Chronic Pelvic Pain — Another Option for a Confounding Problem

Chronic pelvic pain (CPP) is inconsistently defined in the literature and often evades effective management. The relation to different organ systems, pain perception, and patient history can make diagnosis particularly complicated. Having little success with traditional treatment options, many patients turn to cannabis for relief.

Chronic Pelvic Pain
Obstetricians and Gynecologists, CPP involves pain symptoms that appear to stem from pelvic organs and structures and usually continue for more than six months. Other symptoms are consistent with lower urinary tract, sexual, bowel, pelvic floor, myofascial, or gynecological dysfunction; negative cognitive, behavioral, sexual, and emotional consequences can result.1 The pain can be cyclical or noncyclical and affects at least 1 out of 7 women in the United States, although it’s estimated that 50% of cases go undiagnosed. Additionally, the varied nature of this disorder can make it especially difficult to manage, with less than 50% of patients reporting significant decreases in pain.2

Common symptoms of CPP include severe menstrual pain; vaginal bleeding, spotting, or discharge; painful or difficult urination or bowl movements; constipation or diarrhea; bloating or gas; pain during intercourse; pain in the hip or groin; intermittent or severe and steady pain, sharp pain or cramping, or dull aching pain in the pelvic or abdominal area; pressure or heaviness deep within the pelvis; and pain when sitting for long periods of time.1,3

While in many women with CPP the pain is idiopathic, providers should test for underlying etiologies. It’s important to note that pain may be due to underlying problems with the urinary tract or digestive systems and it may be necessary to reach out to specialists in these fields. Eloise Theisen, MSN, RN, AGPCNP-BC, president of the American Cannabis Nurses Association, says, “Chronic pelvic pain is sort of a ‘garbage can’ diagnosis.” In other words, it’s simply a term that encompasses many different types and causes of pain. “In my practice, I do a thorough health history and try to identify the root cause and the characteristics of the pain.”

Some of the underlying etiologies of CPP include musculoskeletal pelvic floor dysfunction, interstitial cystitis/painful bladder syndrome, peripheral neuropathy, chronic uterine pain disorders, cancers of the reproductive tract, fibromyalgia, endometriosis, irritable bowel syndrome, and vulvodynia.1

The gamut of tests recommended by the Mayo Clinic for a patient reporting pelvic pain include a pelvic exam; blood tests to check for STDs and a urinary analysis to check for infections; an ultrasound to detect cysts in the ovaries, fallopian tubes, or uterus; other imaging tests (such as CT or MRI) to help detect abnormal growths or structures; and laparoscopy, particularly as it’s the only way to confirm a diagnosis of endometriosis.3

If an underlying etiology can be found, it should be treated; however, in up to onethird of patients with CPP, the underlying etiology goes undiagnosed and the provider is often tasked with treating the pain itself.4

The various types of pain associated with CPP include nociceptive pain that is usually visceral and brought on by distension, ischemia, or spasms of the pelvic organs; inflammatory pain such as in endometriosis; neurogenic inflammation—an imbalance in inflammatory cytokines; and pain centralization and dysfunction of the hypothalamic-pituitary-adrenal axis.4

CPP often involves more than one type of pain and results from combinations in underlying etiologies and changes in pain processing.3 The disorder frequently eludes effective management; the following common treatments aren’t always effective2:

• over-the-counter pain relievers, including aspirin, ibuprofen (eg, Advil, Motrin IB), or acetaminophen (eg, Tylenol);
• opioids;
• hormone treatments such as birth control pills or other hormonal medications;
• antidepressants that have shown to be helpful for chronic pain;
• neurostimulation (spinal cord stimulation) that blocks nerve pathways so the pain signal can’t reach the brain;
• trigger point injections to a number specific pain sites;
• laparoscopic surgery to remove the adhesions or endometrial tissue through one or more additional small incisions; and
• hysterectomy.

Certain adjunct interventions also have shown to be helpful as part of a comprehensive pain management program, including psychotherapy, biofeedback, pain management techniques, acupuncture, and physical therapy and pelvic floor strengthening exercises.2

Of course, each treatment has a different success rate depending on the individual patient, and some have more severe side effects than do others. The combination of multiple overlapping etiologies, lack of research, and poor understanding of chronic pain in women may lead to treatments that have great cost with little reward. “I often see patients who have tried other treatments for their pain and do not find relief. I usually treat patients who come to cannabis as a last resort, and it can be life-changing for them,” Theisen says.

How Can Cannabis Help Women With CPP?
Cannabis may relieve many types of pain reported by women with CPP.

A 2015 meta-analysis and systematic review reported “moderate-quality evidence to support the use of cannabinoids for the treatment of chronic pain and spasticity.”5 As cramping and spasms are common in CPP, the potential for cannabis to reduce spasms could offer relief.

A 2019 small clinical trial focused on the use of botulinum toxin in women with spasms related to endometriosis. The study found that the injections were effective in treating pain levels, reducing spasms, and reducing the use of opioids for pain management.6

While more clinical studies are needed on cannabis, its potential to reduce spasming supports a potential role in the reduction of CPP.

Theisen notes that inflammation is another common factor in CPP, a mechanism that cannabis may be particularly effective in treating. While most of the data come from animal studies, cannabis has been shown to reduce markers of inflammation.7 Additionally, epidemiologic data and human therapy studies show the potential of cannabis to be particularly helpful in the treatment of inflammatory bowel disease,8 which is a commonly reported comorbidity with CPP.2 Inflammation is another precipitating factor in endometriosis, reported in 50% of women with CPP.2 In addition to decreasing inflammation, cannabis may be effective in treating neuropathic pain.7

“If we know the type of pain, we can recommend cannabis without necessarily knowing the cause of the pain,” Theisen says. While she emphasizes that it’s always better to have a diagnosis, that simply isn’t an option for many women who suffer from CPP; as is true with many conditions, women with CPP are prescribed medicines to treat the symptoms. “When considering any treatment, we are weighing risk vs reward,” she adds. Compared with available pharmacological options (such as opioids and hormone supplementation), cannabis is believed to have a low side effect profile.

Regardless of etiology, CPP, as with many other chronic pain conditions, negatively affects patients’ sleep, mood, and quality of life.2 In some cases, cannabis may be used to alleviate sleep disorders or relieve symptoms of anxiety or depression.9 For example, case studies suggest that medicinal cannabis may be useful in patients with posttraumatic stress disorder.10

The complexities of CPP extend to patients’ psychological health, with nearly 50% of women reporting a history of physical or sexual abuse.2 At the same time, comorbid mood disorders, such as anxiety and depression, are reported in higher rates among women with CPP, and women with both depression and CPP are more likely to be prescribed opioids.11 The complicated history of women’s health issues being dismissed as emotional or a psychological problem makes it ever more crucial for the provider to recognize the bidirectional relationship between pain and mental health.

Often the problem becomes cyclical. Early stress may contribute to chronic pain in adulthood.12 Pain itself can disturb biological processes that lead to pain chronification. Science has found considerable overlap between neuroplasticity changes induced by pain and the same neuroplasticity changes induced by depression.13 Studies suggest that by binding to cannabinoid receptors CB1 and CB2, cannabis may reduce feelings of pain as well as anxiety and depression.14 This is predominantly attributed to the binding of THC to CB1 receptors, which are found abundantly in the central nervous system. CB1 receptors also play a role in pain signaling and on a physiological level and can affect emotions, memory, executive functioning, and reward.

Many patients (and providers) may be uncomfortable with the intoxicating effects of THC and may prefer a cannabis product that’s principally CBD. Products with a high CBD to THC ratio may be effective in treating pain with a lower side effect profile than are products with high THC levels.14

The potential of CBD as a therapeutic is of particular interest to Amanda L. Chu, MD. Chu and colleagues at Penn State Health Milton S. Hershey Medical Center are in the midst of a clinical study that specifically examines the effects of CBD administration. “We are looking at sublingual CBD and its relationship to endometriosis- related pain. We believe it to have anti-inflammatory properties, among others, which is an important contributor of pain in this condition,” she says. “This study was inspired by patient interactions—from patients telling us that they are using CBD and believing that it helps them.”

The study is specific to patients with endometriosis, a CPP condition, which affects roughly 10% of reproductive-aged women globally.15 “CBD would not be my first-line option, but if you have a patient with pain refractory to standardized care, I believe CBD is something to consider,” Chu says. She also emphasizes the need to put more energy into good research on this topic to create products that will be thoroughly vetted.

Theisen describes the increased use of cannabis products for pain relief as “patient led.” Despite lacking clinical studies specifically related to the use of cannabis in CPP, it’s clear that women are turning to cannabis for relief. A recent survey of 89 women with CPP found that patients were effectively self-treating with cannabis to reduce the pain associated with CPP.16

Recommending Cannabis for CPP
While Chu emphasizes that it’s best to understand the cause (or causes) of CPP, she acknowledges that many women consider cannabis after thorough evaluation without successful intervention. She also emphasizes a biopsychosocial approach, which considers the whole patient and avoids treating with only pharmacological options.

What is the best approach for a provider to take with a patient who chooses to try cannabis products? Both Theisen and Chu emphasize the need to begin low and go slow. “I find that particularly women tend to be sensitive to THC, so I begin with a 1:1 ratio,” Theisen says. In her practice, she treats each patient individually and considers the following:

• the route of administration that will be most effective with the fewest side effects;
• what will have the best safety protocol for the patient;
• whether the root cause of the pain has been identified;
• whether the patient has used cannabis before and how they tolerated it; and
• the specific characteristics of a patient’s pain experience.

“We will look at the medications a patient is on and consider if a cannabis product could alleviate that pain with a lower side effect profile than the current medication,” Theisen says. For many providers, this may be a difficult line to follow—we simply do not have the studies. Still, concerning CBD, we have relative certainty products have a low side effect profile.

“We know CBD is generally safe,” says Chu, who emphasizes that she would consider CBD as an adjunct treatment, not as a first-line approach. She also focuses on a joint decision-making process between the patient and provider. “Can CBD give people an alternative to another anti-inflammatory? Maybe. Could they work together? Maybe. Everything we give patients is going to have a side effect; the question is whether or not that is an acceptable side effect for the patient,” Chu says.

Considerations
When recommending cannabis products, there are a number of important considerations.

Route of Administration
Inhalation will have rapid effects but can have negative respiratory effects long term; edibles may be recommended for constant pain but may take some hours to decrease symptoms; and topicals could be beneficial for patients with targeted pain.

THC to CBD Ratio
Theisen recommends a product with THC, recognizing the entourage effect—that CBD and THC work in tandem, along with additional plant properties. CBD may be more useful to treat anxiety, sleep disorders, and inflammatory conditions, and THC may be more effective in treating neuropathic pain.

Dosing
Patients should be reminded to start low and go slow. Advise them to remember that cannabis will accumulate in their systems over time, and it may take days or weeks for them to notice relief. And different routes of administration will require differences in dosing. Theisen acknowledges that dosing can be particularly difficult, as there are no clear guidelines, but she believes this is an opportunity for more individualized treatment. Dosing also depends on the route of administration. For example, in her study, Chu is using 10 mg and 20 mg, administered sublingually once per day for eight weeks. This route of administration was chosen to bypass the liver and increase bioavailable CBD. The ratio of CBD to THC is an important decision to make with patients based on their pain experience and personal histories.

Who Shouldn’t Use Medicinal Cannabis?
Every treatment comes with side effects, and cannabis may not be recommended for everyone. Contraindications can be complex, and it’s crucial to recommend on a patient-by-patient basis. For example, while cannabis may be recommended for posttraumatic stress disorder, strains with high THC content could instigate psychosis. Indeed, THC isn’t recommended for patients with any history or family history of psychosis, although CBD may be beneficial for this population.17 General side effects associated with cannabis include anxiety, drowsiness, dry mouth (especially with edibles), feelings of paranoia, increased heart rate, low motivation, and poor concentration, motor skills, sexual performance, and short-term memory.

CBD can interact with medications commonly taken as blood thinners. Chu also advises that patients with liver problems proceed with caution. Although the risks associated with CBD are generally low, Chu states, “it can occasionally cause minor symptoms such as fatigue, difficulty sleeping, and eating changes, but very rarely, it can affect liver function, particularly with patients on antiseizure medications, such as valproate or clobazam.”

The Future of CPP and Medicinal Cannabis
The fact is that cannabis is becoming widely and easily accessible. Although there’s a lack of robust clinical trials, a patient-led front makes cannabis increasingly popular among women with CPP. According to Theisen, “Patients are using cannabis, and if the provider cannot provide any sort of resource or education, the patient will go to the budtenders, who are largely unqualified to provide any kind of medical guidance.” She recommends that providers be equipped with a list of specialists trained in medicinal cannabis, recent studies, and patient reports. She further emphasizes that providers should be aware of how cannabinoids can reduce the need for other medications that are typically prescribed for CPP, especially opioids and benzodiazepines.

Finally, medicinal cannabis should be seen as another tool in the treatment of CPP and considered as a potential adjunct treatment to a full pain management approach, which accounts for the patient’s physical, mental, and emotional health.

— Jennifer Lutz is a freelance journalist who covers health, politics, and travel. She’s written for both consumer and professional medical magazines as well as popular newspapers. Her writing can be found in Practical Pain Management, Endocrine Web, Psycom Pro, The Guardian, New York Daily News, Thrive Global, BuzzFeed, and The Local Spain. In addition to journalism, Lutz works as a strategies and communication consultant for nonprofits focused on improving community health.

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