Current issues of ACP Journal Club are published in Annals of Internal Medicine


Etiology

Review: Some health risks associated with drinking alcohol are greater for women than for men

ACP J Club. 1999 Mar-April;130:50. doi:10.7326/ACPJC-1999-130-2-050


Source Citation

Bradley KA, Badrinath S, Bush K, Boyd-Wickizer J, Anawalt B. Medical risks for women who drink alcohol. J Gen Intern Med. 1998 Sep; 13:627-39.


Abstract

Questions

Do the health risks of alcohol use differ between women and men? What adverse outcomes associated with alcohol use are unique to women?

Data sources

Studies were identified by searching MEDLINE (1990 to 1996) and PsycINFO (1990 to 1995) using the key words women, woman, and alcohol and by scanning reference lists of relevant studies and reviews.

Study selection

2 reviewers selected studies and meta-analyses that reported data for any of the study questions. Population-based studies were given priority; studies involving alcohol-treatment populations were included only when no data were available from more generalizable studies.

Data extraction

Data on alcohol consumption and outcomes were extracted and summarized by 1 reviewer.

Main results

1 review of cohort studies showed that women who drank 2.0 to 2.9 standard drinks/d had a higher risk for death (relative risk [RR] 1.13, 95% CI 1.10 to 1.16), whereas men did not have an increased risk for death unless they drank ≥ 4 standard drinks/d (RR 1.06, CI 1.03 to 1.10). In 1 study, women (but not men) who drank 3 to 5 drinks/d had a higher age-adjusted risk for death than did lifelong nondrinkers (adjusted RR for women 1.4, CI 1.1 to 1.8). 4 large cohort studies showed that women and men had a similar risk for cardiovascular mortality (i.e., low levels of alcohol use were associated with fewer cardiovascular deaths, and high levels of use were associated with increased cardiovascular mortality). The associations between alcohol use and increased risk for hypertension, ischemic heart disease, and stroke were similar for men and women. Women had a greater risk for death from alcohol-related liver disease than did men. The association between an increased risk for injury and levels of alcohol use per occasion was similar for men and women. Alcohol use was associated with a decreased risk for osteo-porosis after menopause but with an increased risk in heavy-drinking men and alcohol-dependent, premenopausal women. Adverse consequences for women who consumed high levels of alcohol included greater rates of infertility, spontaneous abortion, menstrual symptoms, and breast cancer. Fetal alcohol syndrome was associated with consuming various amounts of alcohol. Studies did not consistently show an association between alcohol use and malignant gynecologic conditions.

Conclusions

Women are more likely to die from all causes and alcohol-related liver disease than are men who report drinking the same amount of alcohol. Women and men who drink alcohol have similar risks for hypertension, stroke, injury, and cardiovascular mortality. High levels of alcohol consumption increase women's risk for infertility, spontaneous abortion, menstrual symptoms, and breast cancer. Variable amounts of alcohol use in women increase the risk for fetal alcohol syndrome.

Source of funding: Health Services Research and Development Field Program and Medicine Service, Seattle Division, VA Puget Sound Health Care System.

For correspondence: Dr. K.A. Bradley, Health Services Research and Development, Mailstop 152, VA Puget Sound Health Care System (Seattle Division), 1660 South Columbian Way, Seattle, WA 98108, USA.


Commentary

Alcohol use is a major public health problem. At least 5% of all deaths in Finland (which has an alcohol consumption level similar to the United States) are directly attributable to alcohol use (1). Given the multifactorial causes of most chronic diseases, the proportion of morbidity and mortality attributable to alcohol is likely to be much higher.

Most alcohol-related, premature deaths occur among men; however, in this thorough clinical review, Bradley and colleagues point out that a growing body of evidence shows that the same level of alcohol use may be more hazardous for women. Recent population studies corroborate these conclusions (2).

The correlation between drinking and sex is most notable in liver cirrhosis: The risk slope is steeper among women who drink. Another remarkable sex-specific difference comes from the causal relation between alcohol consumption and breast cancer.

Although the same J- or U-shaped association between alcohol consumption and cardiovascular diseases seems to exist between both sexes, the authors could not find enough evidence to determine whether this was true for all women or just for certain subgroups. The cardioprotective mechanisms of moderate drinking are poorly understood overall, and the complex hormonal pathways in women make this issue even more complicated.

The review is limited by publication bias, but the number and consistency of published studies is impressive enough to support the notion that women and men have differential risks associated with drinking. Perhaps the major weakness in the literature comes from the fact that most studies rely on average self-reported consumption. The effect of increased exposure, bingeing, and beverage preferences should be examined more carefully in future population studies.

Jussi Kauhanen, MD, PhD
University of KuopioKuopio, Finland


References

1. Makela P, Valkonen T, Martelin T. BMJ. 1997;315:211-6.

2. Thun MJ, Peto R, Lopez AD, et al. N Engl J Med. 1997;337:1705-14.