For the estimated 11% of American women between 15 and 44 living with endometriosis, symptoms like severe pain, fatigue, and nausea can profoundly disrupt their lives. Yet endometriosis remains underdiagnosed, with a lack of effective treatments. That’s why many women are taking symptom relief into their own hands by using cannabis, according to a recent survey published this November in the Journal of Obstetrics and Gynaecology Canada. Other women are turning to cannabidiol (CBD) for pain relief, hoping to address the symptoms without the high. 

“Pain relief in endometriosis is an important topic, as it can impact women on so many levels, including work, relationships, academic studies, and of course their mental health,” says study co-author Mike Armour, Ph.D., a post-doctoral research fellow in women’s health at Western Sydney University’s NICM Health Research Institute. This government-funded group focuses on integrative and complementary medicine research and policy in Australia.

Dr. Armour’s team surveyed nearly 500 Australian women between the ages of 17 and 45 and found that 13% say they use cannabis to self-treat endometriosis symptoms. The authors estimate that their findings suggest approximately 10% of Australian women with endometriosis use cannabis for symptom and pain management.

Why Are Patients Self-Managing Their Symptoms?

Women frequently report that they can’t get endometriosis symptoms under control with recommended medications or surgery; there’s little evidence to show current treatments relieve endometriosis pain. NSAIDS like ibuprofen, for one, don’t appear to be effective, and there’s a strong potential for addiction and abuse with opioid painkillers. In addition, although research suggests hormonal birth control can reduce symptoms, many women stop or avoid using it due to perceived side effects like mood swings and depression. 

“Women with endometriosis often report that despite various medications, they have pain that is difficult to deal with,” Dr. Armour says. That’s why it’s not surprising they’re turning to cannabis and CBD, he adds, since limited studies suggest these drugs may or may not relieve pain.

The Difference Between Cannabis and CBD

Cannabis is the most popular illicit drug in the United States; there has been a steady rise in use every year since 2007, with 7.7% of American adults reporting using it within the past month as of 2017. That may be partly because it’s well on its way to becoming a legal medical therapy. A total of 33 states and the District of Columbia have legalized medical marijuana to date; 11 states and D.C. also permit marijuana for recreational use, with another 16 states having decriminalized the possession of small amounts of the drug.

“Prescribing” CBD and Cannabis

Marijuana remains illegal at the federal level, so prescribing it is still illegal, even in states that have legalized it. However, physicians and some APPs can write a recommendation for and discuss the benefits of the plant if the patient suffers from a qualifying condition covered by their local law (usually severe diseases like cancer, HIV/AIDS, glaucoma, or multiple sclerosis).

Because the Drug Enforcement Agency classifies cannabis as a Schedule 1 drug — with more restrictions than even fentanyl or methadone — officially, there is “no currently accepted medical use and a high potential for addiction.” In addition, it requires a rigorous approval process to study, so there’s little peer-reviewed research. That leaves providers hesitant to recommend a drug that hasn’t been rigorously studied and whose contents and dosage aren’t regulated by the FDA.

Meanwhile, interest in cannabidiol, or CBD, has skyrocketed in recent years. While CBD is an essential component of marijuana, it doesn’t contain tetrahydrocannabinol (THC) and therefore doesn’t cause a “high.” Nevertheless, a full 14% of American adults say they use CBD, according to an August 2019 Gallup poll, most often for pain (40%), anxiety (20%), and insomnia (11%).

Only one CBD-derived drug, which treats seizures in children, has been approved by the Food & Drug Administration (FDA). However, all 50 states have legalized CBD in some form, and retailers have added it to pretty much any product you can imagine — from cheeseburgers to toothpicks to mouthwash.

How Can Cannabis and CBD Affect Endometriosis?

Cannabis mimics endocannabinoids, natural molecules that act on the endocannabinoid system (ECS), which maintains homeostasis in the body. ECS receptors, in turn, are found throughout the human body. The ECS participates in various processes, including pain, stress, sleep, metabolism, immune function, and reproduction. 

While research is lacking, Dr. Armour says there’s another reason to believe cannabis could have a potent effect on endometriosis pain. Both the uterus and ovaries have highly expressed cannabinoid receptors, he explains. Some researchers even think cannabis could slow the growth of endometrial tissue.

“The endocannabinoid system has been found recently to interact with specific mechanisms associated with pain,” explains Dr. Armour. “It also appears to play an important role in cellular proliferation and apoptosis, which may explain why cannabis is used by women with endometriosis. However, little has been done clinically to investigate this currently.”

What the Research Says

While there’s little research into cannabis for pain, one recently published paper found it may effectively reduce pelvic pain and opioid use. In Dr. Armour’s study, on average, respondents rated the effectiveness of cannabis a 7.6 out of 10, with 55% reporting they were able to reduce the need for pharmaceuticals by at least half. In addition, women reported the most significant improvements in sleep and nausea/vomiting, with only 10% saying they experienced adverse side effects, like anxiety, drowsiness, and rapid heart rate. 

CBD, meanwhile, appears to have analgesic, anti-inflammatory, and immunomodulatory properties — but “the jury is out at the moment as to whether it can provide as much potential pain relief in endometriosis as THC does,” says Dr. Armour. 

What Should You Tell Patients With Endometriosis About Using CBD or Cannabis

For now, researchers agree that there’s not enough research to conclude the benefits or risks of cannabis. People at risk of developing addiction or schizophrenia should avoid it altogether, while patients with lung disease should avoid smoking it since it causes airway inflammation, wheezing, and chest tightness.

Understanding the Risks

For patients interested in using cannabis, “talking with a physician who understands the ECS and has experience in prescribing cannabis is an important first step,” says Dr. Armour. “Like all medications, it still comes with certain risks.” CBD, on the other hand, may seem less risky to recommend, as it doesn’t have the psychoactive effect of THC and no known risk of abuse or dependence, notes Dr. Armour. But there still are dangers. Because the FDA doesn’t regulate CBD, confirming the exact ingredients or concentration in any given supplement is impossible. The FDA has found some CBD products contain contaminants like pesticides and heavy metals.

What’s more, CBD can raise the levels of certain medications. “[It’s] been shown in preclinical and case studies to change the way certain medications are metabolized. So it appears to be of more concern than THC in this particular regard,” notes Dr. Armour. He adds that providers should ask patients taking CBD about any other medications they’re on and closely monitor for adverse side effects.

Safer Alternatives

Dr. Armour also calls out the other non pharmacological treatments that can address endometriosis symptoms. Some women find relief from heat packs, hot baths, and hot water bottles. Research suggests that acupuncture twice a week for several months may reduce pelvic pain, although it’s unclear whether the effect lasts after patients complete treatment. And a low-FODMAP diet may help improve any IBS-like symptoms. Just remind patients that this eating plan is for short periods.