Gynecologic Surgical Outcomes in Patients With Ehlers–Danlos Syndrome and Hypermobility Spectrum Disorder: A Multi-Center Study

INTRODUCTION: Ehlers –Danlos syndrome (EDS) is a group of inherited connective tissue disorders characterized by collagen abnormalities compromising tissue integrity. (1–3) The hypermobile subtype (hEDS), accounting for approximately 85% of cases, is associated with chronic pain, dysautonomia, poor wound healing, and increased surgical risk. (4,5) Existing literature highlights potential complications related to tissue fragility, bleeding, pain management, and anesthetic challenges. (5–7) Further studies on gynecologic surgical outcomes would allow for improved understanding of these risks and inform surgical planning, optimize outcomes, and enhance patient counseling. OBJECTIVE: The primary objective of this study was to determine surgical outcomes in patients with EDS undergoing major gynecologic procedures. Secondary objectives included characterizing patient demographics, identifying EDS subtypes associated with poor outcomes, and assessing indications for surgery in this population. METHODS: We conducted a multi-center retrospective cohort review within a single hospital system. Eligible patients were assigned female at birth, aged 18–60, with a diagnosis of EDS, and underwent major gynecologic procedures (hysterectomy, myomectomy, oophorectomy, sacrocolpopexy, excision of endometriosis) for benign indications, between January 1, 2004, and July 31, 2025. Diagnosis of EDS versus hypermobility spectrum disorders (HSD) was confirmed using strict diagnostic criteria (Figure 1). Continuous variables were summarized using means and standard deviations or medians and interquartile ranges and compared using t-tests or Wilcoxon rank-sum tests, as appropriate. Categorical variables were compared using chi-square or Fisher’s exact tests. A p-value < 0.05 was considered statistically significant. Future analysis will include matched controls comparing complications in the HSD/EDS cohort to institutional data. RESULTS: A total of 147 surgical cases were included, 108 patients with EDS and 39 with HSD (Table 1). Preliminary assessment of the HSD and EDS groups showed overall low rates of complications. In comparison of these groups, those with EDS were older at the time of surgery (32.4±11.1 vs 37.1±10.9, p=0.024), had a lower BMI (p=0.042), higher gravidity (p=0.008), higher parity (p=0.006), and more prior cesarean sections (p=0.031). Intraoperative outcomes were similar between groups with no significant differences in estimated blood loss, operative time, or specimen weight. Significantly more patients with EDS received surgery for pelvic organ prolapse (p=0.008), such as sacrocolpopexy. Postoperative complications were rare among both groups. The rate of postoperative complications and the severity, assessed by Clavien–Dindo grade, did not differ significantly between cohorts (Table 2). Among patients with complications, most were classified as Clavien–Dindo grade of II (grades I–II = minor complications, grades III–V = severe). One unplanned conversion to laparotomy occurred in the HSD group. No significant differences were observed in transfusion, readmission, or reoperation rates. CONCLUSIONS: Major gynecologic procedures in patients with EDS and HSD were not associated with higher complication rates. Despite concerns about tissue fragility and bleeding, outcomes were comparable to rates in the general population. (8–10) These findings support the safety of minimally invasive surgery in this population, though larger prospective studies are needed to assess rare and subtype-specific risks. Future analyses will include direct comparison to our institutional general population.Figure 1Table 1Table 2