Text adapted in 2022 from The Primary Care Addiction Toolkit (online only). A complete list of Toolkit authors, editors and contributors is available here.
Harmful Alcohol Use in Women
The gender gap in the prevalence of alcohol use disorder is narrowing due to changes in drinking patterns. The increase in alcohol consumption among women may reflect changes in traditional social roles, patterns of life events, stressors and psychopathology (Ries et al., 2014).
Health care providers have traditionally under-recognized alcohol-related problems in women. There are various reasons for this:
- The stigma associated with heavy drinking by women may cause women to under-report problems.
- The isolation of older women, who are more likely to live alone than older men, makes identification of alcohol-related problems by a spouse or family member less likely.
It is also important to screen women for alcohol problems because women may progress more rapidly from initiation of use to alcohol use disorder (Finnegan, 2013).
Women who consume alcohol during preconception are also at increased risk of continuing to drink during pregnancy.
Medical conditions related to alcohol use in women
Women and men are susceptible to the same medical conditions associated with drinking. However, alcohol-related medical conditions may develop in women at lower levels of consumption than in men, and may progress more rapidly in women (have a "telescoped course").
This telescoped course may be a result of womens’ lower enzyme levels (e.g., alcohol dehydrogenase), which can result in higher serum alcohol levels per drink consumed, and a smaller volume of water compartment distribution than men (Ries et al., 2014).
Women are at particular risk of developing certain health problems related to alcohol use (Centers for Disease Control and Prevention, 2014; Ries et al., 2014).
These include:
- Depression, anxiety, suicide, eating disorders
- Generalized skeletal fragility, which leads to increased fracture risk with falls
- Disrupted menstrual cycling, infertility, sexually transmitted diseases and unintended pregnancy
- Liver damage (cirrhosis)
- Heart disease (cardiomyopathy)
- Cognitive dysfunction (impaired memory and attention)
- Breast cancer (even with moderate drinking; dose-related)
Women who drink alcohol while pregnant are also at increased risk of miscarriage, and babies of women who drink during pregnancy are at risk of fetal alcohol spectrum disorder (FASD).
Benefits of routinely screening women for alcohol use
Routinely screening women for alcohol use:
- Increases the likelihood that women with harmful alcohol use will receive counselling.
- Provides an opportunity to counsel all women of childbearing age to abstain from alcohol when trying to conceive or while pregnant.
- Can help to identify women who are victims of past and present violence and abuse, which are often associated with alcohol problems.
Screening women for harmful alcohol use: Strategies and tools
Alcohol use history
Incorporate questions about alcohol, tobacco and other drug use as a routine part of care:
- Start with simple quantity–frequency questions and ask about the maximum number of drinks per occasion (to assess for binge drinking)
- Note medical conditions that may be possible indicators of alcohol use problems.
For more information on taking alcohol use histories, see Alcohol Use - Screening.
Screening tools
In addition to quantity--frequency questions, screening tools can help to identify an alcohol problem. Screening tools are more sensitive if they are administered as part of an interview (Stevens et al., 2020; Sokol et al., 1989; Waterson & Murray-Lyon, 1989).
Use the T-ACE and TWEAK screening tools to identify problematic drinking during pregnancy.
The TWEAK, CAGE and AUDIT-C are sensitive questionnaires to use with non-pregnant women (Bradley et al., 1996). The T-ACE is more sensitive than the CAGE for detecting alcohol problems in pregnant women (Sokol et al., 1989). The most current Canadian alcohol guidance (2023) suggests that there is no safe amount of alcohol consumption during pregnancy.
When scoring the CAGE screening questionnaire for women, one "yes" response suggests a current or past alcohol problem.
Screening questionnaires are superior to laboratory tests for detecting problem drinking in all populations (Bradley et al., 1998). However, gamma glutamyl transferase (GGT) and mean cell volume (MCV) should be ordered if there is suspicion of an alcohol use disorder. GGT and MCV levels are not always elevated, so a negative test does not exclude an alcohol use disorder.
Positive screens: What to do
A positive screen does not necessarily indicate an alcohol use disorder. It does indicate a need to explore a woman's alcohol use further.
If a woman is trying to conceive or is already pregnant, a positive screen presents an opportunity to discuss the risks of prenatal alcohol exposure.
It is important to direct women who are pregnant to resources in the community that can help and support her as soon as possible (see section on Screening for Alcohol Use in Pregnancy)