Lipedema: A Changing Understanding for Clinical Practice

Insights from Pathways LIVE with Dr. Tobias Bertsch

In a recent episode of Pathways LIVE, hosted by the Canadian Lymphedema Framework, Editor-in-Chief Anna Kennedy spoke with Dr. Tobias Bertsch about the evolving understanding of lipedema and the significant shifts occurring in both research and clinical practice.

The discussion revisited Dr. Bertsch’s influential 2020 Pathways article, Lipedema – A New Paradigm Shift, while exploring how more recent evidence is continuing to reshape thinking around diagnosis, treatment, and patient education.

For lymphoedema clinicians, the conversation highlighted the importance of separating long-held assumptions from current scientific evidence and adapting practice accordingly.

Source: https://www.youtube.com/live/rcPh9NCLkgk

Moving Beyond Traditional Beliefs

One of the strongest themes throughout the discussion was that many historical beliefs about lipedema are no longer supported by current research.

Lipedema is not primarily a lymphatic disorder

Historically, lipedema was often described as a condition involving impaired lymphatic function or fluid accumulation. However, Dr. Bertsch explained that modern imaging and histological studies now show that most patients with lipedema have normal lymphatic function.

This has important implications for treatment. While compression and conservative therapies may still help manage symptoms such as pain and inflammation, lipedema itself should not automatically be approached as a lymphatic failure disorder.

The discussion reinforced the need for clinicians to distinguish between:

  • lipedema,
  • obesity-related tissue changes,
  • and true lymphatic dysfunction.

Is Lipedema Progressive?

Another major shift involves the belief that lipedema inevitably worsens over time.

According to current evidence, lipedema is not necessarily a progressive disease. Research suggests that many patients remain stable for years, particularly when body weight remains stable.

Dr. Bertsch noted that deterioration is far more commonly associated with weight gain and obesity than with an independent disease progression process.

For clinicians, this reframes patient conversations:

  • progression is not inevitable,
  • symptom management is possible,
  • and long-term outcomes may be improved through weight stability and overall health management.

“There is no scientific evidence that lipoedema takes a progressive course. Rather, it is weight gain and obesity that are very often progressive.”

— Bertsch et al., Journal of Wound Care Consensus Document

The Relationship Between Lipedema and Obesity

The discussion strongly emphasised the close relationship between lipedema and obesity.

While lipedema affects fat distribution, it does not override the body’s normal energy balance mechanisms. Most individuals with lipedema are also living with obesity, and obesity itself may worsen symptoms or trigger inflammatory changes.

“There is no evidence that lipoedema leads to weight gain, although weight gain does exacerbate lipoedema symptoms.”

— Bertsch et al., Journal of Wound Care Consensus Document

Importantly, Dr. Bertsch highlighted that weight loss can improve symptoms and, in some cases, may even lead to remission-like outcomes.

Traditional dieting approaches have often been unsuccessful for many patients, but newer interventions — including modern obesity medications and bariatric surgery — are showing more promising results.

This represents a significant shift away from older messaging that suggested lipedema fat was entirely resistant to treatment.

“Most women concurrently have two conditions: obesity and lipoedema.”

— Bertsch et al., Journal of Wound Care Consensus Document

Compression Therapy Still Has an Important Role

Although lipedema may not primarily be a lymphatic disorder, conservative management remains valuable.

The discussion supported the use of:

  • Class 2 compression garments (25–30 mmHg),
  • particularly flat-knit garments,
  • combined with movement and physical activity.

Compression may assist by:

  • reducing low-grade inflammation,
  • improving comfort,
  • decreasing pain,
  • and supporting activity participation.

For lymphoedema clinicians, this reinforces the importance of symptom-focused management rather than positioning compression as a “cure.”

Rethinking Liposuction

Liposuction remains a highly debated area within lipedema care.

Dr. Bertsch noted that while some patients report improvement, there is currently limited independent long-term scientific evidence demonstrating persistent benefits.

The discussion suggested that liposuction should not be presented as a universal solution or cure. Instead, it may be considered selectively when:

  • conservative therapies have failed,
  • weight is stable,
  • and obesity has been appropriately addressed.

This cautious approach aligns with the broader movement toward evidence-based practice and realistic patient expectations.

Psychological Health and Patient Communication

The conversation also challenged assumptions around mental health and lipedema.

Current evidence does not support the idea that lipedema itself causes psychological illness. However, living with chronic pain, stigma, body image concerns, and conflicting information can understandably affect emotional wellbeing.

Dr. Bertsch highlighted that psychological stress may amplify pain perception, reinforcing the importance of compassionate, patient-centred communication.

For clinicians, this means:

  • validating patient experiences,
  • avoiding catastrophic messaging,
  • and supporting informed, balanced education.

The Challenge of Misinformation

A significant concern raised during the livestream was the growing impact of misinformation, particularly through social media.

Dr. Bertsch discussed how some commonly repeated claims about lipedema are inconsistent with current scientific evidence. This has contributed to confusion for both patients and healthcare professionals.

Organisations such as the International Lipedema Association are working to improve access to evidence-based education and reduce the spread of misinformation.

The discussion encouraged clinicians to:

  • critically evaluate sources,
  • remain current with emerging research,
  • and guide patients toward reliable educational resources.

Key Clinical Takeaways

The livestream concluded with several important messages for clinicians working in lymphoedema and related fields:

  • Lipedema is not inherently dangerous or inevitably progressive.
  • Most patients do not demonstrate primary lymphatic failure.
  • Obesity plays a significant role in symptom severity and progression.
  • Weight management may improve symptoms and outcomes.
  • Compression remains valuable for symptom management.
  • Liposuction should be approached cautiously and realistically.
  • Evidence-based education is essential for both clinicians and patients.

As understanding of lipedema continues to evolve, ongoing professional education will remain critical in ensuring patients receive balanced, informed, and scientifically grounded care.

For clinicians working in lymphoedema practice, these evolving perspectives offer an opportunity to refine assessment, improve patient communication, and support more individualised, evidence-based management pathways.

Read - Lipoedema: a paradigm shift and consensus

Sponsor

Thank you to Haddenham Healthcare for sponsoring this article.

Haddenham Healthcare is committed to supporting therapists and patients in managing lymphoedema through innovative, reliable compression garments and tools. We provide education, training, and product guidance to help therapists support patients throughout their treatment journey. By partnering closely with therapists, we help tailor compression solutions to each patient’s individual needs and lifestyle. Resources such as our ‘What Happens Now?’ booklet support patient education, engagement, and confidence following diagnosis, helping patients understand next steps and ongoing self-management. Haddenham works alongside therapists to support positive outcomes and quality of life. 

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