Pushkin.

Hi everyone, Doctor Poyter here, I'm popping in to let you know that we're working on a special episode of Decoding Women's Health.

We're i'll be answering your questions about one of my favorite topics, hormone therapy.

If you've been wondering about the different types of therapy, when it might make sense to start possible side effects?

Are really anything else?

This is your chance to ask.

You can leave us a voicemail at four FI five two one three three eight five, or send an email to Decodingwomen's Health at Pushkin dot fm and let us know if you'd like to stay anonymous, or if you're up for having your voice featured on the show.

I'm so excited for this one.

Hormone support is such a misunderstood area of medicine, and there's a ton of new and fascinating research to talk about together.

I can't wait to hear what you're curious about.

Our first paper.

They said, aren't you worried that these are people who are just looking to be high but stay within the limits of the law.

No, I'm not, because most people that I deal with do not want to be intoxicated.

We have a clinical trial for endometriosis.

And the very first thing almost every one of them has said to me is it's not going to get me high, right, first thing, end of the box.

Because people have whole lives.

They have work, they have children, they have activities, they have partners, they have school lunches, they have dinner dates, they have things.

They don't want to be high all day, every day.

Welcome to Decoding Women's Health.

I'm doctor Elizabeth Poynter, and today on the show, we're talking cannabis.

You know, medical marijuana first came on my radar about ten years ago when it first became legal in the states where I practiced.

That meant as a doctor and as a surgeon, I had another treatment option to explore for my patients who were dealing with pelvic pain, endometriosis, and other chronic pain issues.

The patients that I referred to medical dispensaries generally had positive experiences, and over time, more and more of the women I treated began sharing that they were using cannabis for other conditions, not just for their pain, but also for psychological issues like anxiety and depression.

This was many years ago now, and so much has changed.

Access to these products has exploded in recent years as more states legalized both recreational and medical marijuana.

So before recording today's interview, I did some homework.

I reviewed the latest medical cannabis research from top journals, and for the very first time, I visited my own local dispensary.

It was totally overwhelming.

There were so many options.

The sales representative or bud tender as I learned that she was called, was kind and tried to be helpful, but she seemed to struggle to answer some of the more specific questions that I had about what products might be the best for certain symptoms and conditions.

For many women, and exploring this world for the first time, I can totally see how it might be very difficult to know what to ask for or how to proceed safely in a way that addresses your individual health needs.

Fortunately, today we have an exceptional guide to walk us through all of this.

My guest is doctor Stacey Gruber.

She's a neuroscientist and an international expert on the health effects of marijuana.

This made me do a deep dive into the science of the connabinoid pathway.

Super curious here and it's constantly changing what we know today is different from what we'll know tomorrow.

You know, people used to think these things worked one way, and they don't.

So there's never a dumb moment.

That's the great thing about science.

If you believe in science, I agree with you.

Yes, yeah, that's a whole another episode.

Doctor Gruber is the creator and the director of the Marijuana Investigations for a Neuroscientific Discovery, or the MIND Program, at McClain Hospital.

She's also in a so Sociate Professor of Psychiatry at Harvard Medical School.

The overarching goal of her research is to understand how medical cannabis affects individuals over time.

She and her team study how cannabis use influences things like anxiety, depression, sleep, chronic pain, and reliance on other medications.

They began observing people before they start using medical cannabis and then follow their progress for months and sometimes years to see how things change.

In twenty fourteen, I launched the MIND Program because in twenty twelve, Massachusetts was on the precipice of legalizing cannabis for medical purposes, or I should say relegalizing cannabis was legal in this country.

Was part of our US pharmacopeia it fell out of favor, became illegal, landed in the most restrictive class of the Controlled Substance Act.

But in nineteen ninety six it was reintroduced in California for medical purposes and reapproved.

So in twenty twelve, Massachusetts was about to approve cannabis for medical purposes, and I decided, let's look at the literature and see what we know about the long term effects of medical cannabis use.

Scouring the literature, I found almost nothing, and so that's why I launched this program.

There has never been a program dedicated to looking at the long term impact of medical cannabis use, despite the fact that it was relegalized in California in nineteen ninety six.

Almost everything we know about cannabis has come from studies of recreational consumers, primarily young, healthy recreational consumers, and that's a bit of a problem.

In fact, it's a huge problem.

Individuals who are using for recreational purposes by design, are looking for products with notable THHC or tetrahydrocannabinol, the primary intoxicating constituent of the plant.

In contrast, our medical cannabis patients aren't necessarily looking for that same experience.

In fact, many will tell you I don't want to be altered or high.

As a result, it's very challenging to really understand what the actual impact is on so many of these indications and conditions that people will swear uptown, left and right cannabis or cannabinoids are effect before.

So since twenty fourteen, we've spent a lot of time doing longitudinal observational studies as well as some cross sectional studies and some survey studies, but mostly focused on the what is considered the holy grail getting to the clinical trial models, which is where we are.

So it sounds like patients originally led you to look at cannabis.

What particular aspect of it drew you into looking at cannabis other than the kind of lack of data.

Was it you saw efficacy?

Did you see people getting better using recreational cannabis?

What did you observe that drew you into this area of research.

So the first thing I would say is that going back to the sort of recreational days when I was still spending a lot of time in more general psychiatry, I noticed a very interesting trend.

We spent a lot of time looking at patients with bipolar disorder, and I would hear patients say, you know, when I feel like I'm spiraling out of control, I take a few hits and I feel better.

On the other side, you'd hear patients say, I feel so depressed and down.

I take a few hits.

I feel better.

I had never heard of anything like this, and so this got me thinking, so we did a study.

I wrote a grant to look at mood changes in individuals with bipolar disorder pre and post cannabis use, and we gave people little devices to chart their mood after every time they used cannabis and three other times a day.

And we found that individuals with bipolar disorder who used cannabis actually had greater mood relief, if you will, from their symptoms relative to those patients with bipolar disorder who didn't use cannabis.

What I was hearing was really individuals saying that they felt more stable.

So it was working on both the manic side of the bipolar and the depressive side.

It seemed too for certain people.

So that got me thinking, how could something both provide relief from feeling hypomanic or manic and give you more of a little bit of a lift if you're feeling depressed.

And I was desperate to understand how both could be true, how can we harness some of these things?

And that's really how it began.

And the truth is, cannabis is a remarkable plant with over five hundred compounds.

You know, we have this tendency to say cannabis and we refer to any and all things the plant.

But it's a missoe we shouldn't do that.

It's not one thing and it's not one size fits all.

Yeah, let's dig into that a little bit.

Let's do cannabis one oh one for our listeners.

Okay, so, can you just briefly explain the difference between cannabis and hemp, and cannabis and cannabinoids and kind of the important components, and just give us an overview of cannabis one oh one what we need to know cannabis one on one.

I guess I would start by saying that Cannabis sativa l.

The plant is remarkably complex.

It is comprised of over five hundred compounds.

Some of these are phytocannabinoids, things from the plant that interact with our own system of chemicals.

Receptors throughout the brain and body the endocannabinoid system.

These are things like delta nying THHC or tetrahydric canabinol, the primary intoxicating constituent of the plant that our recreational folks are desperate to find.

No judgment, We're fine with them.

That's what makes us high, right, The THHC.

That's what makes you high, exactly, So primary intoxicating constituents of the plant.

Cannabi diol or CBD is a primary, but not the only, non intoxicating constituent of the plant.

Often touted for medical benefits.

CBD is an anti inflammatory, right.

CBD is touted for its anti inflammatory actions.

It's also got lots of other actions, but yes, it's one of them.

But there are literally dozens and dozens of other cannabinoids that we spend time focusing on.

There are also things like terpenes, the essential oils that give cannabis its characteristic scent and flavor profile.

These essential oils, by the way, present in every plant, have their own biobehavioral health effects.

As it turns out, flabinoids waxy penal.

So the plant is complex.

It's not just THHC and CBD, as people will often pretend a whole plant.

Full spectrum product contains everything from the native plant that made the product, so that's THC, cbd, any and all cannabinoids, terpenes, flabinoids, everything.

A broad spectrum product is identical except that it has no quantifiable amounts of THHC present, again the primary intoxicating constituent of the plant.

There are some people who, for legal or health reasons, cannot have any exposure to delta nine THHC, So broad spectrum products are like full spectrum products, except they don't contain quantifiable amounts of THHC.

Hemp is a variety of cannabis with inherently low levels of delta nine THHC.

It's often referred to as industrial hemp because it was used for industrial purposes.

These are basically at this point excluded from the Controlled Substance Act, which means that products that are created from hemp are not under the same federal jurisdiction.

That is, they are not federally illegal.

If you will, as cannabis or quote marijuana is, can you.

Speak to us a little bit about delivery systems, I mean, smoking, vaping, edible vaginal suppositories for pelvic pain s.

Yes, all the above.

Root matters.

Think of it as a GPS like, it matters which way you go.

So the fastest way to get an effect from using cannabis is or a cannabinoid based product is what I would call a root of inhalation, right, so either smoking or vaping, so we inhale, it goes into the lungs, into the bloodstream, into the brain.

That's what I would call moments to minutes to get an effect.

We use a sublingual delivery system for all of our clinical trials because the area just under the tongue, the salibary mucosa, is incredibly rich and absorbent, and instead of waiting for you to swallow something and digest it, which we're going to get to in a second, with edibles, your body can actually use it much more effectively, much more quickly.

Edibles, whether that's a brownie or a cookie, or a candy, or even a beverage, although beverages are slightly faster anting than cookies and brownies.

So this is the type of product that people are often very happy to explore.

They think it's going to be terrific and they eat it or they drink it, and they wait what they feel is an appropriate amount of time, they don't feel anything, and then they have more.

It takes a very long time, comparatively speaking, for you to get an effect from an edible or consumed product.

That's because you have to digest it.

Interestingly, cannabinoids are processed then by the liver.

Your liver process is all compounds, all drugs, right, and things like delta nine THHC.

The primary intoxicating considering of the plant is actually converted to something even more intoxicating, eleven hydroxy.

I always tell people hold on root of administration is important.

If you're eating it, you have to give yourself plenty of time to feel the effect and to recover from the effect.

Isn't the same as smoking or vaping, where it's almost immediate.

Any damage to the lungs with us smoking.

So you know, there's a lot of dispute about this, and the twenty seventeen Nason Report, the National Academies of Science Engineering in Medicine looked at what indications or conditions there might be real, substantial or moderately significant evidence for it with regard to cannabis being efficacious, and they did review things like head and neck cancers, and the rates were not significantly higher necessarily.

I think it's early still to figure that out.

And really most people acknowledge that the amount of cannabis that people are smoking or vaping and the ways in which they're doing it may be very different from things like cigarette smoking, So maybe that's one of the differences.

But there's lots of debate about the carcinogenic compounds and what's contained, so I think we don't know the whole story yet for sure.

But there are people who would prefer to use a root of inhalation, so smoking or vaping.

Dabbing, of course, is another where people take a very very concentrated Bullus concentrates are exactly as their name suggests, designed to give the consumer or patient a big bang for the buck.

These are primarily THHC focused and start at about forty five or fifty percent PhD and go north of ninety nine percent.

How do you dab?

So, in the case of an actual quote dab this little blob of very concentrated product, you actually need something that you can get very very hot with a blowtorch.

It doesn't look anything like conventional cannabis.

Use.

Like when we think about people passing a blunt or a spliff or a joint or something, or a bong.

You see people with a little blowtorch and a little flat area.

They get very very hot, and as soon as they put this little tiny blob of very concentrated product on it, they inhale.

They get this giant bulus all at once.

Then we get to the you know sort of we had the oromycoastal or transmucostal.

So things like suppositories vaginal or rectal people are using for more localized relief, and they do seem to be efficacious for some folks.

For some things, we never see recreational folks using suppositors.

I will tell you if you had to come across a recreational purssses, yeah, that's my favorite way.

Now nobody says that.

No, how about for enhancement of sexual pleasure?

Do you see that?

Yes, vaginal suppositories.

I think vaginal suppositories began as a way of increasing pleasure and increasing lubrication and decreasing discomfort from many many individuals who are having any kind of discomfort around sex.

And it was also initially tattered as a way of you know, sort of getting yourself in the mood.

But at this point we certainly see a number of products in the marketplace designed to address or ameliorate symptoms relative to meastural related discomfort or other types of discomfort, as well as enhancing sexual pleasure.

And then there's the daily suppositories for women quote of a certain age.

As time marches on, right, lots of people experience the things like vaginal dryness, so some of these oppositors are used on a daily basis, or oils are used.

So what are you finding And let's just speak a little bit about midlife women, right, do you see a number of midlife women using cannabis for medical reasons and not recreational reasons?

And if they are, what are they using it for?

Hot flashes, mood disruptions, sleep anxiety.

So the answer to both those questions is yes, yes, and yes.

The top three indications for medical cannabis use across the country are chronic pain, mood or anxiety, and sleep disruption.

Not surprisingly, these are the three top conditions we hear about in individuals who are either perimenopausal or postmenoposal, so that's not a surprise.

Individuals are increasingly interested in using cannabis or cannabinoid based therapies to help because they have very limited treatment options currently and very limited clinical response.

As it turns out, those who get clinical response from certain conventional medications often complain about side effects, and the cannabis or cannabinoids they may be able to reduce or completely eliminate that aspect from the equation, which is pretty amazing.

So you started the Mind program, you have the Women's Health Initiative within the Mind program.

Can you tell me what kind of questions you're trying to answer with that?

What are your goals?

Where are you moving with that?

I didn't realize what a vastly understudied population we are.

I didn't.

I really didn't.

I didn't think about it.

You know, in psychiatry we think about things that are disproportionately higher in women than men, like anxiety disorders.

Right, things like dementia occur in women more often than in men.

We have all of these things that we need to be mindful of.

Guide Ecologic pain, by the way, affects over one billion with a b B one billion, and we do relatively little, or we've had relatively little in terms of these giant discoveries in terms of allowing people to be better and not just feel better, but actually be better.

Women or the Women's Health Initiative at MIND was a program that was dedicated to looking at conditions or disorders that either disproportionately or exclusively affect women or some non binary folks.

Because there's so little work.

In this area, Stay right there.

We've got lots more from my conversation with doctor Stacey Gruber.

Coming right up, Can you describe a little bit about the endocannabinoid pathway in the human body and how cannabisc and CBD are impacting these pathways?

Sure, I would say it very sort of.

The overarching, you know, ten thousand foot summary is that every mammal has an endocannabinoid system, highly understudied, highly undervalued, and its whole purpose really is what we call homeostasis.

We're keeping things in balance, in check, mood, appetite, pain, all of these things are impacted by the end cannabinoid system, and it's comprised of these chemicals and receptors.

And for chemicals, they're our own cannabinoids.

En do cannabinoids, and we have receptors including CB one and CB two receptors.

CB one receptors primarily throughout the central nervous systems, CB two receptors throughout the periphery.

And it appears that THHC is really a very very strong agonist, that is, it binds very effectively to CB receptors.

So the CB two receptors are all throughout our body, correct, not just our central nervous system.

Throughout the periphery, right, So you know, you see CB two receptors sort of everywhere else a few in the brain, but not like CB one receptors, And that may be one of the reasons that initially people were rather stunned to see that things like Crohn's disease, INFLAMMATORID bowel disease were responsive to different types of cannabinoid based therapies.

Not all, not all cannabinoids are created equally, and we have to be mindful with some actions come reactions, and so it's very important to know which cannabinoids for which types of indications, in which patient populations.

And until relatively recently, we were under the impression that cannabidial or CBD also must exert its effects through the CB one and CB two receptors.

As it turns out it's not true.

It appears that CBD modulates its effects through five ht one A or serotonin receptors, other chemical and receptor systems.

So it's really very easy to understand then how you get a bigger bang for the buck with more quote players on the field.

If you're involving more than one receptor subtype and chemical messenger system, you're going to get more of a response.

Right and medical school, we don't spend a ton of time thinking about the endocannabinoid system.

Nobody hears about it, but it turns out to be incredibly important.

Again, when I think of it, I think as keeping everything in balance, your ability to keep things at status.

Quote, that's its entire goal.

That's the endocannabinoid system.

Can you just give us a broad overview of how cannabis is impacting the brain for an axiolytic effect or a pain of fact and that type of thing, like what is it actually doing in the central nervous system to help our anxiety, to help our pain?

I think that the jury is absolutely still out with regard to the specific absolute mechanisms, because so many different types of products wind up being efficacious, and those different types of products have different constituent profiles, and so you can't necessarily know exactly.

Okay, well, we know it's this receptor system in this one of this one, and I tend to think of us as being comprised of dials and not switches, right, what we really want to do in individuals who are anxious, and I will tell you in general, when we can allow people to take an emotional breath dial down that master gain.

Everything begins to fall into place.

And so I think of all of these things, whether it's anxiety or some of the other mood related symptoms, but particularly for anxiety, it would appear that higher levels of CBD being administered in our case sublingually where people are holding for two full minutes, that's the secret two full minutes multiple times a day, very low to no levels of depending on what we're doing, we do tend to see this down regulation right of this hyper responsive activity.

The real data will come when we can actually look at the underlying change in what we call endocannabinoid tone.

So when you can take samples of individuals before they use these products and then follow them over time and look at how that changes, we'll have a better sense of exactly what's happening, but I like to think of it as again turning down this unbelievable response system.

And people with real anxiety will tell you it is paralyzing.

They can't get out of it, they can't stop ruminating, and so this ability to sort of allow them to shift cognitive set is hugely life changing.

I'm definitely going to steal that we're made of dials, not switches, because I think in modern medicine and pharmacology, we think we're going to turn this pathway off or on, flip it off or on, and it's not.

It's an adjustment in multiple pathways and dials.

I would like to ask you about cognitive health because that is one of the concerns obviously with younger individuals who are using cannabis.

Those are the kinds of questions we started off asking.

I was very interested in understanding the cognitive changes that we might see in individuals who are using medical cannabis.

We spent decades documenting cognitive decrements associated with recreational cannabis use, particularly in those who began using cannabis regularly or consistently early prior to age sixteen.

Not surprising because again, the brain is nerd, developmentally vulnerable, or as I like to say to my cannabis audiences, half baked.

Right, the brain is under construction, not vulnerable just to cannabis, but to other substances alcohol, injury, illness, just vulnerable.

And my question was for those who are beginning medical cannabis use, who are adults beyond this period of vulnerability, would we see the same decrements?

And I will cut to the chase and give you a spoiler alert and tell you absolutely we do not see that, which is amazing.

It is not what people think.

So the brain develops to what age like, where are we most vulnerable to alcohol and cannabis?

Yes, Interestingly, we used to think that the brain was quote done by the time we hit puberty.

This is long ago and far away, and we now know that the brain continues to develop throughout the second and into the third decade of life.

And so when we see individuals who are using cannabis regularly that are you know, let's say, age fourteen or fifteen, that may wind up looking very different in terms of a cognitive profile, maybe a clinical profile for sure, in terms of brain structure and function relative to someone who began using much later in life.

That's a really important finding.

What's the data on cognitive health and older individuals and brain health in terms of cannabis use.

We're just starting to get some of that data on individuals, let's just say from midlife on over the age of forty forty five.

And you know, I used to move that line depending on where the number was and where I was just kidding, But the truth is, it looks very different if you begin to use cannabis later in life as opposed to when you are again neurobiologically or or neurodevelopmentally vulnerable.

Our data suggests that in individuals that we see over the course of one year, and we take people again, we look at them at baseline and we give them a whole neurocognitive battery, and we do the same thing at three months, six months, twelve, fifteen, eighteen, twenty four, and now we go out for years and even just looking at baseline to one year.

When we think of recreational cannabis ues and what we know, especially from young folks, we generally see these frontal executive decrements, so the ability to inhibit an inappropriate response, for example, the hallmark of somebody who is let's say mature versus somebody who is not When we're coming along and we're in our teens.

Unfortunately, our frontal cortex isn't necessarily online as we age.

That's the first part to go.

That's why babies and old people have trouble with inhibiting, right, So they just blurred things out.

There was a pre clinical study that was done years ago in free groups of mice that was really quite stunning.

A group of juvenile mis let's think of them as adolescents, outperformed middle aged and older mice investigators that inserted a tiny little pump delivering only THHC.

And now the adult let's just say middle aged and older adult mice outperformed the young mice and the young mice when exposed to THHG in the tournament.

So the brain is vulnerable to certain types of cannabinoids.

It doesn't appear that it's the same case necessarily for things like CBD, which has been touted as potentially neuroprotective.

So it's important to understand that age matters.

What you do and when you do it makes a difference.

And our folks certainly are not demonstrating decrements across the board in frontal executive tasks.

And from a brain imaging perspective, you know your brain is comprised of gray matter, white matter and CSF and gray matters are hard working neurons.

White matter, you know, this is what connects brain region to brain region for good communication.

And you want white matter to have what we call high integrity or coherence.

We did a study our medical cannabis pations and what we found was that, and again we compare them to treatment as usual, folks.

What we found is relative to baseline with no cannabis on board, we don't see changes or decreases in white matter organization or coherence.

Over time, we see increases that stunned me.

Our studies of recreational consumers, younger cannabis consumers had lower levels of white matter integrity or coherence.

We do not see that in adults who begin using in midlife.

In fact, we see increased white matter coherence.

This is perhaps the most surprising thing for most people.

So, if a woman wants to explore using cannabis to help her health and well being, what are some guidelines for her?

What should she be aware of?

What should she ask if she goes into a dispensary, what kind of questions?

What should she look out for?

I would say the overarching things to be mindful of, like what are the top things you say to people?

Start low and go slow.

As an obvious one, here's the thing that people don't know about cannabinoids.

Necessarily, you can always add, you can take away.

Never Once it's in, it's in.

You can't really throw it up or poop it out like it doesn't work that way.

It's in, okay.

And so what we want to be mindful of is the root of administration and knowing that you can always add to what you've taken.

So it's better to err on the side of less rather than more until you know how you're going to respond to different products, and they are different.

A gummy created for sleep versus pain versus anything else, even by the same company, may very well affect you very differently because the constituent profile is different.

What works for your best friend, your husband, your girlfriend may not work for you.

That's the other thing to be mindful of.

Be mindful of the here just try this phenomenon.

Eh.

I had one patient who said her husband said, oh, this is exactly what you need right now.

And he gave her something that was the equivalent of about fifty milligrams of THHC.

Look didn't dend well.

Low doses of THC are generally considered for many people angxiolytic.

That is, they can help reduce anxiety for the majority of individuals, and in fact, at certain levels everyone, THHD can be exogenic.

That does, it can create or worsen anxiety.

So you have to be very very careful.

And to me, a quote small dose is not what other people's small dose is.

Five miligrams is not a small dose.

That's a full dose.

Governor Hickenlooper and Colorado back in the day twenty twelve, proposed ten milligrams of THC per serving.

That was dropped by Nora Walkoff, the director of NAIDA, the National Institutes on Drug Abuse.

So what's a small dose in my world?

Less than one milligram?

And people laugh, they go, oh, come on, you can't get anything.

No, I can get activity at a receptor, which is what I'm looking for.

And then you have to be careful, like if your gummy is that ten milligrams are five milligrams and you cut it up, you have to make sure it's a homogeneous gummy, right, because some of them are not so homogeneous.

Edibles are the most challenging products in terms of dozing, in terms of making sure that you know, if it's a batch of brownies that a well intended manufacturer has created, does the brownie on the bottom left have exactly the same profiles a brownie in the bottom right, I don't know, And it depends did you tip the pant?

All these things matter, and so not to scare anybody, but again, start with something small, smaller than small.

Start with a quarter of what you think you should have, and then add don't go the other way because unfortunately I get the calls in the middle of the night where people are in the emergency group, and that's decidedly unpleasant and should be avoided.

So start low and go slow.

And what's right for your friend is not right for you, and you've got to figure it.

Out your own.

Metabolism affects things.

What other products or compounds are on board will affect things.

Alcohol on board.

So here's another important fact.

We know that in a quote fed state, that is, with food in your system, cannabinoids have much higher bioavailability.

That is, the ability for your brain and body to use these compounds.

So somebody's going out to a club with their friends and they pregame, so they're going to drink at home.

So what do they do.

They have like a half a cheese pizza, right, something in the gut to help absorb, so they're not out of their minds.

When you do that with cannabinoids, you actually make get I had a much bigger signal from the connappenoids, so it's the opposite.

It's so interesting.

So when people said I had a full stomach, I'm like, oh, oh.

Yeah, So more food equals more effect.

You may get more effect.

Yeah.

I want to pause for a moment here to talk more about what we know about mixing cannabis and alcohol.

Researchers have found that using the two together can worsen their effects on thinking and coordination, and alcohol can significantly increase THHC absorption.

This combination is also linked to more risky behaviors.

Overall, there hasn't been a lot of research in this area yet, so we don't fully understand all of the implications, and of course the effects can vary a lot depending on how much alcohol you're drinking and what kind of cannabis product you're using.

So we've talked about THC five milligrams being on the low end standard dose.

Yeah, what about CBD depends on what you're using it for.

So for some people, at our first clinical trial of anxiety, we pitched very low.

I based it on a product that was being used in San Francisco in the Bay Area that had great response, and it was somewhere between ten and twelve milligrams per mil of CBD, but a whole plant ful spatrum product and very low tcy like less than point three milligrams, So it wasn't going to get you high necessarily, and that was what I was aiming for.

But the amount of CBD that you might think about using is really dictated by what ails you for a mood.

You might need less than you would for chronic pain.

Ourre chronic pain studies start significantly higher.

Most of my studies now use a whole lot more product, a higher concentrated product.

So it depends back to some practical advice.

For a midlife woman who may be having perimenopausal symptoms issues or menopausal issues worse than perimenopause, many times, start low, go slow.

What would you recommend to start with.

I would say systemic administration is generally better.

A lot of times people are caught up in the topical or dermal realms.

You know what, I have cramps.

I'm just going to put some of this salve or this lotion of systemic application.

Something that you take is likely to give you the best response.

A root of inhalation is the fastest way of getting response, but it's not generally the way that most patients want to take quote their medicine.

Not generally, so I would say again, if you're looking to address things like chronic pain, I'm a fan of sublingual solutions as opposed to other things, and you really want to make sure that whatever you're using.

In my humble opinion, whole plant broad or whole plant full spectrum products are highly efficacious For many things.

The individual constituents within the product dictate the outcome, So if you're having trouble with sleep, might look for something with higher levels of CBD and not a huge amount of teaching necessarily, sometimes a little is fine.

After the break, we'll get into safety issues to tell how much THHC is really in a product, regardless of what the label says, We'll be right back looking for another great podcast that decodes women's health.

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This episode asked the question can we make sex better?

dB shares what the research really says about cannabis, desire, arousal, and orgasms.

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So, for a woman in midlife who wants to maybe you feel better, maybe better cognitive function, get better sleep, is there an advantage of going to a medical dispensary versus going to a recreational dispensary?

Very often medical products have a significantly lowered tax rate associated Very often the same products the plant doesn't care what you use it for.

By the way, plant doesn't care at all.

Right, Cannabis is cannabis, But the products themselves are tax very differently, and there may be a different fund of information from the quote patient care advocates or bud tenders that you're talking to.

So there are different types of products that people should probably be exploring if they're interested in having let's say, better sleep versus addressing things like chronic pain or motor anxiety.

Sometimes it's a question of dose with the same type of product, and sometimes it's a whole different set of players we want on the field.

So there are some constituents that people don't talk about too often, although now we're seeing them more often, like CBN or cannabinol.

Actually THHC degrades over time and we get high levels of CBN and old weed.

But CBN has been remarkably effective for some people with regard to decreasing sleep latency, so time to fall asleep and the ability to have better sleep coherence or staying sleep.

I think of CBD is helpful for coherence and CBN is great for latency, but high CBN levels are often helpful for people with sleep disruption and it's not really generally considered intoxicating.

So different combinations of these types of compounds are making their way into the marketplace now, which makes me very happy.

And it's what we do in our clinical trials.

We try to create products and formulate them so that they're optimized to address these different conditions and indications.

So it sounds like this where is like hypothesis generating and then you move into making your own product.

Do you have your own tinc sure that you're making or have made?

Is that correct?

A number of different clinical trials, Each clinical trial generally uses a different type of product.

If you're looking for something for sleep versus focus or concentration versus chronic pain, they're going to look different.

In our group, we spend a lot of time I custom formulate all of our products to capitalize on that idea.

How do women begin to what are safety concerns that women should have?

What do they need to ask, what do they need to what do they need to look for to be safe about this?

If they want to explore using cannabis to relieve some of their symptoms.

So yeah, for symptom relief, And if that's really clear I always tell people no, before you go, be honest with yourself and ultimately the people that you're talking with or dealing with about what your real goal is.

And again, no shame in Ah.

You know, I'd like to take the endge off with my partner on Friday.

Fine mazzle, but very different from I have this intractable pain.

I can't move.

I really I can't get off the couch.

I'm really uncomfortable.

So label claims have been reported to be both under and overstated.

So sometimes product will say that it has a whole lot more of let's say CBD in it than it does, which, by the way, is really heartbreaking when you're talking to somebody who's seventy eight years old on a fixed income and has spent ninety six dollars on a one ounce bottle of something that's supposed to be fifty megs per mel and it's three.

That's a problem.

Sometimes they're understated with regard to things like THHC, where the individual is going to be exposed to a whole lot more THC than they might have anticipated.

The only way to know really what's in your weed, or what's in the product you're using is to ask your dispensary or the point of sale if you're buying it online, or a certificate of analysis to ensure that the product is what they would like it to be.

Dispensaries have to have them by law, and most reputable manufacturers and sellers online will also have coas for all of their products by batch, not just the general one that sort of represented what they made long ago and far away, but the actual product that you're using.

You should be able to match the batch and look at the CoA that will tell you exactly how much of each of the compounds is in your product.

I would remind people that it is not necessarily without its own associated concerns or risks.

So we think about things like drug drug interactions.

This is what I call the least popular girl at the dance phenomenon.

When I bring this up, people say, oh, with that already.

So here's how it goes.

Your liver processes all drugs and so.

As it turns out, cannabinoids impact the liver's enzyme systems.

The cytochrome P four fifty enzyme system highly impacted by cannabinoids, and in fact, CBD affects more of them than DHC so as a result, we are very careful with individuals who are on certain types of medications because you could wind up inadvertently increasing or decreasing the serum level of certain drugs that you would not want to do that with.

For example, an ANTIICOI got a blood fitter.

It's not so great to increase the amount of blood thatitter coursing through your body.

No, thank you.

Women should be mindful of that.

It's not completely benign.

You have to be careful.

So a number of midlife women may be on SSRIs or even hormone replacement therapy so or I call it men a puzzle hormone support.

Sorry, not HRT.

That's old fashion, right, we don't say that anymore, right, therapy support?

Is there any interaction with cannabis.

So there are some to be mindful of.

The best thing to do is to go online and actually look for the drug drug interaction calculator, and you can put in anything you're using.

And the reason I wouldn't be specific is because then you could misinterpret what I'm saying and take it as postulate, and so we don't want to do that.

But to your point, generally, there are a number of conventional medications that are not a concern, and then there are a handful that are, and some of them appear in certain classes like SSRIs for sure, benzodiazepines for sure, anticoagulants or blood thinners, So we want to be mindful of that.

Hoomone replacement not generally an issue, but always best to check with your PCP.

But you can look at a drug drug int Reaction tool online, which is incredibly helpful because sometimes people aren't always forthcoming about what they're using.

That's the other thing.

They don't necessarily want to tell their treat that they're using cannabis or cannabinoids.

And I say this to you if you're one of those folks, don't be afraid.

If your doctor isn't open minded and willing to listen to why you're using, what you're getting from it, and your rationale, you may want to consider talking to someone else.

Let's talk about physician education.

So I'm a pretty curious physician, early adopter of medical marijuana twenty twelve, twenty fourteen in New Jersey, New York.

Good for you, And Demetriosi is pretty curious but know very little about this.

Know a lot more now, But what is the average physician, what is their participation in knowledge of these pathways and the impact that cannabis and the utility and benefit that it can have for women or just patients in general.

Generally, people are underinformed and they are overwhelmed by the headline that will tell you cannabis is terrible for this and awful for that, And it's so important to understand once again, cannabis is not one thing.

It is a multi compound plant, so to refer to anything that comes from it is foolish.

It is also really unfortunately true that most don't have the time to educate themselves about where it may be most effications, where it may be most concerning, or how it may differ from their firmly held beliefs.

Our patients require it, I mean, really, they are looking to us to help make good, sound decisions.

Those decisions should be based on real data, real science, and not rhetoric or your own personal beliefs.

I think that more and more physicians are interested in understanding it because it's coming through the door every day now, and it's usually because one of their quote more responsible patients has raised the question, and so now they're going to dig into it they had a handful before, But you know, those people were probably just looking for a legal way to be high.

I was told the same thing when we first started this program.

We created a metric in our lab called can account, and it allows us to quantify the amount of individual cannabinoids that people are exposed to on a weekly basis, whether you're using a tincture or flower product, or an edible or beverage.

There are ways that you can calculate it based on both what's on the label and a certificate of analysis, how long it takes you to use it, how you're using all these things.

And the truth is when we look at the data at three months, six months, and one year, overwhelmingly just looking at CBD and THHC levels, CBD is exponentially higher than THHC, underscoring the point that these people aren't really chasing a high.

So it's important for physicians, caregivers, healthcare workers, legislators, everybody to sort of let go of what we think we know and allow ourselves to be open to what the science and the data tell us.

It's really important to remember and to remind people who see patients every day all day to have dialogues and not monologues with their patients.

This is supposed to be a conversation, not me telling you what to do.

And I think for a long time and still today, people are very concerned about losing their license if they were to perhaps consider writing a certification for medical cannabis use.

It's not by prescription.

You can't get a prescription for scheduled drug, right, So these things are recommendations or certifications.

And the number of folks that I see who say, yeah, I'm not getting into that.

I don't want to lose my license because when things invariably come around, I don't want to be in the crosshairs.

So I think a lot of it is fear, a lot of it is misperception and a lot of misinformation.

What do women need to know about drug testing?

There's definitely professions where there's drug testing involved, and you may be using a high CBD product that does have some THHC in it.

What do we need to know about that?

We need to know a bunch of things first and foremost.

When people hold up a bottle and they say to mean, look, this is just CBD, it's almost never just CBD, and that's Okay, from a clinical perspective, we don't want it to be just CBD.

Whole plant full or whole plant broad spectrum.

Botics are more efficacious.

However, at our very first clinical trial that I developed for folks with moderate severe anxiety was basically a whole plant full spectrum product and it was sourced from cannabis.

However, that particular chemo ar cultivar that made the base that I then created the product from would be termed hemp today.

I could have used ten times the amount of THHC that I had in that product and still been within the limits of the law.

It had point to two milligrams per millileter very low.

And what we found was after four weeks of a relatively higher CBD containing compound and very low THHC, half the sample was positive for THHC after four weeks, so they would have filled a drunk test.

And so people say to me, but Doc, you know, it's just this hold on broad spectrum.

Products are designed to eliminate that possibility from the equation.

So civil servants, people who are in jobs where they really can't take the chance, or who are uber sensitive to THHC.

And there are many people who are hyper sensitive to THHC and very very small amounts are still too much.

So that's something to be mindful of.

Please be mindful of what you're using in When it doesn't list how much THHD is in the product, ask for a CoA.

Any and all amounts of THC can aggregate in the body, and they do, and you will potentially have a positive drug screen.

How long is the drug string positive for if you've ingested some THC.

Depends on what you're using, how often, and how familiar you are with cannabis.

So some of our more routine users in the old days, the recreational studies that we did, these were what I would call heavy hitters.

These are people who are using multiple times a day.

We had some folks who are still positive at for forty some odd days.

Do you have any personal experience in improving your own health with cannabis?

If you do use it, do you have any any surprising effects or so?

I would tell you that not all people have a positive relationship with THHC unfortunately, and I'm one of them.

Is like the plumber whose house has a leak in the basement, Maybe THHC and I have a detuont other cannabinoids that are non intoxicating.

I'm fine with.

Some people are very very slow metabolizers of certain consiguents like THHC, and a very little bit can go a very long way.

So you have to be very mindful.

If I try something and it's absolutely fine for me with like one milligrammar or a milligram and a half of PC and I don't feel altered, no one's going to feel altered because it takes very very little.

I'm a cheap data.

As it turns out, if.

You had to tell women or advise women, what would be the one thing that you would say about cannabis use and how cannabis can impact their health?

I think I would probably say that there is unprecedented promise with regard to cannabis and cannabinoids for many many indications and conditions that affect us.

That said, you can't believe all the hype, and you have to really educate yourself and ask questions.

In my very humble opinion, people are exploring cannabis and cannabinoid based therapies to reduce their use of conventional medications, to sleep better, to have less pain, to have better mood and also to have better day to day life.

If we think of things as a natural anti inflammatory or ways of improving your own immune system, people are adding these products to their daily health and wellness regimens.

There are certain cannabinoids likes for sure, CBD, but so many others that are the unsung heroes that are actually more effective as anti inflammatory or neuroprotective agents or all sorts of things we don't have time to get into, and so you can create these compounds that you might take on a regular basis or have other people do it and feel a whole lot better than you might otherwise.

I've been in situations where I didn't recognize the patient when I walked into the waiting room because they looked so different from the way they looked a month prior.

I think we're at the very, very beginning stages of what will ultimately be an absolutely unprecedented revolution.

I mean, we really can change some of the ways that people are living.

And I had this last week.

I had a woman say to me, I am for the first time in nine years, I'm considering not having a hesteractomy because I now know what it's like to live without chronic debilitating.

I'm at an eight or nine out of ten pain all day, every day.

What do you do with That's that's amazing right.

Researchers like doctor Gruber are learning more every day about how to use cannabinoid based therapy safely and effectively, but for now, there are a few key things to keep in mind.

Start low and go slow.

Begin with a small dose, even just a quarter of what you think you might need, and increase gradually.

Be clear about what your goal is.

Low doses of THHC, the primary intoxicating part of the plant, may help with anxiety, but be careful because higher levels often trigger anxiety in many people.

Cannabinoids like CBN and CBD may be helpful for sleep.

CBD may also be helpful for things like anxiety and inflammation, and also has potential neuroprotective qualities.

Doctor Grueber has noted that there are other cannabinoids that have shown promise with regard to anti inflammatory and neuroprotective properties, including CBG, CBC, and THCHCB.

Look for full or broad spectrum products.

These formulations take advantage of multiple cannabinoids working together.

Full spectrum products contain the naturally occurring range of cannabinoids, including THHC, CBD, and other minor cannabinoids.

Broad spectrum products are similar to full spectrum products, with the important distinction that they are intended to have no quantifiable amount of THHC.

So doctor Gruber suggests looking into broad spectrum products if you want to avoid feeling altered or high, or if you work in a field that drug tests for THHC, and remember always check the products certificate of analysis to get more accurate information about the compounds that are included in it.

For interactions.

If you're taking other medications, use a reliable drug drug interaction tool online to see if cannabis might interfere and be honest with your doctor.

Let them know what you're using or considering.

If your provider isn't receptive or informed, consider finding someone who is.

There are plenty of clinicians out there who are curious and excited about the medicinal potential of cannabis and who can help you figure out what's right for you.

Coming up on the next episode of Decoding Women's Health will be diving into the world of glp ones, a class of drugs that has completely changed the conversation around metabolic health and weight loss.

In the past few decades, we've only been pushing this narrative of eating less and moving more, which is oversimplified and not the right message.

And I think what has transformed the landscape of weight management is that now we have tools to revillly dress the biology.

Decoding Women's Health is a production of Pushkin Industries and the Atria Health and Research Institute.

This episode was produced by Rebecca Lee Douglas.

It was edited by Amy Gaines McQuaid, mastering by Sarah Buguer.

Our associate producer is Sonia Gerwit.

Our executive producer is Alexandra Garreton.

Our theme song was composed by HANNS.

Brown.

Concept creative development and fact checking by Shavon O'Connor.

A special thanks to Alan Tish, David Saltzman, Sarah Nix, Eric Sandler, Morgan Rattner, Amy Hagdorn, Owen Miller, Jordan McMillan, and Greta Cohne.

If you have a question about women's health in midlife, leave us a voicemail at four F five two O one three three eight five, or send us a message at Decoding Women's Health at Pushkin dot FM.

I'm doctor Elizabeth pointer and thanks for listening.

Until next time.

Welcome to sex Ed with dB.

I'm your host, dB.

Let's get into it.

Hey everyone, welcome back dB here, your favorite sex educator and pleasure expert, and today we're talking about cannabis and sex.

Now, maybe you've heard people say that we'd make sex amazing, or maybe you've tried it and thought was that hotter than usual?

Or was I just way too invested in the way my partner's hair smelled because I was super high and it smelled so good.

Either way, there's a lot of hype and a lot of myths around getting high and getting it on.

So today we are breaking down on what the science actually says.

As usual, we'll talk about how cannabis might affect desire, arousal, and orgasm, why dose matters more than you think, and then not so fun side effects that you should know before you try it.

We'll even dig into what researchers have discovered about weed's role in pain reduction and sexual satisfaction.

And if you've ever wondered whether cannabis could take your bedroom game higher or if it's just smoke and mirrors.

Oh sorry, it's such a bad pun, but it's so good you are in the right place.

So first up, are people who use weed really having more sex?

What do the data show?

Back in twenty seventeen, researchers at Stanford looked at over fifty thousand Americans and found something kind of interesting.

Daily cannabis users reported having more sex than non users.

Women went from about six times a month to seven point one, and men went from five point six to six point nine.

Now, before we start just kind of handing out blunts as relationship therapy, here's the thing.

This is self reported.

It's not proof that weed causes more sex.

It's just that people who use it tend to say that they have more sex.

Could be the weed, could be that people who are more open to cannabis are also open to other sexual activities.

Hard to say, but interesting nonetheless, And that leads us nicely into this pleasure piece because even if frequency isn't directly caused by cannabis, plenty of people swear that it changes how sex feels.

In a twenty twenty three study with around eight hundred people, over seventy percent said that weed made sex better, more desire, more intense orgasms, and touch that felt off the chart good.

Let me repeat that eight hundred people were in this study.

Over seventy percent said that weed made sex better.

So fascinating.

Hello dB here, thank you so much for listening.

If you liked what you heard in this clip, you can find the rest of this episode and more by searching sex ed dB on your podcast app of choice, or by heading to sex edi dB dot com.