High Times

Its 2021 and another endometriosis awareness month! Although the spectre of 2020 is firmly behind us now there are still many challenges ahead, particularly for people with chronic health conditions, so I hope you are all keeping as well as possible and good things are waiting for you in the coming year. Its traditional to make new years resolutions (its also traditional to give up on them by February!), so I’m going to resolve to make more blog posts this year, there’s no shortage of endo research to report on!

Its fair to say that many people with endometriosis need to supplement their medical therapies with self-management strategies. These strategies can take many different forms: exercise regimes, dietary changes, herbal medicines, alternative therapies and meditation are just a few examples of self-management strategies. The trouble is, people experience endometriosis in different ways, so a therapy option for one person, may work better or not at all in someone else - this applies as much to medical therapies as it does to self-management therapies. Therefore, its not surprising that people are constantly looking for other self-management strategies to try to manage their endometriosis symptoms.

One particular approach, that has been used widely for pain relief in the past, is making a comeback today – the use of medical marijuana. Numerous reports have shown that the use of medical marijuana for chronic pain conditions has improved the quality of life for the sufferer and reduced the need to prescribe highly addictive opioid-based painkillers (for example see here and here). No medication is without drawbacks though and cannabis-based medications are no exception. The second paper I linked to above highlighted that adverse gastrointestinal side effects were more common in cannabis-based therapies given orally (i.e. as in liquid or edible forms) as opposed to inhaling (like smoking or vaping), and other studies indicate that a decline in mental health is noted in some cases.

As I said though, no medication is free from side effects, so the most important point for patients is to make informed decisions about their treatments, i.e. making sure they are given all the information about benefits and drawbacks of any kind of therapy before deciding to proceed.

Because of the illegality of cannabis in many countries, it means that official, well researched and objective information about type/dosage/side effects of cannabis therapies for chronic pain relief isn’t made widely available to the public. Drug formulations that are available as prescriptions are also not subject to regulation in the same way as prescription medications, meaning the quality of these products are not guaranteed. This, of course, doesn’t stop people from wanting to try cannabis-based therapies, particularly if traditional medical options have failed.

But what about endometriosis and cannabis-based therapies? Unsurprisingly there hasn’t been a great deal of research into cannabis as a valid therapy for endometriosis associated pain, certainly there haven’t been properly conducted clinical trials, which make drawing definite conclusions difficult. Therefore, we have to rely on surveys from patient experiences.

A survey of people using cannabis for self-management of endometriosis associated symptoms in New Zealand (a country where cannabis is currently illegal, but medicinal marijuana is permitted) found that, of those that used cannabis, 95.5% used it for pain relief and to improve sleep quality. Overall, around 80% reported improvements to pain symptoms, sleep and nausea, with just over 81% stating that they could reduce their normal medication intake. Interestingly this is echoed, to a lesser extent, in an Australian study that found that 56% of women taking cannabis-based medications were able to reduce their pharmaceutical medications by at least half, although 1 in 10 women did experience adverse side effects, they were rated as ‘minor’. This study also found improvements in sleep quality and nausea like the New Zealand study. Another Australian study ranked self-management strategies for endometriosis by effectiveness and found that cannabis, heat, and CBD oil were the most effective. A study from Canada looking at cannabis use pre- and post-legalisation also found that once cannabis was legalised, many more women with chronic pelvic pain started using it recreationally and this led to lower likelihood for daily opioid-based painkillers.

Although the evidence is fairly limited, it points toward cannabis-based medical treatments being beneficial for the chronic symptoms of endometriosis. Some larger more well-designed clinical trials would be nice to actually prove the effects, but when a substance has dubious legal status, studying it becomes a bureaucratic nightmare.

What is it then that makes cannabis a potential medical option for pain relief? Cannabis, like many other plants, contains a vast array of different chemicals with different effects on humans. So far over 450 different chemicals have been identified in cannabis, with around 70 classified as a group of related chemicals called phytocannabinoids. The main phytocannabinoids are delta 9-tetrahydrocannabinol (better known as THC), and cannabidiol (aka CBD). THC is generally considered to produce the pain relief and reduction of anxiety effects (but has negative effects on memory, cognition and mood), whereas CBD reduces inflammation as well as pain relief and mediate the negative effects of THC to a degree.

A number of different cell types in the human body, like nerve cells and certain immune cells, have receptors for cannabinoids. This means that cannabinoids can bind to these receptors and alter the function of those cells. The presence of cannabinoid receptors on nerve cells is particularly interesting when talking about endometriosis because it means the right combinations of cannabinoids might be able to reduce pain signalling and intensity (for a review of cannabis and neuropathic pain see here).

Is there a future for cannabis, or cannabis derived chemicals, in the treatment of endometriosis? Potentially yes, but there no drug in existence that is 100% effective for everyone and free of side effects. However, we live in a world where people will self-medicate with these substances anyway, so it benefits patients, doctors and scientists to fully understand the benefits and drawbacks of cannabis.

Cover photo by aphiwat chuangchoem from pexels.com