1.1. Introduction This study compares the impact of two surgical treatments for endometriosis—hysterectomy with laparoscopic salpingo-oophorectomy (radical surgery) versus conservative laparoscopic surgery—on chronic pelvic pain and sexual quality of life in women aged 40 to 50. 1.2. Methods In a prospective cohort study, 145 women diagnosed with stage 4 endometriosis were recruited from the endometriosis clinic at Hazrat Rasool Hospital, Tehran. Participants were randomly assigned to undergo either radical surgery (75 patients) or conservative surgery (70 patients). Data were collected through physical exams, interviews, surveys, and lab tests. Primary outcomes included chronic pelvic pain measured by the Visual Analog Scale (VAS) and sexual quality of life assessed using the Sexual Quality of Life Questionnaire for Women (SQOL-F). Patients were evaluated at baseline, and then at 6 and 12 months post-surgery. 1.3. Result Baseline comparisons showed significant differences between the two groups in terms of age, BMI, and number of children. Radical surgery resulted in greater long-term pain reduction but was associated with lower overall patient satisfaction compared to conservative surgery. Six and twelve months post-operation, the radical surgery group reported zero dissatisfaction, whereas the conservative group had higher dissatisfaction rates (25.7% and 27.1%, respectively). The conservative group showed a significant improvement in sexual quality of life scores one year post-surgery, despite initial lower scores. Radical surgery was more effective in reducing chronic pelvic pain over the study period. 1.4. Conclusion While radical surgery offers superior pain relief for stage 4 endometriosis, conservative surgery may provide better outcomes in terms of sexual quality of life and patient satisfaction. The findings highlight the importance of individualized treatment plans for women with severe endometriosis.