Electroacupuncture Ameliorates Endometriosis-Associated Ovarian Dysfunction by Activating Nrf2 Pathway to Upregulate GPX4 Function and Inhibiting Ferroptosis

Background Endometriosis (EMs) often leads to ovarian dysfunction and infertility. Its mechanism is closely associated with oxidative stress and ferroptosis induced by pelvic iron overload. Electroacupuncture (EA) has potential in treating reproductive disorders, but its mechanism of action on ovarian ferroptosis in EMs remains unclear. This study aimed to investigate the protective effect of EA on ovarian function in an EMs mouse model and its underlying molecular mechanisms. Methods A mouse model simulating chronic hemorrhage in EMs was used. Mice were randomly divided into a Normal group, Sham group, EMs group, and EA group. Ovarian function (estrous cycle, ovarian weight/index, serum sex hormones, ovarian histopathology), iron metabolism levels (peritoneal fluid/ovarian Fe ² ⁺, ferritin, Prussian blue staining), oxidative stress levels (ovarian ROS, GSH content, T-SOD activity, Nrf2 and its downstream HO-1/SOD2/NQO1 mRNA), and ferroptosis levels (ferroptosis markers GPX4, SLC7A11, FTH1, ACSL4, COX-2 protein and mRNA, and MDA levels) were assessed using qRT-PCR, Western blot, IHC, colorimetric methods, and histochemistry. Results EA intervention significantly improved ovarian function in EMs mice. This was reflected in the normalization of the estrous cycle, increased ovarian weight/index, restored serum sex hormone levels, increased number of primordial follicles, and reduced atretic follicles. EA effectively alleviated ovarian iron overload (reduced Fe ² ⁺, ferritin, iron deposition) and oxidative stress (inhibited ROS, increased GSH, enhanced T-SOD activity). Mechanistically, EA activated the Nrf2 pathway (upregulated Nrf2, HO-1, SOD2, NQO1), upregulated key anti-ferroptosis molecules (GPX4, SLC7A11) and ferritin (FTH1). Furthermore, EA downregulated pro-ferroptosis factors (ACSL4, COX-2) and reduced lipid peroxidation (MDA). The results demonstrated that EA effectively blocked the ferroptosis process in ovarian granulosa cells by activating the Nrf2 pathway to upregulate GPX4 activity and suppressing ACSL4-mediated lipid peroxidation. Conclusions This study confirms that iron overload–oxidative stress–granulosa cell ferroptosis is a key pathological mechanism of EMs-induced ovarian damage. EA effectively inhibits ovarian granulosa cell ferroptosis by activating the Nrf2 pathway to upregulate GPX4 activity and suppress ACSL4-mediated lipid peroxidation, thereby ameliorating EMs-associated ovarian dysfunction. This provides important experimental evidence supporting EA as a complementary therapy for EMs-related infertility.