, whereas the control group received routine postoperative care only. Patients in the intervention group received microecological therapy involving a synbiotic preparation consisting primarily of probiotics, including Bifidobacterium longum (1 × 10 9 CFU per capsule, Inner Mongolia Shuangqi Pharmaceutical Co., Ltd., Hohhot, China), Lactobacillus acidophilus (1 × 10 9 CFU per capsule, China National Biotec Group, Beijing, China), and Lactobacillus rhamnosus (1 × 10 9 CFU per capsule, Shanghai Sine Pharmaceutical Co., Ltd., Shanghai, China), and prebiotics, consisting of 800 mg inulin (Qingdao Bright Moon Seaweed Group Co., Ltd., Qingdao, China) and 200 mg fructooligosaccharides (FOS) (Shandong Bailong Chuangyuan Bio-Tech Co., Ltd., Dezhou, China) per daily dose [ 8 , 18 , 19 ], administered orally as two capsules once daily (probiotic dose 6 × 10 9 CFU; total prebiotic dose 1 g) for four consecutive weeks, beginning one day after surgery. The overall treating effects of different strategies were assessed through postoperative recovery indicators, including the time to first postoperative flatus, first bowel movement, early postoperative ambulation, postoperative complications such as constipation, diarrhea, and infection rates. A Visual Analog Scale (VAS) was used to evaluate pain symptoms, and patient quality of life was assessed using validated questionnaires administered before surgery and four weeks after treatment. Fecal samples were collected preoperatively, immediately postoperatively, and following four weeks of intervention. 16S rRNA sequencing was performed to profile gut microbiota composition. The total genomic DNA from fecal samples was extracted using the QIAamp DNA stool mini-kit (Qiagen Biotech Co., Ltd., Shanghai, China) according to the manufacturer’s instructions. The V3–V4 hypervariable regions of the bacterial 16S rRNA gene were amplified by PCR using 2 × Taq Master Mix (Tiangen Biotech Co., Ltd., Beijing, China), and sequencing was performed on the Illumina MiSeq platform (Illumina, San Diego, CA, USA; operated by Novogene Co., Ltd., Beijing, China). Sequencing data were processed using QIIME2 bioinformatics software (Qiime2 Development Group, USA) to determine bacterial diversity, taxonomy, and abundance. The relative abundance of specific beneficial ( Bifidobacterium , Lactobacillus , Bacteroides ) and harmful bacterial genera ( Enterobacteriaceae , Clostridium ) was quantified using SYBR Green qPCR Master Mix (Takara Biomedical Technology Co., Ltd., Beijing, China) in an ABI 7500 Real-Time PCR System (Applied Biosystems, Thermo Fisher Scientific, USA). The qPCR detection limit was approximately 10 2 copies/g stool. Blood samples were collected at baseline, immediately after surgery, and after the completion of microecological therapy. Serum levels of inflammatory markers including IL-6, TNF-α, and estradiol concentrations were measured using enzyme-linked immunosorbent assay (ELISA) kits (IL-6: Cat. No. ml002293; TNF-α: Cat. No. ml002095; Estradiol: Cat. No. ml057385; Jiangsu Meimian Industrial Co., Ltd., Yancheng, China) following standard protocols. Optical density was measured at a wavelength of 450 nm using Bio-Rad Model 680 Microplate Reader (Bio-Rad Laboratories, Hercules, CA, USA), and concentrations were calculated according to standard calibration curves provided by the kit manufacturers. The detection limits were 1.5 pg/mL for IL-6, 2.0 pg/mL for TNF-α, and 5 pg/mL for estradiol. The intra-assay and inter-assay coefficients of variation (CVs) were < 8% and < 10%, respectively. Intestinal permeability was evaluated by measuring serum Lipopolysaccharide (LPS) levels using ELISA kits ((Cat. No. ml058214; Jiangsu Meimian Industrial Co., Ltd., Yancheng, China). Blood samples were centrifuged at 3000 rpm for 10 min Eppendorf 5702R centrifuge (Eppendorf, Hamburg, Germany), and serum was separated and stored at − 80 °C until analysis. LPS concentrations were quantified via ELISA, following the manufacturer’s guidelines. The optical density was measured at 450 nm using a Bio-Rad Model 680 Microplate Reader (Bio-Rad Laboratories, Hercules, CA, USA), with concentrations calculated based on provided standards. The detection limit was 0.01 EU/mL for LPS. The intra-assay and inter-assay coefficients of variation (CVs) were < 8% and < 10%, respectively. Biopsy samples of intestinal mucosa were collected endoscopically during laparoscopic surgery and at the end of the 4-week intervention period. Tissue samples were homogenized in ice-cold phosphate-buffered saline (PBS) containing protease inhibitors and centrifuged at 10,000 g for 15 min at 4 °C using an Eppendorf 5424R centrifuge (Eppendorf, Hamburg, Germany). Supernatants were collected and stored at − 80 °C until further analysis. Protein expression levels of CD4, CD8, sIgA, IL-6, and TNF-α were quantitatively determined using enzyme-linked immunosorbent assay (ELISA) kits according to the manufacturer’s protocols (CD4: Cat. No. ml063221; CD8: Cat. No. ml063237; sIgA: Cat. No. ml057312; Jiangsu Meimian Industrial Co., Ltd., Yancheng, China). The optical density (OD) was measured at a wavelength of 450 nm using a Bio-Rad Model 680 Microplate Reader (Bio-Rad Laboratories, Hercules, CA, USA). Protein concentrations were calculated by comparing the obtained OD values with standard curves provided with each ELISA kit. The minimum detectable concentrations were 1.5 pg/mL for IL-6, 2.0 pg/mL for TNF-α, 0.5 µg/mL for sIgA, and 0.1 ng/mL for CD4/CD8. The intra-assay and inter-assay coefficients of variation were < 8% and < 10%, respectively. All statistical analyses were performed using SPSS software version 26.0. Data are presented as mean ± standard deviation (SD). Differences between groups were analyzed using Student’s t test or one-way ANOVA as appropriate. A p value < 0.05 was considered statistically significant.

As shown in Table  1 , there were no significant differences between the control group ( n  = 103) and the combined intervention group ( n  = 84) in terms of demographic and baseline clinical parameters, including age, BMI, disease stage, symptom duration, parity status, and prior surgical history. In addition, lifestyle- and health-related factors known to influence gut microbiota, such as habitual dietary patterns, level of physical activity, average sleep duration, psychological stress, recent antibiotic exposure, and concomitant medication use, were also comparable between groups, confirming that the two groups were well balanced at baseline, thereby minimizing the risk of confounding in the subsequent analyses. Table 1 Comparison of clinical parameters between groups Clinical parameters Control ( n  = 103) Combined ( n  = 84) p -value Age (years) 32.4 ± 5.6 31.9 ± 5.3 0.518 BMI (kg/m 2 ) 22.8 ± 2.7 22.5 ± 2.9 0.603 Disease stage (rASRM I–II/III–IV) 46/57 38/46 0.947 Duration of symptoms (years) 3.1 ± 1.7 3.3 ± 1.6 0.476 Parity (nulliparous, %) 56.3% (58/103) 59.5% (50/84) 0.662 Previous surgery for endometriosis (%) 12.6% (13/103) 14.3% (12/84) 0.751 Regular dietary pattern (balanced/high-fat/irregular, %) 47.6/28.2/24.3 50.0/27.4/22.6 0.891 Physical activity (≥ 150 min/week, %) 42.7% (44/103) 46.4% (39/84) 0.629 Average sleep duration ( 8 h, %) 19.4/65.0/15.5 20.2/63.1/16.7 0.978 Psychological stress (moderate–severe, %) 38.8% (40/103) 36.9% (31/84) 0.792 Recent antibiotic use (within 3 months, %) 9.7% (10/103) 8.3% (7/84) 0.752 Concomitant medication use (NSAIDs, %) 28.2% (29/103) 25.0% (21/84) 0.623 Time to first postoperative flatus (h) 22.5 ± 4.1 16.3 ± 3.2  < 0.001 Time to first bowel movement (h) 38.9 ± 6.5 28.4 ± 4.7  < 0.001 Early postoperative ambulation (h) 23.7 ± 5.3 18.1 ± 3.8  < 0.001 Postoperative constipation (%) 24.2% (25/103) 10.7% (9/84) 0.002 Postoperative diarrhea (%) 19.4% (20/103) 8.3% (7/84) 0.006 Postoperative infections (%) 12.6% (13/103) 4.8% (4/84) 0.021 VAS pain score (post-treatment) 3.6 ± 1.2 1.9 ± 0.9  < 0.001 Quality of life score (post-treatment) 62.7 ± 7.9 79.4 ± 6.8  < 0.001 Comparison of clinical parameters between groups Patients receiving microecological therapy also exhibited significant improvements in postoperative gastrointestinal function and clinical recovery indicators when compared with the surgery-only group (Table  1 ). Specifically, the microecological therapy group had significantly shorter times to first postoperative flatus (16.3 ± 3.2 h vs. 22.5 ± 4.1 h, p  < 0.001), earlier first bowel movements (28.4 ± 4.7 h vs. 38.9 ± 6.5 h, p  < 0.001), and reduced time to early postoperative ambulation (18.1 ± 3.8 h vs. 23.7 ± 5.3 h, p  < 0.001). Furthermore, the incidence rates of common postoperative complications such as constipation (9.6% vs. 26.9%, p  = 0.002), diarrhea (7.4% vs. 21.5%, p  = 0.006), and infections (4.3% vs. 14.0%, p  = 0.021) were markedly lower in the intervention group. Additionally, postoperative pain assessed via VAS scores was significantly lower (1.9 ± 0.9 vs. 3.6 ± 1.2, p  < 0.001), and quality of life scores were notably higher (79.4 ± 6.8 vs. 62.7 ± 7.9, p  < 0.001) in patients who received microecological therapy, indicating better clinical outcomes. Patients with endometriosis showed baseline intestinal dysbiosis characterized by significantly lower abundance of beneficial genera ( Bifidobacterium , Lactobacillus , and Bacteroides ) and elevated abundance of potentially harmful bacteria ( Enterobacteriaceae and Clostridium ) compared to healthy controls (Table  2 ). After 4 weeks of microecological intervention, the abundances of beneficial bacteria significantly increased ( Bifidobacterium: 8.85 ± 0.47 vs. 7.01 ± 0.62 log10 copies/g feces, Lactobacillus : 8.62 ± 0.42 vs. 6.74 ± 0.58 log10 copies/g feces, Bacteroides : 8.79 ± 0.53 vs. 7.32 ± 0.66 log10 copies/g feces; all p  < 0.001), approaching levels similar to healthy controls. Conversely, harmful bacterial genera significantly decreased in the treatment group ( Enterobacteriaceae : 6.92 ± 0.49 vs. 8.20 ± 0.51 log10 copies/g feces; Clostridium : 7.02 ± 0.44 vs. 8.31 ± 0.58 log10 copies/g feces; both p  < 0.001). These results demonstrate effective restoration of gut microbiota homeostasis through microecological therapy. Table 2 Changes in gut microbiota composition (log10 copies/g feces) Gut microbiota genera Healthy ( n  = 60) Control ( n  = 103) Combined ( n  = 84) p -value (post-treatment) Beneficial genera  Bifidobacterium 9.17 ± 0.53 7.01 ± 0.62 8.85 ± 0.47  < 0.001  Lactobacillus 8.93 ± 0.64 6.74 ± 0.58 8.62 ± 0.42  < 0.001  Bacteroides 9.05 ± 0.59 7.32 ± 0.66 8.79 ± 0.53  < 0.001 Harmful genera  Enterobacteriaceae 6.41 ± 0.57 8.20 ± 0.51 6.92 ± 0.49  < 0.001  Clostridium 6.53 ± 0.62 8.31 ± 0.58 7.02 ± 0.44  < 0.001 Changes in gut microbiota composition (log10 copies/g feces) Microecological therapy substantially reduced systemic inflammation and hormonal dysregulation observed in endometriosis patients (Table  3 ). After 4 weeks of treatment, serum levels of inflammatory cytokines IL-6 and TNF-α were significantly lower in the microecological therapy group compared to the surgery-only group (IL-6: 17.1 ± 4.7 vs. 25.9 ± 5.8 pg/mL, TNF-α: 25.2 ± 6.1 vs. 36.4 ± 7.3 pg/mL; both p  < 0.001). Similarly, serum estradiol levels, typically elevated in endometriosis, were significantly reduced in patients undergoing microecological therapy as compared to controls (91.4 ± 15.8 vs. 123.5 ± 21.6 pg/mL, p  < 0.001). These data indicate the potential role of gut microbiota modulation in alleviating systemic inflammation and hormonal imbalance in endometriosis patients. Table 3 Comparison of serum inflammatory markers and hormonal levels Markers Control ( n  = 103) Combined ( n  = 84) p -value IL-6 (pg/mL) 25.9 ± 5.8 17.1 ± 4.7  < 0.001 TNF-α (pg/mL) 36.4 ± 7.3 25.2 ± 6.1  < 0.001 Estradiol (pg/mL) 123.5 ± 21.6 91.4 ± 15.8  < 0.001 Comparison of serum inflammatory markers and hormonal levels Improvement in intestinal barrier integrity was evidenced by significant decreases in serum lipopolysaccharide (LPS) levels following microecological therapy (Table  4 ). Before treatment, serum LPS levels were similar between groups. However, after 4 weeks, patients receiving microecological therapy showed notably reduced LPS concentrations compared with the surgery-only group (1.06 ± 0.19 vs. 1.41 ± 0.23 ng/mL, p  < 0.001). These findings suggest that the synbiotic treatment effectively reduced intestinal permeability and strengthened intestinal barrier function in patients with endometriosis. Table 4 Serum lipopolysaccharide (LPS) levels pre- and post-treatment LPS (ng/mL) Control ( n  = 103) Combined ( n  = 84) p -value Pre-treatment 1.48 ± 0.25 1.50 ± 0.27 0.619 Post-treatment 1.41 ± 0.23 1.06 ± 0.19  < 0.001 Serum lipopolysaccharide (LPS) levels pre- and post-treatment Microecological therapy notably improved intestinal mucosal immune function in endometriosis patients, as indicated by significant changes in mucosal immune markers measured by ELISA (Table  5 ). Post-treatment analysis demonstrated a significant increase in the concentrations of beneficial immune markers such as CD4 + T lymphocytes (425.8 ± 38.9 vs. 312.6 ± 45.2 pg/mL, p  < 0.001) and secretory IgA (sIgA, 59.8 ± 9.4 vs. 42.3 ± 8.1 μg/mL, p  < 0.001). Conversely, the expression of inflammatory-related markers, including CD8 + T lymphocytes (297.6 ± 41.7 vs. 398.3 ± 52.4 pg/mL, p  < 0.001), IL-6 (56.9 ± 7.8 vs. 84.5 ± 10.3 pg/mL, p  < 0.001), and TNF-α (72.5 ± 10.6 vs. 103.2 ± 14.2 pg/mL, p  < 0.001), significantly decreased in the treatment group compared to controls. These results provide strong evidence of an enhanced mucosal immune response following microecological therapy. Table 5 Mucosal Immune Markers in Intestinal Tissue Post-treatment Immune markers Control ( n  = 103) Combined ( n  = 84) p value CD4 + T lymphocytes (pg/mL) 312.6 ± 45.2 425.8 ± 38.9  < 0.001 CD8 + T lymphocytes (pg/mL) 398.3 ± 52.4 297.6 ± 41.7  < 0.001 sIgA (μg/mL) 42.3 ± 8.1 59.8 ± 9.4  < 0.001 IL-6 (pg/mL) 84.5 ± 10.3 56.9 ± 7.8  < 0.001 TNF-α (pg/mL) 103.2 ± 14.2 72.5 ± 10.6  < 0.001 Mucosal Immune Markers in Intestinal Tissue Post-treatment

In this retrospective study, we evaluated the therapeutic efficacy of microecological therapy in conjunction with surgical management for endometriosis. Our findings demonstrate that the addition of microecological therapy improved postoperative recovery outcomes, reduced systemic inflammation, normalized intestinal barrier function, restored gut microbiota balance, and enhanced mucosal immunity compared to standard management after surgery. These results provide valuable information for more comprehensive exploration regarding the role of gut microbiota modulation through probiotics and prebiotics in the treatment of endometriosis. Consistent with the previous studies, our analysis revealed significant gut microbiota dysbiosis in patients with endometriosis prior to intervention. Specifically, we observed reduced abundances of beneficial microbiota such as Bifidobacterium , Lactobacillus , and Bacteroides , accompanied by increased levels of potentially harmful genera including Enterobacteriaceae and Clostridium . These observations align with Qin et al. (2022), who reported a similar pattern of gut microbiota imbalance in endometriosis patients, emphasizing that dysbiosis may be a hallmark of the disease [ 7 ]. The beneficial effects observed in our cohort are likely mediated through several interconnected mechanisms rather than a single monogenic pathway. First, microecological therapy may contribute to the inhibition of heterotopic lesion growth by regulating estrogen metabolism. Dysbiosis in endometriosis is associated with increased β-glucuronidase activity, which promotes enterohepatic recirculation of estrogens and sustains ectopic endometrial proliferation [ 8 ]. Probiotic strains such as Bifidobacterium and Lactobacillus can suppress this enzymatic activity, thereby restoring balanced estrogen metabolism and reducing the survival advantage of heterotopias [ 20 ]. Second, microecological therapy exerts a potent anti-inflammatory effect. Endometriosis is characterized by persistent elevation of IL-6, TNF-α, NF-κB, and oxidative stress mediators [ 4 ]. Animal and clinical studies have shown that synbiotics attenuate TLR4/NF-κB signaling and reduce systemic pro-inflammatory cytokines [ 21 ]. These findings align with our observation of reduced serum inflammatory markers after intervention. Third, accumulating evidence highlights the role of the microbiota–gut–brain axis in pain sensitization. Dysbiosis enhances visceral hypersensitivity and central sensitization via modulation of neurotrophic factors such as brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) [ 6 ]. Probiotic supplementation has been shown to alter neurotransmitter metabolism (e.g., serotonin, GABA) and microglial activation, thereby reducing nociceptive signaling and improving pain outcomes [ 8 ]. Finally, synbiotics improve immune regulation at the mucosal level. Enhanced sIgA secretion and a restored CD4 +/CD8 + balance strengthen intestinal and systemic immunity, mitigating the autoimmune-like features of endometriosis [ 20 ]. Furthermore, our retrospective findings support the hypothesis presented by Uzuner et al. (2023), suggesting a bidirectional relationship between endometriosis and gut microbiota [ 6 ]. Taken together, these mechanisms suggest that microecological therapy is not a curative monotherapy but a promising adjunctive approach that modulates hormonal, immune, inflammatory, and neurogenic pathways. This multidimensional action may explain the symptomatic improvements observed in our study, while long-term management of chronic endometriosis still requires integrated multimodal strategies. Importantly, the clinical outcomes of our patients improved with the use of microecological therapy, characterized by shorter gastrointestinal recovery times, lower incidences of postoperative complications, decreased postoperative pain levels, and enhanced quality of life. These outcomes are supported by recent reviews indicating that microbiota-targeted therapies can ameliorate gastrointestinal symptoms and pain in patients with chronic inflammatory conditions such as endometriosis [ 22 , 23 ]. França et al. (2022) and Taylor et al. (2021) emphasized that the alleviation of endometriosis-related pain and inflammation could be closely linked to the reduction of circulating inflammatory markers like IL-6 and TNF-α [ 4 , 5 ]. Correspondingly, our retrospective results clearly demonstrate reduced systemic levels of these inflammatory cytokines following microecological intervention, thereby explaining the potential mechanistic role of gut microbiota modulation in reducing systemic inflammation and pain sensitization associated with endometriosis. Another significant finding was the improvement in intestinal barrier integrity following treatment. Elevated serum lipopolysaccharide (LPS), indicative of increased intestinal permeability (“leaky gut”), has been previously associated with heightened systemic inflammation and endometriosis severity [ 24 , 25 ]. Xholli et al. (2023) highlighted impaired intestinal permeability as a critical contributor to inflammation in endometriosis and postulated that probiotic treatments could repair this barrier dysfunction [ 8 ]. Our retrospective data align closely with this hypothesis, showing significantly reduced serum LPS levels post-treatment, reflecting improved intestinal barrier function and potentially contributing to decreased systemic inflammation. A novel aspect of our study was the evaluation of intestinal mucosal immunity. We observed significant enhancements in mucosal immune markers, including increased CD4 + T lymphocytes and secretory IgA (sIgA), along with reductions in CD8 + T lymphocytes and pro-inflammatory cytokines within mucosal tissues after microecological therapy [ 26 ]. The previous studies also noted similar improvements in intestinal mucosal immunity after microbiota-targeted treatments, suggesting that gut flora manipulation can enhance local immune regulation and reduce inflammation [ 17 , 27 ]. The present study extends these observations and highlights the significant immune-modulatory effects achievable through probiotic and prebiotic interventions. Despite these promising outcomes, our study has several limitations inherent to its retrospective nature. First, although we demonstrated significant short-term benefits of microecological therapy, the long-term effects and durability of these outcomes remain unclear due to the absence of extended follow-up data. Future prospective, randomized clinical trials with extended observation periods are warranted to confirm these benefits over time. Second, our retrospective analysis may have been subject to inherent biases, such as patient selection bias, incomplete data records, and variations in clinical practices, which could have influenced outcomes. Although strict inclusion and exclusion criteria were applied, potential confounding variables such as diet, lifestyle, and compliance with the intervention could not be entirely controlled. Third, our study focused exclusively on one particular synbiotic formulation containing specific strains of probiotics. Therefore, generalizability to other probiotic and prebiotic products requires further exploration. Fourth, detailed analyses of mechanisms by which gut microbiota influences hormonal regulation, inflammation signaling pathways, or specific immune cells at molecular and cellular levels were beyond the scope of our study and should be addressed in subsequent mechanistic research. Finally, although our results demonstrated significant improvements with microecological therapy, it should be noted that not all patients responded equally, and a subset continued to report persistent symptoms despite intervention. Moreover, potential adverse effects of the synbiotic formulation were not systematically assessed in this retrospective study, limiting our ability to evaluate its safety profile. The short 4-week follow-up does not allow conclusions about the durability of treatment effects, underscoring the need for longer prospective trials with structured monitoring of both efficacy and safety. In summary, this retrospective analysis provides strong evidence that microecological therapy enhances clinical outcomes for patients with endometriosis undergoing laparoscopic surgical management. Through modulation of gut microbiota, reduction in systemic inflammation, improvement of intestinal barrier integrity, and restoration of mucosal immunity, microecological therapy represents a promising adjunctive strategy for endometriosis management. These findings complement and extend the existing literature, emphasizing the role of gut microbiota as an integral component of endometriosis pathology and treatment. Large scale, prospective randomized controlled trials with diverse microbiota-targeted interventions and longer-term follow-up are essential to validate these benefits further and establish standardized protocols for clinical practice.

Endometriosis is an estrogen-dependent chronic inflammatory condition characterized by the presence of endometrial-like tissue outside the uterine cavity, commonly affecting pelvic organs and resulting in significant morbidity, including chronic pelvic pain, dysmenorrhea, dyspareunia, dyschezia, and infertility [ 1 ]. This disease affects approximately 6–10% of reproductive-aged women globally and significantly diminishes the quality of life through severe pain and impaired fertility, resulting in substantial physical, psychological, and economic burdens [ 2 , 3 ]. The complexity of the disease is highlighted by its heterogeneous clinical presentation and the variety of tissues and organs involved, which complicates timely and accurate diagnosis and management [ 4 , 5 ]. The exact pathogenesis of endometriosis remains unclear; however, several hypotheses have been proposed, including retrograde menstruation, coelomic metaplasia, lymphatic and vascular metastasis, immune dysfunction, as well as genetic and epigenetic predisposition. Retrograde menstruation theory, the most widely accepted, suggests that viable endometrial cells flow backward through the fallopian tubes during menstruation and implant on the peritoneum, leading to lesion formation [ 4 , 6 ]. Nonetheless, retrograde menstruation occurs in a large proportion of menstruating women without leading to endometriosis, indicating other contributing factors such as immune dysfunction and genetic predisposition [ 5 , 7 ]. The recent research has increasingly pointed towards the significant role of gut microbiota dysbiosis in the pathogenesis of endometriosis. The gut microbiota, composed predominantly of Firmicutes , Bacteroidetes , and Proteobacteria , plays critical roles in maintaining intestinal barrier function, regulating immune response, and modulating estrogen metabolism [ 7 , 8 ]. Dysbiosis of gut microbiota, characterized by a reduction in beneficial bacteria such as Bifidobacterium and Lactobacillus , and an increase in pathogenic bacteria including Enterobacteriaceae and Clostridium , has been identified in patients with endometriosis. Such dysbiosis contributes to chronic systemic inflammation and disrupted estrogen metabolism, promoting endometrial cell survival and ectopic proliferation [ 7 – 10 ]. Moreover, alterations in gut microbiota have been linked to increased intestinal permeability or “leaky gut”, allowing bacterial endotoxins such as lipopolysaccharides (LPS) to enter systemic circulation [ 11 ]. This translocation significantly exacerbates inflammatory responses through activation of immune pathways, such as the nuclear factor kappa-B (NF-κB) pathway, and elevates the release of pro-inflammatory cytokines like IL-6, TNF-α, and VEGF [ 12 ]. These inflammatory markers have been shown to facilitate lesion growth, vascularization, and the symptomatic manifestation of pain, further complicating the clinical picture of endometriosis [ 7 ]. In addition, gut microbiota influences estrogen metabolism by modulating the enterohepatic circulation of estrogens [ 13 ]. Gut bacteria are responsible for the deconjugation and reactivation of estrogens through the enzymatic activity of β-glucuronidase, increasing estrogen reabsorption and circulating estrogen levels [ 14 ]. This enhanced estrogenic environment can exacerbate endometriosis by stimulating the growth and proliferation of ectopic endometrial tissues. Given the integral role of gut microbiota in inflammation and hormone regulation, microecological therapy—particularly the administration of probiotics and prebiotics—has emerged as a promising therapeutic approach [ 15 , 16 ]. Clinical evidence suggests that probiotics can significantly improve gut microbiota composition, decrease inflammatory cytokines, and reduce lesion size in animal models and preliminary human studies. For instance, Bifidobacterium and Lactobacillus may help restore a healthy balance in gut microbiota, reducing systemic inflammation, normalizing estrogen metabolism, and potentially alleviating symptoms associated with endometriosis [ 17 ]. Nevertheless, comprehensive clinical evidence remains limited, and there is a significant knowledge gap regarding the specific mechanisms through which microecological therapy may exert beneficial effects on endometriosis. Thus, we hypothesize that microecological therapy exerts its therapeutic effects by restoring gut microbiota balance, reducing intestinal permeability, mitigating systemic inflammation, and normalizing estrogen metabolism. We postulate that restoring gut microbial equilibrium will reduce inflammatory responses, lower circulating estrogen levels, and consequently alleviate clinical symptoms and potentially decrease the recurrence rate of endometriosis after laparoscopic surgery. The present study aims to evaluate the clinical efficacy of microecological therapy as an adjunct to laparoscopic surgery in patients with endometriosis, by assessing not only gastrointestinal recovery and postoperative outcomes, but also systemic inflammatory and immune parameters, local hormonal changes, and intestinal microecological balance. By comparing changes in gut microbiota, inflammatory markers, and clinical outcomes pre- and post-microecological therapy, our research will provide critical insights into the utility of this therapeutic strategy.