Cannabis for pelvic pain? As more women are diagnosed, endometriosis treatment is changing

Research is opening up new ways of thinking about this chronic disease. Patients who want to consider medicinal cannabis should discuss the pros and cons with their GP.

DR MAGDALENA SIMONIS

Patients should be honest about their cannabis use when they discuss pain with their doctors. Picture: iStock

8 min read

5:00AMJune 04, 2025

Should you take medicinal cannabis to manage the pain of endometriosis? Do you need surgery? As more Australian women are being diagnosed with endometriosis, new and ongoing research means there have been changes in our approach to treating the disease, with new guidelines for when to have surgery and big shifts in how doctors should approach the condition and its diagnosis, as well as how to deal with the pain.

The incidence of endometriosis in Australia is now one in seven women and girls, but the diagnosis is being made more quickly.

The Australian Institute of Health and Welfare 2025 report says it now takes about six years for a woman to be diagnosed – about half the time it took back in 2018, when the National Action Plan for Endometriosis was launched.

There have also been substantial changes in research, so that the Royal Australian and New Zealand College of Obstetricians and Gynaecologists now refers to its guidelines on the disease as “living guidelines”, which means they will be updated as our understanding of this complex condition improves.

How you should tackle the pain is just one of the big questions to consider.

What is endometriosis?

Endometriosis is a chronic inflammatory condition that causes immense grief to those with severe symptoms and, in turn, affects their loved ones. It can occur in girls from pre-puberty across all stages of a woman’s reproductive life and presents with a range of symptoms that might vary and are not always associated with menstruation, making the diagnostic process complicated. The most common symptoms associated with endometriosis are severe painful periods, pain with sex, infertility, pelvic pain and heavy menstrual bleeding. Some present with bloating, fatigue, pain without periods, mental health issues and chronic complex pain syndromes. Endometriosis impacts attendance at work and school, which is a loss to the individual and society resulting in an economic burden estimated at $9bn a year. As for the types and causes, theories postulate around genetic factors, auto-immune factors, cells that can innately change from being benign to becoming nasty disease sites, spreading much like cancer cells, spreading to places outside the pelvic cavity to the lungs and even brain. Some suggest they are embryonic remnants that then become activated. There is much we do not yet understand.

Endometriosis may produce a range of symptoms but pelvic pain is common and can be debilitating. Picture: iStock

So what are the big changes in approach?

Cannabinoids for pelvic pain and endometriosis

We are hearing and seeing more around the use of cannabinoids for management of chronic pain syndromes and this is being studied for endometriosis too. Although the research on the effects of cannabinoids for severe pelvic pain is looking positive where other options have been ineffective, my personal stance on these remains guarded until further research becomes available.

Medicinal cannabis and illicit cannabis come from the cannabis plant, but they differ greatly in their cultivation and manufacture. One is legal and one is not. The legal versions are very expensive and without going into the details of their properties, the majority of prescribed options are being issued by online telehealth providers who have opportunistically captured a vulnerable market. They’ve been reported to dispense cannabinoids pretty much upon request, without investing adequate time in taking a history and follow-up, and charging a high cost.

Another major concern is that patients who require strong pain medication also take cannabinoids and have not revealed this to their regular health practitioner, presumably to avoid being judged or talked out of taking them. The notion that because a product is “ancient” and therefore validated by historical use (rather than the rigours of science) is incorrect. Take sugar, for example. It’s a natural product too and yet there is a global effort to tax things containing sugar due to its harm to health.

Doctors are hearing and seeing more around the use of cannabinoids for management of chronic pain syndromes. Picture: Getty Images

The effects of cannabis are dependent on what is contained within the medicinal cannabis product you take. Should you be prescribed a cannabidiol (CBD) dominant medicine, this is classified as a Schedule 4 drug (prescription-only medicine), whereas if you are prescribed a product with higher levels of delta-9 tetrahydrocannabinol (THC), which is the component that can make you “high”, that is classified as a Schedule 8 (controlled drug). Both can only be prescribed by authorised medical doctors. Growing and using your own “home brand” to avoid paying for prescribed forms means it is impossible to identify how much and which of the 140 different cannabinoids that have been identified within the cannabis genus you are taking. Being “a naturally occurring plant” is not synonymous with “safe”. Cannabinoids should not be taken if you are planning to fall pregnant and not while pregnant. They should not be taken when driving and they may interact with other prescribed medications. If this is something you wish to explore, have an open discussion with your general practitioner, gynaecologist or pain specialist, who will discuss the pros and cons.

Your GP is primed to manage endometriosis over your life

When you first attend your general practitioner regarding the array of symptoms you have, you might be offered a survey to fill in, which will help the doctor better understand how the symptoms are affecting your life. The Raising Awareness Tool for Endometriosis (RATE) is one of the RANZCOG-recommended questionnaires for use in this setting. It is publicly accessible, and filling this in online will assist the conversation with your doctor. After speaking with your doctor about your symptoms and how they affect your daily activities and life, an examination will be performed with some baseline tests, which will include referral for a transvaginal ultrasound. This is a major shift as a first-line investigation.

Ultrasound for accurate diagnosis

A transvaginal ultrasound, although intrusive, is preferred for accuracy. This involves the insertion of a wand-like instrument into the vagina, which can be uncomfortable, especially for those experiencing pain with sex. The skill of the sonographer (a technician) determines the quality of the images so it’s worth making sure you are referred to a specialist ultrasound centre, where either the gynaecologist or highly skilled sonographer performs the test. You can expect to be out of pocket anything from $50 to $300 but the ultrasounds performed by specialists also yield higher accuracy rates for the severe form, referred to as deep infiltrating endometriosis (DIE).

As with most specialised health services, the further away from a metropolitan area, the less accessible they are; however, upskilling existing sonographers is on the horizon.

For those with very severe symptoms suggestive of advanced endometriosis, pelvic magnetic resonance imaging (MRI) can be ordered by a gynaecologist, which when ordered for staging of disease prior to surgery attracts a Medicare rebate.

Magnetic resonance imaging can be used to help diagnose endometriosis and assess how advanced is the disease. Picture: iStock

If transvaginal ultrasound is not possible or not appropriate due to age or sexual history, and MRI is not available, a transabdominal ultrasound (taken from the surface of the tummy), can be arranged, but these do not yield as much detail.

A normal pelvic ultrasound does not mean you do not have endometriosis so the discussion around next treatment options will usually include a list of options such as hormonal treatments in the form of combined oral contraceptives and progestogens (oral, injection, implant or intra-uterine device) to control heavy periods and reduce pain. These are still a good first-line therapy at all ages.

Additional interventions such as over-the-counter analgesics, physiotherapy or psychological support will be included. Keeping a short-term symptom diary helps the discussion about ongoing management and shared decision-making.

If first-line treatments have not resulted in significant improvement after three months, an alternative hormonal treatment can be tried. It can be frustrating working through the options, and managing flares of pain requires working with a multidisciplinary team. As with any chronic inflammatory condition, this requires regular three-monthly reviews and taking a long-term view of the disease.

Reach out to advocacy and peer groups for support such as QENDO, Endo Zone and Endometriosis Australia. They know what you are going through and can provide further emotional support and validation in a world where you might feel alone, scared and misunderstood.

Surgery is no longer a first line for diagnosis

The approach to surgery has changed, but it’s still important for severe endometriosis and deep pelvic pathology

If significant improvement is not achieved at least within the first six months, discuss getting a referral to a specialist gynaecologist, as private and public waiting lists are long. Although surgery is no longer required as a first-line option to diagnose endometriosis according to the living guidelines, severe forms of endometriosis can be missed by pelvic examination and ultrasound. Other conditions can coexist, and although laparoscopy might not find endometriosis, it might detect adenomyosis, pelvic inflammatory disease, ovarian torsion (twisting on its ligament) or pelvic engorgement syndrome, to name a few. Paradoxically, removal of endometriosis is not a cure of disease, although this provides relief of symptoms for a time, and repeat laparoscopies can create more scar tissue, so hormonal therapy should be offered post-operatively, unless you are trying to fall pregnant.

Endometriosis is an expensive condition

The waiting lists for laparoscopy in the public system can be as long as 18 months, resulting in many choosing to pay for this in the private system, with huge out-of-pocket costs. In adolescents, laparoscopy should ideally be performed by a paediatric and adolescent gynaecologist or a gynaecologist with expertise in adolescent health. While waiting for laparoscopy, supportive counselling and physiotherapy along with pain management should be continued. It all adds up, when you include allied health services such as pelvic pain physiotherapists. The government-funded endometriosis and pelvic pain hubs provide holistic care for endometriosis but referral to these allied health services is at your own cost.

Where you get your information from matters

For too many years, the primary care sector has had little or no guidance and education around endometriosis, as it was considered something only gynaecologists could diagnose and manage. This gap is now rapidly being addressed, and general practitioners are receiving updates and education around endometriosis through RANZCOG and the Royal Australian College of General Practitioners, with structured resources to support the consultation.

Advocacy groups such as EndoZone, QENDO, Endometriosis Australia and the Jean Hailes Foundation, to name a few, provide accurate information and can help steer you in the right direction for treatment. They are run mostly by women with lived experience and now work closely with the health sector, bridging clinician-patient communication gaps. Having access to reliable information can help you make informed decisions about your care, and is empowering.

Magdalena Simonis is Associate Professor at the Department of General Practice University of Melbourne and a member of the National Action Plan for Endometriosis Expert Advisory Group. Magdalena also helped develop RATE as a member of the Endometriosis Online Learning Steering Committee member.

This column is published for information purposes only. It is not intended to be used as medical advice and should not be relied on as a substitute for independent professional advice about your personal health or a medical condition from your doctor or other qualified health professional.

References