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Additionally, estrogen-stimulated cyclooxygenase-2 (COX-2) activity drives prostaglandin E2 (PGE2) synthesis, creating a positive feedback loop that enhances local estrogen production and inflammation, further facilitating ectopic implantation ( 2.2 Immune system dysfunction and chronic inflammation Immune system dysfunction and chronic inflammation are central pathological features underlying endometriosis-associated infertility, characterized by aberrant immune cell activation, cytokine dysregulation, and impaired immune surveillance

The purported primary mechanisms are increased estrogen processing, meaning preventing gynecomastia in the first place