Women and CBD: Increased Interest, but Caution Is Warranted

Cannabidiol (CBD) isn’t new in the pharmacy space, but Lisa Faast, PharmD, describes it as a “nascent category” because of the questions surrounding its legality. Also muddying the waters is its similarity to marijuana, she says.

Cannabis includes 2 compounds: Δ-9-tetrahydrocannabinol (THC) and CBD¹; THC produces the high associated with marijuana use.² And according to the FDA, it is “currently illegal to market CBD by adding it to a food or labeling it as a dietary supplement.”¹ If a product has a maximum of 0.3% THC, it’s legal because it is mostly CBD.

Still, Faast expects changes from the FDA, despite the fact that selling CBD products is legal, because of the amount of clinical research that shows these products “benefit patients on a very broad scale.”

Anecdotal Evidence Supports CBD Use

Faast described a conversation she had with a woman who experienced endometriosis severe enough to require multiple surgeries. After using a vaginally-applied CBD product, the woman’s life was, Faast said, changed. “A lot of women have already tried…the [nonsteroidal anti-inflammatory drugs], the birth control, the hot compresses; they’ve tried everything, but [they’re] still not having a normal life.”

For vaginal application, there aren’t any major drug interactions a pharmacist needs to worry about. And, frequency of use varies widely. “It really depends on the woman and her symptoms,” she said. “Some women only have bad cramps rarely; others have bad cramps every month. It’s one of those things where [if] you know you have [pain] every month, it’s recommended that you use [one applicator] every day.…Each patient finds their own ‘rhythm,’ but for patients with endometriosis, they’re probably going to want to take it daily.”

If a woman knows she has debilitating cramps 2 days a month, she may consider taking the CBD product 2 days before her period starts, which will prevent the pain, Faast added. And since each woman’s experience is different, Faast typically asks patients about the frequency of their menstrual cramps or endometrium-related pain before making any dosing recommendations.

A Cautionary Tone

Although these products are popular, pharmacists should pay attention to CBD products in the women’s health space. “There's a growing prevalence of use...but there’s still limited data on safety due to various different reasons,” said Jamie Lo, MD, associate professor of obstetrics and gynecology at Oregon Health and Science University in Portland. These products, she added, can be difficult to study due to the lack of reproducibility, and because they’re not approved by the FDA they are not comparable.

Lo compared CBD product usage to measures of alcohol consumption. “It’s not like you’re saying, ‘I had 4 cans of beer and 2 glasses of wine.’ That’s a lot easier to quantify the contents. [With] CBD,…It’s just not regulated.”

Responding to Women’s Questions

It’s important for pharmacists to be prepared for a variety of questions from women regarding CBD products, and those questions will be determined by the age of the patient, said Lo. Women are most likely to ask about the impact of CBD products on their fertility and pregnancy, in addition to the ability of CBD products to alleviate menopausal symptoms and menstrual and other types of pain, she explained.

The THC in CBD products can impact women’s menstrual cycles and their ability to get pregnant. In her research about daily THC edible use among female monkeys, Lo and her co-authors found that the monkeys with a 28-day menstrual cycle could see that cycle stretch to 38 days.³

In another article, Lo and colleagues observed that the use of cannabis “has been associated with altered reproductive hormones, menstrual cyclicity, and semen parameters.…In females, cannabis use has been associated with infertility and abnormal embryo implantation and development.”⁴

Other findings from the article: Cannabis use during pregnancy and while breastfeeding can lead to preterm birth or impact an infant’s size at birth, in addition to having neurodevelopmental consequences and sociobehavioral and cognitive development impacts. Lo also found that there isn’t enough information available about the impact of cannabis to understand its potential impact on reproductive health and fetal development.

Her advice? Pharmacists can counsel patients that “there’s a lot of research in this area in the pre-clinical and human studies [showing] that CBD and THC products may be associated with adverse impacts on reproductive health and fertility. As such, you should talk to your health care provider if you’re thinking about conceiving in the future before use.”

References

1. What you need to know (and what we’re working to find out) about products containing cannabis or cannabis-derived compounds, including CBD. FDA. Reviewed March 5, 2020. Accessed August 28, 2022. https://www.fda.gov/consumers/consumer-updates/what-you-need-know-and-what-were-working-find-out-about-products-containing-cannabis-or-cannabis

2. The controlled substances act. Drug Enforcement Administration. Updated July 25, 2018. Accessed August 28, 2022. https://www.dea.gov/drug-information/csa 

3. Ryan KS, Mahalingaiah S, Campbell LR, et al. The effects of delta-9-tetrahydrocannabidinol exposure on female menstrual cyclicity and reproductive health in rhesus macaques. F S Sci. 2021;2(3):287-294. doi:10.1016/j.xfss.2021.05.001

4. Lo JO, Hedges JC, Girardi G. Impact of cannabinoids on pregnancy, reproductive health and offspring outcomes. Am J Obstet Gynecol. 2022;S0002-9378(22)00420-3. doi:10.1016/j.ajog.2022.05.056