Women, ageing and medical cannabis
Aliza Sherman and Sheri Matteo, of women’s health and wellness network Ellementa, talk medical cannabis for women experiencing the menopause.
Night sweats. Anxiety. Irritability. Sleeplessness. Brain fog. Vaginal dryness. Decreased libido. As women age, there is a litany of undesirable symptoms that characterise menopause, the cessation of menses resulting from the normal evolution of the female reproductive system over a lifetime. Born with a finite number of oocytes depleting systematically after conception, women are subject to hormonal fluctuations that can wreak havoc on their health and wellness at midlife – but can medical cannabis change this?
Reproductive endocrinology has been well studied, and it is understood that menopause, and its accompanying complications, result from erratic and progressively decreasing oestrogen levels. Hormone replacement therapy (HRT) can mitigate symptoms such as hot flashes and vaginal dryness, but there are cardiovascular and potential cancer risks in long-term exogenous hormone exposure, making HRT inadvisable for some women and undesirable for many others. While herbal remedies, such as wild yam, maca and black cohosh, will work short-term for some, the herbal remedy that anecdotally demonstrates the most promise for women in midlife is cannabis.
Cannabis and the endocannabinoid system
Cannabis has been used for thousands of years in the treatment and relief of numerous conditions, including women’s health, notably as an analgesia during menses, as an appetite stimulant, and as a nerve tonic. In the US, cannabis wasn’t regarded as an illicit substance until the 1940s, and yet in 2013, the American Herbal Pharmacopoeia (AHP) published a two-part series that detailed the therapeutic use of cannabis, classifying it as ‘botanical medicine’.
Cannabis can be effective in relieving some of the more unpleasant and uncomfortable symptoms of menopause by its direct interaction with a woman’s endocannabinoid system (ECS). The ECS came to light in 1992 when Israeli researcher Raphael Mechoulam and his associates, Dr Lumir Hanuš and Dr William Devane, discovered an endogenous cannabinoid – or endocannabinoid – they named ‘anandamide’. The name derives from the Sanskrit ‘ananda’ meaning ‘bliss’. Researchers found that when anandamide is deficient, both women and men may experience stress-induced anxiety and irritability.
Two critical parts of the ECS are G protein-coupled receptors (GPCRs) – called CB1 and CB2 – and both respond positively to cannabis. GPCRs act as gatekeepers of molecular signals. GPCRs take stimuli from outside of cells in the body and convert them to signals inside cells. GPCRs are involved in every important physiological process within our bodies, from immune system function to regulating metabolism to how we taste and smell food.
GPCRs are so important in the medical field that over 40% of all pharmaceutical drugs target them. Common drugs that target GPCRs include triptans for migraines, beta blockers for hypertension, albuterol for asthma, Tagamet and Zantac for stomach ulcers, loratadine for allergies, and fentanyl and oxycodone for pain. GPCRs are also targets for cancer drugs on the market and in development.
Cannabis targets CB1 and CB2 receptors like pharmaceuticals target GCPRs; however, cannabis has been shown to have less adverse side effects than typical pharmaceuticals.
Cannabis also has an extreme ‘lack of toxicity’, meaning you cannot take a lethal dose of cannabis – it is physiologically impossible.It is important to note, however, that medical cannabis research has been hampered by prohibition in countries like the United States, thus the absolute safety of cannabis has not been established. We do know that cannabis increases heart rates and should be used with caution for those with arrhythmias. Cannabis can also trigger acute psychiatric episodes in people predisposed to mental illness.
We now know that reproductive hormones and endocannabinoids interact bidirectionally. Endocannabinoids decrease activity in the hypothalamic-pituitary axis and reproductive hormones affect protein expression in the ECS. Oestrogen may increase the synthesis of anandamide or it may inhibit the enzyme known to degrade it, FAAH (fatty acid amide hydroxylase). Thus, decreasing oestrogen levels also cause a decrease in our endogenous ‘bliss’. In addition, research has demonstrated retrograde signalling of oestrogen-stimulated endocannabinoids suppresses gamma-Aminobutyric acid (GABA) release from ECS receptors. GABA is known to reduce anxiety and induce sleep by interfering with negative thoughts and memory function.
Choosing the right forms of cannabis
One frustration for many women willing to try cannabis for relief during menopause is the lack of clear and consistent dosing instructions. Modern women expect efficient and reliable results from pharmaceuticals. The therapeutic effects of cannabis are highly individualised.
Pharmaceutical cannabinoids such as Marinol have specific indications for extreme conditions and cannot be obtained without a doctor’s prescription. Given the many forms and formulations of consumable cannabis, it is not surprising that therapeutic responses vary greatly. With no clinical trials to inform recommendations, medical practitioners are hesitant to prescribe cannabis to patients, not to mention the legal restrictions in various countries.
According to Dr Lakisha Jenkins, a naturopathic doctor and founding member of the California Cannabis Industry Association, cannabis patients need to do their homework first.
“Then take the research and go on a road of self-discovery. Individuality takes precedence over any traditional medicine taken, especially cannabis,” says Jenkins.
With over 100 cannabinoids identified so far in the Cannabis sativa plant, many are currently being researched now for their individual healthful benefits. For example, CBD is demonstrating efficacy for inflammation/anxiety/spasticity, tetrahydrocannabinolic acid (THCa) for pain, and CBN for sleep. The interaction of the different cannabinoids present in varying concentrations of each specific cannabis strain creates what is referred to as an ‘entourage effect’.
This effect is a synergistic dance of chemicals present in ‘whole plant extracts’, utilising the entire plant to derive the maximum number of compounds in the plant. Maintaining the integrity of the plant’s chemical makeup in manufactured cannabis products such as concentrates and oils potentiates the benefits and mitigates the side effects of the individual components.
How cannabis is consumed affects onset and duration of therapeutic effects. For acute conditions, such as insomnia, inhalation by smoking or vaping will have a rapid onset of relief. According to Jenkins, sublingual forms of cannabis also provide fairly rapid onset and consistent results.
“When you ingest an edible, it goes through your entire digestive system, so you’d have to be pretty precise with the number of milligrams you consume,” she explains. “And you’d need to know what your metabolism is like that day, even if your digestive system is sluggish because hormones affect digestion. Edibles are not as specialised or dialed in.”
Edibles can require up to two hours to take effect, often leading inexperienced consumers to ingest more than they need to relieve their symptoms, inducing more of an overly relaxed, disoriented or ‘stoned’ state. While not harmful, too much cannabis can result in an uncomfortable or frightening experience for some. The common recommendation for preliminary cannabis consumption is to ‘start low and go slow’.
”Jenkins’ advice for choosing the right cannabis product includes:
- Look for CBD-rich strains. CBD plays a strong role in interacting with other cannabinoids to help balance hormones
- Pick CBD-rich strains with THCa, the acid precursor to THC, to activate the CBD without the high of THC
- Look for terpenes that are uplifting like limonene.
A cannabis strain’s unique terpene profile, for example, creates a ‘thumbprint’ that contributes to its potential effects. Removing or altering the terpenes changes how it affects the ECS as well as how it affects each individual.
A daily cannabis microdosing routine can reduce the unpleasant physical and mental symptoms of menopause while still allowing women to function throughout their day. A microdose is usually considered 2.5mg of THC; however, this may vary depending on an individual’s tolerance, metabolism, and size. Microdosing THC along with the cannabinoid CBD can help with symptoms of menopause in a number of ways, for example by:
- Alleviating stress and anxiety. In higher doses, cannabis may cause anxiety or paranoia in some people; however, in lower doses, it can have a calming, relaxing effect
- Promoting sleep. Lack of sleep can affect stress levels and increase irritability throughout the day. A deeper, more restful sleep can fortify your ability to cope with daily stressors and hormonal changes. Indica strains generally have higher concentrations of CBD and CBN, for relaxation and drowsiness
- Alleviating brain fog. While some of the brain fog that comes with menopause is directly related to hormone deficiencies, better sleep plus accessing THC with a sativa strain of cannabis could help with focus and clarity
- Reducing inflammation and pain. “Many painful conditions are known to become more pronounced during menopause,” says Elizabeth Moriarty, clinical herbalist, formulator and founder of Luminary Medicine Company. “It may well be that we become less tolerant of pain when we find ourselves deficient in anandamide that contributes to our overall sense of wellbeing.”
- Promoting a feeling of wellbeing. According to Moriarty, research shows that cannabidiol inhibits the degradation of anandamide. In essence, CBD works to protect one’s bliss
- Relaxation and the euphoria associated with being ‘high’ may also enhance libido. Cannabis-infused vaginal suppositories and lubricants can make menopausal intercourse more enjoyable.
Those who regularly use cannabis as herbal medicine are willing to take the time to find the right strain and the right mode of consumption. They describe having a ‘relationship’ to the plant and calibrate their intake over a period of time, monitoring the results, until they experience the outcomes they are seeking.
Medical cannabis is in its infancy. Research of the therapeutic benefits of cannabis specific to women is still lacking, but anecdotal evidence points to a number of positive effects. Cannabis shows promise as a safe alternative to HRT, antidepressants, anti-anxiolytics and sleep aids.
- Casper, RF. (2017) Clinical manifestations and diagnosis of menopause. In Martin, K. (Ed) UpToDate. Retrieved 9 January 2019 from:https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-menopausesearch=menopause&source=search_result&selectedTitle=1
Please note, this article will appear in issue 8 of Health Europa Quarterly, which is available to read now.
Aliza Sherman and Sheri Matteo, of women’s health and wellness network Ellementa, talk medical cannabis for women experiencing the menopause.
More Women Trying Pot to Manage Menopause
Oct. 19, 2020 — A new study finds 1 in 4 women have tried cannabis to manage menopause symptoms. Laura Hamilton is one of them. SheвЂ™s used pot recreationally since she was in college, but was surprised when she realized it was helping ease her menopause symptoms, which included insomnia, mood changes, vaginal dryness, and hot flashes.
вЂњIt really made a difference. I wondered if I was imagining it, so I started giving it to my friends, and it helped them too,вЂќ she says. вЂњIf I smoke it at night, I sleep like a baby. I also infuse it in an olive oil or coconut oil and drizzle it on a salad or avocado toast, and it helps stabilize my mood. It doesnвЂ™t make me giddy or feel out of it — it just helped with the peaks of the moods and the emotional roller coaster I was going through.вЂќ
Hamilton says she also uses the oil on her skin to help with vaginal dryness. However she uses it, she says she notices a difference after about 30 to 45 minutes, and it lasts for several hours.
But not everyone has the same kind of experience. Lisa Renee of Trumansburg, NY, tried cannabis to manage her menopause symptoms. After eating half a sugar cube-sized edible, she had hours of unpleasant and uncomfortable symptoms that she didnвЂ™t like and couldnвЂ™t wait to end. She says she felt drunk and anxious, flipped through a bliss and panic cycle, felt intense madness, worried about everything from death to her teeth, and she was also вЂњentirely too aware of my tongue.вЂќ
вЂњIt was sort of terrifying, sort of funny, ultimately kind of exhausting and seemed like a bad route for me. That said, I have always been sensitive to such things,вЂќ Renee says. вЂњI think IвЂ™m not a great candidate for pot as a menopause balm.вЂќ
A new study shows that many women are exploring or want to explore this untraditional way to treat menopause symptoms.
While cannabis is considered an illegal substance under federal guidelines, 33 states and the District of Columbia have passed laws making its use legal for medical and/or recreational use.
The study presented last month at the 2020 annual meeting of the North American Menopause Society (NAMS) found:
- About 27% of women in Northern California (one of the states where marijuana use is legal) who took part in the Midlife Women Veterans Health Survey were using cannabis or had in the past to manage menopause symptoms, including hot flashes, night sweats, and insomnia.
- Another 10% said they were interested in using cannabis to manage menopause symptoms in the future.
- Those numbers were higher than the 19% of women who reported using traditional methods to manage menopause symptoms like hormone therapy.
вЂњThis study highlights a somewhat alarming trend and the need for more research relative to the potential risks and benefits of cannabis use for the management of bothersome menopause symptoms,вЂќ says Stephanie Faubion, MD, medical director for the North American Menopause Society.
The studyвЂ™s lead author, Carolyn Gibson, PhD, a psychologist and health services researcher at San Francisco VA Health Care System, says itвЂ™s worth noting that some women reported using many approaches to manage menopause symptoms, too, including hormone therapy and/or other prescribed medications, in addition to cannabis. вЂњIt is surprising that [cannabis] was more commonly reported than hormone therapy — the front-line treatment for common menopause symptoms,вЂќ she says.
How Safe Is Cannabis for Menopause?
Gibson says itвЂ™s not well understood whether cannabis use is a safe or effective way to manage menopause symptoms. вЂњExisting evidence does raise concerns about the impact of some forms of cannabis use on cognition, cardiovascular health, and mental health.вЂќ
The CDC says research shows:
- 1 in 10 people who use marijuana will get addicted.
- Marijuana directly affects the brain; in particular, the parts connected to вЂњmemory, learning, attention, decision-making, coordination, emotions, and reaction time.вЂќ
- Long-term or frequent use increases the risk of psychosis or schizophrenia. Women who are addicted to marijuana have more panic attacks and anxiety disorders, and they get marijuana use disorder more quickly after first using the drug, compared to men.
But Michelle Sexton, a doctor of naturopathic medicine at the University of California, San Diego, who has long studied cannabis and now works as a patient educator, says itвЂ™s important to know that cannabis comes in different strengths. She likes to compare it to peppers, whose level of spice ranges dramatically, whether youвЂ™re eating a bell pepper or a ghost pepper.
вЂњI think when people view cannabis through a lens of harm and addictive potential, itвЂ™s at a certain high-level dose,вЂќ she says. вЂњBut when we use a product on the bell pepper-end of the cannabis spectrum, we arenвЂ™t talking about the concentrates and highly potent cannabis that people are using for recreation, and using those bell pepper doses just isnвЂ™t well understood. We really need more research to look at the therapeutic dosing model to see if there is in fact a harm reduction at these lower doses.вЂќ
How Women Are Using Cannabis for Menopause
Mitchell Kramer, MD, chair of the Department of Obstetrics and Gynecology at Huntington Hospital in New York, says while he does have patients who use marijuana for severe menopausal symptoms, he doesnвЂ™t recommend it as a first-line treatment.
вЂњWe have a number of studied and medically approved effective therapies for the management of menopause,вЂќ he says.
But for patients with severe symptoms who are вЂњunable, unwilling, or who have tried standard therapies, medical marijuana would be a reasonable therapy to consider. If patients want to use cannabis, he recommends using medical marijuana from a licensed, credentialed prescriber rather than the local dealer whose product may be of questionable quality.
Sexton says she helps people navigate the retail landscape, because вЂњthat is a minefield. вЂ¦ When a patient walks into a dispensary, the workers arenвЂ™t equipped to practice medicine, and they often recommend products they like, which may be totally inappropriate for the patient.вЂќ
She says in general, THC helps lower body temperature, which can help with hot flashes. PotвЂ™s mellowing effects may help settle your mood and improve sleep, but everyoneвЂ™s reaction may differ. вЂњAs with any medication, you will have responders and non-responders. But across the board, especially for sleep, we see great responses.вЂќ
THC, or tetrahydrocannabinol, is the ingredient in marijuana that causes a вЂњhigh.вЂќ
Sexton says women of menopausal age need to be especially mindful of the dose they are taking. In California and many other states, for example, she says edibles are sold at an individual serving of 10 milligrams.
вЂњThat is way too much for older people in general and also for a novice,вЂќ she says. вЂњWe are using really low-THC doses so people arenвЂ™t getting impaired or having extreme euphoria.вЂќ
But other doctors warn about the use of cannabis at all. вЂњThe escalation of cannabis use in this country is associated with the increasing rates of opioid use, suicide in young people, and mental health issues, among myriad other things — autism, heart disease,вЂќ says Faubion, whoвЂ™s also the director of the Mayo Clinic Center for WomenвЂ™s Health in Jacksonville, FL.
If concern about cancer risk with hormone therapy is driving a womanвЂ™s decision, some doctors say women should discuss that with their providers to better understand the reality.
вЂњThere are many women out there who are symptomatic and not receiving any type of therapy,вЂќ Faubion says. вЂњThere is a lot of misinformation out there about hormone therapy and cancer risk. We are coming to understand that the breast cancer risk may be more associated with the progestogen component of the hormone therapy rather than the estrogen. Hormone therapy use is associated with decreased risk of some other cancers such as colon cancer. Thus, many women are avoiding hormone therapy use because of confusion about cancer and other risk.вЂќ
вЂњThe concept that there is little else out there to treat menopause, and that it is not safe or that hormone replacement therapy causes cancer, is false and uninformed,вЂќ agrees Kramer.
Gibson says she hopes health care providers consider asking about cannabis use and other approaches that patients may be trying outside of what has been prescribed or recommended.
In Canada, where cannabis is legal for medical and recreational uses, Laura Hamilton left a job in finance and is now a cannabis educator for women — advising them how to use it for menopause and other life changes. вЂњThere is a lot of information out there, and it can be hit or miss until you find the right strain and dose, so I decided I wanted to help people, encourage them not to be afraid to look into it, and give them permission to look at the plant — not through the prism of the war on drugs, but instead for all the benefits it can bring to your life.вЂќ
As for Lisa Renee, she says she doesnвЂ™t know if her experience is instructive for others, but she does know for certain that she is not a great candidate for pot. She has gone on to try CBD capsules and cream and feels those have helped, although sheвЂ™s post-menopausal now and her symptoms have largely eased.
вЂњI do have friends who swear that pot has helped them through it, and CBD seems to have offered me some late relief. Ultimately, as with everything menopausal, each journey is personal.вЂќ
PaulВ Armentano, deputy director, National Organization for the Reform of Marijuana Laws (NORML), Vallejo, CA.
Stephanie Faubion, MD, medical director, North American Menopause Society; director, Mayo Clinic Center for WomenвЂ™s Health, Jacksonville, FL.
Carolyn Gibson, PhD, psychologist and health services researcher, San Francisco VA Health Care System.
Laura Hamilton, Ontario, Canada.
Mitchell Kramer, MD, chair, Department of Obstetrics and Gynecology, Huntington Hospital, Huntington, NY.
Lisa Renee, Trumansburg, NY.
Michelle Sexton, ND, San Diego, CA.
Medium.com: вЂњMarijuana, Menopause and Me,вЂќ April 19, 2018.
Governing.com: вЂњState Marijuana Laws in 2019 Map.вЂќ
CDC: вЂњMarijuana Fast Facts and Fact Sheets,вЂќ вЂњWhat is marijuana?вЂќ вЂњHow is marijuana used?вЂќ
News release, North American Menopause Society, Sept. 28, 2020.
FDA: вЂњFDA and Cannabis: Research and Drug Approval Process.вЂќ
THC helps lower body temperature, which can help with hot flashes. PotвЂ™s mellowing effects may help settle your mood and improve sleep, but everyoneвЂ™s reaction may differ.