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Alcohol dependence in women: Comorbidities can complicate treatment

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Ms. F, a 53-year-old high school English teacher, is referred to you by her family physician after she was suspended from work for suspected intoxication. She was divorced 2 years ago from her husband of 20 years, and she says her drinking has escalated to 2 bottles of wine every night. She wants to reduce her alcohol use but experiences shakiness, nausea, and diaphoresis when she tries to cut back.

Ms. F began drinking at age 16 “to feel more comfortable in social situations” and has experienced binge drinking with intermittent blackouts. She denies illicit drug use and legal consequences from drinking. Her father died from cirrhosis at age 58. Her mother suffers from depression but is in remission with medication.

Ms. F is hesitant to date or establish intimate relationships. She has stopped attending church, a book club, and her 15-year-old daughter’s booster club activities.

For years, little was known about alcohol use and alcohol-related problems in women such as Ms. F.1 Alcohol dependence studies rarely included women, so findings and treatment outcomes observed in men were assumed to apply to both genders.

Awareness of gender differences in addiction has grown (Box 1).2-5 Biological and psychosocial differences between alcohol-dependent women and men now are understood to influence etiology, epidemiology, psychiatric and medical comorbidity, course of illness, and treatment outcomes. This article discusses recent insights into planning treatment to address specific needs of alcohol-dependent women.

Box 1

Alcohol dependence in men and women: Gender gap narrows

Epidemiologic surveys consistently show higher rates of alcohol use disorders in men than women, but recent data suggest a narrowing of the gender gap. Studies from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) from 1991 to 1992 and 2001 to 2002, found:

  • a significant increase in the 12-month prevalence of alcohol abuse among men (4.7% to 6.9%) and women (1.5% to 2.6%).
  • a significant decrease in alcohol dependence among men (6.3% to 5.4%) but not women (from 2.6% to 2.3%).
  • a significant increase in rate of alcohol dependence among African-American women age 18 to 29 (from 2.1% to 3.8%).
  • the gender differential in alcohol dependence narrowed from 3.8% to 3.1%.2,3

Similarly, studies conducted 60 years ago showed that boys were more likely than girls to report first alcohol use between ages 10 and 14 (4:1 ratio). Now the age of first alcohol use is relatively equivalent in boys and girls.3 This convergence is disconcerting and suggests that screening and prevention initiatives for adolescents need to increase their focus on girls.

Overall, these observations support the ‘convergence hypothesis,’ which holds that the gap between men’s and women’s alcohol consumption has narrowed as women’s use of alcohol has increased.4,5

Accelerated consequences

As a group, women may consume less alcohol than men but progress more rapidly to alcohol-related illnesses and negative consequences. Specifically, alcohol-dependent women develop liver disease, hypertension, and gastrointestinal hemorrhage more rapidly than alcohol-dependent men.3 Cognitive deficits and brain atrophy also develop sooner in alcohol-dependent women than men.6 Causes of this accelerated progression—”telescoping”—include gender-specific biological differences:

  • Women have lower levels of gastric alcohol dehydrogenase—the enzyme that initiates alcohol metabolism—and therefore experience a higher blood alcohol concentration than men drinking the same amount of alcohol.
  • Women have less total body water and less capacity to dilute alcohol than men.

These factors lead to higher alcohol concentration per drink delivered to target organs via systemic circulation in women than men.3

‘At-risk’ drinking. Gender-related physiologic differences have led to different thresholds for defining “at-risk drinking” and binge drinking for men and women (Table 1).7 Alcohol use also has negative effects on women’s reproductive system and menstrual cycle. Women with alcohol dependence have higher rates of sexual dysfunction, irregular menstrual cycles, early menopause, and amenorrhea as compared with nonalcohol-dependent women.8

Table 1

Different thresholds: Number of drinks* that increases risk for alcohol-related problems

*A standard drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits
Source: Reference 7

Motives for drinking

Research suggests different motives for alcohol use in girls and women vs boys and men. Women appear more likely to use alcohol to “self-medicate” negative affect or emotional pain (Box 2).9-12 Men are more likely to use alcohol to enhance pleasurable emotional states, “feel high” or because of social pressures to conform.5

Box 2

Women’s alcohol use motives: Different than men’s?

Drinking partners. Compared with men’s motives for alcohol use, women’s drinking motives are more strongly influenced by their spouse’s or partner’s drinking patterns. In a large twin study (N = 5,974), 13% of alcohol-dependent women vs 3% of alcohol-dependent men reported that their spouse had a history of alcohol problems.9 Thus, consider the addiction status and drinking patterns of a woman’s partner when developing a treatment plan and relapse prevention strategies.

Trauma and alcohol use. Converging lines of evidence suggest that a relationship among trauma, posttraumatic stress disorder, and substance use disorders is particularly important for women. Early life stress—particularly sexual abuse—is more common in girls than in boys and is associated with the risk of developing substance use disorders.10

Women in alcohol treatment programs report more moderate (87%) and severe (40%) intimate partner violence than women in community samples (28% and 8%, respectively), as well as higher rates of childhood physical abuse (37% vs 11%, respectively).11 Moreover, alcohol abuse places women at risk for repeated victimization and serves to perpetuate a cycle of victimization and addiction.12 These are critical issues to assess and address when treating women with alcohol dependence.


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