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CHICAGO -- While there is next to no literature on cannabis use in menopause, clinicians should be prepared for questions about it from their patients, an expert said here.

To illustrate the interest in medical cannabis among this population, Oyedeji Ayonrinde, FRCPsych, MBA, of Queen's University in Ontario, Canada, discussed how the topic of his talk -- cannabis at a conference about menopause -- drew interest from two customs officials on his way to the conference, one in Melbourne and one in San Francisco.

"[The woman in Melbourne] went on for 2 minutes about how she used cannabis for her symptoms, and [the woman in San Francisco] said that she's been considering that herself. She asked 'Do you have any on you?' and I thought it was a trip," he said at the North American Menopause Society (NAMS) annual meeting.

In a lively talk that covered the wide range of cannabis products that patients might be asking about or partaking in -- everything from a joint to vaping cartridges to cannabis-flavored chocolates and fruit drinks -- Ayonrinde discussed how rapidly knowledge in the cannabis space is moving, and how patients might weigh scientific knowledge versus lived experience.

"[When patients say] 'Doctor, you talk about these things -- how much weed have you used?' my standard response is 'You don't need to have been pregnant to be an obstetrician,'" Ayonrinde said.

And there is a lot of interest in weed, marijuana, and especially CBD (cannabidiol) for people who are doing Google searches on menopause. Ayonrinde cited Google search data that found that "CBD for menopause" was the breakout search, or most rising term, of the last 5 years in searches for menopause.

Ayonrinde even reached back into history, to the 1899 Merck Manual, which referenced cannabis as a treatment for various women's health issues, including labor, headache, hysteria, insomnia, ovarian cancer and "climacteric disorders" (a.k.a. menopause).

However, the current medical literature has yet to catch up with patient interest. Ayonrinde said that reports on cannabis from the World Health Organization and the National Academies of Science and Medicine both mention menopause "zero times."

"It's pretty much a call to arms that [neither of these] mention menopause even once," he said.

This was not the case for clinicians at NAMS, who shared their patient experiences during a question and answer session. One clinician from Canada said that medical cannabis was "an extremely frequent request from my patients." Another ran a women's health clinic, and said her chronic pain patients were interested in "purified CBD products" with little to no tetrahydrocannabinol (or THC, the main active ingredient in cannabis).

A third clinician noted that she and her colleagues had recently published an of cannabinoids and female sexual function, which included animal studies, but no randomized, placebo-controlled trials.

In addition to pain and sexual dysfunction, Ayonrinde cited research that found certain forms of cannabinoid receptor type 2-targeted therapies could have an effect on osteoporosis, as they could help restore bone metabolism lost after menopause.

But he also noted how cannabis has sex-dependent differences in metabolism. Ayonrinde cited pre-clinical studies that found increased metabolism of THC to 11-hydroxy THC (the main active metabolite of THC) in females compared to males. There were also dose-dependent sex differences, with one study showing women showed greater subjective effects of orally administered THC at the lowest dose (5 mg), while men showed the greatest subjective responses at the highest dose (15 mg).

This also plays a role in dependence, withdrawal and abuse, he said, noting combined data from four clinical trials that found women reported higher ratings of abuse-related effects relative to men when they smoked "active" cannabis. Women also have a shorter onset of dependence, or shorter intervals between onset of use and regular use, as well as more severe withdrawal symptoms than men, Ayonrinde said.

But because there are no "standardized doses" of cannabis, clinicians are faced with an ethical issue when patients approach them, given that if the "dose" is not titrated correctly, their patients may end up with side effects. Ultimately, given the sex differences in the effects of cannabis, his advice to clinicians was to "start low and go slow."

"I can see the logic and science [behind] why people going through menopause [seek out cannabis] for symptom relief," Ayonrinde said.

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