'In the weeds': navigating the complex concerns, challenges and choices associated with medicinal cannabis consumption for endometriosis

People with endometriosis report consuming cannabis to manage their symptoms. Given the range of differing legalities and access pathways across the world, this study aimed to investigate the drivers and barriers to cannabis use worldwide. An online, anonymous, cross-sectional survey was distributed internationally by endometriosis organisations and was open to anyone consuming cannabis for endometriosis symptoms. Survey questions included motivations for both starting and ongoing cannabis consumption, concerns over cannabis use, reasons for stopping cannabis, and communication of cannabis consumption with healthcare providers. Eight hundred and eighty-nine responses were collected across >10 countries. Illicit cannabis (56.7%) was the most common access pathway. 99% of respondents stated they would continue to use cannabis to manage their endometriosis-based symptoms, with 90% reporting they would recommend its use to a friend or relative with the disease. The most common motivation(s) for cannabis consumption were inadequate pain control (68.6%) and bothersome side effects of medications (56.3%). Similar motivations were reported for ongoing cannabis consumption, with concerns over dependence/addiction on pharmaceutical medications (43.9%) being another common motivation. Those using illicit cannabis were significantly less likely (P < 0.0001) to disclose their cannabis consumption to medical professionals. Cannabis was viewed as superior to pharmaceuticals both in terms of effectiveness and side-effect profile. Despite this, concerns around cost, breaking the law, judgement due to stigma, and current drug-driving laws were reported. Illicit usage and lack of medical oversight raise concerns over potential drug interactions or withdrawal effects due to reduction in pharmaceutical medications because of cannabis. Lay summary: Survey participants reported that it is most common internationally for people using cannabis to manage endometriosis pain and associated symptoms to access this illegally, despite medical access being available in many countries. Many respondents also reported that cannabis was more effective and had a more tolerable side-effect profile than pharmaceutical medications they had used previously. However, over half of respondents were concerned about the negative impact of stigma associated with cannabis and how this might affect their day-to-day lives. Other concerns were potentially breaking the law where they live, possibly losing their driving licence due to drug-driving laws, or losing their job due to workplace drug-testing policies. Such concerns may be why more than 30% of participants reported not disclosing their cannabis consumption to their doctor. This is concerning because medical supervision is important to monitor for side effects and potential drug interactions, which people using cannabis may not know exist.