Lipedema is a complex condition that must be addressed as more than simply a weight problem. Although it may be mistaken for obesity in its early stages, the condition presents multiple challenges, including delayed diagnosis, difficulties with treatment adherence, stigma, and limited evidence for pharmacologic therapies.

During the International Congress on Obesity (ICO) 2026, organized by the World Obesity Federation and held in Mexico City, Mexico, specialists discussed the main difficulties in diagnosing this condition, which affects approximately 11% of the adult population, primarily women.

They agreed that improving management requires better clinical recognition, uniform diagnostic criteria, and a multidisciplinary, individualized approach that combines lymphatic support, metabolic care, and surgery for patients who need it.

In 2018, the World Health Organization classified lipedema in the International Classification of Diseases, 11th Revision, under noninflammatory disorders of subcutaneous fat. Lipedema is a chronic, progressive disease characterized by a disproportionate increase in subcutaneous adipose tissue, primarily in the lower extremities. It is associated with substantial physical disability, chronic pain, thromboembolism, and psychosocial distress.

Diagnostic Challenges

Celia M. Egan, MD, a metabolic health specialist and director of Obesity Medicine and Metabolic Health at True Women’s Health in the US, explained that one of the main difficulties in detecting lipedema is the absence of a definitive imaging test. Although MRI can show patterns of fibrosis intermingled with adipose tissue, there is no established diagnostic criterion based on imaging.

As a result, diagnosis still relies on physical examination and medical history, but this approach has limitations because, in its early stages, lipedema can be mistaken for obesity or lymphedema.

“One of the biggest challenges for healthcare professionals is distinguishing between lipedema, obesity, and lymphedema. The distinction can be complicated because a woman with lipedema may also have obesity. However, a disproportionate distribution of fat in the thighs and legs — especially without the cardiometabolic profile one would expect for that degree of adiposity — can be an important clue,” she said.

Egan added that physical examination should identify painful tissue in the legs as well as swelling (edema). Although edema also occurs with lymphedema, it does not usually leave pitting — an indentation that remains after pressure is applied to the skin — in cases of lipedema.

“These differences can be difficult to recognize during a clinic visit. However, lymphedema can be unilateral, which makes it easier to distinguish,” she said.

Lipedema causes tissue accumulation mainly in the hips, thighs, and calves, and in advanced stages it can involve the arms. “The distribution is usually bilateral and symmetrical, with a disproportion between a relatively thin trunk and lower extremities of greater volume,” she noted.

Egan emphasized that pain in the limbs is a common symptom, with patients often reporting tenderness to touch, heavy legs, swelling after prolonged standing, bruising, cold skin, varicose veins, and painful nodules.

She also noted that, in addition to pain, patients with lipedema often experience mobility problems because fat deposits form around the knees and hips.

Another characteristic feature is that the tissue does not change in response to lifestyle modifications such as a low-fat diet or exercise. Even tissue in the limbs often persists after bariatric surgery.

“These women have spent years trying to understand why, even though they cut calories or exercise more, they don’t lose weight. Many come to the clinic after doctors have questioned their efforts,” she said.

For that reason, Egan recommended explaining the diagnosis in detail, specifying the type and stage of lipedema, and above all, approaching patients with empathy and support throughout treatment.

Lipedema is classified into five types based on the anatomic distribution of fat, while its progression and degree of fibrosis are categorized into four clinical stages.

For example, the Schmeller and Meier-Vollrath classification system categorizes lipedema into four stages on the basis of changes seen in the skin and on palpation:

• Stage 1: The skin surface is normal, and the adipose tissue has a soft consistency, although small nodules may be palpable. 
• Stage 2: The skin surface is irregular and firm because of increased nodular structure. 
• Stage 3: The skin surface is deformed by adipose tissue, especially around the hips and ankles, and nodules of varying sizes are palpable. 
• Stage 4 (lipolymphedema): Involvement of the lymphatic vessels and lymph nodes is substantial. The ankle cuff sign is lost. 

Because there is no universal classification for lipedema, “the classification remains a subject of debate, and efforts are still being made to ensure that physicians use uniform criteria.” The stages are rated from 1 to 4 and, in general, reflect the degree of fibrosis. In the early stages, there is excess adipose tissue but little fibrosis, and the skin may remain smooth. As the disease progresses, the tissue becomes firmer and more nodules appear, she added.

Egan explained that the difficulty in classifying disease progression stems from the fact that some patients in the early stages may also experience episodes of lymphedema. Therefore, lymphedema does not automatically place them in stage 4, while stage 1 may go unnoticed because many women with obesity have a similar appearance.

Regarding treatment, she emphasized that the goal should not be weight loss itself, but rather relief of pain, improved mobility, and reduced swelling. She said that treatment is based on a diet that avoids ultraprocessed foods and refined carbohydrates, increases intake of vegetables and protein, and includes physical activity such as walking, cycling, or water-based exercise. She also noted that compression garments and lymphatic massage are recommended.

As for medications, Egan said that anti-obesity drugs may be used when medically indicated to help manage appetite or reduce cravings, but not all of them alter lipedema tissue.

Regarding GLP-1 receptor agonists, she said that in practice, clinicians have observed reduced pain and swelling, along with reduced limb volume in some patients, but cautioned that the evidence remains limited.

Surgery Only When Symptoms Persist

Max Sirota, MD, plastic and reconstructive surgeon specializing in advanced lipedema care, said that management of lipedema must be multidisciplinary, addressing everything from nutrition and physical activity to patients’ psychological well-being. Surgery also has a role, he said, but only in patients for whom conservative treatment — based on a low-fat diet and exercise — fails to produce results.

He explained that surgery is considered when conservative treatment reaches its limits and pain or mobility problems persist despite good adherence, meaning that not all patients need it.

“New consensus statements and guidelines are being developed. In current practice, we add surgery when conservative treatment reaches its limits and symptoms persist despite good adherence to treatment, when mobility is impaired, or because we seek to slow the progression of lipedema before complications arise,” he said.

The US Standard of Care for Lipedema states that reduction surgery is currently the only available technique to remove abnormal lipedema tissue, including adipocytes, nodules, fibrotic extracellular matrix, and other nonadipocyte components. The main surgical procedures are liposuction and lipectomy, with liposuction being the most common.

According to that document, surgery is the only treatment that slows disease progression and ideally should be performed before complications and resulting disability develop. Lipedema reduction surgery includes liposuction, excision, and manual removal while preserving blood and lymphatic vessels.

Sirota noted that before undergoing surgery, patients should follow conservative treatment for at least 6 months to reduce swelling and fibrosis, minimize bleeding during the operation, and facilitate recovery. It is also recommended that the venous and lymphatic systems be evaluated, that any substantial venous insufficiency be treated, and that the procedure be staged when a large volume of tissue needs to be removed.

He cautioned that liposuction for lipedema is not equivalent to a conventional cosmetic procedure and therefore should be performed by experienced teams in a hospital setting using techniques that protect the lymphatic vessels. Improper execution, he said, can lead to secondary lymphedema and other complications.

He also noted that recent study results show that 72.9% of patients experienced pain reduction and 93% reported improved mobility. Benefits were also reported in self-esteem and confidence, along with reductions in anxiety and depression. However, he said that more research is needed on surgical outcomes.

“Surgery is not a cure: It reduces pain and improves quality of life, but the patient must maintain lifelong care. Treatment is multidisciplinary: It is neither purely conservative nor purely surgical; the combination of both offers the best results,” he said.

Sirota added that the best outcomes are achieved by integrating lifestyle changes, pharmacologic treatment when indicated, compression and lymphatic support therapies, physical therapy, and surgery. Surgery allows removal of tissue that cannot be modified through conservative management, but it does not eliminate the need for ongoing care.

Egan and Sirota declared having no relevant financial relationships.

This story was translated from Medscape’s Spanish edition.