Adenomyosis and Menopause: Dealing with It During the Transition

Prolonged bleeding, worsening abdominal cramps, and pelvic pain during midlife are sometimes overlooked as normal signs of hormonal changes, but they may be symptoms of adenomyosis.

Adenomyosis is a condition in which the tissue that lines the uterus starts growing into the muscle wall of the uterus. This can lead to heavier periods, intense abdominal pain, and pelvic discomfort. Because these symptoms are similar to other conditions, such as endometriosis or fibroids, it can be challenging to diagnose adenomyosis.⁽¹⁾

This article explains how symptoms of adenomyosis can vary through the stages of menopause: perimenopause, menopause, and postmenopause. It also explores the diagnosis and treatment options for adenomyosis.

What is adenomyosis, and how does it differ from endometriosis?

Adenomyosis and endometriosis are often mistaken for one another, but they’re distinct conditions with different tissue growth patterns and symptoms.

Defining Adenomyosis

Adenomyosis is a condition where the inner lining of the uterus, known as the endometrium, grows into the muscular wall of the uterus, called the myometrium. This misplaced tissue continues to act as it normally would — thickening, breaking down, and bleeding with each menstrual cycle. However, because it’s trapped within the muscle, it can lead to swelling, stomach cramps, and heavy bleeding. The condition can affect the uterus in a widespread (diffuse) way or be localized to a specific area (focal or cystic). ⁽¹⁾

The exact cause of adenomyosis isn’t fully understood. Research suggests it may occur when endometrial tissue invades the uterine muscle after childbirth or surgery. Other theories suggest that developmental origins may lie in the womb or the migration of stem cells into the muscle layer.⁽²⁾

Estrogen appears to play an important role. This hormone stimulates the growth of endometrial tissue, including the tissue trapped in the muscle. That’s why adenomyosis is most common during the reproductive years when estrogen levels are higher.

Symptoms of Adenomyosis 

The symptoms of adenomyosis can vary. Some people experience no symptoms at all, while others may have the following:

• Heavy or long-lasting periods

• Severe menstrual cramps (dysmenorrhea)

• Chronic pelvic pain

• Pain during sex (dyspareunia)

Key Differences: Adenomyosis vs. Endometriosis

Adenomyosis and endometriosis are often confused because they both involve endometrial tissue growing where it shouldn’t. However, they’re two distinct conditions.⁽³⁾

• Adenomyosis: Endometrial tissue grows inside the muscular wall of the uterus.

• Endometriosis: Endometrial tissue grows outside the uterus, often on the ovaries, fallopian tubes, or other pelvic organs.

How is adenomyosis diagnosed, especially around the menopausal transition?

Adenomyosis can be difficult to diagnose because its symptoms often mimic other conditions like fibroids or endometriosis. It may come to light during perimenopause if symptoms like heavy bleeding or pelvic pain persist when periods should be easing. New or abnormal bleeding near or after menopause always warrants investigation to rule out other causes, including cancer.

Clinical Examination

A pelvic exam may reveal an enlarged, tender, or boggy uterus. However, these signs aren’t always present, especially if other conditions coexist.

Imaging Tests

Some tests that can help diagnose this condition include the following:

• Transvaginal Ultrasound (TVUS): This is a common first step. It may show a globular uterus, thickened muscle, small cysts, or a disrupted border between tissue layers.

• Magnetic Resonance Imaging (MRI): This offers clearer detail, especially when ultrasound is inconclusive. A thickened junctional zone (over 12 mm) strongly suggests adenomyosis.

TVUS is typically recommended first due to cost and availability, with MRI reserved for complex cases.

How does adenomyosis change during perimenopause?

Perimenopause is marked by fluctuating hormone levels, especially estrogen. For people with adenomyosis, this hormonal instability can make symptoms worse before they get better.

Estrogen stimulates the growth of endometrial tissue, including the tissue embedded in the uterine muscle. When estrogen levels spike or fall unpredictably during perimenopause, it can lead to the following symptoms:⁽⁴⁾

• Heavier or more irregular periods

• More intense menstrual cramps

• Worsening pelvic pain

• Increased fatigue or anemia from blood loss

For some, these symptoms can disrupt work, relationships, and overall quality of life, at a time when the body is already going through significant changes. While adenomyosis may eventually improve after menopause, the transition can be especially difficult to manage without proper support and treatment.

What happens to adenomyosis symptoms during menopause?

Menopause is defined as 12 months without a period. During this time, estrogen levels drop significantly, and because adenomyosis depends on estrogen to grow, many people notice an improvement in their symptoms.

Heavy bleeding and cramping may lessen or stop altogether. The uterine tissue becomes less active without ongoing hormonal stimulation.

Mild symptoms may continue in some cases, especially if the adenomyosis is severe or if hormone therapy containing estrogen is introduced. However, symptoms tend to be much more manageable than they were before menopause.

Can adenomyosis persist or cause symptoms after menopause (postmenopause)?

While it’s rare, adenomyosis can occasionally continue to cause symptoms after menopause. Most people experience significant relief once estrogen levels drop and menstrual cycles stop, as the tissue becomes less active without hormonal stimulation.⁽⁵⁾

Does adenomyosis go away after menopause?

In most cases, symptoms like heavy bleeding and cramping fade as the body produces less estrogen. Although the adenomyotic tissue may remain in the uterine wall, it typically becomes inactive.

Postmenopausal Adenomyosis Symptoms

In a small number of cases, some symptoms may linger, most often pelvic pressure or discomfort. The most concerning symptom is postmenopausal bleeding. While adenomyosis can be one cause, any bleeding after menopause should always be evaluated to rule out other conditions, including endometrial cancer.⁽⁶⁾

A few factors may increase the chances of symptoms continuing after menopause, including the following:

• Severe adenomyosis before menopause

• Use of estrogen-only hormone replacement therapy (HRT)

• Natural estrogen production from body fat 

Managing Adenomyosis During Menopause

Managing adenomyosis during the menopause transition focuses on relieving symptoms and improving quality of life. While many people find that symptoms ease after menopause, others may need continued support to feel their best.

Treatment options depend on the severity of symptoms and the stage of menopause. Below are several approaches that may be considered.⁽⁷⁾

Non-Hormonal Options

These are often the first line of treatment, especially for those with mild symptoms or those who wish to avoid hormone-based therapies.

• NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Drugs like ibuprofen or celecoxib help relieve pain by reducing prostaglandin levels, which are responsible for uterine contractions and inflammation. Celecoxib has also shown potential in reducing disease activity in animal models.

• Lifestyle Adjustments: Heat therapy, gentle exercise, pelvic floor relaxation, and stress management may help reduce the intensity of cramps and improve general well-being.

Hormonal Options

Hormonal treatments can help reduce pain, bleeding, and other adenomyosis-related symptoms by lowering or balancing hormone levels, especially estrogen, which fuels the growth of adenomyotic tissue. These therapies may be used during perimenopause or considered carefully during postmenopausal hormone replacement.

• Progestin-Based Therapies: These release progestin to thin the uterine lining, reduce inflammation, and suppress tissue growth. The levonorgestrel-releasing IUD is a common choice due to its localized effect, long-acting nature, and low risk of systemic side effects.

• Combined Oral Contraceptives (COCs): By stabilizing hormone levels, these pills can reduce bleeding and cramping. They’re typically used during perimenopause but are usually discontinued after menopause begins.

• Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists: These therapies reduce estrogen production and can shrink adenomyotic tissue. They’re effective in relieving pain but may cause menopausal-like side effects and are often limited to short-term use.

• Aromatase Inhibitors: These medications block the enzyme aromatase, which helps produce estrogen in fat and other tissues. This reduction in estrogen can shrink adenomyotic growths and ease symptoms, though more research is needed to confirm long-term safety.

• Hormone Replacement Therapy (HRT): In some cases, HRT may be used to manage menopausal symptoms such as hot flashes, sleep issues, and mood changes. Combined HRT (estrogen plus progestogen) is necessary to protect the uterine lining and reduce the risk of stimulating adenomyotic tissue. However, HRT may not be suitable for everyone. A practitioner can help weigh the benefits and risks based on an individual’s medical history, severity of symptoms, and personal goals. In some cases, adjusting the type, dose, or delivery method (such as using transdermal estrogen instead of oral estrogen) may reduce the chance of symptom recurrence while still providing relief from menopause-related discomfort.

Minimally Invasive Procedures

These may be considered if medications aren’t effective or well-tolerated.

• Uterine Artery Embolization (UAE): This procedure involves cutting off the blood supply to adenomyotic tissue, reducing bleeding and pain. Although it may be less commonly used now, it remains an option for select cases.

• Endometrial Ablation: This procedure destroys the uterine lining to reduce bleeding. However, it may not reach deep adenomyotic tissue and is best for those not planning future pregnancies.

• High-Intensity Focused Ultrasound (HIFU): This is a non-invasive technique that targets and destroys focal adenomyosis using heat. The procedure is still under evaluation, but it may offer fertility-preserving relief in select cases.

Surgical Options

Surgery is typically reserved for severe cases or when other treatments have failed.

• Hysterectomy: This is the only definitive cure, as removing the uterus eliminates symptoms entirely. It may be especially appropriate for those with persistent pain, bleeding, or pressure and who do not plan to maintain fertility.

• Myomectomy or Partial Resection: These procedures involve removing localized adenomyotic tissue while preserving the uterus. However, they may not fully eliminate symptoms and may carry a risk of recurrence.

Conclusion

Adenomyosis can be hard to diagnose as its symptoms often change or mimic those of other conditions. While many experience relief during the menopausal transition when hormone levels drop, some may still have pain, heavy bleeding, or pressure.

Talking with a trusted healthcare provider is key. A registered practitioner can confirm the diagnosis with the right tests and help choose the best treatment plan, whether it involves medication, hormone therapy, or surgery. Regular follow-up care can ensure that the chosen treatment continues to meet the individual’s needs and helps improve everyday quality of life.

This personalized approach to care gives women a clear path forward, ensuring they receive support tailored to their unique health needs during and after the menopause transition.