Chemical Dependency

Women, Alcohol and Health

Women represent one-third of the estimated 14 million alcohol-abusing or alcohol-dependent people in the United States. Studies show that although women tend to drink less and generally have fewer alcohol-related problems than men, women who drink heavily may equal or surpass men in the number of resulting alcohol-related problems. Women become intoxicated after ingesting quantities of alcohol smaller than those quantities needed to produce the same effect in men.

Several reasons may underlie this disparity:

• • Women tend to have lower body water content and more fatty tissue than men of the same size. Because alcohol is more soluble in water than in fat and diffuses uniformly through all body water, the blood alcohol concentration (BAC) resulting from a given volume of alcohol is higher for women than for men.
• • Activity levels of gastric alcohol dehydrogenase (ADH), a stomach enzyme that breaks down alcohol, are thought to be lower in adult women than in adult men. Lower levels of ADH activity would allow more alcohol to be made available to women's ody systems.
• • Fluctuations in women's hormone levels during the menstrual cycle affect the rate of alcohol metabolism, resulting in higher BAC's at different points of the cycle.

Research also suggests that the existence of a genetically influenced form of alcoholism is as likely for women as it is for men. As in men, two types of alcoholism appear to occur in women: early onset and late onset. Early-onset alcoholism appears to be more genetic than environmental in origin, whereas late-onset alcoholism appears to be influenced more by environmental factors.

Health Risks

Women may be at greater risk than men for incurring alcohol-related problems. For example, female alcoholics have death rates ranging from 50 to 100 percent higher than male alcoholics; female alcoholics are more likely to die from suicides, alcohol-related accidents, circulatory disorders, and liver disease. Correlations exist, too, between alcohol consumption and increased risk for problems such as breast cancer and reproductive disorders, as well as heart and brain damage.

Women are at increased risk for alcohol-induced liver disease. Compared with men, women drinkers have a higher incidence of liver disease (e.g., cirrhosis of the liver or alcoholic hepatitis) even though they generally consume less alcohol for shorter periods of time. Differences in how men's and women's bodies process alcohol likely are responsible for the enhanced tissue damage suffered by women. Gender differences also may exist in the progression of alcohol-induced liver disease in women; evidence shows that injury to the liver advances more rapidly and is more likely to be fatal in women than in men.

Another area of research receiving attention is the possible link between alcohol use and breast cancer. The study of breast cancer's relationship to alcohol consumption is a new line of research, and the connection is not yet proven. Epidemiological research indicates that women who drink are approximately 1.2 to 2.0 times more likely to develop breast cancer than women who do not consume alcohol. More research is needed to determine whether alcohol consumption actually leads to breast cancer or whether other environmental variables, such as nutrition and diet, are the primary risk factors.

Long-term alcohol consumption may also disrupt the functioning of hormone-producing glands. For example, alcohol's interference with the hormonal regulation of the reproductive system can lead to various reproductive disorders, including cessation of menstruation, irregular or absent menstrual cycles, painful menstruation, early menopause, and risk of spontaneous abortion. In addition, alcohol consumption during pregnancy can lead to a range of birth defects, including the most severe form, known as fetal alcohol syndrome. Fetal alcohol syndrome is the leading known preventable cause of mental impairment.

A complex relationship exists between alcohol consumption and bone metabolism: At high levels of consumption, alcohol produces a deficiency of hormones that regulate calcium distribution, leading to a loss of calcium in the body. Calcium loss can lead to osteoporosis, a crippling disease that affects four to six million older Americans, primarily women. In its most severe form, osteoporosis leads to shrinking height, back pain, spinal deformity, and increased risk of bone fractures. However, low levels of alcohol consumption lead to an increase in estrogen production in postmenopausal women, actually decreasing the risk for osteoporosis as well as for coronary heart disease.

Prevention and Treatment Issues

Efforts to prevent alcohol-related problems, as well as strategies to delay the onset of drinking or encourage abstinence, are aimed at both changing the individual's behavior and reshaping the environment (e.g., defining and governing appropriate drinking behavior and controlling alcohol availability). Researchers are exploring prevention efforts and intervention strategies that target women in general as well as specific groups of women (e.g., pregnant women, women who have been victims of abuse, and women of ethnic or racial minorities).

Despite frequently reported barriers to treatment such as lack of child care, about 25 percent of alcoholism clients currently in traditional treatment centers in the United States are women. Though women comprise a seemingly small percentage of the treatment population, the proportion of female alcoholics to male alcoholics in treatment is similar to the proportion of all female alcoholics to male alcoholics. In addition to using traditional alcoholism programs, women tend to seek other methods of alcoholism treatment (e.g., psychiatric services or personal physicians).

Research suggests that women who successfully complete treatment programs tend to have a slightly higher rate of abstinence than do men.

Fetal Alcohol Syndrome

In 1973, the medical journal, Lancet, published the findings of researchers K.L. Jones and D.W. Smith: Recognition of the Fetal Alcohol Syndrome in Early Infancy. This article coined the term "fetal alcohol syndrome" (FAS) to describe a pattern of abnormalities observed in children born to alcoholic mothers. Early researchers postulated that malnutrition might be responsible for these defects. However, the pattern of malformation associated with FAS is not seen in children born to malnourished women, and alcohol has been found to be acutely toxic to the fetus independently of the effects of malnutrition.

Criteria for defining FAS are: 1) prenatal and/or postnatal growth retardation (weight and /or length below the 10^th percentile); 2) central nervous system involvement, including neurological abnormalities, developmental delays, behavioral dysfunction, intellectual impairment, and skull or brain malformations; and 3) a characteristic face with short palpebral fissures (eye openings), a thin upper lip, and an elongated, flattened midface and philtrum (the groove in the middle of the upper lip).

Mental handicaps and hyperactivity are probably the most debilitating aspects of FAS, and prenatal alcohol exposure is one of the leading known causes of mental retardation in the Western World. Problems with learning, attention, memory, and problem solving are common, along with incoordination, impulsiveness, and speech and hearing impairment. Deficits in learning skills persist even into adolescence and adulthood.

It is generally accepted that the adverse effects of prenatal alcohol exposure exist along a continuum, with the complete FAS syndrome at one end of the spectrum and incomplete features of FAS, including more subtle cognitive-behavioral deficits, on the other. Thus, infants with suboptimal neurobehavioral responses may later exhibit subtle deficits in such aspects of daily life as judgment, problem solving, and memory.

According to a Center for Disease Control (CDC) study, incidences of FAS per 1,000 total births for different ethnic groups in the United States were as follows: Asians 0.3, Hispanics 0.8, whites 0.9, blacks 6.0. Several factors, such as cultural influences, patterns of alcohol consumption, nutrition, and metabolic differences have been suggested to play a role in this difference.

Apart from epidemiology, the key questions in FAS research include, How much alcohol is too much? and, When is the fetus at greatest risk? The major problem in addressing these questions is the lack of a specific physiological measure that accurately reflects alcohol consumption. There is no biological marker currently available to measure alcohol intake, and self-reports of alcohol consumption may be unreliable , perhaps especially so during pregnancy. Findings reported by M. Morrow-Tlucak et al. in Alcoholism: Clinical and Experimental Research [13(3):399-401, 1989], Underreporting of alcohol use in pregnancy: Relationship to alcohol problem history, suggest that women with more serious alcohol-related problems are those more likely to underreport their alcohol consumption when interviewed during pregnancy.

While it is apparent that children who meet the criteria for FAS are born only to those mothers who consume large amounts of alcohol during pregnancy, studies have reported neurobehavioral deficits and intrauterine growth retardation in infants born to mothers who reported themselves to be moderate alcohol consumers during pregnancy.

Given the range of defects that result from prenatal alcohol exposure, the search for an overall threshold for fetal risk may be unreasonable. Instead, each abnormal outcome in brain structure and function and growth might have its own dose-response relationship. Animal research has shown that different profiles of alcohol-related birth defects are related to critical periods for specific aspects of fetal development. Thus, heavy alcohol consumption throughout pregnancy results in a wide variety of effects characteristic of FAS, while episodic binge drinking at high levels results in partial expression of the syndrome, with the abnormalities being unique to the period of exposure. Vulnerability of individual organ systems may be greatest at the time of their most rapid cell division.

Enoch Gordis, M.D., Director, National Institute on Alcohol Abuse and Alcoholism, offers this commentary on alcohol use during pregnancy:

"From a scientific perspective, the link between moderate drinking and alcohol-related birth defects has not been clearly established. Whether there is a threshold below which alcohol can be consumed without harming the fetus is not known: self-reported data showing a relationship between moderate use and alcohol-related birth defects may often underestimate the true level of drinking. Researchers are working on developing an objective marker for alcohol consumption that will help clarify these questions and assist clinicians in identifying alcohol-abusing patients as a part of routine prenatal care, using, for example, blood samples typically drawn during an initial examination.

> Clinicians, however, must offer advice to their patients based upon the best available scientific evidence. Although some clinicians believe that recommending total abstention for pregnant women may subject them to unwarranted guilt about drinking small amounts of alcohol, most accept the need for clinical caution. Because we do not know at what point alcohol damage begins, it is prudent to recommend, as I do, that pregnant women abstain from alcohol use pending confirmation of alcohol's role vis-a-vis fetal development."

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This file has been excerpted and adapted from material prepared by the National Institute on Alcoholism and Alcohol Abuse.