National Institute on Alcohol Abuse and Alcoholism No. 10 PH 290 October 1990

Alcohol and Women

Much of our knowledge of alcoholism has been gathered from studies conducted with a predominance of male subjects. Recent studies involving more female subjects reveal that drinking differs between men and women.

Studies in the general population indicate that fewer women than men drink. It is estimated that of the 15.1 million alcohol-abusing or alcohol-dependent individuals in the United States, approximately 4.6 million (nearly one-third) are women (1). On the whole, women who drink consume less alcohol and have fewer alcohol-related problems and dependence symptoms than men (2,3), yet among the heaviest drinkers, women equal or surpass men in the number of problems that result from their drinking (3).

Drinking behavior differs with the age, life role, and marital status of women. In general, a woman's drinking resembles that of her husband, siblings, or close friends (3). Whereas younger women (aged 18-34) report higher rates of drinking-related problems than do older women (3,4), the incidence of alcohol dependence is greater among middle-aged women (aged 35-49) (5).

Contrary to popular belief, women who have multiple roles (e.g., married women who work outside the home) may have lower rates of alcohol problems than women who do not have multiple roles (6). In fact, role deprivation (e.g., loss of role as wife, mother, or worker) may increase a woman's risk for abusing alcohol (7). Women who have never married or who are divorced or separated are more likely to drink heavily and experience alcohol-related problems than women who are married or widowed. Unmarried women living with a partner are more likely still to engage in heavy drinking and to develop drinking problems.

Heath and colleagues (8) studied drinking behavior among a select sample of female twins to identify possible environmental factors that may modulate drinking behavior. They reported that, among women, marital status appears to modify the effects of genetic factors that influence drinking habits. Marriage or a marriage-like relationship lessens the effect of an inherited liability for drinking.

Several researchers have explored whether drinking patterns and alcohol-related problems vary among women of different racial or ethnic groups. Black women (46 percent) are more likely to abstain from alcohol than white women (34 percent) (9,10). Further, although it is commonly assumed that a larger proportion of black women drink heavily, researchers have disproved this assumption: Equal proportions of black and white women drink heavily (3,9). Black women report fewer alcohol-related personal and social problems than white women, yet a greater proportion of black women experience alcohol-related health problems (11).

Data from self-report surveys suggest that Hispanic women are infrequent drinkers or abstainers (12,13), but this may change as they enter new social and work arenas. Gilbert (14) found that reports of abstention are greater among Hispanic women who have immigrated to the United States; reports of moderate or heavy drinking are greater among younger, American-born Hispanic women.

The interval between onset of drinking-related problems and entry into treatment appears to be shorter for women than for men (15,16). Moreover, studies of women alcoholics in treatment suggest that they often experience greater physiological impairment earlier in their drinking careers, despite having consumed less alcohol than men (17,18). These findings suggest that the development of consequences associated with heavy drinking may be accelerated or "telescoped" in women.

In addition to these many psych osocial and epidemiological differences, the sexes also experience different physiological effects of alcohol. Women become intoxicated after drinking smaller quantities of alcohol than are needed to produce intoxication in men (19). Three possible mechanisms may explain this response.

First, women have lower total body water content than men of comparable size. After alcohol is consumed, it diffuses uniformly into all body water, both inside and outside cells. Because of their smaller quantity of body water, women achieve higher concentrations of alcohol in their blood than men after drinking equivalent amounts of alcohol. More simply, blood alcohol concentration in women may be likened to the result of dropping the same quantity of alcohol into a smaller pail of water.

Second, diminished activity of alcohol dehydrogenase (the primary enzyme involved in the metabolism of alcohol) in the stomach also may contribute to the gender-related differences in blood alcohol concentrations and a woman's heightened vulnerability to the physiological consequences of drinking. Julkunen and colleagues (20) demonstrated in rats that a substantial amount of alcohol is metabolized by gastric alcohol dehydrogenase in the stomach before it enters the systemic circulation. This "first-pass metabolism" of alcohol decreases the availability of alcohol to the system. Frezza and colleagues (21) reported that, because of diminished activity of gastric alcohol dehydrogenase, first-pass metabolism was decreased in women compared with men and was virtually nonexistent in alcoholic women.

Third, fluctuations in gonadal hormone levels during the menstrual cycle may affect the rate of alcohol metabolism, making a woman more susceptible to elevated blood alcohol concentrations at different points in the cycle. Research findings to date, however, have been inconsistent (22,23,24).

Chronic alcohol abuse exacts a greater physical toll on women than on men. Female alcoholics have death rates 50 to 100 percent higher than those of male alcoholics. Further, a greater percentage of female alcoholics die from suicides, alcohol-related accidents, circulatory disorders, and cirrhosis of the liver (25).

Increasing evidence suggests that the detrimental effects of alcohol on the liver are more severe for women than for men. Women develop alcoholic liver disease, particularly alcoholic cirrhosis and hepatitis, after a comparatively shorter period of heavy drinking and at a lower level of daily drinking than men (26,27). Proportionately more alcoholic women die from cirrhosis than do alcoholic men (28).

The exact mechanisms that underlie women's heightened vulnerability to alcohol-induced liver damage are unclear. Differences in body weight and fluid content between men and women may be contributing factors (29). In addition, Johnson and Williams (30) suggested that the combined effect of estrogens and alcohol may augment liver damage. Finally, alcoholic women may be more susceptible to liver damage because of the diminished activity of gastric alcohol dehydrogenase in first-pass metabolism (21).

Drinking also may be associated with an increased risk for breast cancer. After reviewing epidemiological data on alcohol consumption and the incidence of breast cancer, Longnecker and colleagues (31) reported that risk increases when a woman consumes 1 ounce or more of absolute alcohol daily. Increased risk appears to be related directly to the effects of alcohol (32). Moreover, risk for breast cancer and lower levels of alcohol consumption are weakly associated. Data from other studies (33), however, do not concur with these findings, suggesting that more research is needed to explore the relationship between drinking and breast cancer.

Menstrual disorders (e.g., painful menstruation, heavy flow, premenstrual discomfort, and irregular or absent cycles) have been associated with chronic heavy drinking (34,35) . These disorders can have adverse effects on fertility (36). Further, continued drinking may lead to early menopause (37,38).

Animal studies have provided data that replicate the findings of studies in humans to determine the effects of chronic alcohol consumption on female reproductive function. Studies in rodents and monkeys demonstrated that prolonged alcohol exposure disrupts estrus regularity and increases the incidence of ovulatory failure (39,40,41).

Researchers have begun to examine whether women and men require distinct treatment approaches. It has been suggested that women alcoholics may encounter different conditions that facilitate or discourage their entry into treatment.

Women represent 25.4 percent of alcoholism clients in traditional treatment centers in the United States (42). Although it appears that they comprise a small proportion of the treatment population (25 percent women compared with 75 percent men), the proportion of female alcoholics to male alcoholics in treatment is similar to the proportion of all female alcoholics to male alcoholics (30 percent women to 70 percent men). In addition, women drinkers pursue avenues other than traditional alcoholism programs, such as psychiatric services or personal physicians, for treatment (43).

Women alcoholics may encounter motivators and barriers to seeking treatment that differ from those encountered by men. Women are more likely to seek treatment because of family problems (44), and they often are encouraged by parents or children to pursue therapy. Men usually are encouraged to pursue therapy by their wives. Fewer women than men reach treatment through the criminal justice system or through employee assistance programs (45). Lack of child care is one of the most frequently reported barriers to treatment for alcoholic women (46).

Sokolow and colleagues (47) attempted to compare treatment outcome between men and women and reported that, among those who completed treatment, abstinence was slightly higher among women than among men. Women had a higher abstinence rate if treated in a medically oriented alcoholism facility, whereas the abstinence rate was higher for men treated in a peer group-oriented facility. Treatment outcome was better for women treated in a facility with a smaller proportion of female clients and better for men in a facility with a larger proportion of female clients. This study provided preliminary data on gender-specific treatment outcome; however, the trials were not controlled. Although the question of whether women should have separate treatment opportunities is an important one, the supporting evidence still has not been found.

Alcohol and Women--A Commentary by
NIAAA Director Enoch Gordis, M.D.

The extent of women's participation in alcoholism treatment appears to equal roughly the prevalence of alcohol-related problems among women. Even so, some women may face barriers that limit access to treatment. Limited financial resources may be one barrier. For example, many women do not have access to the employer-paid alcoholism treatment provided by larger industries, where men tend to predominate in the work force. Child-care concerns and the fear that an identified alcohol problem will cause the loss of dependent children also may create barriers to treatment. With regard to treatment, many questions remain to be answered by research, including whether specialized treatment in a women-only program is more effective than treatment in a mixed-gender setting.

Previous concerns about a lack of women as research subjects in alcohol studies are beginning to be addressed. However, there have been recent charges that alcohol research on women is discriminatory (48,49). Research on fetal alcohol and drug effects and the fear of discriminatory actions, such as imprisoning pregnant women solely because of their addiction, is central to this controversy. The issue of fetal effects and how to prevent and treat them will not go away simply because discriminatory policies have been suggested. The challenge for alcohol research will be how both sexes can benefit from the fruits of science.

References

(1) WILLIAMS, G.D.; Grant, B.F.; Harford, T.C.; and Noble, B.A. Population projections using DSM-III criteria: Alcohol abuse and dependence, 1990-2000. Alcohol Health & Research World 13(4):366-370, 1989. (2) MALIN, H.; Coakley, J.; and Kaelber, C. An epidemiologic perspective on alcohol use and abuse in the United States. In: Alcohol Consumption and Related Problems. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health Monograph No. 1. DHHS Pub. No. (ADM)82-1190. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1982. pp. 99-153. (3) WILSNACK, R.W.; Wilsnack, S.C.; and Klassen, A.D., Jr. Women's drinking and drinking problems: Patterns from a 1981 national survey. American Journal of Public Health 74(11):1231-1238, 1984. (4) HILTON, M.E. Drinking patterns and drinking problems in 1984: Results from a general population survey. Alcoholism: Clinical and Experimental Research 11(2):167-175, 1987. (5) WILLIAMS, G.D.; Stinson, F.S.; Parker, D.A.; Harford; T.C.; and Noble, J. Demographic trends, alcohol abuse and alcoholism, 1985-1995. Alcohol Health & Research World 11(3):80-83, 91, 1987. (6) WILSNACK, S.C.; Wilsnack, R.W.; and Klassen, A.D. Epidemiological research on women's drinking, 1978-1984. In: Women and Alcohol: Health-Related Issues. National Institute on Alcohol Abuse and Alcoholism. Research Monograph No. 16. DHHS Pub. No. (ADM)86-1139. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1986. pp. 1-68. (7) WILSNACK, R.W., & Cheloha, R. Women's roles and problem drinking across the lifespan. Social Problems 34(3):231-248, 1987. (8) HEATH, A.C.; Jardine, R.; and Martin, N.G. Interactive effects of genotype and social environment on alcohol consumption in female twins. Journal of Studies on Alcohol 50(1):39-48, 1989. (9) CLARK, W.B., & Midanik, L. Alcohol use and alcohol problems among U.S. adults: Results of the 1979 national survey. In: Alcohol Consumption and Related Problems. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health Monograph No. 1. DHHS Pub. No. (ADM)82-1190. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1982. pp. 3-52. (10) HERD, D. Drinking by black and white women: Results from a national survey. Social Problems 35(5):493-505, 1988. (11) HERD, D. The epidemiology of drinking patterns and alcohol-related problems among U.S. blacks. In: Spiegler, D.; Tate, D.; Aitken, S.; and Christian, C., eds. Alcohol Use Among U.S. Ethnic Minorities. National Institute on Alcohol Abuse and Alcoholism. Research Monograph No. 18. DHHS Pub. No. (ADM)89-1435. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1989. pp. 3-50. (12) HOLCK, S.E.; Warren, C.W.; Smith, J.C.; and Rochat, R.W. Alcohol consumption among Mexican American and Anglo women: Results of a survey along the U.S.-Mexico border. Journal of Studies on Alcohol 45(2):149-154, 1984. (13) CAETANO, R. Drinking patterns and alcohol problems in a national survey of U.S. Hispanics. In: Spiegler, D.; Tate, D.; Aitken, S.; and Christian, C., eds. Alcohol Use Among U.S. Ethnic Minorities. National Institute on Alcohol Abuse and Alcoholism. Research Monograph No. 18. DHHS Pub. No. (ADM)89-1435. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off. 1987. pp. 147-162. (14) GILBERT, J. Alcohol consumption patterns in immigrant and later generation Mexican American women. Hispanic Journal of Behavioral Sciences 9(3):299-313, 1987. (15) HASIN, D.S.; Grant, B.F.; and Weinflash, J. Male/female differences in alcohol-related problems: Alcohol rehabilitation patients. International Journal of the Addictions 23(5):437-448, 1988. (16) PIAZZA, N.J.; Vrbka, J.L.; and Yeager, R.D. Telescoping of alcoholism in women alcoholics. International Journa l of the Addictions 24(1):19-28, 1989. (17) MORGAN, M.Y., & Sherlock, S. Sex-related differences among 100 patients with alcoholic liver disease. British Medical Journal 1(6066):939-941, 1977. (18) HILL, S.Y. Vulnerability to the biomedical consequences of alcoholism and alcohol-related problems among women. In: Wilsnack, S.C., and Beckman, L.J., eds. Alcohol Problems in Women. Antecedents, Consequences, and Intervention. New York: Guilford Press, 1984. pp. 121-154. (19) JONES, B.M., & Jones, M.K. Women and alcohol: Intoxication, metabolism and the menstrual cycle. In: Greenblatt, M., and Schuckit, M.A., eds. Alcoholism Problems in Women and Children. New York: Grune & Stratton, 1976. pp. 103-136. (20) JULKUNEN, R.J.K.; Tannenbaum, L.; Baraona, E.; and Lieber, C.S. First pass metabolism of ethanol: An important determinant of blood levels after alcohol consumption. Alcohol 2(3):437-441, 1985. (21) FREZZA, M.; DiPadova, C.; Pozzato, G.; Terpin, M.; Baraona, E.; and Lieber, C.S. High blood alcohol levels in women: The role of decreased gastric alcohol dehydrogenase and first-pass metabolism. New England Journal of Medicine 322(2):95-99, 1990. (22) ZEINER, A.R., & Kegg, P.S. Menstrual cycle and oral contraceptive effects on alcohol pharmacokinetics in caucasian females. In: Galanter, M., ed. Currents in Alcoholism. Vol. 8. New York: Grune & Stratton, 1981. pp. 47-56. (23) MARSHALL, A.W.; Kingstone, D.; Boss, M.; and Morgan, M.Y. Ethanol elimination in males and females: Relationship to menstrual cycle and body composition. Hepatology 3(5):701-706, 1983. (24) SUTKER, P.B.; Goist, K.C., Jr.; and King, A.R. Acute alcohol intoxication in women: Relationship to dose and menstrual cycle phase. Alcoholism: Clinical and Experimental Research 11(1):74-79, 1987. (25) HILL, S.Y. Biological consequences of alcoholism and alcohol-related problems among women. In: Special Populations Issues. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health Monograph No. 4. DHHS Pub. No. (ADM)82-1193. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1982. pp. 43-73. (26) SAUNDERS, J.B.; Davis, M.; and Williams, R. Do women develop alcoholic liver disease more readily than men? British Medical Journal 282:1140-1143, 1981. (27) TUYNS, A.J., & Pequignot, G. Greater risk of ascitic cirrhosis in females in relation to alcohol consumption. International Journal of Epidemiology 13(1):53-57, 1984. (28) NICHOLLS, P.; Edwards, G.; and Kyle, E. Alcoholics admitted to four hospitals in England: General and cause-specific mortality. Quarterly Journal of Studies on Alcohol 35(3):841-855, 1974. (29) PATWARDHAN, R.V.; Desmond, P.V.; Johnson, R.F.; and Schenker, S. Impaired elimination of caffeine by oral contraceptive steroids. Journal of Laboratory and Clinical Medicine 95(4):603-608, 1980. (30) JOHNSON, R.D., & Williams, R. Genetic and environmental factors in the individual susceptibility to the development of alcoholic liver disease. Alcohol and Alcoholism 20(2):137-160, 1985. (31) LONGNECKER, M.P.; Berlin, J.A.; Orza, M.J.; and Chalmers, T.C. A meta-analysis of alcohol consumption in relation to risk of breast cancer. Journal of the American Medical Association 260(5):652-656, 1988. (32) WILLETT, W.C.; Stampfer, M.J.; Colditz, G.A.; Rosner, B.A.; Hennekens, C.H.; and Speizer, F.E. Moderate alcohol consumption and the risk of breast cancer. New England Journal of Medicine 316(19):1174-1180, 1987. (33) LOWENFELS, A.B., & Zevola, S.A. Alcohol and breast cancer: An overview. Alcoholism: Clinical and Experimental Research 13(1):109-111, 1989. (34) WILSNACK, S.C.; Klassen, A.D.; and Wilsnack, R.W. Drinking and reproductive dysfunction among women in a 1981 national survey. Alcoholism: Clinical and Experimental Research 8(5):451-458, 1984. (35) HUGUES, J.N.; Coste, T.; Perret, G.; Jayle, M.; Sebaoun, J.; and Modigliani, E. Hypothalamo-pituitary ovarian function in thirty-one women with chronic alcoholism. Clinical Endocrinology 12(6):543-551, 1980. (36) M ENDELSON, J.H.; Mello, N.K.; Bavli, S.; Ellingboe, J.; Bree, M.P.; Harvey, K.L.; King, N.W., Jr.; and Seghal, P.K. Alcohol effects on female reproductive hormones. In: Cicero, T.J., ed. Ethanol Tolerance and Dependence: Endocrinological Aspects. National Institute on Alcohol Abuse and Alcoholism. Research Monograph No. 13. DHHS Pub. No. (ADM)83-1258. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1983. pp. 146-161. (37) GAVALER, J.S. Effects of moderate consumption of alcoholic beverages on endocrine function in postmenopausal women: Bases for hypotheses. In: Galanter, M., ed. Recent Developments in Alcoholism. Vol. 6. New York: Plenum Press, 1988. pp. 229-251. (38) RYBACK, R.S. Chronic alcohol consumption and menstruation. Journal of the American Medical Association 238(20):2143, 1977 (Letter). (39) MELLO, N.K.; Bree, M.P.; Mendelson, J.H.; Ellingboe, J.; King, N.W.; and Sehgal, P. Alcohol self-administration disrupts reproductive function in female Macaque monkeys. Science 221(4611):677-679, 1983. (40) SANCHIS, R.; Esquifino, A.; and Guerri, C. Chronic ethanol intake modifies estrous cyclicity and alters prolactin and LH levels. Pharmacology Biochemistry & Behavior 23(2):221-224, 1985. (41) GAVALER, J.S.; Van Thiel, D.H.; and Lester, R. Ethanol: A gonadal toxin in the mature rat of both sexes. Alcoholism: Clinical and Experimental Research 4(3):271-276, 1980. (42) National Institute on Drug Abuse. Highlights from the 1989 National Drug and Alcoholism Treatment Unit Survey (NDATUS). Rockville, MD: the Institute, 1990. (43) BECKMAN, L.J., & Kocel, K.M. Treatment-delivery system and alcohol abuse in women: Social policy implications. Journal of Social Issues 38(2):139-151, 1982. (44) GOMBERG, E.S. Women and alcoholism. In: Franks, V., and Burtle, V., eds. Women in Therapy. New York: Brunner-Mazel, Inc., 1974. pp. 169-190. (45) ROMAN, P.M. Treatment issues. In: Women and Alcohol Use: A Review of the Research Literature. National Institute on Alcohol Abuse and Alcoholism. DHHS Pub. No. (ADM)88-1574. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1988. pp. 38-45. (46) WILSNACK, S.C. Alcohol abuse and alcoholism in women. In: Pattison, E., and Kaufman, E., eds. Encyclopedic Handbook of Alcoholism. New York: Gardner Press, 1982. pp. 718-735. (47) SOKOLOW, L.; Welte, J.; Hynes, G.; and Lyons, J. Treatment-related differences between female and male alcoholics. Focus on Women 1(1):42-56, 1980. (48) STELLMAN, J.M., & Bertin, J.E. Sciences's anti-female bias. The New York Times, June 4, 1990. (49) POLLITT, K. "Fetal rights": A new assault on feminism. The Nation, March 26, 1990, pp. 409-417.

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