Endometriosis Surgery Becomes More Complex With Older Age Despite Plateauing Severity, Study Finds

Endometriosis severity appeared to level off after early adulthood, but the complexity and burden of surgery continued increasing with age, according to a large study that highlighted how the disease may evolve differently over time.¹

Investigators analyzed more than 1200 patients with pathology-confirmed endometriosis and found that advanced disease severity plateaued after early adulthood, while the technical difficulty of surgery continued increasing into later reproductive years. The authors said the findings suggested that fibrosis, adhesions, and anatomical distortion may continue accumulating even when the disease stage itself stabilizes.

The retrospective cohort study, published in the journal Fertility and Sterility, evaluated 1293 patients aged 18 to 51 years who underwent laparoscopic or robot-assisted surgery for endometriosis at a US quaternary care center between 2013 and 2023. Researchers stratified patients into 4 age groups: 25 years or younger, 25 to 35 years, 35 to 45 years, and older than 45 years.

Endometriosis affects an estimated 10% of women worldwide, although symptoms often begin much earlier in life. A recent review highlighted that endometriosis in perimenopausal and postmenopausal patients has historically been underrecognized because the condition has long been viewed as a disease limited to reproductive-age women.²

However, emerging evidence suggests that endometriosis can persist—or in some cases newly present—later in life, even after declining estrogen levels associated with menopause. Researchers noted that symptoms in older patients may differ from the classic cyclical pelvic pain seen in younger populations, contributing to delayed diagnosis and missed opportunities for treatment. The review also emphasized that fibrosis, adhesions, and chronic inflammation may continue affecting quality of life in older patients, reinforcing the importance of age-specific management strategies for endometriosis care.

Additionally, prior studies have produced conflicting findings on whether the condition steadily worsens with age or instead stabilizes after adolescence or early adulthood.¹ To address those uncertainties, the investigators of the present analysis used the American Association of Gynecologic Laparoscopists (AAGL) classification system to examine both disease stage and surgical complexity across age groups.

The cohort was predominantly composed of patients aged 35 to 45 years (43.6%), followed by those aged 25 to 35 years (37.7%). Patients 25 years or younger accounted for 8.4% of the cohort, while 10.2% were older than 45 years.

Pain-related symptoms were more common among younger patients. Dysmenorrhea affected 91.7% of patients 25 years or younger compared with 78.8% of patients older than 45 years. Gastrointestinal symptoms were also more frequent among younger individuals, affecting 63.3% of the youngest group vs approximately 41% of the older groups. Noncyclic pelvic pain was reported by nearly half of patients aged 25 years or younger.

At the same time, infertility became a more common surgical indication with age. Only 0.9% of the youngest group underwent surgery primarily for infertility, compared with 25% of patients aged 35 to 45 years.

Operative findings revealed substantial age-related differences in disease burden. Stage 3 or 4 endometriosis was identified in 18.3% of patients aged 25 years or younger, compared with 44.5% of those aged 25 to 35 years and 50.5% of those aged 35 to 45 years. Prevalence then plateaued at 47% among patients older than 45 years.

Multivariable analysis showed significantly higher odds of advanced disease among all older age groups compared with patients younger than 25 years. Patients aged 25 to 35 years had an adjusted OR (AOR) of 2.47 for stage 3 or 4 disease, while those aged 35 to 45 years had an AOR of 2.54, and those older than 45 years had an AOR of 2.84.

However, surgical complexity continued rising beyond the age at which the disease stage appeared to stabilize. AAGL level C surgical complexity increased from 21.1% in the youngest group to 58.3% among patients older than 45 years. Compared with patients younger than 25 years, those aged 35 to 45 years had more than double the odds of undergoing high-complexity surgery (AOR, 2.13), while patients older than 45 years had more than quadruple the odds (AOR, 4.46).

“Association of Gynecologic Laparoscopists disease stage peaks around the ages of 25-35 years and subsequently plateaus, whereas surgical complexity continues to increase beyond this age, reaching the highest odds in patients aged >45 years, likely reflecting cumulative fibrosis, adhesions, and anatomical remodeling,” the authors wrote.

The prevalence of endometriomas also increased with age. Endometriomas were present in 15.6% of patients aged 25 years or younger compared with 40.6% of those aged 35 to 45 years. Investigators found no statistically significant association between age and bowel endometriosis after adjustment for confounding variables.

Surgical burden also increased with age. Mean surgery time rose from approximately 126 minutes in the youngest patients to more than 213 minutes among those older than 45 years. Estimated blood loss and length of hospital stay also increased across age groups. Overall complication rates were highest among patients older than 45 years at 12.1%.

The authors said the findings could support more individualized treatment strategies across the lifespan. Younger patients with significant symptoms may benefit from earlier intervention, whereas mildly symptomatic older patients could potentially be managed more conservatively. Surgeons treating older patients may also need to anticipate greater operative complexity because of fibrosis and adhesions.

The study had several limitations. Because the analysis was retrospective and cross-sectional, investigators could not directly observe disease progression within individual patients over time. The study population also came from a specialized referral center, potentially biasing the cohort toward more severe cases requiring surgery. In addition, the findings may not apply to patients managed nonoperatively because the study included only surgical cases.

Still, the investigators said the results offered evidence that different aspects of endometriosis may evolve differently with age.

“Early diagnosis and personalized intervention, particularly in younger patients with aggressive phenotypes, may help prevent disease progression and mitigate increasing surgical complexity and complications later in life,” the authors concluded.

References

1. Yagur Y, Schneyer RJ, Hamilton KM, et al. Is endometriosis a progressive disease? Examining age-related trends in disease severity and surgical complexity. Fertil Steril. 2026;125(3):477-487. doi:10.1016/j.fertnstert.2025.09.024

2. Raheem M, Condous G, Espada Vaquero M. Endometriosis during peri-menopause and post-menopause: a review of the literature. J Clin Med. 2025;14(22):8067. doi:10.3390/jcm14228067