Is Endometriosis a Progressive Disease? Examining Age-Related Trends in disease Severity and Surgical Complexity.

Abstract

OBJECTIVE To study the relationship between age and the phenotypic expression and surgical complexity of endometriosis using the AAGL classification. DESIGN Retrospective cohort study. SUBJECTS Patients aged 18-51 years with pathology-confirmed stage III-IV endometriosis. EXPOSURE We analyzed patients who underwent laparoscopic or robotic-assisted endometriosis surgery between 2013 and 2023 at a quaternary care institution in the United States. Patients were stratified into four age groups (≤25, 25-35, 35-45, >45). MAIN OUTCOME MEASURES The primary outcome was age related differences in disease severity (AAGL Classification), surgical complexity (AAGL Level A-D), the presence of endometrioma and bowel endometriosis. Secondary outcomes included association with clinical presentation, imaging findings, and surgical complications. RESULTS A total of 1,293 patients met inclusion criteria. AAGL stage III-IV prevalence increased with age, peaking at 50.5% in the 35-45 age group, then stabilizing at 47.0% in the >45 year group (p<.001). AAGL surgical complexity continued to rise steadily with Level C increasing from 21.1% (≤25 years) to 58.3% (>45 years). In multivariable regression, compared to patients aged <25 years, those aged 25-35, 35-45, and >45 had significantly higher odds of AAGL Stage III-IV disease (adjusted odds ratio [aOR] 2.47, 95% CI 1.35-4.49; 2.54, 95% CI 1.40-4.61; and 2.84, 95% CI 1.42-5.66, respectively). Surgical complexity (AAGL Level C-D) significantly increased beyond age 35, with aOR of 2.13 (95% CI 1.22-3.72) for ages 35-45 and 4.46 (95% CI 2.32-8.59) for patients >45. The odds of having endometriomas was higher for all age groups compared to age <25 (aOR 3.05, 95% CI 1.73-5.39 for ages 25-35, aOR 3.24, 95% CI 1.84-5.70 for ages 35-45, and aOR 2.58, 95% CI 1.34-4.96 for ages >45). No significant association between age and bowel endometriosis was found. CONCLUSIONS AAGL disease stage peaks around ages 25-35 and subsequently plateaus, while surgical complexity continues to increase beyond this age, reaching the highest odds in patients over 45, likely reflecting cumulative fibrosis, adhesions, and anatomical remodelling. These findings highlight the importance of individualized, age-specific treatment approaches to reduce surgical complexity later in life. Future research should further refine these age-based management strategies.