Chronic pelvic pain in women is common and frequently difficult to treat. Chronic pelvic pain often develops in the setting of endometriosis, interstitial cystitis/bladder pain syndrome, and vulvodynia. Cannabinoids are a promising treatment modality for non-cancer chronic pain, but have not been studied in women with chronic pelvic pain nor in specific chronic pelvic pain conditions. This review focuses on the interaction of the endocannabinoid system with the menstrual cycles, with endometriotic lesions, and within the bladder. Furthermore, it provides a brief overview of existing literature of the effects of endocannabinoids on chronic pain generally, with a focus on neuropathic pain. Finally, it discusses limited data available regarding the use of cannabinoids in women with chronic pelvic pain conditions. In the opinion of the authors, cannabinoids are a reasonable treatment modality for refractory chronic pelvic pain, especially if a neuropathic component is suspected. Practitioners should expect a modest effect on pain levels with an acceptable safety profile.

Introduction With the legalization of both medical and recreational marijuana in some countries and a few US states, its use has become more widely prevalent. Both exogenous cannabinoids such as tetrahydrocannabinol (THC) and endogenous cannabinoids (endocannabinoids) have been shown to affect female gonadotropin pathways and female sexuality. Yet, our understanding of the mechanisms and effects on female sexual function is limited. Aim To review the literature regarding the effects of both endogenous and exogenous cannabinoids on female sexual function in both animals and humans. Methods We performed a PubMed search for English-language articles in peer-reviewed journals between 1970 and 2019. We used the following search terms: “cannabinoids,” “endocannabinoids,” “marijuana,” “cannabis,” and “female sexual function” or “sexual function.” The main outcomes of the papers were reviewed. Main Outcome Measure The main outcome measure was sexual function in females. Results A total of 12 human studies and 8 animal studies that evaluated the relationship between cannabinoids and female sexual function were included. Study types in animals were blinded, prospective, placebo-controlled trials. Human studies were based primarily on questionnaire data. The data indicate dose-dependent effects on female sexual desire and receptivity, such that low doses generally facilitate or have no effect but high doses inhibit. Conclusions More research is needed to develop a better understanding of the effects of cannabinoids on female sexual function. There does appear to be an effect on both animals and humans, but whether the effect is positive or negative along dose and species lines requires more study. With the legalization of marijuana occurring in more countries and more US states, there needs to be more well-controlled studies evaluating the effects.

Highlights Declining estrogen levels are associated with the onset of rheumatoid arthritis. Granulosa cell tumors secrete estrogens leading to hyperestrogenism. Rheumatoid arthritis has been associated with hypoestrogenism and menopause. Removal of granulosa cell tumors may cause a steep decline in estrogen levels precipitating rheumatoid arthritis.

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