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As Endometriosis Awareness Month (March 2022) shines a light globally on the plight of women from puberty to menopause suffering from the condition, consultant rheumatologist Dr Wendy Holden at Sapphire Clinics, shares her expert insight into the disease.
In the UK, around one in 10 women aged between 25 and 40 are currently living with endometriosis. In endometriosis, cells similar to the ones in the lining of the womb grow elsewhere in the body, most typically elsewhere in the pelvis.
These cells react to the changing hormones during the menstrual cycle. They grow thicker in size as oestrogen levels peak in the middle of the cycle and then they break away and start to bleed (like the lining of the womb during a period ). This blood is slowly reabsorbed by the body but the process can cause inflammation, pain, and the formation of scar tissue.
Many women with endometriosis don’t feel “heard” – it can be a difficult condition to diagnose as its symptoms can be similar to other conditions and a definitive diagnosis cannot be made without keyhole surgery. In fact, research shows that there is an average 7.5 year gap for women between the onset of symptoms and receiving a firm diagnosis.
Pain, sleep, and anxiety are closely interlinked for many patients with endometriosis and one of the keys to managing the condition is to break this negative cycle.
To explain, chronic pain interrupts sleep, lack of sleep means it’s more difficult to cope with pain during the day, focusing on everyday tasks is challenging and it’s harder to introduce positive lifestyle changes such as exercise – this in turn can result in poor mental health such as anxiety and depression. This can subsequently heighten the severity and impact of the pain.
Pain as a result of endometriosis can be crippling. The condition sees the growth of tissue similar to that in the lining of the womb, but outside the womb itself (typically in or around the pelvic structures such as the bladder, ovaries, colon and rectum). Pain can be experienced by women in multiple ways, at different times and varying intensity including:
- Painful periods. The pain typically begins a few days before the period and usually lasts the whole of the period. It is different to normal period pain which is usually not as severe and doesn’t last as long.
- Painful sex
- Pain in the lower abdomen and pelvis
- Pain on passing a bowel motion
- Pain on passing urine
- Low back pain
Managing pain linked to endometriosis is vital. First line treatment options include simple pain killers (e.g. paracetamol, ibuprofen, mefenamic acid and opioids) or hormonal treatment (combined or progesterone only contraceptives) or a combination of both.
For most women, symptoms can be controlled by a combination of these approaches or individually. However, some women may not achieve sufficient resolution of their symptoms despite best treatment. For these patients it is often necessary for them to be reviewed by specialists in women’s health to consider whether surgery may be an appropriate management option.
However, even for those for whom surgery is an option, up to 50 per cent of patients may get recurrent deposits of endometriosis or continue to have chronic pelvic pain. The management for chronic pain is challenging and there is always a pressing need to identify and develop novel therapeutics.
One emerging treatment option for those with chronic pain refractory to first-line treatments is medical cannabis, which was legalised to be prescribed by specialist medical consultants under regulations published in the UK in November 2018.
Medical cannabis is only available for patients who haven’t experienced sufficient relief of symptoms from conventional treatments, but in my experience, for eligible endometriosis patients, medical cannabis may result in pain relief, improved sleep and reduced anxiety.
Women find sleep is particularly disturbed during “flare ups” especially when endometrial tissue abnormally located outside the uterus responds to hormones and tries to shed during a period which results in inflammation of the surrounding tissues causing pain.
We can all recognise that a poor night’s sleep can make it more challenging to overcome life’s hurdles. In fact, for those with chronic pain due to endometriosis, this can heighten the awareness of pain making it more unbearable. So, trying to get on top of sleep patterns is an important part of the treatment pathway for women with endometriosis. Good “sleep hygiene” is definitely worth implementing, starting with a regular bedtime and healthy wind down routine which could include limiting “blue screen” use (e.g. mobile phones and laptops) before bed, trying herbal tea with chamomile or a warm bath with lavender oil.
If this fails to achieve the desired effect, there are licensed therapies which can be used in the treatment of sleep disorders and I would encourage anyone to talk to their GP about the diverse range of options available to them.
Endometriosis can be hard to deal with emotionally, with many women feeling like they have been dealt a “difficult hand” with the long-term impact of chronic pain and fatigue affecting their ability to work and socialise.
Moreover, those who experience pain during intercourse may find it hard to be intimate with their partner. Finally, a lot of women that I see are concerned about their fertility with endometriosis. Whilst many women with endometriosis conceive without difficulty, up to one-third will need reproductive assistance. These issues can be hard to cope with and can lead to anxiety and/or depression.
I always advise patients to also address any mental health issues that arise as a result of or separately to endometriosis. Depending on the severity of the problems, for some patients this could be incorporating simple techniques into their daily routine such as exercise, mindfulness, meditation and breathing techniques.
For others, support in the form of talking therapies (such as cognitive behavioural therapy) and anti-depressants may be required. For this, the best port of call is your friendly, local GP.
Cannabis legalisation not linked to adverse birth outcomes – study
Researchers studied the relationship between the liberalisation of cannabis laws and key indicators of child health
Legalisation of cannabis in the US is not linked to any significant adverse outcomes for child health, according to a recent study.
New data shows that changes in legal status of cannabis in US states is not associated with increases in adverse clinical birth outcomes.
Researchers at Purdue University studied the relationship between the liberalisation of state-level cannabis laws and two key indicators of child health – birthweight and gestational age.
Their findings were published in the journal Population Research and Policy Review.
While the authors reported a trend which indicated a reduction in average birthweight and gestational age for some groups of women following the relaxation of cannabis penalties, they acknowledged that these changes were not linked to any “increases in clinically meaningful birth indicators associated with adverse child health.”
The findings are similar to those reported in a 2021 study which found “no statistically significant effect of medical cannabis laws on the proportion of newborn hospitalisations”.
The authors concluded: “Our findings indicate that cannabis policy liberalisation may be contributing to lower average birth weights and reduced average gestational age, but not in a manner that has increased low birthweight (<2500 g) infants or preterm (<37 weeks) births.
“These results indicate that while cannabis policies have not led to increases in adverse clinical birth outcomes overall, these trends are worth monitoring to ensure that increases in clinically relevant child health outcomes do not emerge as the nationwide trend toward liberalised cannabis policy persists. “
They added: “Although our study does not show substantial changes in adverse birth outcomes, policymakers should be attentive to opportunities to strengthen child health by considering policies that minimise consumption, particularly heavier forms of consumption, by prospective parents.”
While the evidence base around the effects of cannabis use during pregnancy on perinatal is growing, studies assessing the potential impacts of cannabis exposure are mixed.
Some observational data has identified a link between exposure and low birth weight and/or an increased risk of preterm birth. However others have failed to substantiate these claims once adjusting for other factors, such as tobacco smoking.
The majority of the existing studies have been done on recreational cannabis, accessed through the illicit market, which tends to contain higher levels of THC than that in medicinal cannabis.
There have been very limited, if any, studies exploring the effect of prescribed cannabis on perinatal health, as advice from clinicians is that women should refrain from using cannabis medicinally or otherwise whilst pregnant or breastfeeding.
Can cannabis help with menopause?
Juicy Fields explores how cannabis could help women with some of the symptoms brought on by menopause.
Juicy Fields explores how cannabis could help women with some of the mental and physical symptoms brought on by menopause.
Menopause is one of the most challenging transitions women face as they go through dramatic physical, psychological, and vaginal/uterine changes.
The stage is characterised by symptoms such as insomnia, night sweats, hot flashes, pain, inflammation, and mood swings.
Although there are various medical alternatives to deal with the unwanted and uncomfortable symptoms, a study conducted in 2021 by the Canadian Institutes of Health Research showed that women experiencing menopause (perimenopause, menopause, and postmenopause) in Alberta were significantly using cannabis to relieve symptoms. Sixty five per cent of the participants had ever used cannabis to relieve menopausal symptoms, while 35 per cent of the group were using marijuana during the period the study was conducted.
Another study presented to the North American Menopause Society (NAMS) in 2020 had similar conclusions. In a sample of 232 women from Northern California, 27 per cent indicated using cannabis to manage hot flashes, night sweats, and insomnia.
Ten per cent of the participants expressed interest in using cannabis, while only 19 per cent utilised hormone therapy to combat menopause symptoms. From the studies, one can conclude that women are shifting from hormonal medication and switching to organic, natural alternatives, specifically cannabis. This piece explores everything about menopause and its symptoms and how cannabis can help alleviate these conditions.
What is menopause?
Menopause is a period in a woman’s life that can stretch 10 or more years. During this period, their reproductive hormones go through a natural decline. This marks the end of the menstrual cycle and, consequently, their fertility. It is divided into three stages;
Perimenopause: this includes the years leading to menopause. Most women experience this during their early to mid-40s, although others can begin early during their 30s or late 40s. The woman will experience biological disturbances characterized by irregular menstrual cycles and varying hormone levels during this time.
Menopause: this is when a woman stops having her menstrual period for 12 consecutive months. One will not know when they are experiencing menopause until the 12 months have gone by. Common symptoms during this stage include vaginal dryness, night sweats, hot flashes, and sleep issues.
Postmenopause: this refers to the period after a woman has stayed 12 consecutive months or more without menstruating – after menopause. Symptoms like hot flashes and night sweats begin to fade or disappear entirely.
Physical, psychological, and vaginal symptoms of menopause
As mentioned earlier, menopause is a life-changing transition with its fair share of problems. It is attached to a host of symptoms, which can be classified as either physical, psychological, or vaginal.
Physical: symptoms include fatigue, pain and inflammation, heart palpitations, headaches, dizziness, stiffness, insomnia, and chest discomfort.
Psychological: symptoms include anxiety, depression, lowered sex drive, lack of concentration, memory loss, and mood changes.
Vaginal/uterine: symptoms include dryness and pain during sexual intercourse.
The relationship between cannabis, the endocannabinoid system, and cannabis
Does cannabis help with menopause? To answer this question, we must first look into the endocannabinoid system. This is a system comprising endocannabinoids, receptors, and neurotransmitters. This cell-signaling system utilizes these components to support normal body functioning, aka homeostasis. It regulates and controls various immune system, cardiovascular, nervous, and reproduction (including fertility and menopause) functions.
During menopause, the ECS is disrupted, which causes changes in various related biological systems. Cannabis interacts with the ECS on different molecular levels to support its function of maintaining homeostasis, thus relieving the menopause symptoms.
The research into how cannabis directly relieves menopausal symptoms is currently unavailable. However, cannabis is known to have potent analgesic, anxiolytic, antidepressant, appetite-stimulating, sleep-inducing, antiemetic, and muscle-relaxing properties that can play a significant role in managing symptoms like pain, inflammation, mood swings, depression, anxiety, and sleep issues. Below is a highlight of top menopause symptoms and how cannabis can help combat them.
Hot flashes and night sweats
These symptoms are the primary reasons why women turn to cannabis. THC, the most abundant cannabinoid in cannabis, is associated with lowered body temperatures. The cannabinoid supports thermoregulation, which is handy for women experiencing hot flashes and night sweats. Ever heard of THC-induced hypothermia? This may happen when THC is taken in high doses. Identifying the right amount of cannabis to consume may help mitigate the disturbing hot flashes and night sweats.
Mood swings, anxiety, depression, and concentration
Anecdotal and scientific evidence point out the effectiveness of cannabis’ mood-boosting and regulating, antidepressant, and focus-boosting properties. Its anxiolytic capability is dependent on various factors, such as the dose taken and the consumer’s tolerance level. These psychological issues affect most women undergoing menopause due to the numerous changes, discomforts, and uncertainties they go through.
Vaginal dryness and low sex drive
Cannabis can help with vaginal dryness and low sex drive in either of two ways; first, its calming, relaxing, and mood-boosting properties coupled with clear-headedness may support a return of the sex drive. Secondly, CBD lubricants have been known to decrease inflammation in the vaginal area, increase blood flow in the area, and support muscle relaxation.
Pain and inflammation
Cannabis is a powerful analgesic and anti-inflammation agent. It is utilised by numerous cannabis consumers to treat pain resulting from conditions such as arthritis, fibromyalgia, MS, sciatica, and headaches. Athletes have been known to incorporate cannabis in their pre- and post-workout regimes to combat muscle aches, pains, and injuries.
Fatigue and insomnia
Cannabis is a powerful muscle relaxant that, when consumed, melts all the tightness and tension away. It also promotes full-body relaxation and sleep. It helps restore one’s sleep pattern and promotes a regular sleep cycle.
Although not directly, cannabis has been proven to help relieve menopausal symptoms such as hot flashes, pain, anxiety, inflammation, depression, sex drive, and insomnia. There is a need for more research to link the two together. This will facilitate the identification of proper cannabis strain genetics and dosage for managing perimenopause, menopause, and postmenopause symptoms.
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Medical cannabis and endometriosis – “I can live a normal life”
Thirty-two-year-old Megan has lived with the symptoms of endometriosis since her teens.
Megan, an Australian medical cannabis patient living with endometriosis, shares how the plant has helped in managing her symptoms.
Thirty-two-year-old Megan has lived with the symptoms of endometriosis since her teens. At times she’s experienced such intense pain that she struggled to leave her house.
“I honestly believe I would have ended up suicidal within the next few months if I didn’t pursue and get approved for medicinal cannabis when I did,” she said.
During Endometriosis Awareness Month in March, Cannabis Health interviewed several patients across the globe who live with the often-debilitating symptoms of the inflammatory condition.
Endometriosis is present in about one in 10 women and non-binary people aged between 25 to 40 in the United Kingdom – but can affect people at any age.
Cells similar to those lining the womb grow elsewhere in the body, such as the bladder, ovaries, colon and rectum, and react to changing hormones in the menstrual cycle.
They grow thicker in the middle of the cycle and then break away and start to bleed before being slowly reabsorbed by the body. This process can cause inflammation, pain and new scar tissue.
Megan, who lives in Australia, explained that she was only officially diagnosed with endometriosis in February this year.
Lengthy diagnosis is common as the condition can mirror others and is widely misunderstood among many doctors – the average time from onset of symptoms is seven and a half years.
“I’ve always had painful periods – I just always thought they were meant to be painful,” Megan told Cannabis Health.
“I didn’t question it until early 2018 my periods stopped for about three months and when they returned it was like everything was turned up and the pain was excruciating.”
In early 2019 Megan was told she had adenomyosis, a condition in which the inner lining of the uterus breaks through the muscle wall of the uterus.
Symptoms can include lower abdominal pressure, menstrual cramps, bloating and heavy periods.
Her GP at the time suggested that she may have endometriosis as well, but it was not confirmed until surgeons performed a laparoscopy – keyhole surgery of the abdomen or pelvis.
People who have endometriosis often suffer from painful periods, painful sex, pain in the lower abdomen, pain on passing a stool and urinating, or lower back pain.
This can then lead to difficulty sleeping, an inability to focus on daily tasks, and in some cases a mental health decline.
Over the years Megan has tried NSAIDs, codeine and oxycodone in an attempt to manage the pain.
“I’m somewhat unlucky that I don’t respond to a lot of painkillers… so I was always ‘pushing through’ the pain and essentially burning myself with heat packs,” she said.
Meanwhile, she was using cannabis recreationally, but it took a comment from her partner to realise that it was also helping to dull the symptoms of her two conditions.
“I was mid-flare about 12 months ago and we’d run out of cannabis. It was a long weekend in my city so all the dealers we knew were sold out,” she recalled.
“I was curled up in bed with my heat packs and my partner said then I should see if I can get into trials for medicinal cannabis or a prescription for it.
“He’d picked up that it was the only thing that would help my pain and being reliant on black market wasn’t ideal long term.”
She was initially nervous to make an appointment at a clinic, because she did not think she would get approved.
“Everyone downplays endo so much, I was worried I’d get the same kind of dismissal about my symptoms and pain that so many doctors had done in the past,” she said.
She finally applied for a prescription last summer, and because she was able to show all the painkillers she had tried that had not worked, the process to approval was fairly quick.
Among the methods she uses to take cannabis are ingesting CBD and THC oils, and cannabis flower to vape.
“The CBD oil helps with overall symptoms – definitely reduces anxiety and nausea and has a huge impact on reducing pain,” said Megan.
“THC oil I’ll use more on days when the pain is worse than my normal levels, or when I get a random flare up some days, it helps to take THC oil and flower together to get through it.”
Despite how much it helps her, Megan has experienced some negative comments due to her use of cannabis, particularly before she was given a prescription.
“I think a lot of people still just view it as this evil illegal drug and don’t understand that it’s such a powerful and useful plant and tool in treating people’s illnesses,” she explained.
However, after getting a prescription she said her friends and family had been “surprisingly supportive”.
She continued: “I’m not sure if it’s because it’s issued via a prescription that makes people more approving of it, or if it’s just because they can see the effect it’s had on me since starting it. Maybe a combination of both.”
Getting a prescription for cannabis made a huge difference to her wellbeing.
“With cannabis I can live a pretty normal life,” she added.
But in the long term, Megan is worried for women who have endometriosis, and the dismissive nature of some doctors when it comes to the benefits of cannabis for pain.
“I’m scared for the next generation of endo warriors who are going to be pushed onto these incredibly strong medications,” she said.
“I really struggle to comprehend how some doctors will be happy for their patients to be on really strong pharmaceuticals every day to manage their pain, but can still be so anti-cannabis.”
Alongside the cannabis, the laparoscopy – during which surgeons removed some of the offending cells – also helped to significantly ease the pain of the endometriosis.
She stressed that it is vital that more surgeons are trained in expert excision surgery as a more permanent solution for patients.
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