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Guideline No. 425a: Cannabis Use Throughout Women’s Lifespans – Part 1: Fertility, Contraception, Menopause, and Pelvic Pain

      Abstract

      Objective

      To provide health care providers with the best evidence on cannabis use with respect to women’s health. Areas of focus include general patterns of cannabis use as well as safety of use; care for women who use cannabis; stigma; screening, brief intervention, and referral to treatment; impact on hormonal regulation; reproductive health, including contraception and fertility; sexual function; effects on perimenopausal and menopausal symptoms; and use in chronic pelvic pain syndromes.

      Target Population

      The target population includes all women currently using or contemplating using cannabis.

      Outcomes

      Open, evidence-informed dialogue about cannabis use, which will lead to improvement in patient care.

      Benefits, Harms, and Costs

      Exploring cannabis use through a trauma-informed approach provides the health care provider and patient with an opportunity to build a strong, collaborative, therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of cannabis use disorders. Use should not be stigmatized, as stigma leads to poor “partnered care” (i.e., the partnership between the patient and care provider). Multiple side effects of cannabis use may be mistaken for other disorders. Currently, use of cannabis to treat women’s health issues is not covered by public funding; as a result, individual users must pay the direct cost. The indirect costs of cannabis use are unknown. Thus, health care providers and patients must understand the role of cannabis in women’s health issues, so that women can make knowledgeable decisions.

      Evidence

      PubMed, EMBASE, and grey literature were searched to identify studies of “cannabis use and effect on infertility, contraception, perimenopause and menopausal symptoms, and pelvic pain” published between January 1, 2018 and February 18, 2021. All clinical trials, observational studies, reviews (including systematic reviews and meta-analyses), guidelines, and conference consensus statements were included. Publications were screened for relevance. The search terms were developed using the Medical Subject Headings (MeSH) terms and keywords (and variants), including cannabis, cannabinoids, marijuana, dexanabinol, dronabinol, tetrahydrocannabinol; the specific terms to capture women’s health were estrogen, estradiol, medroxyprogesterone acetate, vaginal contraception, oral contraceptives, fertilization, amenorrhea, oligomenorrhea, pelvic pain, dysmenorrhea, endometriosis, interstitial cystitis, vulvodynia, and menopause.

      Validation Methods

      The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

      Intended Audience

      All heath care providers who care for women.

      SUMMARY STATEMENTS

      • 1.
        Cannabis use is increasing, and women are commonly using cannabis for recreational and medical reasons (high).
      • 2.
        Use of cannabis, especially products containing tetrahydrocannabinol, can induce or worsen psychosis and worsen depression (high).
      • 3.
        Study results concerning the association between cannabis and anxiety are conflicting, and this association requires further evaluation (high).
      • 4.
        Use of cannabis, similar to use of other intoxicating substances, may be associated with high-risk sexual activity (low).
      • 5.
        There is no evidence that contraceptive methods are altered by cannabis use (low).
      • 6.
        There is limited evidence that frequent cannabis use may affect female fertility (moderate), but frequent use can diminish male fertility (moderate).
      • 7.
        There is no evidence for cannabis use for management of perimenopausal symptoms (very low).
      • 8.
        There is no evidence that cannabis products improve chronic pelvic pain (low).

      RECOMMENDATIONS

      • 1.
        Women should be screened for cannabis use, as they are for other substance use (strong, moderate), and further exploration of its impact should be initiated (strong, moderate).
      • 2.
        Cannabis use can be screened for using appropriate screening tools (conditional, moderate)
      • 3.
        A trauma-informed care approach and harm reduction should be used when inquiring about cannabis use (strong, low).
      • 4.
        The fact that a woman uses cannabis should not influence her choice of contraceptive method (strong, moderate).
      • 5.
        Couples should be counselled that cannabis use appears to affect male fertility and may have an impact on female fertility (conditional, moderate).
      • 6.
        Sleep disturbances in the perimenopausal period should be characterized and other management modalities trialed before women consider using any cannabis product for this indication (strong, moderate).
      • 7.
        Women should be counselled about the lack of evidence for using cannabis products to treat chronic pelvic pain (strong, moderate).

      Keywords

      Abbreviations:

      2-AG (2-arachidonoyl glycerol), CB1 (cannabinoid 1), CB2 (cannabinoid 2), CBD (cannabidiol), CUDIT-R (Cannabis Use Disorder Identification Test Revised), CYP (cytochrome P450), GABA (gamma-aminobutyric acid), GnRH (gonadotropin-releasing hormone), mRNA (messenger ribonucleic acid), PTSD (post traumatic stress disorder), Δ9-THC or THC (delta-9-tetrahydrocannabinol), SBIRT (Screening, Brief Intervention and Referral to Treatment), TRH (thyrotropin-releasing hormone), TrpV1 (transient receptor potential cation channel subfamily V member 1)
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