Endometriosis raised coronary artery disease risk 47%, but only outside Europe

Endometriosis has been linked to elevated cardiovascular disease risk in some prior research, but findings across individual studies have varied, and how that risk breaks down by specific cardiovascular condition and by geography hasn't been systematically mapped. A meta-analysis published this month in Annals of Medicine pools cohort studies covering more than three million women to characterize both dimensions [s1].

The design

Researchers systematically searched PubMed, Embase, and the Cochrane Library for cohort studies on endometriosis and cardiovascular disease risk published through December 2024 [s1]. Pooled hazard ratios with 95% confidence intervals were calculated using random-effects models, with subgroup analyses stratifying results by specific cardiovascular disease subtype, by continent, and by country development level [s1]. Heterogeneity and publication bias were assessed using standard statistical methods [s1]. Eleven cohort studies, covering 3,100,610 participants total, were included [s1].

What it found

Overall, endometriosis was associated with a 22% increased risk of all-cause cardiovascular disease (hazard ratio 1.22, 95% CI 1.08–1.38) [s1], though this pooled estimate carried substantial heterogeneity (I² = 94.6%), signaling real disagreement across the individual studies. Breaking the outcome down by specific cardiovascular disease subtype revealed larger, more specific risks: myocardial infarction (hazard ratio 1.29, 95% CI 1.10–1.50) and coronary artery disease specifically (hazard ratio 1.47, 95% CI 1.29–1.67), plus a smaller elevated risk for cerebrovascular events like stroke (hazard ratio 1.18, 95% CI 1.12–1.25) [s1]. No elevated risk was found for heart failure specifically [s1].

The geographic breakdown is where the study's most striking pattern appears: Asian cohorts showed a hazard ratio of 1.36 (95% CI 1.25–1.48) and North American cohorts 1.37 (95% CI 1.16–1.61), while European cohorts showed no elevated risk at all — hazard ratio 0.93 (95% CI 0.64–1.34), an interval that crosses 1.0 and includes the possibility of no association whatsoever [s1].

The geographic split is the finding that most needs explaining

A pattern where Asian and North American cohorts show a roughly 36–37% increased cardiovascular risk associated with endometriosis, while European cohorts show essentially no association, is a genuinely large and puzzling discrepancy that the meta-analysis itself doesn't resolve. Plausible contributors the pooled analysis can't distinguish between include differences in how endometriosis is diagnosed and coded across health systems (surgical confirmation versus clinical diagnosis, for instance), differences in background cardiovascular risk and cardiovascular care access across regions, differences in the specific populations captured by each region's available cohort studies, or genuine biological or environmental effect modification by population — the study reports the pattern without being able to adjudicate between these explanations.

Reading the subtype-specific risks alongside the null heart-failure finding

The pattern across cardiovascular disease subtypes — elevated risk for coronary artery disease and myocardial infarction specifically, more modest elevation for stroke, and no elevation at all for heart failure — is itself informative, since it suggests endometriosis's cardiovascular association isn't a uniform, generic increase in "heart disease risk" but appears concentrated in specific vascular and ischemic conditions rather than in structural or functional heart failure. That specificity lends some biological credibility to the overall finding, since a truly spurious or purely artifactual association would be less likely to show this kind of differentiated pattern across distinct cardiovascular disease subtypes.

What this doesn't establish

This is a meta-analysis of observational cohort studies, not a randomized or interventional design — it can establish association, not that endometriosis directly causes cardiovascular disease, and confounding by shared risk factors (chronic inflammation, pain-related reduced physical activity, or other endometriosis-associated conditions) can't be ruled out by pooling observational data alone. The extremely high heterogeneity in the overall pooled estimate (I² = 94.6%) is a real limitation even after subgroup analysis explains some of it, and 11 studies is a modest number to split further into geographic and disease-subtype subgroups, which shrinks the sample and widens uncertainty within each smaller subgroup analysis.

What the authors recommend

The study's authors describe their findings as underscoring "the need for targeted cardiovascular monitoring" in women with endometriosis, particularly in the higher-risk populations identified [s1] — a call for clinical awareness given the consistency of the coronary-specific signal across two of the three geographic regions studied.

What to watch

Whether the geographic discrepancy is investigated directly — through consistent diagnostic criteria and matched populations across regions — and whether prospective studies can better isolate whether endometriosis itself, versus associated risk factors, drives the elevated coronary risk found here. This article is not medical advice.

Sources

1. Endometriosis and cardiovascular disease risk: a meta-analysis of cohort studies — Annals of Medicine, 19 June 2026