Understanding Lipoedema: Beyond the Myths to Better Outcomes

An interview with Dr. med. Tobias Bertsch, Chief Physician and Medical Director at the Földi Clinic, European Center of Lymphology

Lipoedema is often misunderstood, frequently misdiagnosed, and surrounded by persistent myths that can hinder effective treatment. In this interview, Dr. med. Tobias Bertsch, Chief Physician and Medical Director at the Földi Clinic, European Center of Lymphology, shares insights drawn from decades of clinical experience and international collaboration. A pioneer in lipoedema care, Dr. Bertsch is the founder of the European Lipoedema Forum and lead author of several key consensus documents shaping global standards in diagnosis and treatment.

Background & Clinical Perspective

Maree

How do you differentiate lipoedema from similar conditions such as lymphoedema, lipohypertrophy, or obesity during clinical assessment?

Dr Bertsch

Differentiating lipoedema from conditions like lymphoedema, lipohypertrophy, and obesity requires a clear understanding of specific diagnostic criteria and clinical presentation. According to the International Consensus on Lipoedema and the new German Guidelines, there are two primary criteria for diagnosing lipoedema:

  1. A symmetrical, disproportionate increase in adipose tissue in the legs (and less commonly in the arms).

  2. Significant pain in the affected areas, which often impacts quality of life.

In addition to these physical signs, lipoedema is commonly accompanied by psychological distress. Many patients feel stigmatized by societal beauty standards and struggle with self-acceptance and fitness. This emotional toll can contribute to further weight gain. It’s also important to recognize that more than 85% of lipoedema patients are already obese, making obesity more often a comorbidity than a differential diagnosis.

Lymphoedema, on the other hand, typically presents with noticeable fluid accumulation and is frequently associated with obesity. Unlike lipoedema, pain is rarely reported; instead, patients describe sensations of discomfort and tension.

Another condition to consider is lipohypertrophy, which also involves a symmetrical, disproportionate increase in adipose tissue in the legs but occurs without the pain characteristic of lipoedema.

At the Foeldi Clinic in Germany, the European Center for Lymphology, we have worked with these diagnostic criteria for many years, using a comprehensive, multi-faceted approach to accurately assess and manage lipoedema and its related conditions.

Challenges in Diagnosis

Maree

Why do you think lipoedema remains under diagnosed or misdiagnosed in many clinical settings?

Dr Bertsch

In my experience, lipoedema is more often misdiagnosed or overdiagnosed than underdiagnosed. Women with larger legs, who feel they do not fit current beauty ideals, may believe they suffer from lipoedema; similarly, women with obesity may attribute their condition to a lipoedema diagnosis. Approximately 80% of women referred with a diagnosis of “lipoedema” to Germany’s two largest centers—Charité in Berlin and the Foeldi Clinic—are misdiagnosed, meaning they do not actually have lipoedema.

Furthermore, I believe continuous education is vital. Unfortunately, many healthcare professionals still rely on outdated myths about lipoedema which lacks scientific and clinical validity. The International Lipoedema Association provides evidence-based resources to improve diagnosis and treatment for lipoedema patients.

Maree

What are some of the misconceptions you’ve encountered from both patients and health professionals regarding lipoedema?

Dr Bertsch

Typical myths around lipoedema include:

  • Lipoedema is an oedema condition and presents with fluid in the legs (or arms)
  • Lipoedema is a lymphatic disease
  • Lipoedema should be treated with MLD
  • Lipoedema is progressive
  • Lipoedema presents in stages
  • Lipoedema causes mental illness
  • Lipoedema leads to weight gain
  • Weight loss has no effect on lipoedema
  • Lipoedema typically presents with easy bruising and leg swelling throughout the day
  • Lipoedema should always be treated with liposuction as a first-line approach

We now have substantial evidence that these statements are misconceptions. To improve therapy for lipoedema patients, we must integrate current evidence and adopt a mindset focused on better outcomes. The ILA website hosts short videos addressing these myths.

Maree

Are there particular patient presentations or case studies that stand out as examples of delayed diagnosis?

Dr Bertsch

In my experience, diagnosis is typically delayed in cases involving severe obesity and lymphoedema as coexisting conditions. We often see patients who present with all three conditions: obesity, lymphoedema, and lipoedema. It is essential not to overlook obesity in such cases, as it is often the primary disease and requires focused intervention.

Improving Identification

Maree

What should lymphoedema clinicians look out for during initial assessments that might suggest lipoedema?

Dr Bertsch

As mentioned above, the two key diagnostic criteria—symmetrical, disproportionate adipose tissue in the legs (less often in the arms) and significant pain impacting quality of life—are essential. Additional indicators include mental stress, lack of self-acceptance, feelings of stigmatization, a history of weight gain, and reduced fitness levels.

Maree

Are there specific screening questions or tools that have been helpful in identifying lipoedema early?

Dr Bertsch

Questions around significant weight gain, mental health issues, and overall quality of life are critical. Depression, anxiety, PTSD, eating disorders, or a history of sexual abuse are often part of the patient’s background, as these experiences can influence pain perception. I always ask for permission before discussing these sensitive topics.

There is no specific diagnostic test or screening tool for lipoedema, and in my view, one is not necessary.

Collaboration & Referral

Maree

What role do you think multidisciplinary care plays in better outcomes for people with lipoedema?

Dr Bertsch

At the Foeldi Clinic, we believe a holistic, interdisciplinary treatment approach is essential to address the multiple challenges experienced by lipoedema patients. This approach is already implemented in our clinic, is reflected in the International Consensus Document (JWC Lipoedema Supp0210.indd), and has been adopted in the new German Guidelines on Lipoedema.

Maree

Who should be part of the multidisciplinary team?

Dr Bertsch

In recent years, the focus in treating lipoedema has shifted to better reflect the roles of obesity and psychological health. Therefore, the multidisciplinary team should include a psychologist and a nutrition expert. Therapists also play a key role, particularly in movement and compression therapy, as they help patients break the cycle of immobility driven by pain and weight gain—which in turn leads to further immobility.

If bariatric surgery is being considered, a physician specialized in internal medicine and a bariatric surgeon should be consulted. Where liposuction is indicated—**in select cases under appropriate conditions—**an experienced plastic surgeon should also be involved.

Education & Awareness

Maree

What changes would you like to see in how lipoedema is taught or discussed in training of medical practitioners, nurses and allied health professionals?

Dr Bertsch

It is crucial that we adjust our thinking and take new evidence into account. As healthcare professionals, we have a duty to stay agile and responsive to new evidence. The paradigm shift in our understanding of lipoedema over the past several years must be embraced if we want to offer the best care. Specifically:

  • MLD is not necessary for lipoedema and diverts resources away from lymphoedema patients who truly need it.
  • Liposuction is not a treatment for obesity or mental health conditions.
  • A holistic concept must be adopted that also addresses mental health and obesity.

Maree

If you could share one key message with lymphoedema clinicians about lipoedema, what would it be?

Dr Bertsch

Rely on serious, scientific evidence when diagnosing and treating lipoedema patients. (www.theila.net)

Summary

Key takeaways for clinicians:

  • The two core diagnostic criteria for lipoedema are symmetrical, disproportionate adipose tissue (typically in the legs) and significant pain impacting quality of life.
  • Obesity is often a comorbidity, not a differential diagnosis, and must be addressed in treatment planning.
  • Misdiagnosis is common; around 80% of patients referred with a lipoedema diagnosis to leading German clinics do not meet diagnostic criteria.
  • Common myths—such as lipoedema being a lymphatic disease or requiring MLD—are not supported by current evidence.
  • A multidisciplinary, holistic approach that includes psychological and nutritional support is essential for effective management.
  • Clinicians are encouraged to rely on evidence-based resources, such as those provided by the International Lipoedema Association, to improve patient outcomes.

About Dr. med. Tobias Bertsch

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Dr. Bertsch is the Medical Director and Chief Physician of the Foeldi Clinic, European Center of Lymphology in Germany, specialized in lymphedema, lipoedema-syndrome, and obesity. He is the founder and Past-President of the International Lipoedema Association (ILA), the world’s first and only professional association in this field. The members of ILA are exclusively health professionals.

From 2016 to 2019 Dr. Bertsch also served as Secretary General of the German Society of Lymphology. In 2019 he was the Congress President of the German Congress of Lymphology.

Dr. Bertsch is the leading author of the article series “Lipoedema – myths and facts”. These articles have spread worldwide, contribute to an essential paradigm shift we currently see in the diagnoses and treatment of lipoedema. Furthermore, he organized the International Lipoedema Forum with distinguished experts in this field from 23 nations worldwide. Together with the renowned psychologist Gabriele Erbacher Dr. Bertsch also is lead author of the International Consensus Document on Lipoedema which was published in October 2020. This Consensus is supported by renowned experts and key opinion leaders from 23 countries worldwide.

In 2012, Dr. Bertsch earned Specialist Certification of Obesity Professional Education (SCOPE), the only internationally-recognized certification in obesity management for health care professionals. Furthermore, he is a certified obesity expert at national level (DAG, DEG).

Dr. Bertsch developed a unique, multi-disciplinary therapy program for patients with morbid obesity, obesity-associated lymphedema, and lipedema. This very successful program includes bariatric and plastic surgery – when indicated – in addition to conservative treatment with Complete Decongestive Therapy (CDT).

Dr. Bertsch is one of only 2 physicians in Germany who consult in an outpatient setting of a lymphology hospital (Foeldi-clinic), meaning that patients with suspected lymphatic diseases or lipoedema can be examined and treated in the outpatient setting of the Foeldi Clinic after referral. This is covered by the German health insurances. He and his team treat with approximately 7000 patients per year (inpatients and outpatients).

Dr. Bertsch lectures extensively throughout Germany and has presented lectures in the Netherlands, Switzerland, Poland, Ireland, Spain, Greece, Denmark, Belgium, Sweden, Italy, UK, Turkey, Canada, Argentina, Australia and several times in the United States.

Further reading

You might also be interested in some of the previous lipoedema resources LES has published: