As legalization of marijuana spreads, 7% of pregnant women in the U.S. are using this unregulated drug to help reduce morning sickness. But is it safe?

In some states that legalize marijuana, dispensaries can be as common as coffee shops. Like smoking cigarettes or alcohol consumption, anyone over the age of 21 can easily walk into a store and buy a variety of compounds recreationally for their own use. But there are risks to be aware of, especially for pregnant women. Are the people behind the counter knowledgable enough to give sound advice to pregnant women seeking medical advice?

A study at the University of Colorado looked into the type of information being provided by staff members of marijuana dispensaries. Investigators posed as 8-week pregnant patients and called 465 dispensaries which resulted in useful information from 400 locations. Investigators asked employees if they had products that were “safe for morning sickness.” Other questions were about any known risks to the mother or baby with taking these products and whether they should check with their own health care provider. Results were: 69% of staff members recommended marijuana products for morning sickness, and 36% said that it was safe to use in pregnancy. Only 32% recommended that the patient check with her physician, but after prompting, 81% eventually recommended it.

This may not be happening in every state, but this study gives you a glimpse of how many pregnant women are likely not asking their provider for advice on the safety of using marijuana for morning sickness. But instead are seeking medical advice from marijuana sales people who not only have a conflict of interest and lack of medical knowledge but also a lack of cautionary approach on the topic.

Currently marijuana products contain from 0.3% tetrahydrocannabinol (THC) up to 15% and, even some concentrations up to more than 50% THC. THC acts on CB1 receptors that have psychotropic effects. Cannabidiol (CBD) acts through its effects on serotonin and not CB1 receptors for the most part. Cannabis, the marijuana plant, contains up to 100 cannabinoids with the two that we most know about described above. Dependence and addiction affects about 9% of users. This is compared to 15% of the population addicted to alcohol. This can lead to the risk of addiction to the newborn, let alone other potential consequences of cannabinoid exposure in utero.

There have been studies showing that children exposed in utero to cannabis performed more poorly in visual problem solving, motor coordination, had attention deficits and childhood sleep problems for up to a decade compared to unexposed children. Yes, thats right. According to a University of Colorado, Boulder study and lead author John Hewitt, director of CU’s Institute for Behavioral  Genetics, marijuana use can impact children’s sleep long term!!

Other potential effects include increased risk of stillbirth, low birth weight (if using cannabis more than once per week) and  preterm labor (those using cannabis and smoking cigarettes). A few older studies have not shown any differences in adverse outcomes with pregnant users vs nonusers. With marijuana products not being regulated and not knowing the specific ratios of THC/CBD,  it can be very confusing to know what may harm mother and/or baby.

One thing for sure, marijuana use has not been proven to be safe in pregnancy. It is recommended not to use cannabis products during pregnancy-whether for recreational or medical purposes. Consult your practitioner about other safe and effective natural options for nausea and vomiting of pregnancy.

The medical use of cannabis is legal with physician prescription in  35 states. The recreational use is legal in 14 states.

Even though the use of cannabis is federally illegal, some of its derivative compounds have been approved by the Food and Drug Administration fo prescription use. For non-prescription use, cannabidiol derived from industrial hemp is legal at the federal level, but legality and enforcement varies by state. This map can identify what your state laws are regarding the use of marijuana  State map of marijuana.

References: https://disa.com/map-of-marijuana-legality-by-state

Dicson, B, et al. Recommendations from cannabis dispensaries about first-trimester cannabis use. Obstet Gynecol. 2018;131: 1031-1038.

Hudson, T. Marijuana in Pregnancy-Please Don’t. Townsend Letter. Women’s Health Update. Feb/March 2019. p. 30-33.

About 6- 15% of myocardial infarctions (heart attacks) are associated with nonobstructive coronary disease on angiography. This means that far less than 50% of heart attacks are due to blocked arteries. Also, these types of heart attacks occur more commonly in women.

A multinational study was done in which investigators enrolled 170 women with myocardial infarction with nonobstructive coronary arteries (MINOCA). These women were scheduled to undergo cardiac magnetic resonance imaging (MRI) and coronary optical coherence tomography (OCT). The OCT test uses infrared light to acquire cross-sectional images of the coronary artery using an intravascular catheter. This allows it to have a higher resolution than intravascular ultrasound.

In 145 women who underwent OCT, 67 had a possible or definite culprit lesion, such as plaque rupture or layered plaque. In 116 women who had an MRI, 62 had an ischemic (reduced blood flow) pattern of abnormalities and 24 had a nonischemic pattern, such as myocarditis or nonischemic cardiomyopathy (heart disease causing an enlarged heart). Overall,  A cause for MINOCA was identified in 98 women, with an ischemic etiology in 74, and nonischemic in 24 women.

This study shows the benefit of using multiple imaging tests to identify the mechanism of MINOCA in most cases. It showed almost two thirds of cases related to an ischemic cause, despite the absence of severe obstructive coronary disease by angiography. Women tend to have microvascular disease which affects them four times more than men. They also have different symptoms of myocardial infarction than men. Both genders can exhibit symptoms of chest pain or discomfort but women are more likely to experience shortness of breath, nausea/vomiting and back or jaw pain. It’s best for physicians to order multimodality imaging especially for women with these symptoms to prevent the progression of a heart attack.

Reference: Reynolds, HR et al. Coronary optical coherence tomography and cardiac magnetic resonance imaging to determine underlying causes of MINOCA in women. Circulation 2020 Nov 14; [e-pub]. (https://doi.org/10.1161/CIRCULATIONHA.120.052008).

Dementia is a concern for all of us as we age. Almost 2/3 of Alzheimer disease (AD) cases occur in women which indicates that this condition may be influenced by sex-specific factors. Researchers used data from a prospective cohort study (following a group of similar individuals over time who differ with respect to certain factors) looking at cognitive function and aging in Cache County, Utah. Investigators used data among 2114 women baseline age over 65, primarily white and an average 13 years of education. The factors they reviewed were estimated lifetime exposure to estrogen, both endogenous (years of ovulation) and exogenous (years of menopause hormone therapy) as well as timing of when hormone replacement was initiated.

Estrogen exposure was analyzed relative to cognitive status based on a modified Mini Mental State Exam conducted 3 times over 12 years of followup. Other variables that could influence the outcome included education level, APOE genotype, exercise, overall health. body mass index, depression status, type of hormone therapy, and age.

Longer exposure of estrogen exposure (both endogenous and hormone therapy use) were associated with prevention of age-related cognitive decline. Starting hormone therapy within 5 years of menopause onset was associated with better late-life cognitive function compared with delayed initiation of hormone therapy.

A prospective Finnish study also suggested that starting hormone therapy soon after menopause and continuing it long term reduced the risk for AD. This U.S. analysis now provides further support for this hypothesis that hormone therapy (initiated soon after menopause) can provide cognitive benefits.

Reference: Matyi, JM bet al. Lifetime estrogen exposure and cognition in late life: The Cache County Study. Menopause 2019
Dec; 26:1366.
Liu JH. Does estrogen provide “neuroprotection” for postmenopausal women? Menopause 2019 Dec; 26:1361.
Neurology 2017; 88:1062.

Sexual dysfunction is a prevalent problem among adult women. According to a large nationwide study in the U.S., 5% of women had arousal problems that caused distress or concern. Between 17% and 45% of postmenopausal women say they have pain with intercourse. Among older adults, 23% of women ages 57 to 80 said they did not find sex pleasurable and 5% have a problem achieving orgasm. Sex drive decreases gradually with age in both men and women but women are more likely to be affected. The answer for many postmenopausal women is vaginal estrogen, which is the main hormone that is depleted in vaginal tissues. This treatment can be very effective. But many women prefer not to use hormones.

One option for women is a patented formula that has been used for years in European countries called Ristela. It is a blend of nutritional ingredients shown to improve sexual function in women. This product was presented at the International Society for the Study of Women’s Sexual Health Annual Meeting 2019.

The formulation is composed of Pycnogenol (French Maritime Pine Bark extract), amino acids L-Arginine and L-Citrulline, and a propriety rose hip extract. Pycnogenol is a powerful antioxidant that has been studied in more than 160 clinical trials. It works synergistically with the other ingredients to enhance nitric oxide production and enhance blood flow. Nutrients and oxygen are also able to reach sensitive tissues in the body including the reproductive organs and brain. Research suggests that Ristela improves overall sexual function including vaginal dryness.

Three clinical trials were done in which 263 women on Ristela were reviewed. The studies were 60 days long and used the total score on the Female Sexual Function Index (FSFI). This is a questionnaire that assesses sexual domains such as sexual desire, arousal, orgasm, satisfaction and pain. All women had moderate sexual dysfunction as determined by their baseline FSFI scores. Total antioxidant capacity, and plasma free radicals were scored by measuring oxidative inhibition, reactive oxygen metabolites, and antioxidant potential in the plasma. The FSFI scores improved in all trials in the Ristela group vs the control group. The third trial was conducted in 100 healthy premenopausal women, ages 37-45. After 1 month, total median FSFI score increased by 85.5% in the Ristela group vs 35.3% in the control group. After 2 months, scores increased by 121.4% in the Ristela group vs. 31.5% in the control group (p<0.0001). There were no adverse reactions using Ristela. The first trial was conducted in healthy postmenopausal women (ages 45-55) and the second trial included healthy peri-menopausal women (ages 40-50). Both trials showed significant improvement in FSFI scores in the Ristela groups.

Ristela is a safe, effective treatment option for improving sexual response in pre, peri and postmenopausal women. Talk to your practitioner in how to order this product. Samples are dispensed in physician offices with instructions on ordering.

Reference: Shifren, JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women. Obstet Gynecol 2008; 112:970-978.
Parish, S., Kellogg-Spadt, S. A review of cli ical study data on Ristela, a supplement blend for improved sexual function in women. Poster presentation at the International Society for the Study of Women’s Sexual Health Annual Meeting 2019. Abstract published: Journal of Sexual Medicine 2019.

Combined hormonal oral contraceptives (CHC) have been around since the 1960’s. Concerns about the estrogen component in them and whether they impair bone formation in teenage girls has risen especially since this is the age that bone formation is so crucial.
Researchers conducted a meta-analysis (examined data from several independent studies on the same subject) to compare changes in bone density determined by duel-energy x-ray absorptiometry (DEXA) in healthy adolescent users and nonusers of estrogen-progestin CHC. There were 9 studies that involved a total of 1535 adolescents aged 12-19 years. Pooled analysis showed that the use of estrogen-progestin CHC was associated with significantly lower bone density at 24 months.

So even though findings confirm concerns that combined birth control pills negatively effect bone density in adolescents, I’m not sure we can blame it all on the estrogen component. The dose of hormone that may cause this effect wasn’t clear in the study. Even though the American Academy of Pediatrics are endorsing long-acting reversible contraceptive (LARC) options as being safer and effective, we need to remember that at least one progestin only option (Depo-provera) has been studied and was related to lower bone density. The contraceptive implant known as Nexplanon is also a synthetic progesterone. Both of these progestins are systemically absorbed which is why they are so effective in preventing pregnancy, but do they also effect bone density?

I believe it is still unclear which contraceptive method is best in reference to protecting bone health. We need to consider the costs and benefits of all of these methods. For instance, injectable contraceptives and implants provide effective longterm birth control yet do not involve a daily regimen. So for a women who may not remember or be able to take a pill at the same time daily, an oral birth control pill would not be the choice for her and would increase her risk of an unintended pregnancy. A LARC would be best for this particular patient but I would screen her for other risk factors for bone loss. This includes checking a Vitamin D level, evaluate her calcium and mineral intake as well as her gut health (to make sure she has healthy absorption), and increase weight bearing and strength training exercises.

Screening teens for bone health is always a good idea, but is essential for girls that desire ANY hormonal contraceptive. This will determine a baseline which then can be monitored yearly.

Lopez LM, Grimes DA, Schulz KF, Curtis KM; Chen M. Hormonal contraceptives and bone health in women. Cochrane.org.2014 June.
Goshtasebi A et al. Adolescent use of combined hormonal contraception and peak bone mineral density accrual: A meta-analysis of international prospective controlled studies. Clin Endocrinol (Oxf) 2019 Jan 7; [e-pub].