Objectives <p>This study aimed to compare the efficacy and safety of ultrasound-guided percutaneous microwave ablation (PMWA) and laparoscopic adenomyomectomy for the treatment of symptomatic uterine adenomyosis.</p> Methods <p>We conducted a retrospective case–control study of patients with symptomatic adenomyosis treated between January 2019 and December 2021. Visual analog scale (VAS) for pain and adenomyosis symptom severity score (SSS) were assessed before treatment and at 3, 6, and 12&#xa0;months post-treatment. Uterine volume, lesion volume, hemoglobin (Hb) recovery, recurrence, technical outcomes, and complications were compared between the two groups. Operative parameters and recurrence rates were further analyzed based on adenomyosis type (focal vs. diffuse).</p> Result <p>A total of 175 patients were included (PMWA: n = 95; Laparoscopy: n = 80). Both treatments significantly reduced VAS and SSS scores, shrunk uterine and lesion volumes, and improved Hb levels at all follow-up points (<i>p</i> &lt; 0.05). For focal adenomyosis, operative time was similar between groups, but PMWA resulted in significantly less intraoperative blood loss and shorter hospital stay (<i>p</i> &lt; 0.05). However, the recurrence rate was higher in the PMWA group (13.2% vs. 0%, <i>p</i> &lt; 0.05). For diffuse adenomyosis, PMWA demonstrated significant advantages over laparoscopy in operative time, blood loss, and hospital stay (all <i>p</i> &lt; 0.05), with no significant difference in recurrence rate.</p> Conclusion <p>Both PMWA and laparoscopic adenomyomectomy are effective micro-non-invasive treatments for symptomatic adenomyosis. Our findings suggest a stratified treatment approach: laparoscopic adenomyomectomy may be preferable for focal lesions due to lower recurrence, while PMWA offers superior perioperative outcomes for diffuse disease. Individualized treatment selection based on lesion type is recommended.</p>