Adenomyosis 101: treatment, symptoms, and support

Top things to know:

• Adenomyosis happens when tissue similar to the uterine lining grows into the muscle wall of the uterus

• The most common symptoms are painful periods, heavy or prolonged bleeding, and pelvic pain

• Not everyone has symptoms; some only discover it while investigating fertility concerns

• Tracking your pain in the Clue app and bringing that data to a healthcare provider can help start a conversation about adenomyosis

What is adenomyosis?

Adenomyosis occurs when tissue similar to the uterine lining (the endometrium) grows within the muscular wall of the uterus (the myometrium) (1,2).

This tissue still responds to hormonal changes throughout the menstrual cycle. It may thicken, break down, or bleed, but because it is trapped within the uterine muscle and has nowhere to go, it can cause inflammation, pain, and enlargement of the uterus (1,3,4).

Adenomyosis can affect the entire uterine wall (diffuse adenomyosis) or appear in localized areas (focal adenomyosis, also called adenomyomas). It is a benign condition, meaning it is not cancerous  (1,2).

Adenomyosis may be more common than current estimates suggest because many people have no symptoms, and the condition is often mistaken for endometriosis or fibroids. Among people with gynecological symptoms, adenomyosis may affect up to 1 in 2 (5).

It’s most commonly diagnosed in people in their 30s and 40s, although younger people can also be affected (6-8). Symptoms typically improve after menopause as estrogen levels decline (7).

What are the symptoms of adenomyosis?

Around 1 in 3 people with adenomyosis have no symptoms (9). For others, symptoms range from mild to severe and may affect daily life, work, relationships, and overall wellbeing. 

The most common symptoms include (2):

• Painful periods

• Heavy menstrual bleeding

• Chronic pelvic pain

• Pain during sex

• An enlarged uterus

• Fatigue related to heavy bleeding

Symptoms often become more noticeable during the later reproductive years and may improve after menopause (9,10).

If symptoms are affecting your daily life, it's worth speaking with a healthcare provider. Severe pain and heavy bleeding are common symptoms of adenomyosis, but they are not something you have to simply live with.

Painful periods and cramping

Painful periods (dysmenorrhea) are one of the most common symptoms of adenomyosis (11). The pain is typically felt in the lower abdomen and pelvis and may radiate to the lower back and inner thighs (12). It may start before the period and continue after bleeding ends.

For some people, the pain can be severe and may not respond well to common pain relievers, including nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (13). Severe pain may also be accompanied by symptoms such as nausea, lightheadedness, or fatigue.

Unlike “typical” period cramps, adenomyosis pain may become more severe over time, particularly during the later reproductive years (10). 

If period pain is disrupting your daily life, it’s worth discussing with a healthcare provider. Painful periods are common, but severe pain is not something you have to simply accept.

Heavy periods and abnormal uterine bleeding

Heavy menstrual bleeding (HMB) is one of the most common symptoms of adenomyosis (11,14). It is a type of abnormal uterine bleeding (AUB), an umbrella term for changes in menstrual bleeding that are considered outside the typical range. 

Signs of HMB may include (15,16):

• Soaking through a pad or tampon every 1–2 hours

• Passing large blood clots

• Bleeding for more than 8 days

• Needing to change period products during the night

Adenomyosis is recognized as a structural cause of abnormal uterine bleeding (17). Some people also experience unpredictable bleeding between periods or very frequent menstrual cycles (17).

Over time, heavy blood loss can lead to iron deficiency or anemia, which may cause symptoms such as fatigue, shortness of breath, and dizziness (18). If you’re noticing these symptoms, it’s a good idea to bring them up with your healthcare provider. 

Tracking your bleeding patterns in the Clue app over several cycles can help identify changes that may otherwise be difficult to spot. 

Chronic pelvic pain and pressure

Pelvic pain is considered chronic when it lasts for more than six months and is present even outside of periods (2,19). People with adenomyosis often describe a dull ache, heaviness, or feeling of fullness in the pelvis (19). For some, it can affect daily activities, movement, sleep, and intimacy (6).

Logging pain and its intensity in the Clue app can help distinguish cyclical from chronic pain. This distinction can be useful for both diagnosis and treatment.

Pain during sex

Adenomyosis can cause pelvic pain during or after penetrative sex (dyspareunia) (3). This pain may feel sharp, stabbing, or pressure-like. It is often felt in the lower abdomen or around the cervix, and may vary across the cycle (20).

Pain during sex can negatively impact intimacy, affecting relationships and self-esteem (21). 

Pain during sex is also a common and valid symptom to discuss with a healthcare provider. If you feel comfortable, consider mentioning when the pain happens, where you feel it, and whether it changes across your cycle.

Enlarged uterus and other physical symptoms

Adenomyosis can cause the uterine muscle wall to enlarge, sometimes up to the size of a 12-week pregnancy (4). This may lead to visible swelling in the lower belly, pressure or fullness sensations, and sometimes more frequent urination or constipation (22,23).

Imaging (such as a transvaginal ultrasound or MRI) can help confirm the cause, since fibroids can produce similar findings (11).

Fatigue, mood changes, and other symptoms

Heavy bleeding can lead to iron deficiency or anemia, which may cause persistent fatigue, difficulty concentrating, and breathlessness (17). 

Pain can also disrupt sleep, which may contribute to irritability and low mood (24).

Nausea, headaches, and back pain around periods are also reported (25). All of these symptoms are worth raising at healthcare appointments, not only pain and bleeding.

What causes adenomyosis?

The exact cause of adenomyosis is not fully understood, and research is ongoing (7). 

Several theories may help explain how adenomyosis develops. Two of the most widely accepted are:

• Invasion of endometrial tissue into the uterine muscle: Tissue from the endometrium invades the uterine muscle. Factors such as prior uterine surgery, pregnancy, and birth may increase the likelihood of this occurring (26).

• Misplaced stem cells: Stem cells present in the uterus from early development may later transform into endometrial-like tissue within the uterine muscle (26). 

Estrogen seems to play an important role in the growth of adenomyosis. This may help explain why symptoms often improve after menopause when estrogen levels naturally decline (8,9).

Although certain factors are associated with adenomyosis, having risk factors does not guarantee someone will develop the condition. Many people diagnosed with adenomyosis have no known risk factors.

How is adenomyosis diagnosed?

Diagnosis can take time because symptoms overlap with those of other conditions, including endometriosis and fibroids. Today, imaging now allows most cases to be identified without surgery (3). 

Diagnosis typically combines:

• Your medical history

A healthcare provider will start by asking about your experiences, including period pain, bleeding patterns, pelvic pain, past pregnancies, and any history of uterine surgery (3,26).

• Pelvic exam

During a physical exam, a healthcare provider might notice the uterus feels enlarged or tender. Clinicians sometimes describe this  as a "boggy" uterus, which basically means the uterine walls feel softer and thicker than usual (27).

• Transvaginal ultrasound (TVUS)

A transvaginal ultrasound is usually the first imaging test used to evaluate suspected adenomyosis. It allows healthcare providers to assess the structure of the uterus and look for characteristic signs of the condition (3,26,28).

• MRI

If ultrasound findings are unclear, an MRI may be recommended. It can help confirm adenomyosis and distinguish it from other conditions, including fibroids and some forms of endometriosis (1).

Is there a test for adenomyosis?

There is no single test that can diagnose adenomyosis. Instead, diagnosis combines symptom history, examination, and imaging (1). Because diagnosis often relies on symptom history, keeping a record of pain, bleeding, and other symptoms may help support conversations with healthcare providers.

Adenomyosis vs. endometriosis: what’s the difference?

Adenomyosis and endometriosis are similar, but the main difference is where the tissue is growing. In endometriosis, tissue similar to the uterine lining grows outside the uterus (on the ovaries or the fallopian tubes, for example) (5).

In adenomyosis, it grows within the uterine muscle wall (1). 

Both conditions can cause (5):

• Painful periods

• Chronic pelvic pain 

• Pain during sex

Key differences (29,30):

• Adenomyosis is more often associated with an enlarged uterus and very heavy bleeding 

• Endometriosis is more often linked to pain with bowel movements, pain around ovulation, and infertility without heavy bleeding

Many people have both conditions simultaneously, although endometriosis is thought to be more common overall (5). Imaging or laparoscopy may be needed to distinguish them, and treatment approaches may overlap (1,31).

How is adenomyosis treated?

There is no cure for adenomyosis, but many people find meaningful relief with the right plan. Treatment decisions depend on symptom severity, age, and reproductive goals, and should always be made in consultation with a healthcare provider.

You are the expert on your own body. 

Tracking your symptoms in Clue before and after starting a new treatment is a great way to see what’s actually working and what isn't.

Pain relief and non-hormonal options

NSAIDs (such as ibuprofen) work best when started 1–2 days before bleeding begins (32). If they are not providing enough relief to manage a typical day, that is a sign to speak with a healthcare provider. You don’t have to just "push through."

Tranexamic acid is an option for those who cannot or prefer not to use hormonal therapies. It is taken during the period and helps reduce overall blood loss (13). 

Supportive approaches such as heat pads, gentle movement, and pelvic floor physiotherapy may also help (33).

Hormonal treatments

Most first-line treatments aim to reduce or stabilize estrogen and progesterone, helping to reduce bleeding and pain (3). 

Common options include (3,13,17):

• Combined hormonal contraception (such as the pill, patch, or ring)

• Progestin-only pills or injectables

• Hormonal IUDs, which are among the most effective options

• GnRH analogues, which are generally used as second-line treatments

The right choice depends on symptoms, health history, and reproductive plans.

Procedures and surgery

When other treatments have not helped enough, a specialist may discuss procedural or surgical options such as:

• Uterus-sparing procedures (such as adenomyomectomy) may be appropriate for people who wish to become pregnant in the future, although they’re not without risks (3).

• Uterine artery embolization, which blocks blood flow to adenomyomas. Studies have shown it can reduce painful periods and heavy bleeding (3).

• A hysterectomy (surgical removal of the uterus) is considered the definitive treatment for adenomyosis, but it is only appropriate for those who do not wish to become pregnant in the future (34). Seeking a second opinion is always reasonable if you are considering this option.

When to see a healthcare provider

Seek with a healthcare provider if you experience any of the following (22):

• Period pain or pelvic pain that interferes with work, school, daily activities, or intimacy 

• Heavy menstrual bleeding, including soaking through protection every 1–2 hours, passing large clots, or bleeding for longer than  8 days

• Pelvic pain lasting longer than six months, including pain outside of periods 

• Pain during sex

• Fatigue, dizziness, or breathlessness 

Seek urgent medical attention if you experience sudden, severe pelvic pain, fainting, or bleeding that soaks through protection every hour for several consecutive hours (22).

Anyone who is told their pain is “just part of being a woman” deserves a second opinion. If you feel that your symptoms are being dismissed, keeping a record of pain, bleeding, and other symptoms can help support conversations with healthcare providers and specialists.

FAQs

Does adenomyosis affect fertility?

Adenomyosis can make becoming pregnant more difficult, although the reasons are not fully understood (3). It may impair uterine lining function, interfere with embryo implantation, or increase the risk of miscarriage (4,8).

Many people with adenomyosis do become pregnant, with or without fertility treatment. Anyone concerned about their fertility should speak with a gynecologist or reproductive specialist.

How can adenomyosis affect mental health?

Living with chronic pain, heavy bleeding, and a condition that is often misunderstood or dismissed can take a real toll on mental health. Research has found that people with adenomyosis have higher rates of anxiety and depression than people without the condition and those with fibroids (8,35).

These effects are not a sign of weakness. Chronic pain and heavy bleeding can affect sleep, relationships, work, and daily activities, all of which can impact emotional wellbeing. Cognitive behavioral therapy (CBT), mindfulness, and meditation all have evidence supporting their use in managing chronic pain (5,37).

Mental health deserves the same attention as physical health.

How do you treat adenomyosis without surgery?

NSAIDs, tranexamic acid, and hormonal options (such as the combined pill or a hormonal IUD) can significantly reduce pain and bleeding. Supportive approaches such as heat therapy and pelvic floor physiotherapy may also help (3,13,17,33). The right treatment plan depends on symptoms and reproductive goals, and should be developed in consultation with a healthcare provider.

What does “adenomyosis belly” look like?

Some people notice visible swelling in the lower abdomen, sometimes called “adenomyosis belly.” This can be caused by an enlarged uterus, which may sometimes reach the size of a 12-week pregnancy. The abdomen may appear bloated or swollen and can feel firm or tender. The appearance varies from person to person and depends on the degree of uterine enlargement (4,25).