If you're experiencing spotting between periods, heavy menstrual flow, and severe period pain, you're not alone.

There are a few gynecologic conditions that can cause these symptoms, and what makes things even more difficult is that they love to hang out together.

We're hearing more and more about fibroids and endometriosis (which is great--we need more awareness and support for these conditions!). We're not hearing as much about another gynaecologic condition that affects rough 20-35% of you with a uterus. This conidtion often co-exists with endometriosis and fibroids but is distinct from it.

It's adenomyosis. (I know, it's not particularly easy to spell or pronounce!)

If you haven't ever heard of it, you're not alone. Isolated adenomyosis (meaning you have it and nothing else) only happens in about 10% of cases. Usually, it’s found alongside other conditions like fibroids (50% of cases), endometriosis (11%), and polyps (7%). Plus, in about 30% of cases, it's completely asymptomatic!

If you'd rather watch a video or listen to a podcast episode dedicated to adenomyosis, check out my episode of Phase to Phase: The Hormone Health Show on adenomyosis here.

What exactly IS adenomyosis?

To understand adenomyosis, we need to do a quick anatomy review. Your uterus is made up of three distinct layers:

• Outermost layer = perimetrium
• Middle layer of muscle = myometrium
• Innermost layer that grows and sheds during a menstrual cycle = endometrium

Adenomyosis is a condition in which endometrial glands and tissue (from the inside layer) migrate and grow where they're not supposed to: inside the muscular middle layer (the myometrium).

Because this migrating tissue is hormonally active, it responds to your cyclical hormonal changes every menstrual cycle, just like the inside of your uterus does. Except now, that tissue is trapped inside the muscle.

This can lead to:

• Higher surface area of tissue in your uterus
• Smooth muscle overgrowth around the adenomyosis tissue
• Abnormal uterine contractions
• Extra blood vessel formation
• More inflammatory compounds being created (remember: inflammation is a normal part of the menstrual process, but we get a bigger amount of immune compounds like prostaglandins in adenomyosis)

Symptoms to look out for: What is abnormal uterine bleeding? What can adenomyosis look like?

The most common symptoms associated with adenomyosis are period pain and abnormal uterine bleeding. This is a blanket term we use for changes in the amount, duration, frequency, or regularity of your blood loss.

Here's what that might look like in real life:

• Periods lasting longer than 7 to 9 days.
• Bleeding between your periods, after intercourse/penetration.
• Passing significant blood clots on a regular basis (we’re talking loonie-sized or bigger).
• And losing more than 80 milliliters of blood per period, OR a significant change for you--if your normal is 35mL and you suddenly jump to 70mL regularly, that should raise some alarm bells.

What does 80 ml actually look like? Unless you use a menstrual cup or disc, measuring flow volume in milliliters is tough! In reality, heavy bleeding looks like flooding through products, needing to double up on pads/tampons, or having to change a fully saturated product more often than every two hours. Here's a blog post to help you out too.

Who is at higher risk for adenomyosis?

Your adenomyosis is not your fault (I want to make sure you remember that!). That said, there are a few established risk factors:

• Prior uterine surgery, including C-sections, D&Cs, or a myomectomy (fibroid removal)'
• Multiparity, meaning you've had multiple pregnancies
• Prolonged or elevated estrogen exposure, including getting your first period at a very young age, having shorter menstrual cycles, tamoxifen use, or having a high amount of central adiposity or fatty tissue that is hormonally active and can contribute to estrogen levels over time

How is adenomyosis diagnosed?

Historically, MRIs were the gold standard. Today, transvaginal ultrasounds are highly specific, sensitive, and vastly more accessible. If you're experiencing heavy bleeding or period pain or the symptoms listed above, a transvaginal ultrasound will help your care team rule in or out adenomyosis, fibroids, polyps, or endometrial hyperplasia. You may need further investigation. If you have adenomyosis, the changes that occur with this condition can make it feel tender and "boggy" (yes, that is the actual technical term!) when your doctor palpates your uterus.

Can adenomyosis cause infertility?

The data here is still evolving because adenomyosis is so frequently lumped in with endometriosis and/or fibroids. However, in assisted reproductive technology settings, adenomyosis is associated with higher rates of pregnancy loss (2 to 3 times more likely), preeclampsia, preterm delivery, and small-for-gestational-age babies. Not everyone with adenomyosis will struggle with fertility! Having adenomyosis does NOT guarantee infertility--you have a higher risk. But if you're fertility track, early intervention and comprehensive testing are vital.

Adenomyosis treatment and management: conventional, integrative, and naturopathic Options

There is NO one-size-fits-all solution for adenomyosis. Your treatment plan depends on your age, whether you are close to menopause, your fertility goals, your access to care, and your personal risk tolerance. This has to be a decision you make with your medical team.

Conventional Medical Options

• Symptom management can look like over-the-counter anti-inflammatory meds like NSAIDs (think ibuprofen) or prescription pain relievers. For heavy bleeding, tranexamic acid can be a consideration.
• Hormonal therapies like combined oral contraceptives, progestin-based therapies, or hormonal IUDs (often considered a first-line treatment because they can actually reduce the size of the uterus in adenomyosis).
• Surgical intervention: Ranging from the focal removal of lesions (especially for fertility patients) to a hysterectomy (often reserved for those closer to menopause or who do not desire future fertility and are very symptomatic).

Integrative & Naturopathic Options

There's limited isolated and robust data on natural interventions specifically for adenomyosis. What we have is data borrowed from endometriosis and fibroids (which makes sense, because they so often travel together and share so many symptoms!). The goal here is to set you up for success and make sure your periods and symptoms aren't getting in the way of your life or health goals!

• Work on the foundations of health, like getting regular physical activity, restful sleep, managing stress, and adopting a heart-healthy, plant-forward diet rich in whole foods, low in saturated fat from red meat, and high in omega-3s. (We borrow a lot of this data from endometriosis research for general hormonal health, symptomatic relief, fertility care, and even your overall long-term health!).
• Targeted supplementation based on correcting any nutrient deficiencies you have, like vitamin D and iron. Menstruators with heavy bleeding often walk around severely iron deficient, leading to hair loss, brittle nails, and crushing fatigue.
• Herbal medicine and other nutraceuticals: Ginger is one of our primary herbs for period pain and heavy bleeding (and it helps with the nausea that can accompany severe pain!). However, a cup of ginger tea isn't going to cut it for 10/10 pelvic pain; we look for a therapeutic target dose of 1200 to 1500 mg per day. There are other herbs like crampbark, antioxidants, and pain supplements like PEA or palmitoylethanolamide that can be used in different situations. Herbs and meds can even be used topically for pain relief.
• Physical modalities: Pelvic floor physiotherapy, acupuncture, massage, and TENS machines can be extremely helpful for pain management.

Friendly PSA: This is not medical advice. Always consult a healthcare provider like a naturopathic doctor before adding herbs or supplements to your routine to ensure you are hitting the right therapeutic dose in a manner that is safe and that is appropriate for you. Natural supplements and therapies come with risks and interactions just like everything else!

The hidden toll of heavy bleeding (and how to advocate for yourself)

I will sound like a broken record saying this, but: TRACK YOUR CYCLES. Use an app, a calendar, or a notebook. Track your pain levels, the number of products you bleed through, and how many days you are sidelined. Our memories are imperfect! Bringing data to your doctor's appointment completely shifts the power dynamic in the room.

Finally, we need to talk about the immense toll that heavy bleeding and chronic pain take on your quality of life. It drains your physical energy, your mental health, your social life, and your wallet.

Between paying out-of-pocket for endless period products and iron supplements to replenish what you're losing, the financial burden is very real. When you build a treatment plan and think about how you want to proceed with your medical care, these factors HAVE to be part of the conversation.

You did not cause your adenomyosis, and you deserve comprehensive, compassionate care. Make sure to listen to the full episode on Adenomyosis on Phase to Phase: The Hormone Health Show and share it with someone who needs to hear this.

I also have a book, "The Period Literacy Handbook", to help you understand your body, hormones, and periods a whole lot better if you're wanting to learn more.

If you're looking to work with a healthcare provider who can help you navigate all the confusing information out there, I'd be honoured to be part of your health team. I see patients in Innisfil (near Barrie), East Gwillimbury (near Newmarket), or virtually across Ontario.