Adenomyosis, what to track

The day-to-day companion to the full endo & adeno guide, focused on the three signals that get adenomyosis taken seriously: bleeding volume, clot size, and cramp severity. Up to 1 in 5 people with a uterus have adeno, and in perimenopause the bigger estrogen swings often turn the volume up: floods, clots, cramping that doubles you over. Two months of honest tracking is the fastest route to the right scan and the right conversation. If you want the broad picture (what it is, MHT decisions, hysterectomy outcomes), start with the full guide.

Adenomyosis behaves differently from endometriosis even though they share a lot of biology. Knowing the differences sharpens the conversation with a doctor or specialist.

Endometrial-like tissue growing inside the uterine wall. In endometriosis the rogue tissue grows outside the uterus, on ovaries, bowel, bladder. In adenomyosis it's the same kind of tissue but inside the muscle of the uterus itself (the myometrium). Each cycle it responds to estrogen, builds, and tries to shed, but it's trapped inside muscle, so the result is a uterus that becomes enlarged, boggy and inflamed. That's why the cramping feels different from a normal period: it's the uterus contracting around tissue that has nowhere to go.

The three classic signals: heavy bleeding, big clots, severe cramping. Heavy menstrual bleeding (soaking pads or tampons hourly, flooding, large clots, anything bigger than a 50p coin or a US quarter) plus severe cramping plus a uterus that feels heavy and tender even between periods is the textbook adeno picture. Many people describe the cramping as 'labour-like' rather than 'period-like'. If two of three are true and they're getting worse, this deserves imaging.

Imaging can usually see it, if someone looks. Adenomyosis has fairly characteristic features on transvaginal ultrasound and MRI: a bulky uterus, thickened junctional zone, small cysts in the muscle wall, asymmetric uterine walls. A good MRI is the most accurate non-surgical diagnosis. A 'normal scan' from a non-specialist sonographer doesn't rule it out, ask specifically for an adenomyosis-aware ultrasound or MRI.

Perimenopause usually makes it worse, temporarily. Estrogen swings get bigger and more erratic in your 40s, and adeno is estrogen-fed. Many people see the bleeding get heavier, the clots get bigger, and the cramping get longer in perimenopause, sometimes leading to a long-overdue diagnosis. It often quietens after menopause when estrogen drops, but not always (fat tissue keeps making estrogen, and MHT can re-activate it).

Up to a third of people with adeno also have endometriosis. They're sister conditions and they often co-exist. If you have severe period pain, pain with sex, cyclical bowel or bladder symptoms, that's the endo overlap, and it deserves looking into too. The full sibling story is in the endometriosis & adenomyosis guide; this page is the adeno-specific tracking companion.

Hysterectomy is genuinely curative, for adeno specifically. This is the single biggest practical difference from endometriosis. Adenomyosis lives in the uterine wall, so removing the uterus removes the disease. For people who are done with the uterus, hysterectomy resolves adeno completely. For people who want to keep the uterus, uterine-sparing options exist (adenomyomectomy, uterine artery embolization), but they're specialist territory and they're not first-line.

Most of the day-to-day toolkit overlaps with endometriosis. The decisions that look different for adeno are flagged below.

The hormonal IUD (Mirena) is often the strongest first move. For adenomyosis specifically, the levonorgestrel IUD has the strongest evidence among hormonal options, it thins the endometrium, dramatically reduces bleeding volume, and often takes the cramping down with it. Many people who were heading toward hysterectomy buy years of better quality of life from a Mirena. It's not magic for everyone (insertion can be rough on a bulky uterus, and some people expel it), but it's worth asking about first.

Continuous combined pill or progestin-only options. Skipping the bleed (continuous combined pill, dienogest, norethindrone) takes the monthly trigger away. For adeno the goal is the same as for endo: stop the cycle that's feeding the disease, and let the uterus calm down. Each option has trade-offs, a specialist conversation, not a default doctor (family doctor) one.

Uterine-sparing surgery, if you're not done with the uterus. Adenomyomectomy (cutting out adenomyosis tissue while preserving the uterus) and uterine artery embolization (cutting off blood supply to the affected area) are real options for people who want to keep their uterus, for fertility reasons or otherwise. Both are specialist procedures with mixed long-term evidence. Worth knowing exist; not first-line.

Hysterectomy, the cure, when it's the right call. If you're done with the uterus and the disease is severe, hysterectomy is curative for adeno. Unlike with endo, you don't need a high-volume specialist excision surgeon, a competent gynecologist doing the procedure removes the disease by definition. Ovaries usually stay (they don't have adeno). The decision is about whether you want a hysterectomy, not whether it'll work.

Iron, actually iron, not vibes. Years of heavy bleeding with adeno cause iron-deficiency anemia routinely, and it's massively under-treated. If you're getting breathless on stairs, exhausted, dizzy, foggy, ask for ferritin (not just hemoglobin). Oral iron, or IV iron if oral doesn't work or you can't tolerate it. This single intervention often changes more day-to-day than any of the hormone options.

Tranexamic acid for the worst bleed days. Non-hormonal, taken only on heavy days, reduces bleeding volume by about a third for many people. Not a long-term fix, but a useful tool for getting through a bad month while the bigger plan (Mirena, hormonal suppression, surgical decision) is being worked out.

Pelvic-floor physiotherapy. Years of cramping create chronic pelvic-floor tightness, painful sex, bladder urgency, constipation that overlay on top of the adeno itself. A pelvic-floor physio trained in persistent pain is one of the most under-prescribed game-changers. Internal work matters; ask for it.

If you're considering MHT with adenomyosis. If the uterus is gone, the adeno is gone, and MHT choices are reasonably straightforward. If you've kept the uterus, you'll need a combined regimen (estrogen + progestogen, or tibolone), estrogen-only MHT can re-activate residual disease. This is a specialist menopause conversation, not a default-doctor one.