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Epigenetic modifications, including hypomethylation of ER and aromatase promoters, further sustain this estrogen-driven phenotype, with endocrine-disrupting chemicals (EDCs) such as dioxins and phthalates potentially exacerbating these epigenetic alterations ( Progesterone resistance, characterized by impaired progesterone receptor (PR) signaling despite bioavailable progesterone, perpetuates ectopic lesion survival and contributes to infertility ( The interplay of estrogen dominance and progesterone resistance disrupts endometrial homeostasis, directly impacting fertility

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In contrast, NAC, bearing a negative charge at physiological pH, demonstrates slower cellular uptake due to its N-acetyl group, which hinders both passive and active membrane transport

Therefore, regardless of the presence of neurological symptoms, SCD should be suspected in patients with skin hyperpigmentation, as the neurological manifestations can be a late finding [2]