Hot Flashes & Pot

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If you’re considering trying pot to escape hot flash hell, here’s guidance on the best way to do that, and the science of why it might help.

Lauren Streicher, M.D., a renowned ob/gyn and menopause expert, is the founder and medical director of the Northwestern Medicine Center for Menopause and the Northwestern Medicine Center for Sexual Health. Her newest book, Hot Flash Hell, is all about the stages and symptoms of menopause and how to cool the heat, including her perspective on marijuana, excerpted here.

If you’ve heard a friend mention that she’s easing hot flashes and other annoying side effects of menopause with marijuana, she’s not alone: In a 2020 study, 27% of menopausal women reported that they used some form of cannabis—the scientific name of the marijuana plant—to alleviate hot flashes, insomnia, vaginal dryness, mood swings, and brain fog. That’s more than 1 in 4 women—compare that to the mere 7% of women who take systemic estrogen to alleviate symptoms. Women are smoking pot, drinking cannabis-laced beverages, and infusing marijuana in oil and putting it not only on their avocado toast but also on their vulva and in their vagina.

Turning to cannabis to ease menopausal symptoms isn’t new either: According to historian Ethan Russ, cannabis was used as far back as the 7th century for myriad women’s ailments. It even pops up as a treatment of meno­pause in the 1899 edition of the Merck Manual, a popu­lar medical textbook. At the turn of that century, all the major pharmaceutical companies—Eli Lilly, Parke-Davis (now Pfizer), and Squibb—sold cannabis as a powder, tablet, and tincture.

So what’s the story—can smoking a joint or imbibing cannabis in some other way really cool the heat and soothe other menopause symptoms? (Before you jump in, remember: Marijuana isn’t legal everywhere.)

Are there studies on marijuana and hot flashes?
Though there are some wildly enthusiastic anecdotal reports about the effectiveness of pot to ease hot flashes, there have been inadequate scientific studies—meaning studies done on large groups of women over an extended period of time, with a control group using fake pot as a comparison. In other words, when it comes to cannabinoids (the compounds found in cannabis), there aren’t the kinds of studies that are required for pharmaceutical agents to become FDA-approved. In addition, most studies on the effect of cannabinoids include only men—and women are not little men.

Aside from being expensive, studies on the impact of cannabis on menopause symptoms would be difficult to conduct. The pharmacology is complex: There are well over 100 cannabinoids, and all have different physical and psychological effects. The dosage and type of cannabis are difficult to standardize and are also dramatically altered by variables, such as the other medications someone might be taking.

Don’t get me wrong: I think the use of cannabinoids to relieve menopause symptoms is very promising, and based on the known properties of cannabinoids, there is good reason that they would be beneficial in alleviating many symptoms of menopause. It just would be nice to have more research as to what kind of cannabis and what dosage works best, so that I and other physicians can make informed recommendations to our patients. But having said that, here is what is known based on the science of cannabinoids as well as observational, anecdotal data.

The impact of cannabis on our bodies
First, an interesting fact: The human body makes its own cannabi­noids. The human endocannabinoid system is a complex, nerve-signaling system composed of neurotransmitters that bind to cannabinoid receptors. It’s responsible for regulating multiple body functions, including appetite, metabolism, pain, mood, learning, memory, sleep, stress, bone health, and cardiovascular health—pretty much ev­erything that keeps humans functional and balanced.

And it turns out that hormones, specifically estrogen, play a critical role in the endocannabinoid system, and some experts propose that the disruption in that system when estrogen is low is responsible for menopause symptoms—and they say it’s also why using cannabis can decrease hot flashes.

The marijuana plant and hot flashes
There are two cannabinoids extracted from the flow­er of the marijuana plant that have potential roles in managing menopause symp­toms: tetrahydrocannabinol (THC) and cannabidiol (CBD). And, no surprise, only the female flower contains these elements.

THC is the psychoactive component of cannabis (that’s the component that brings on the high). It mimics some aspects of the natural endocannabinoid in our bodies that helps regulate body temperature, which is theoretically why THC is the key to reducing hot flashes.

CBD is extracted from hemp flowers. It contains trace amounts of THC but doesn’t have psy­choactive properties, so it will not get you high. Although it may not reduce hot flashes specifically, it does decrease pain and inflam­mation, in addition to helping you get a good night’s sleep. (The anti-inflammatory properties of both cannabinoids also may help with bone loss and cardiovascular disease.)

So, does pot relieve hot flashes?
Since this hasn’t been scientifically studied, what I’m going to say is based on the known pharmacolo­gy of cannabinoids and anecdotal information from folks in this world. But yes, it does appear that cannabis can be effec­tive in decreasing the frequency and severity of hot flashes.

Again, the THC in cannabis mimics the endocannabinoid that helps regulate body temperature. This effect when using cannabis is dose dependent. Large amounts of THC cause your internal temperature to drop, while small amounts can cause your internal temperature to rise. In other words, THC can regulate your internal thermostat, but it is important to use the right amount.

How to use cannabis for hot flashes
Eat it? Smoke it? Rub it on? How you take cannabis is important—not only in terms of what it will do for you, but also when it comes to onset of action (meaning, how quickly it hits you) and potential side effects. The onset of action, peak levels, and total duration of ef­fect listed here are very approximate, but I’ve included them to give you an idea.

Smoking or vaping
Inhaling cannabis has the advantage of an immediate effect, but the disadvantage is potentially harming your re­spiratory tract. It’s also not an activity you can do discreetly.

Onset of action: Within minutes
Peak levels: About 15 to 30 minutes
Total duration: About two or more hours

Edibles include foods infused with cannabis, such as gummies, chocolate, ice cream, smoothies, and cookies—the possibilities are endless. The effect is delayed, which sometimes leads to overdos­ing (more on that at the end). Edibles are not psychoactive unless they contain more than trace amounts of THC.

Onset of action: 30 to 90 minutes
Peak levels: Two to six hours
Total duration: At least four to eight hours

Sublinguals are tinctures, sprays, or strips placed under the tongue that are quickly absorbed into the bloodstream through a plexus of blood vessels, rather than making the trip through the digestive system like edibles do. The advantage is a relatively quick onset of action, along with bypassing the gut and the lungs. Also, it appears that THC is absorbed better as a sublingual than as an edible.

Onset of action: Within minutes
Peak levels: About 10 minutes
Total duration: Hours or even days (highly variable)

What’s the right dose for cannabis?
I’ll give you some general dosing guidelines, but they are not based on scientific studies. I’m just telling you what’s being said by the experts I’ve talked to. The dosage is a free-for-all, and even the phar­macists who work in the industry and appear very knowl­edgeable are basing their recommendations on anecdotal reports and individual experience as opposed to scientific studies. Remember, most of the folks who work in dispen­saries are not medical practitioners, and they may not be aware of a potential drug interaction or other medical variables. Also, it’s a known fact that young women metabolize cannabis more slowly than men, and women who are post-menopause metabolize it more slowly than those who are pre-menopause. This makes sense, given that cannabis metabolism is fa­cilitated by estrogen, and women who are post-menopause don’t have any.

There is no one-size-fits-all dosing, and because cannabis is a botanical, you cannot count on the same level of con­sistency as you would with a commercial pharmaceutical. Keeping a journal is a good idea until you figure out what works best for you. Small, spaced-out doses (micro-dosing) is smart.

Here are guidelines for hot flash relief sup­plied by Luba Andrus, a registered pharmacist and cannabis pharma­cologist with whom I consulted; she routinely works with menopausal women.

Guidelines for THC
Sublingual is preferred
Start at 1.25 mg once or twice daily
Titrate up (increase the dose) every five to seven days
2 mg to 4 mg works for most women

Guidelines for CBD
Sublingual is preferred
Use an indica-dominant product (a dispensary can guide you)
Start at 2.5 mg twice daily
Titrate up (increase the dose) every four to seven days
Continue until 20 mg is reached
Keep in mind that it can take upwards of 30 days to feel the full effect, so be patient.

Guidelines for THC/CBD-combined products
Sublingual is preferred
CBD/THC ratio should be 20:1 or higher (22% to 26% THC and 0.76% CBD is a common combo)
Products with a high THC:CBD ratio are best taken in the evening or at bedtime.

Heed these warnings
Cannabinoids have the potential to interact with cer­tain medicines, such as blood thinners and antiseizure drugs. In some cases, they can potentially make other medications less effective. Talk to your doctor!

Cannabis is generally felt to be safe, but the side effects may include brain fog, dry mouth, unsteady gait, diar­rhea, and drowsiness. A glass of water at the bedside is a good idea since you may wake up thirsty in the middle of the night. Some other important advice:

• Don’t drive while under the influence!

• Cannabis users need up to twice the sedation for med­ical procedures. If you partake, be sure to tell the an­esthesiologist.

• The effects of cannabinoids are dose related. Low to moderate doses appear to have positive effects on sex­ual function and responsiveness (loss of inhibition, in­creased sensitivity). High doses can be a problem and are associated with an increase in paranoia and anxiety. There is such a thing as too much of a good thing.

• Again, menopausal women are more vulnerable than men to an overdose. So especially when it comes to edibles, start at a low dose and make sure you wait 90 minutes before taking any more, because it can take that long for it to kick in. And keep in mind that many edibles are sold in individual servings of 10 mg of THC, which is way more than most menopausal women should be ingesting.