Objective To evaluate the efficacy and safety of high intensity focused ultrasound （HFIU） combined with endometrial ablation in the treatment of adenomyosis （AM） patients with heavy menstrual bleeding （HMB）. Method A total of 199 patients with AM combined with HMB who underwent HIFU treatment at the Obstetrics and Gynecology Center of Affiliated Hospital of Chengdu University of TCM from July 2020 to September 2022 were selected and divided into two groups according to the ablation range. The combined ablation group included 80 cases with lesion and endometrial ablation （endometrial ablation rate ≥ 30%）， while the lesion ablation group 119 cases with simple lesion ablation. A 1∶1 propensity score matching was performed on the two groups， resulting in 59 patients in each group. A 6-month follow-up was conducted. The clinical manifestations （menstrual volume， degree of dysmenorrhea， uterine and lesion volume）， quality of life （MS-QOL， UFS-QOL）， and postoperative adverse reactions between the two groups before and 6 months after surgery was compared. Results Menstrual volume， degree of dysmenorrhea， uterine and lesion volume， MS-QOL score， and UFS-QOL score of the both groups were improved 6 months after surgery， when compared to those before surgery （P < 0.05）. Significantly reduced menstrual volume， degree of dysmenorrhea， and lower MS-QOL score were observed in the combined ablation group when compared with the lesion ablation group （P < 0.05）， but there was no statistical significance in uterine and lesion volume and UFS-QOL score （P > 0.05）. There was no difference in the incidence of adverse reactions between the two groups （P > 0.05）， but the combined ablation group had longer vaginal bleeding and fluid flow time （P < 0.05）. Conclusion The combined HIFU and endometrial ablation can effectively reduce menstrual flow， alleviate dysmenorrhea， and improve quality of life in patients with AM combined with HMB. Although it increases vaginal bleeding and fluid flow time， reasonable symptomatic management can effectively prevent the occurrence of adverse consequences such as infection.