Always Pure Organics’ research assistant Alexandra Gkoutzidou explores the evidence behind the use of CBD to treat and manage the symptoms of endometriosis.
What is Endometriosis?
The endometrium is the lining of the uterus that hosts the zygote after fertilisation of the egg. If the egg does not get fertilised, meaning does not embed itself to the endometrium, the endometrium sheds off, causing menstruation.
Then the endometrium will be reconstructed in expectation of the next zygote and shed off again if that does not happen. The endometrium, therefore, is destroyed and reconstructed every month.
When endometrium cells grow in different part of the uterus (other than the endometrium lining) or even the body, this is called endometriosis. The endometrium cells will shed and regrow every month no matter their location in the body, causing lesions, painful periods (dysmenorrhea), pelvic pain, infertility, or subfertility.
Statistically one in 10 people with a fertile uterus suffer from endometriosis, but its cause is not clear yet.
The role of the endocannabinoid system
It appears that the endocannabinoid system (ECS) plays an important role in the normal processes of the female reproductive system[3, 9].
Studies show that proper regulation of the ECS is important to maintain a healthy regulated reproductive system. It has been observed that endocannabinoids’ and their degradative/oxidative enzymes’ expression fluctuate in the female reproductive organ in accordance with the stage of the menstrual cycle.
The levels of these endocannabinoids are raised to increase fertility during ovulation and then fall during the luteal phase of the menstrual cycle. Research has shown that this fluctuation of the ECS is not as well-regulated for people suffering from endometriosis.
The results have shown that people with endometriosis have low amount of CB1 receptors in the uterus and abnormal levels of endocannabinoids in their blood during their menstrual cycle.
Evidence shows that in the reproductive system, the use of cannabinoids operates in more than one way.
The way the cannabinoids operate in this system is related to both the amount of expressed cannabinoids and also in the phase of the menstrual cycle. The use of cannabinoids to treat endometriosis, is therefore a complicated case and in such cases it is important to consult a doctor instead of self-medicating, because high levels of the “wrong” cannabinoid, or even at the wrong time of the month could possibly affect ones fertility or cause other gynaecological issues.
What does the evidence say?
McHugh et al , researched the effect of THC and N-arachidonyl in the migration of endometrial cells in an animal cell culture. It was observed that while the above two cannabinoids induce migration of the endometrial cells, CBD prohibits it. While this research gives way to more in-depth research for the effect of CBD in human endometriosis, it does not provide sufficient data to claim that CBD is beneficial against endometriosis.
There are two clinical trials currently taking place, researching just that. The first is an open label phase II trial, studying an 1:1 ratio of THC and CBD administered to endometriosis patients to reduce hyperalgesia.
The second is a phase III double blind placebo study, where patients will receive norethindrone acetate, a type of hormonal treatment, in accompany with 10 or 20mg of CBD for the management of endometriosis pain.
Regardless, a lot of people are already using cannabis and/or CBD to treat the pain derived from endometriosis. Research that took place in Australia investigated the self-management strategies amongst Australian women with endometriosis . This online research was published on social media and invited women to share their own methods of treating their endometriosis symptoms.
The authors suggested that the anonymity of an online research could increase engagement, due to the fact a lot of people use illegal substances to treat pain symptoms. The most common strategies used were self-care and lifestyle choices like heat, rest and meditation, but the most highly effective rated self-reported methods were cannabis, heat, hemp/CBD oil, and dietary changes.
Anecdotal evidence suggests that the use of CBD, THC and possibly other cannabinoids could help treat the pain related to endometriosis, but given the role the ECS has in the uterus there should be more in-depth research in order to realise the factual role CBD plays in endometriosis (if any). The pain sensory system is different to the reproductive system. The role of CBD in pain is well understood and the analgesic effect of CBD in endometriosis pain is probably related to it instead of an effect to the endometrial cells [5, 10, 11].
Nonetheless, CBD has been shown to have positive effects for patients with diseases related to ectopic movement of cells in the body, like cancer and psoriasis. Indeed, CBD has been shown not only to inhibit some cancer cells growth, but also to mediate these cell’s movement to other parts of the body (metastasis) [14, 15, 16].
Similarly, psoriasis is a disease which one of its symptoms is the over production of new skin cells too quickly, that causes the scales. In that case, CBD has been shown to positively affect the skin making it more elastic, better hydrated and reducing the amount of scales by promoting the balanced production of cells and minimising the ectopic production . Similarly, CBD could possibly benefit the ectopic production of endometrial cells but it is yet to be researched.
The levels of cannabinoids in the uterus are strongly related to the phase of the menstrual cycle and they are formed so to increase fertility [9, 13]. Therefore, it is ill advised to use any cannabinoids if you are trying to get pregnant or have a related health problem without advising your doctor and testing whether the endocannabinoid levels are correct during your cycle. A well balanced ECS is the target so always follow the dosage directions.
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 DOI 10.1186/1471-2202-11-44
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My endometriosis was misdiagnosed as an eating disorder
Sophie underwent a laparoscopy in December that revealed she had stage four endometriosis.
Endometriosis is a painful, long term condition affecting one in 10 women in the UK. Sophie Harrop talks to Cannabis Health about coping with pain, cannabis and living with a hidden illness.
Endometriosis is a condition where tissue similar to the lining womb starts to grow in other areas of the body. It can grow around other organs causing chronic pain. The condition leaves patients in debilitating pain, feeling sick and with difficulty getting pregnant. It can take on average seven years to diagnose in the UK.
Sophie was diagnosed with endometriosis in 2015 after experiencing pains in her side and severe fatigue which meant she slept a lot.
“I got diagnosed by laparoscopy in 2015 after I developed really bad period pains in the right side of my body. I started to feel like something wasn’t right as I was getting a lot of pain so I decided to go to the doctors,” she said.
“I got lucky in that some people can have endometriosis and wait up to eight or 10 years to get diagnosed but it only took me a year. I’m very grateful for getting to that point because it was very stressful.”
Doctors initially assessed her in terms of her weight and diagnosed her with an eating disorder.
“I’ve always been very thin but I eat like an animal, I just have a high metabolism,” said Sophie.
“When I went to the doctors, they thought it was something to do with an eating disorder or Irritable Bowel Syndrome (IBS). There were so many different things that they suggested to me.”
Her doctor suggested she keep a food diary so they could track the amount she was eating. The diary proved that she was eating as much as she said, but she was disheartened.
“I can’t express to you how much I have something wrong with me, but it’s not an eating disorder,” Sophie continued.
“I’m quite a strong-minded person but to others who aren’t, I feel it’s very damaging. People are brought up to think doctors are always right, but I was annoyed they were coming up with these things.”
Sophie had a laparoscopy in December 2020, which revealed she had endometriosis across her bowel and bladder. The condition is measured in different stages, that map the depth and areas affected by the tissue.
Sophie was told she was stage four which means it is the most severe. At this stage, endometriosis is now widespread and deeply implanted. There may also be cysts on one if not both ovaries.
Life with endometriosis
Sophie had been brought up to be a “tough cookie” and hadn’t realised how bad things were until her laparoscopy. She says her mother also struggled to believe that the pain was that bad, until her scan.
“I never realised how bad it was until the laparoscopy,” said Sophie.
“In your mind, you start to wonder if you have made it up, and my mum never believed me. She came into my room afterwards in disbelief at how bad it was.”
She added: “At the time, I was working at a builder’s merchants as a marketing manager. I was the only woman among 22 men, with a very strict boss. If I had days where I didn’t feel well, he would tell me to get into work. It was hard to be around all these men because I was in so much pain and no one understood it. That’s what I find with endometriosis, it’s so hard to express how you feel.”
Sophie, described a feeling of heaviness, she explained: “When it’s bad, I get this feeling as if I am 90 stone. It’s a feeling like I have something attached to me pulling me down. People can’t relate because no one knows what this feels like, but when you find other endometriosis sufferers, they understand.”
Endometriosis, mental health and ADHD
Sophie now relies on a combination of both medical cannabis and CBD to help her symptoms. She has also been diagnosed with Attention Deficit Hyperactive Disorder (ADHD) and finds this combination of eases the different symptoms of both conditions.
At the time of her laparoscopy, Sophie was already consuming cannabis. She explained that the nurses laughed at her when she said she would prefer to treat her pain with cannabis, rather than the prescription drugs she was being offered. It was a chance encounter with CBD that piqued her interest in what cannabinoids could offer.
“My friend’s dad opened a CBD company and introduced me to it. I had a really bad sunburn with very badly burned thighs. He gave me a little pot of cream which I applied then the next day it was gone. I had to find out more about it, she says.
“Since then I have done a lot of studies and nearly completed a course on medical cannabis and CBD. I spend every day of my life learning more about it.”
The mental health impact of endometriosis which is another area which Sophie feels is misunderstood. She uses CBD to help her mental health, but finds that THC is more effective in helping the pain caused by the condition.
“People don’t understand the mental factor of endometriosis. It’s triggered by stress, so if I’m going through stressful periods in my life then I am more bed-bound and in a lot of pain. I notice with my menstrual cycle that somedays I have days where it feels like the world is against me.
“I take CBD every day without fail but when I had a couple of days off THC, I noticed the pain was still there in the same places, but it was sharper. It was like I had barbed wire in my stomach that was on fire.”
Chronic illness and sports
Sophie is an incredibly active person who takes part in a range of sports, especially hiking which she shares on social media. She wanted to show that not all chronic illnesses are visible and that patients should not be judged by what they post online.
She has now opened an online store and uses her platform to educate customers about the benefits of CBD. She isn’t motivated by the money when it comes to being in business, but wants to provide enough information to empower people to make their own decisions about their health.
“I get a lot of people who say to me that I haven’t got endometriosis, and that I’m not chronically ill by judging me off my social media. It frustrates me because I would never wish the pain or illness on anybody.
“The reason I go out and do these things is that I have a lot of drive and could be in so much pain but will still get up and out as I would rather be in nature. It makes me feel physically better than sitting in my bed,” she said.
“I want to educate people to have the confidence to go try cannabis. Everyone is different and I want to be able to give people the confidence to do their own research and understand their own bodies. I’m not anti-doctor as I wouldn’t be where I am today without my gynaecologist and my amazing surgeon but at the same time, I wish people would think for themselves rather than just going off the doctor’s opinion.”
When it came time to choose the products she would work with, she immediately knew she wanted to include CBD coffee.
“I have my own coffee brand. The reason I introduced coffee into it was that I would always forget to take my dose in the morning but then in the evening, I’m fine. I created the CBD coffee because I thought it could be added into your life quite easily.”
Sophie finds the CBD industry incredibly rewarding to work in.
“I’m so passionate about this industry, she adds.
“People say to me that I’m literally the happiest person ever, but everyone has bad days. We have to have the bad days to appreciate the good days. I definitely feel my happiness and energy comes from cannabis and its helping to balance everything out.”
Endometriosis patients report cannabis helps pain and gastrointestinal issues – study
“Inhaled forms had higher efficacy for pain, while oral forms were superior for mood and gastrointestinal symptoms.”
A new Australian study revealed that patients with endometriosis effectively manage their pain and other symptoms with cannabis.
Endometriosis is a condition where tissue similar to the lining of the womb grows around other organs in the body. It is estimated that it takes seven and a half years to diagnose someone with the condition in the UK. Some of the symptoms include severe pain, period pain, difficulty getting pregnant, feeling sick and pain during sex.
The researchers examined the self-reported efficacy of cannabis among 252 Canadian patients with endometriosis. The patients had legally obtained cannabis products that they used at home while reporting symptom changes over time on an app.
The patients record 16,000 cannabis-use sessions over three years through the app for researchers to analyse.
The results showed that participants found their cannabis use was effective for helping with endometriosis-related pain and gastrointestinal issues. They also reported improvements in their mood following consumption.
Some of the symptoms monitored by the researchers included: cramps, pelvic pain, gastrointestinal pain, nausea, depression, and low libido.
The majority of patients stated their preferred method was inhalation. The researchers noted that: “Inhaled forms had higher efficacy for pain, while oral forms were superior for mood and gastrointestinal symptoms.”
The authors wrote:
“With emerging evidence internationally demonstrating that women are utilising illicit cannabis as a self-management strategy for the pain and the associated symptoms of endometriosis, this paper demonstrates that Canadian women are also utilising legally obtained and quality-assured products to manage endometriosis symptoms across domains such as pelvic pain, gastrointestinal symptoms and mood.”
“Clinical trials investigating the tolerability and effectiveness of cannabis for endometriosis pain and associated symptoms are urgently required.”
The study titled: “Effects of cannabis ingestion on endometriosis-associated pelvic pain and related symptoms,” appeared in PLoS ONE journal.
Medical cannabis and managing symptoms of endometriosis
An expert discusses the role of cannabis in managing symptoms of endometriosis
An Australian survey of women with endometriosis stated that 13 percent use cannabis to manage their symptoms, pharmacist Dr Stacia Woodcock discusses the findings.
Endometriosis occurs when the lining of the uterus (the endometrium) grows outside of the uterine cavity in other areas of the body, most frequently involving the ovaries, fallopian tubes, and pelvic lining.
The primary symptoms of endometriosis are pelvic pain before and during menstruation (including painful urination and defecation), pain during sexual intercourse, nausea, fatigue, and infertility.
Treatment most commonly includes non-steroidal anti-inflammatory drugs and oral contraceptive therapy, which have been shown to be most effective for only mild to moderate endometriosis symptoms.
The high incidence of pain associated with endometriosis and the limited treatment options currently available make cannabis an attractive option for many women looking for symptom relief.
This national survey of women with endometriosis in Australia provides an interesting insight into the use of cannabis for the self-management of endometriosis symptoms.
Sinclair et al. conducted a three-month online survey of Australian women aged 18–45 years of age, with a surgically confirmed diagnosis of endometriosis to assess the use of self-management treatment modalities for endometriosis symptoms, including the use of cannabis.
Among the 76 percent of women who reported using some form of self-management treatment for endometriosis, 13 percent reported using cannabis for symptom control.
Study participants rated the effectiveness of cannabis for pain reduction on a 10-point scale, with 56 percent of patients also reporting a decrease in pharmaceutical treatment by at least 50 percent.
In terms of pain relief, cannabis was found to be the most effective treatment modality, showing greater efficacy than other self management interventions such as heat or dietary changes.
The greatest alleviation of symptoms with cannabis use, secondary to pelvic pain, were seen in insomnia and nausea/vomiting. Adverse effects associated with cannabis were reported at 10 percent, compared with higher rates seen in alcohol (52.8 percent), exercise (34.2 percent), yoga/Pilates or heat packs (15.9 percent).
This survey opens the door to some very interesting questions regarding both the use of cannabis medicinally as well as the way cannabis is viewed as a treatment modality.
The inclusion of cannabis in the survey as a “self-management tool” alongside lifestyle interventions, such as exercise or yoga, or recreational substances such as alcohol rather than as a pharmaceutical intervention is counterintuitive to the understanding of how cannabis works within the body.
Continuing to classify cannabis in this manner undermines efforts to legitimise its use as a clinical treatment option rather than a recreational lifestyle intervention.
Additionally, the survey limited participation to patients with a surgical diagnosis of endometriosis.
This is significant in that endometriosis is historically challenging to diagnose, with estimated incidence of undiagnosed endometriosis at 11 percent of the population and time from presentation of symptoms to a definitive diagnosis averages six to 11 years for most patients.
This means there is likely a large population of undiagnosed patients self-managing endometrial symptoms, as the delayed diagnosis can result in significant deterioration in patient quality of life and disease progression.
The use of cannabis within this study population is likely much higher than the survey indicated, as patients with a surgical diagnosis are much more likely to have been given pharmaceutical interventions than those without a definitive diagnosis.
Cannabis use within the surveyed patients is very poorly defined, which presents another challenging factor in evaluating its effects.
The primary dosage form of cannabis used was inhalation via smoking, which is the shortest-acting dosage form available for cannabis administration and does not represent the ideal duration of action for symptom relief of a disease associated with chronic symptoms.
Additionally, the amount of delta-9-tetrahydrocannabinol (THC) and cannabidiol present in the cannabis used by survey participants was not quantified, which also affects patient outcomes based on the variable pharmacology of different cannabinoid ratios within the body.
The reporting of tachycardia, drowsiness, and anxiety as the most common side effects of cannabis use indicates high THC cannabis is likely for the majority of patients, as these side effects are typically associated with increased levels of THC.
This presents an additional concern as THC activates GPR18 receptors, which have been associated with an increase in the migration of endometrial tissue when stimulated, meaning that
until further studies can investigate the role this plays in the progression of endometriosis, caution should be used with high THC ratios of cannabis so as to prevent the possible exacerbation of the disease.
Finally, it is important to note that only 13 percent of surveyed patients who used self-management treatment options reported cannabis use.
Australia legalised medical cannabis in 2016, but did not include chronic pain as a qualifying symptom for treatment.
This means that physicians cannot recommend medical cannabis to patients with endometriosis through the existing legal program in Australia, which limits patient access to illicit market products that have not been tested and regulated.
It also indicates a huge knowledge gap for both patients and healthcare practitioners when it comes to the use of cannabis for the management of endometriosis symptoms.
Clinician oversight needed to incorporate medical cannabis into endometriosis treatment
In conclusion, the use of cannabis for endometriosis symptom management appears to be an effective alternative to traditional self-management treatment options, especially when it comes to decreasing pain, nausea, and insomnia.
However, the lack of education and clinical studies surrounding the different cannabinoid ratios
and their possible effect on endometrial tissue presents a challenge for patients and practitioners seeking to incorporate medical cannabis into endometriosis treatment in a safe and effective way.
Patients are largely flying blind and potentially putting themselves at risk for worsened disease progression when they choose to use illicit cannabis for the self-management of their endometriosis symptoms.
Dr Stacia Woodcock is director of education at the International Research Center on Cannabis and Health in New York.
This article was originally published in the American Journal of Endocannabinoid Medicine (AJEM).
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