Women and alcohol: How much is too much?

Permission was granted to reproduce this article from the following publication: American College of Obstetricians and Gynecologists. Woman and alcohol: How much is too much. ACOG Today. 2011; 6:6-8.

Women have unique vulnerabilities to alcohol that men do not have, and the significant risks they face from inappropriate use and abuse of alcohol range from pregnancy complications and long-term damage to their children to an increased risk of breast cancer and the danger of sexual assault and sexually transmitted infections.

When Diana Cheng, MD, first began working with the Maryland Department of Health and Mental Hygiene, she was surprised at the results that were coming in from the state’s annual Pregnancy Risk Assessment Monitoring System (PRAMS) survey, which among other issues, studies alcohol consumption and risk surrounding pregnancy.

“About 30% of women patients reported to us that they weren’t giv­en counseling by their ob-gyn abouCover of ACOG magazine "How much is too much"t alcohol and the impact it could have on a pregnancy,” Dr. Cheng marveled. “And fully 20% of them weren’t even asked if they drank alcohol during their pregnancy. We were very alarmed by that.”

The Maryland PRAMS survey, whose findings appeared in the Green Journal in February 2011, demonstrates that many ob-gyns are not screening women for alcohol problems, even during such a high-stakes time as in pregnancy. “For a provider, it is not effective to just briefly ask a patient, ‘Do you drink alcohol?’ and then check a yes-or-no box,” said Patrick S. Ramsey, MD, MSPH, with Texas Perinatal Group and adjunct associate professor of maternal/fetal medicine with Uniformed Services University of the Health Sciences and University of Texas School of Public Health. “Ob-gyns need to use validated screening tools.”

A new College document, At-Risk Drinking and Alcohol Depen­dence: Obstetric and Gynecologic Implications, Committee Opinion #496, points out that real alcohol screening—not lip service—is a crucial responsibility of physicians, and ob-gyns must make a sub­stantial effort to learn techniques for rapid, effective screening as well as brief intervention, patient education, and referral for their patients who drink alcohol at at-risk levels.

Understanding the risks

Alcohol and pregnancy

In October 2010, a British study published in the Journal of Epide­miologyand Community Health seemed to contradict the common understanding that there is no safe level of drinking during pregnancy. Looking at five-year-olds whose mothers had had no more than one or two glasses of wine a week during pregnancy, the researchers found no negative effects of such light drinking.

This study confused both women and doctors, said Dr. Cheng, who noted that in Maryland at least, the number of women who admit to drinking during pregnancy has steadily increased.

picture of a women drinking wine“Now, 10% of women say they drank alcohol during the last three months of pregnancy,” she said. “And 2% of women admit to binge drinking during pregnancy, which is probably even more risky. For women who were already ambivalent about abstinence during pregnancy, this study made them more ambivalent.”

“While we can’t prove that small amounts of alcohol dur­ing pregnancy are harmful, it’s like playing with matches near the ammunition depot: Why risk it?” asks Jacquelyn Starer, MD, chairperson of the American Society of Addiction Medicine’s Work Group on Women and Substance Use Disorders. “We don’t know what the safe level is, if there is any. Certainly, during the organogenesis stage, even a very small exposure to alcohol can cause harm during a critical time of organ development.”

Approximately 40,000 babies every year are born with some sort of after-effects from a mother’s alcohol use dur­ing pregnancy, said Dr. Ramsey. “That’s a lot of babies. It’s not all fetal alcohol syndrome (FAS), the most severe form of alcohol spectrum disorders. Even smaller doses of alcohol can lead to behavioral disorders and mental handicaps that fall short of true FAS.” This broader umbrella of cognitive, learning, and behavioral disabilities is known as FASD, fetal alcohol spectrum disorder.

Breast cancer and other risks

Alcohol and health can be a double-edged sword. A number of studies have suggested that moderate alcohol consumption—generally defined as one drink (5 ounces of wine, 1.5 ounces of hard liquor, or one 12-ounce beer) per day for women, and two such drinks for men—can have a protective effect against heart disease.

However, as noted in The College’s new Committee Opinion, data indicate that women who drink between two and five drinks per day may have up to a 41% increased incidence of breast cancer, and risk in­creases linearly with consumption throughout this range. Women who have already survived breast cancer need to be particularly on guard. Last year, a prospective study involving nearly 2,000 women diagnosed with early-stage breast cancer, published online August 30 in the Jour­nal of Clinical Oncology, found that drinking at least two glasses of wine per week was associated with an increased risk of both recur­rence and death from breast cancer.

Alcohol use may exacerbate depressive symptoms, and acute alcohol use is associated with suicide. High rates of positive blood alcohol con­centrations have been found among suicide victims.

Sexual assault and STIs

When women drink, they can fall prey to “telescoping”— a term mean­ing they encounter the behavioral and medical consequences of alcohol much more quickly than men. “They don’t metabolize alcohol as well as men do, so everything that can happen as a result of drinking happens faster to women than to men,” said Dr. Starer.

And that can often put women at risk of being victimized. Binge drinking (defined for women as consuming more than three drinks per occasion or more than seven drinks per week) is on the rise among US women, according to the Centers for Disease Control and Prevention: From 1999–2002, binge drinking by women in the 18–44 age group increased nationally by 13%. Among 18–34-year-olds who binge drink, almost one-third report drinking eight or more drinks per occasion. Many studies have found that anywhere from 30–50% of college-age women binge drink.

The consequences can be devastating. Alcohol is involved in 90% of campus rapes, according to Columbia University’s National Center on Addiction and Substance Abuse. Women who binge drink also engage more often in risky sexual behaviors, leading to more frequent cases of sexually transmitted infections. Women who binge drink are five times more likely to have gonorrhea, for example.

“Drinking excessively makes women vulnerable,” said Dr. Starer. “It impairs their judgment and they get into dangerous situations that they may not even remember. Ob-gyns need to educate their patients about the risks involved in this kind of drinking.”

How to screen?

Many ob-gyns are uncomfortable asking their patients about alcohol consumption, fearing that they will be seen as judgmental. Dr. Starer said one way around that concern is to incorporate alcohol screening into general history taking.
“I personally have found that the most successful way to get the in­formation is to work my way in through the family history,” she said. “Rather than starting right out by asking a patient, ‘Do you drink?’ I’ll ask about alcohol in the family history, which people are much more willing to talk about. If you let them talk, often they’ll bring it around to themselves.”

The new Committee Opinion guides ob-gyns in talking to patients about alcohol use and includes screening tests that identify at-risk drinking patterns, and information on when and how to re­fer alcohol-dependent women for professional treatment.
A screening tool that is particularly accurate for all women of reproductive age is the TACE test when a provider asks four questions of a patient (see below).

TACE Screening Tool

T – Tolerance: How many drinks does it take to make you feel high? (More than 2 drinks = 2 points)
A – Annoyed: Have people annoyed you by criticizing your drinking? (Yes = 1 point)
C – Cut down: Have you ever felt you ought to cut down on your drinking? (Yes = 1 point)
E – Eye-opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Yes = 1 point)

A total score of 2 points or more indicates a positive screening for at-risk drinking

If screening identifies a problem, then what? Be nonjudg­mental and forgiving, Dr. Starer advised. “Make it clear that we’re working from this point forward and not so much focusing on what’s happened already, which we can’t do anything about.”
“Your patient needs to feel that you’re there to help her, not to scold her,” Dr. Ramsey agreed. “Being confrontational puts up walls and elicits lies.”

After letting the patient talk first about why she drinks, and what the attraction is, the clinician can ask in an open-ended way, “Do you think there are down sides?”

“You can also ask, ‘Do you think you should change any­thing you’re doing? How would you go about that?’”Dr. Starer said. “That’s the point at which you can make suggestions and referrals to resources, and conclude with firm recommen­dations. During pregnancy, particularly, women are highly motivated to change their behavior.”