I feel fortunate to write my inaugural “Stirring the Pot” column on the intersection of women’s health and cannabis… a dream for me, as both a gynecologist and a cannabis physician. Let’s dive in to cannabis as a treatment option for endometriosis.
A particular patient comes to mind. I met Cora as a pre-teen. Her mother brought her in because Cora was curled up in bed for the first three days of each menstrual period. They tried a heating pad, Motrin, Tylenol and Pamprin, none of which gave her sufficient relief. I suggested adding a birth control pill. This helped a little, but not as much as I had hoped. I ended up adding narcotic pain medications. This combination worked for years. Then it stopped working.
Cora was admitted to the hospital because of unrelenting pain. We opted for exploratory surgery to see if there was an identifiable cause for her pain. I was only able to see a tiny amount of endometriosis, and I removed it. That made little difference. Ultimately, we induced temporary menopause to improve her symptoms. It helped, but was a treatment that could not be sustained because of side effects and a wish on her part to have a baby one day. After a year she ended up back on birth control and narcotics.
As a doctor, I had taken the Hippocratic Oath including the phrase to “above all, do no harm.” Cora put that to the test. I wanted to alleviate her pain, but felt uncomfortable with using addictive substances to do it. She would call every month like clockwork for 30 Percocet tablets. When medical cannabis became legal in my state, I brought up the topic to her. She was not a recreational consumer and was afraid to try it as a treatment option. She gave in when her insurance required pre authorization every month for her narcotics.
The very first period after starting cannabis was shocking. She used one-third of the Percocet she normally used. Over time, with careful fine tuning of her cannabis, she was able to stop all narcotics and relied exclusively on cannabis to manage her cramps.
For those of you who might not understand endometriosis, it is a condition where some of the cells that normally line the inside of the uterus (endometrial cells) and come out in menstrual blood, end up outside the uterus, usually in the pelvis on the surfaces of the uterus, ovaries and tubes. Interestingly, endometriosis be found throughout the body. Each month, these cells respond to the hormones of the menstrual cycle and release blood cells and inflammatory components that cause pain and scarring.
How did these endometrial cells get outside of the uterus? The most common theory is that they drop out of the tubes when menstrual blood backs up instead of coming out normally. This might explain endometriosis in the pelvis, but not in the lungs other distant places. Another theory is that the cells travel in the bloodstream or the lymphatic channels to their destination. A final theory is that the implants are produced from pluripotent stem cells and they develop right where those cells are found, not really originating in the uterus. Regardless of how they get there, these endometriosis cells wreak havoc.
The mainstay of managing endometriosis is to stop hormonal stimulation. This is commonly accomplished with birth control pills, patches or rings. Hormonal IUDs (no estrogen) can also work. If these do not work, then there are medications given as shots or pills that will induce temporary menopause. These are not long term solutions, but can be extremely helpful. Usually they are given for up to two years and then the patient is transitioned back to birth control.
Pregnancy can be remarkably helpful in managing endometriosis and for some women it is “curative.” If it recurs after childbearing is complete, physicians may offer definitive therapy in the form of a hysterectomy and removal of the ovaries, but this is usually considered last resort.
Since endometriosis is common, affecting up to 10% of women, and needs managing for decades, we seek approaches that are easy and effective.
Cannabis and Women’s Health
Can cannabis really help manage endometriosis? Yes. There are papers published about endometriosis and cannabis. Overwhelmingly, users report that cannabis helps with symptoms of endometriosis. Menstrual cramps are, by far, the most common complaint of these patients. However, endometriosis can cause pain with intercourse, fertility challenges, bowel and bladder discomfort and generalized pelvic pain.
Other than when trying to conceive, cannabis can be used to help alleviate those symptoms. It is unlikely that the cannabis actually treats the endometriosis, but given the anti-inflammatory component of cannabis, it may well help to manage inflammatory-related changes, like scarring, that are part of the pathology of endometriosis.
Often patients will ask what particular strain is best to use for endometriosis. I can’t really say that there is one best cannabis strain to use. Each person has an Endocannabinoid System that is responsible for their unique interaction with cannabis. In much the same way that some patients prefer Motrin over Advil or one birth control over another, a certain strain of cannabis may be a miracle for one person’s endometriosis symptoms and not work at all for someone else.
It is necessary to start somewhere to treat and here are a few recommendations.
Cannabis is composed of cannabinoids like CBD and THC, terpenes (smell elements), and flavonoids (taste elements). When used together, these components form an “entourage effect” that is more effective than using any of them alone. Therefore, using 100% pure CBD or 100% THC is unlikely to be the answer. For novices, starting with cannabis that is a balance of CBD and THC, called 1:1, is a good idea. Over time, more THC can be added as needed to maximize pain management.
Adding THC is like seasoning soup. It is always easy to add more salt to the soup than to over-salt at the start. To use cannabis as a medicine, it is desirable for the effect to be reliable and reproducible. When purchasing a product by ratio (CBD:THC 1:1 for example), the cannabinoids are extracted from the plant and then mixed back in the desired proportion. In this way, the ratio you buy one day should be the same a month or a year later.
On the other hand, buying a strain such as Grandaddy Purple or OG Kush may work, but because strains are plants, they may not have the exact make-up year to year, and could become unavailable if the growers did not produce it. Imagine going to the pharmacy for a blood pressure pill only to be told that it is a little different from the year before and might or might not work as well, or that it needs to be substituted because it wasn’t made anymore.
Once you figure out the ratio or type of cannabis to use for your endometriosis, the next step is to decide which delivery system would be best for you. Vaping or smoking flower has the advantage of working very quickly, usually in under 10 minutes. I like to recommend it to use, as needed, in addition to longer-acting products. For women who have pain with intimacy because of endometriosis, flower or vape pens can be a miracle when used 10-15 minutes ahead of time.
Usually a sublingual drop, or tincture, can be used 2-3 times per day after a meal, as a baseline approach. If pain is suddenly worse, inhaling from a vape pen, inhaler or smoking flower, can get the extra relief needed. Oral or edible products are the most long-lasting and can be used instead of a sublingual drop. Caution needs to be taken because they can take 1-2 hours to take effect and last for up to 8+ hours. They are less predictable, but can be incredibly helpful. Lastly, I like to suggest suppositories. They are generally used intravaginally for endometriosis, but can be used rectally, especially for those with endometriosis in the space between the vagina and the rectum.
Cannabis dosing is entirely dependent on the patient. For cannabis naïve people, I start with 2.5mg of THC and increase upward every few days, depending on the effect. For those who use regularly, I suggest starting at 5mg of THC or more, and layering products for best effect. Suppositories are the exception and can be started at 30mg without untoward effect. It can take time to figure out what works, but it is well worth it for the relief.
Back to Cora. She moved away. I got an email in which she shared that she stopped everything after getting married. Luckily, she got pregnant easily, which is not always the case with endometriosis patients. She gave birth to a baby girl and is waiting to finish breastfeeding before re-engaging with cannabis, if she needs it, when her periods start back again.