Background: Adenomyosis is an estrogen-dependent uterine disorder commonly associated with heavy menstrual bleeding, dysmenorrhea, uterine enlargement and anemia. In perimenopausal women, hormonal treatment is often preferred to preserve the uterus and avoid surgery. However, real-world evidence on treatment outcomes in this age group remains limited, particularly in Bangladeshi clinical settings. This study evaluated clinical outcomes, satisfaction and tolerability of hormonal therapy. Methods: This retrospective observational study was conducted at the Department of Obstetrics and Gynaecology, Mugda Medical College & Hospital, from June 2023 to July 2024. A total of 150 women aged 40–52 years with ultrasonography-confirmed adenomyosis received LNG-IUS, dienogest, or GnRH agonists and had a six-month follow-up. Clinical, hematological, satisfaction and adverse-effect data were extracted from records. McNemar’s test was used for paired outcomes, with p<0.05 considered significant. Results: At six months, menorrhagia decreased from 92.0% to 4.0%, severe pelvic pain/dysmenorrhea from 78.7% to 12.0%, uteromegaly from 49.3% to 14.7% and anaemia from 69.3% to 17.3% (all p<0.001). Amenorrhea was achieved by 58.7% of participants, while 86.7% were satisfied or highly satisfied with treatment. Irregular spotting/breakthrough bleeding was the most frequent adverse effect (29.3%), followed by weight gain (17.3%). Overall, adverse effects were manageable. Conclusion: Hormonal therapy was associated with six-month improvement in bleeding, pain, uterine enlargement and anemia, with high treatment satisfaction and tolerable adverse effects. These findings support hormonal therapy as a uterus-conserving option for symptomatic adenomyosis in perimenopausal women.