The pain you were told was normal was not normal.

Endometriosis lesions are most often on the ovaries (where they form chocolate cysts called endometriomas), the pelvic peritoneum, the bowel, the bladder, and the ligaments holding the uterus. Adenomyosis is the same kind of tissue burrowed into the muscular wall of the uterus itself, making it enlarged, boggy and painful. Same tissue logic, different address, which is why the experience overlaps so heavily and the two often co-exist.

Endo and adeno lesions secrete inflammatory cytokines and prostaglandins, recruit immune cells, and create chronic local inflammation that drives pain, adhesions and central sensitization over time. This is why fatigue, brain fog, gut issues and full-body pain are part of the picture for many women, it isn't only a pelvic problem.

Average diagnostic delay is 7 to 10 years for endo. Ultrasound and MRI can detect endometriomas, deep infiltrating endo, and adenomyosis (which has fairly characteristic imaging features, bulky uterus, junctional zone thickening, cysts in the muscle wall) but routinely miss superficial peritoneal endo. The historical gold standard for endo is laparoscopy with biopsy; adeno is increasingly diagnosable on a good MRI. A normal scan does not rule either out.

Estrogen swings in perimenopause are bigger and more erratic than in the 30s, and bigger surges feed both endo and adeno. Many women describe theirs getting worse in their 40s: heavier bleeding, longer pain windows, more bowel involvement, a uterus that feels heavier and crampier than it used to. This is the rule, not the exception.

Both are estrogen-driven, so for many women symptoms ease when periods stop. But not all. Fat tissue continues to make estrogen after menopause. Adhesions, scar tissue and nerve damage built up over decades don't disappear with the last period. And women on HRT can see disease activity restart, sometimes mildly, sometimes significantly. Post-menopausal endo and adeno are real and under-recognized.

This is the biggest practical difference between the two. Adenomyosis lives in the uterine wall, so removing the uterus removes the disease, hysterectomy is genuinely curative for adeno. Endometriosis lesions live outside the uterus, so they remain after a hysterectomy unless they're also excised. 'I had a hysterectomy and the pain came back' is the classic endo story. For endo, excision of all visible disease by a specialist surgeon is what changes long-term outcomes, not the hysterectomy itself.

Date, severity (1 to 10), location (pelvis / lower back / bowel / bladder / leg / a heavy crampy uterus), and what it cost you that day (work, sex, exercise, sleep). Two months of this is more useful in a clinic appointment than ten minutes of trying to remember.

Endo and adeno pain are classically worst in the days before and during bleeding, but in perimenopause and in deep infiltrating disease (or severe adeno) it can be daily. Knowing whether your pain is cyclical, daily, or 'cyclical layered on top of daily' changes treatment.

Cyclical diarrhoea, constipation, blood in stool or urine around your period, painful bowel movements, urinary urgency that worsens with bleeding, these are flags for bowel or bladder endometriosis and warrant a specialist scan.

Heavy, prolonged, clot-filled bleeding and short cycles are classic adenomyosis flags (and often the loudest signal in perimenopause). Track pad/tampon changes, flooding, clots bigger than a 50p / quarter, and how many days you bleed. This is the kind of evidence that gets you taken seriously and onto the right scan.

Deep dyspareunia (pain on deep penetration) often points to deep infiltrating endo, adhesions or pelvic-floor involvement. Worth tracking specifically: many women stop having sex rather than reporting it, and doctors or specialists don't ask.

Endo- and adeno-related fatigue is real and is now in the literature as a recognized symptom, not just 'the pain is exhausting'. Tracking it as a separate symptom helps make the case for treating these conditions systemically, not just locally.