Nioaka N Campbell, MD, Univ. of South Carolina SOM

Alcohol Medical Scholars Program, 2006



I.                    INTRODUCTION


SLIDE 2              A.   Alcohol use/Alcohol Use Disorder (AUD): important in women’s health 


                        1.  43% of ♀ in 2003 – current drinkers1

                        2.  4.5M ♀  – alcohol abuse 2-4

                        3.  2.5M ♀  – alcohol dependence 5


B.     Alcohol use and AUDs in women are under-studied


1.  Most past AUD research has been on males, only 14% ♀ included

      2.  ↑ Lifetime prevalence of AUDs is: 13% abuse, 20% dependence in ♂ 

           vs. 6% abuse, 8% dependence in ♀ 2,6,7

                        3.  Gender differences in previous research: ? accuracy 4,6,7

                                    a.   Levels of intoxication differ in ♀

i.          ‘At risk’ drinking limit >3 drinks/time vs. 4 

            drinks/time for men

ii.                   Lower body weight, alcohol levels may be 30% higher with same amount

                                                iii.         ↓ gastric alcohol dehydrogenase activity

SLIDE 4                                 4.  Women’s drinking patterns approaching the men 7

                                    a.   Gender gap narrowing: prevalence of >5 drinks/time –

                  23% gap in 1975 ↓ to 12% gap in 2001 

                                    b.   College ♀ adopt patterns of ♂ men in co-ed dorms 8

                                    c.   Rates not significantly different ages 12-17, (17%) 1

                  C.  Women have gender specific sequelae from AUDs


                        1.   In one study, showed up to 2X ↑ death rate in ♀ with AUD vs. ♂ 6,4

2.      Third leading cause of death (indirect) in both genders ages 35-55 9

3.      Some consequences we will later discuss10:

                                    a.  ↑ liver disease over shorter time

                        b.  ↑ alcohol induced CNS damage

                        c.  ↑ risk breast cancer  


SLIDE 6         D.  Women are less likely to be identified and diagnosed with an AUD:

<50%  ♀ with AUD were identified by primary physician, although ♀ are more often contact primary care doctor 11,12

E.  This lecture reviews alcohol use/AUDs in women. Will cover:


1.      Epidemiology

2.      The course of alcoholism in women

3.      Gender specific consequences

4.      Identification and assessment

5.   Thoughts on treatment

II.              EPIDEMIOLOGY

SLIDE 8,9                  A.  Race/Ethnicity comparisons 1,13,14

1.      Caucasian ♀:

a.       Highest prevalence of use vs. other racial groups

b.      55% past month use

c.       87% lifetime use

2.      African American ♀:

a.       37% past month use

b.      73% lifetime use

c.       More likely to abstain: 46% vs Caucasian 34%

SLIDE 10                               3.   Hispanic ♀:

d.      40% past month use

b.   73% lifetime use 

c.   ↑ rates heavy drinking in American born, young ♀

d.  62% of foreign born ♀ abstain

4.   Native American ♀:

            a.  Highest use of ‘heavy drinking’: >5 drinks/time, 30% 

            b.  Past month 36%

c.  Lifetime use 81%

d.  Abstinence in past mo., 65%


SLIDE 11                   B.  Abstinence 13,15,16

 1.  Women have ↑ % abstainers

       2.  % current/past yr. abstainers in 2004: 43% ♂, 56% ♀ 

       3.  1997 lifetime data: 22% ♀ abstain, 13% ♂

                   a.  ↓ abstention with increasing education, both sexes

                   b.  ↓ abstention with ↑ salaries,

                        $40,000 or more: <10% ♂, <20% ♀


SLIDE 12                   C.  Current alcohol use 1,10,13

                        1.  57% ♂ vs. 44% ♀ current use in 2004

                        2.  Highest use ages 18-24: 76% ♀ vs 80% ♂

                        3.  15% women vs  21% men ‘heavy drinking’:

                 >5 drinks/time, >1x in past mo., ages 18-25            


   SLIDE 13                 D.  Defining alcohol use disorders 7,17

1.  Alcohol abuse – clinically significant impairment or distress in ≥1 in a

     12-month period:  

                        a. Failure to fulfill major obligations (e.g. absences/suspensions)

                        b. Physically hazardous (e.g. driving while intoxicated)

                        c. Legal problems (e.g. disorderly conduct, DUIs)

d. Social/interpersonal problems (e.g. arguments, physical fights)


                SLIDE 14                           2.  Alcohol dependence – clinically significant impairment or distress in

     ≥ 3 in a 12-mo period:

            a. Tolerance (increased amt needed for effect, diminished effect)

b. Withdrawal (autonomic hyperactivity, tremor)

c. Larger amounts/longer period than intended

d. Persistent desire/unsuccessful attempts to cut down

e. Excessive time spent with or obtaining alcohol

f. Activities given up due to alcohol (social, occupational,   

    recreational activities)

g. Continued use despite problems

   SLIDE 15                            3.  Prevalence of lifetime abuse: 13% ♂ vs 6% ♀

            4.  Prevalence of lifetime dependence: 20% ♂ vs 8% ♀


SLIDE 16                   E.  Differences on consequences

                        1.  Alcohol related driving fatalities 1,10

                                 a.  9% women vs. 18% men likely to drive while drinking

                                 b. Women in fatal alcohol related collisions is rising,

                                     12% in 1980 to 16% in 1996    

2.  Victimization 8,18:

a.  Rape, alcohol associated – 70,000 annually in US colleges

                                    b.  College ♀ drinkers 3.5x ↑ nonconsensual sex than nondrinkers

                                    c.  Physical assault, alcohol related – 600,000 in US colleges

3.  Domestic violence: 19

                                  a.  Women victims have 2-3X ­ risk of AUD 1,10      

          b.  67-90% of men/batterers have AUD

SLIDE 17                               4.  Unemployment: 47.6 % ♀ vs 32.7% ♂ with AUD (may be partially

                             accounted for by homemakers) 20

                        5.  Antisocial behavior is correlated with AUD in both genders,

                             but ♂ with AUD have↑ antisocial PD, 15% vs women, 5% 7

                        6.  Health consequences 10

                                  a. Alcohol induced liver disease develops faster, with less alcohol –

              ↑ liver enzymes with 20g/day over a month in ♀ vs 40g/day in ♂  

                      c. CNS damage: 21

i.                     Approximately  55% ♂and ♀ w/AUD have ↑ ventricular size

ii.                   ♀ with AUD had 11% smaller gray matter volume than nonalcoholic ♀

                      d. Hangover: ♂ 18 or older >40% reported, vs. 27% ♀ 22






   A.  General course of AUD, male and female 15, 23:

1.  First use age 12-14

                        2.  First intoxication age 14-18

                        3.  Alcohol related problems develop age 18-25

                        4.  AUD develops age 23-33

                        5.  Death age 55-60 (15 yrs earlier than avg)


   B.  Course specifiers for Women 15, 23:

                        1.  Avg age of first use in ♀ is 14 yrs, tends to be slightly later than ♂, gap


                        2.  Age to seek tx for AUD is same, avg 40 4, 24

                        3.  Telescoping effect – only 1-2 yr difference: 6

                                                a. Onset of drinking until the time treatment is sought 

                                                b. Medium interval from 1st drink to onset of alcohol related

                                        problems: 3 yrs ♀ vs. 3.5 yrs in ♂ 6


SLIDE 19                        C.  Health Problems and AUDs 8, 18, 25

                        1.  DSM-IV Axis I disorders 17, 26:                   

a. Comorbidity: following % do not distinguish independent  

    disorders from substance induced disorders, which are different

    conditions, with different prognosis and treatments

b. 65% rate of comorbidity in ♀ vs 44% in ♂                                

    (DSM-IIIR or DSM-IV Axis I diagnosis + AUD)

c. Major Depression:

i.   Women’s lifetime risk 1.7X > ♂

ii.  ♀ with AUD: have up to 4X risk of depressive D/O 

     vs. other ♀ (includes substance induced D/O) 

                                    d.  Suicide attempts: 40% ♀ with AUD (8% other ♀)  

e.  Anxiety disorders:

                                                i.   ♀ with AUD: odds 3x ↑ than other ♀, includes

                                                     independent anxiety D/O and substance induced

iii. One study found 30% ♀ with AUD met criteria for  


                                    f.  Eating disorders: One study found approx. 28% of ♀ with AUD

                 had an eating disorder, other studies not as high %

                                    g.  Important to assess for psychiatric symptoms versus

                                         independent disorders in comorbidity with AUDs

                        2.  Further gender specific health consequences 27:

                                    a.  Increased risk of breast cancer:

                                    i.   Large study (300,000 ♀, 4 countries)

                 9% ↑ relative risk with each drink/day (10g), linear

                 relationship up to 60g/day (6 drinks)

            ii.  Dose response relationship w/ as low as 1-2 drinks/day

            iii. Proportion of breast CA attributed to alcohol is 2% in

                 U.S., up to 15% in Italy (? alcohol use more prevalent)

                                    b.   Disruption of menstrual cycles, hormonal functioning: 5,26

                                          ↑ in estrogen levels 3X upper limit in postmenopausal ♀, 1-2

      drinks/day may be protective yet further studies are needed

SLIDE 20,21                                      c.   Fetal alcohol syndrome/spectrum (FAS) 28, 29, 30 

i.         Syndrome characterized by varying components: 

- malformations in facial structure

- prenatal and postnatal growth retardation

- functional/structural CNS abnormalities

- spontaneous abortions

- mild to moderate mental retardation

ii.   Affects 1% of US population

iii.  National survey found that 59% of ♀ age 15-44 drank

      alcohol while pregnant

iv.  Cost associated with caring for children with FAS:

      approximately $200M/year in U.S.

v.  Dietary guidelines in US since 1990 advised

     abstention for women pregnant or planning








                 A.  Women do not fit stereotype

                        1.  Often go to primary doctors, who don’t ask (<50% ♀ alcoholics

                             identified) 11, 12

                                                a. ♀ may not have AUD as presenting complaint, have to assess

            b. ↑ stigma and guilt associated, “immoral promiscuous ♀”,

                causing doctors not to ask and ♀ not to tell

            c. Stereotype of a ‘drunk’ does not fit most ♀, grandmas, etc.

2.  History is still the most important tool

            a.   Alcohol problems screening should be part of routine interview  

                 (reduces stigma if every patient is asked)

b.      Avoid asking closed ended questions: minimizes the information given, ex) “you don’t drink, do you?”

c.   Open ended questions increase dialogue, ex) “how much do

      you drink?” 

d.   Follow-up should be specific and direct: frequencies, quantities

      (a drink is different things to different people) 

e.   Addressing alcohol related problems is key to identifying key

      issues and treatment needs – work, school, legal, social

e.       Non-judgmental attitudes increase therapeutic alliance,

      ex) “you drink how much!!?”-not good


SLIDE 23                   B.  Psychosocial Factors in ♀ 7, 17

                        1.  Social sanctions: ♀ perceived that 50% of others would disapprove of

                             ♀ drunk vs. 30% would disapprove of a ♂

2.      Women more likely to drink alone, 30% have drinking partner

      (compared to 50% men) 6

                        3.  Protective factors: 4

a. Multiple roles: mother, employed, spouse

b. Married

c. Female athletes

4.  Factors associated with increased risk: 4

a. Divorced, never married or separated

b. Earlyonset drinking: up to 40% later AUD 1, 10

                                    c. History of neglect as a child 31

                                    d. Other psychiatric disorder(s) - see IIIC above

                                    e. ♀ with childhood sexual abuse 18                                                                                           f. Tobacco (61% drinkers use tobacco versus 16% nondrinkers) 1,32


SLIDE 24                   C.  Genetic Risk Factors 33, 34, 35

                        1.  50-60% variation of AUD risk in both sexes is genetic

                        2.  Metaanalysis of twin and adoption studies: 40% ↑ risk alcoholism in

                             children of ♀ with alcoholism regardless of environment, (small

                             sample sizes)


            SLIDE 25                   D.  Further challenges in assessment:         

            1.  Lack of practitioner time in taking a thorough history

 2.  Lack of objective assessments specific for women 30

a.  Self report instruments (to identify risk only), developed with ♂

    subjects predominately:

:                        i.   CAGE- “cut down, annoyed, guilty, eye-opener”,

ii.  MAST(Michigan Alcoholism Screening test)- 24 yes/no

iii. AUDIT (Alcohol Use Disorders Identification test) – 10 

     items,  > specificity in ♀ (0.95 with cutoff of 7),

     may need to ↓cutoff to not miss ♀ at risk

b.      Results of these tests may differ not only with gender but race

i.         Study of minority ♀: 23% were above cutoff # with MAST vs 5% with CAGE (would have identified less)

ii.   White ♀ 4X likely to score above cutoff on

      tolerance items vs Black ♀ (difference from the specific

      question or due to ethinicity?)

c.       Screening developed specifically for pregnancy:

i.                     Developed to include with routine exam/screening (again, to reduce stigma)

ii.                   Health Behaviors Questionnaire – 10/15 minutes

iii.                  T-ACE – similar to CAGE yet tolerance replaced guilt as a question, guilt is usually + in this group



SLIDE 26      

            A.  Many women with AUD do not receive treatment: 1, 4, 20

            1. 1 out of 4 ♀ with AUD receive tx

                                    2. Specialty tx facilities: 900,000 ♂  vs 400,000 ♀ (facilities with

                                        primary treatment of AUDs)

3. 2% men received treatment vs 1% women in 2003

4.  ♀ make up 25% of clients in traditional tx centers


                        B.  Barriers to treatment 1, 6

            1.   Social stigma

2.      Fear of loss of children or inability to care for them

3.      Lack of child care

4.      Fear of legal sanction 20

a.       14 states consider substance use in pregnancy to be child abuse

b.      9 states require health care professionals to report suspected prenatal substance abuse or dependence

5.      Limited resources 20

a.       In Los Angeles treatment clients, 39 % of ♀ had less than a high school education vs 19% ♂ 

b.      As before, higher rates unemployment in ♀, may be due to homemakers, ?


C.  Characteristics of current treatment programs 20, 36

                        1.  38% programs offered womens groups

                        2.  21% pregnant/postpartum groups

                        3.  6% programs are women only

                                    4.  8% programs offer child care services


D.  Mixed gender versus women-only programs 4, 20, 37, 38

1.  Women only facilities:

a.  ♀ had 2X rates of program completion vs mixed, with

     reported improved 2yr f/u outcomes (% unknown)

b. Children 5X less likely to be placed in foster care

c.  Historically provide pediatric care, children's activities,

     and housing assistance

d.  Serve higher proportions of minority clients

2.      Mixed gender programs:

a.       Less able to attract/retain vulnerable ♀, history of physical or sexual violence and single parents

b.      Historically less focus on child care, transportation,etc.




E.  Center for substance abuse treatment, DHHS task force guidelines for

      women: 39

           1.  Take thorough intake and assessment

            2.  Offer family services, child care if possible

      3.  Vocational rehabilitation should be consulted when needed

            4.  Legal assistance referrals where appropriate

            5.  Preferred ♀ for first intake or ♂ trained in gender issues

6.      Overview individual strengths and skills of ♀ (empowerment)

7.      Address other general and mental health disorders


VI.                        SUMMARY


A. Alcohol use and AUDs are significant issues in women’s health

            1.  Affects millions of women

            2.  3rd leading cause of death

            3.  Associated with other medical and mental health disorders

            B. Course of alcohol use and AUD in women is varied and gender specific

                        1.  Women have unique vulnerabilities, risk factors and

                             supportive factors

2.  Consequences from alcohol use and AUDs can differ from men

                        C. Assessment/ Treatment of AUDs in women may need to be specialized

            1.  Screening should be routine and thorough

            2.  Every effort to reduce stigma and empower should be taken

            3.  Specific women-only treatment programs may be of benefit

4.  Treatment should include psychosocial aspects of women,

SLIDE 30                                                childbearing,etc







      1.   Results from the 2004 National Survey on Drug Use and Health: National

            Findings.  www.oas.samhsa.gov Accessed November 2005.    


      2.   Svikis DS, Reid-Quinones K.  Screening and prevention of alcohol and drug use

            disorders in women.  Obstetrics and Gynecology Clinics.  2003; 30:71-88.      


      3.   Williams GD, Gant BF, Hartford TC, Noble BA.  Population projections using

            DSM-III criteria: Alcohol abuse and dependence, 1990-2000.  Alcohol Health &

            Research World. 1989; 13: 366-370.


4.   Alcohol Alert from National Institute of Alcohol use And Alcoholism.  Alcohol

      and Women. 1990; No 10.  http://www.niaaa.nih.gov Accessed November 2005.


5.    Alcohol Alert from National Institute of Alcohol use And Alcoholism.  Alcohol-

       An important women’s health issue. 2004; No 62.  http://www.niaaa.nih.gov

       Accessed November 2005.


      6.  Walter H, Gutierrez K, Ramskogler K, Hertling I, Dvorak A, and Lesch OM. 

     Gender-specific differences in alcoholism: Implication for treatment.  Archives of

     Women’s Mental Health.  2003; 6:253-258.


7.  Nolen-Hoeksema S.  Gender differences in risk factors and consequences for

     alcohol use and problems.  Clinical Psychology Review.  2004; 24: 981-1010.


8.  Ham LS, Hope DA.  College students and problematic drinking: a review of the

     literature.  Clinical Psychology Review.  2003; 23:719-59.  


9.  Bissell L, Slkorina JK.  One hundred alcoholic women in medicine: an interview

      study. JAMA 1987; 257:2939-44.


10. Alcohol Alert from National Institute of Alcohol use And Alcoholism.  Are

      women more vulnerable to alcohol’s effects? 1999; No 46. 

      http://www.niaaa.nih.gov Accessed November 2005.


11.  Brienza RS, Stein MD.  Alcohol use disorders in primary care – do gender 

       specific differences exist?  J Gen Intern Med 2002; 17:387-97.


12.  Moore RD, Bone LR, Geller G, Mamon JA, Stokes EJ, Levine DM.  Prevalence,

      detection and treatment of alcoholism in hospitalized patients.  JAMA 1989;



13. Substance Abuse and Mental Health Services Administration, Office of Applied

      Studies.  National household survey on drug abuse: Population estimates 1997.  

      Rockville MD: U.S. Department of Health and Human Services, 1998.

14.  Collins RL, McNair LD.  Minority Women and Alcohol Use.  National Institute

       on Alcohol Abuse and Alcoholism of the National Institutes of Health.  2003.

       http://pubs.nia.nih.gov/publications/arh26-4/251-256.htm Accessed December



      15.  Schuckit MA, Daeppen JB, Tipp JE, et al.  The clinical course of alcohol-related

 problems in alcohol dependent and nonalcohol dependent drinking women and

       men.  Journal of Studies on Alcohol. 1998; 59:581-590.


16.  Midank L and Room R.  Epidemiology of Alcohol Consumption.  Alcohol

       Health and Research World.  1992; 16:183-190.


17.  Kessler RC, Crum RM, Warner LA, Nelson CB, Schulenberg J, Anthony JC.

       Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other

       psychiatric disorders in the National Comorbidity Study.  Archives of General

       Psychiatry 1997; 54:313-321.


18.  Slutske SS.  Alcohol use disorders among US college students and their non-

       college-attending peers.  Archives of General Psychiatry.  2005; 62:321-327.


19.  Zilberman ML and Blume SB.  Domestic violence and substance abuse.  Rev

       Bras Psiquiatr. 2005 Oct;27:s51-s55. Epub 2005 Nov 10.


20.  Brady TM, Ashley OS.  Women in Substance Abuse Treatment:

             Results from the Alcohol and Drug Services Study (ADSS).  Dept. of Health and

             Human Services.  Substance Abuse and Mental Health Services Administration,

             Office of Applied Studies.


21.  Hommer DW, Momenan R, Kaiser E, Rawlings RR.  Evidence for a Gender-

        Related Effect of Alcoholism on Brain Volumes.  Am J Psychiatry 2001;



22.  Swift R and Davidson D.  Alcohol hangover: mechanisms and mediators. 

       Alcohol Health and Research World. 1998; 22:54-60.          


23.  Schuckit MA, Anthenelli RM, Bucholz KK, et al.  The time course of

 development of alchohol-related problems in men and women.  Journal of

       Studies on Alcohol. 1995; 56: 218-225.


24.  Johnson PB, Richter L, Lebler HD, McLellan AT and Carise D.  Telescoping of

       drinking-related behaviors: gender, racial/ethnic, and age comparisons.  Subst

       Use Misuse.  2005; 40:1139-51.


    25.  Wechsler H.  Binge drinking on America’s college campuses: Findings from the

     Harvard School of Public Health College Alcohol Study.  2000. 


    Accessed November 2005.


26.  Chander G, and McCaul ME.  Co-occurring psychiatric disorders in women with

       addictions.  Obstetrics and Gynecology Clinics.  2003; 30:218-227.


27.  Singletary KW, Gapstur SM.  Alcohol and Breast Cancer.  JAMA.  2001;



28.  Miles DR, Svikis DS, Kulstad JL, Haug NA.  Psychopathology in pregnant drug- 

       Dependent women with and without comorbid alcohol dependence.  Alcohol Clin

       Exp Res.  2001; 25:1012-1017.


29.  Wattendorf DJ, Muenke M.  Fetal Alcohol Spectrum Disorders.  American

       Family Physician.  2005; 72:279-82.


30. Svikis DS, Reid-Quinones K.  Scrrening and prevention of alcohol and drug use

      disorders in women.  Obstet Gynecol Clin C Am.  2003; 30:447-468.


31. Widom CS, Ireland T, Glynn PJ.  Alcohol abuse in abuse and neglected children

      followed-up: Are they at increased risk? J Stud Alcohol. 1995; 56:207-217.


32.  Saules KK, Pomerleau CS, Snedecor SM, Mehringer AM, Shadle MB, Kurth C,

       Krahn DD.  Relationship of onset of cigarette smoking during college to alcohol 

       Use, dieting concerns, and depressed mood: results from the Young Women’s 

       Health Survey.  Addict Behav.  2004 Jul; 29:893-9.


33. Slutske WS, Hunt-Carter EE, Nabors-Oberg RE, Sher KJ, Bucholz KK, Madden

      PA, Anokhin A, Heath AC.  Do college students drink more than their non-

      college attending peers? Evidence from a population-based longitudinal female

      twin study.  Journal of Abnormal Psychology.  2004 Nov;113:530-40.


      34.  Prescott CA, Kendler KS.  Longitudinal stability and change in alcohol

      consumption among female twins: Contributions of genetics.  Development

      Psychopathology. 1996; 8:849-866.


35.   Prescott CA.  Sex differences in the genetic risk for alcoholism.  Alcohol

       Research and Health:  Sex differences in the genetic risk for alcoholism.  2002;

       winter: 264-273


36.  Substance Abuse and Mental Health Services Administration Office of Applied

       Statistics.  Treatment Episode Data Set (TEDS) 1994-1999.  National

       Admissions to Substance Abuse Treatment Services.  DASIS Series: S-16

       (Publication no. (SMA) 02-3668).  Rockville, Maryland: SAMHSA;2001.


37.  Dahlgren L, Willander A.  Are special treatment facilities for female alcoholics

       needed? A controlled 2-year follow-up study from a specialized female unit

       (EWA) versus a mixed male/female treatment facility. Alcohol Clin Exp Res

       1989; 13:499-504.


38.  Connors GJ, Maisto SA, Zywiak WH. Male and female alcoholics' attributions

       regarding the onset and termination of relapses and the maintenance of

       abstinence.  J Subst Abuse. 1998; 10:27-42.


39.  Van der Walde H, Urgenson FT, Weltz SH.  Women and alcoholism: A

       biopsychosocial perspective and treatment approaches.  Journal of Counseling

       and Development: JCD.  2002; 80: 145-153.