Screening women​

The importance of screening women for alcohol problems

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 recognize and address only 24 per cent of alcohol-related problems in women compared to 67 per cent of alcohol-related problems in men (Bradley et al., 1998). There are various reasons for this difference:

• The social consequences of heavy drinking such as employment, economic or legal difficulties are less likely to be overt in women than in men.
• 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

Women are susceptible to the same medical conditions associated with drinking as men. However, alcohol-related medical conditions may develop in women at lower levels of consumption than in men, and may progress more rapidly in women ("telescoped course").

This difference may be because women reach a higher serum alcohol level per drink consumed due to lower enzymes levels (e.g., alcohol dehydrogenase) 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).

Pregnancy and alcohol use

Women who drink alcohol while pregnant are at increased risk of miscarriage.

Babies of women who drink during pregnancy are at risk of fetal alcohol spectrum disorder (FASD).

Benefits of routine screening

Routinely screening women for alcohol use:

• increases the proportion of women with alcohol-related problems who 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 (Miller et al., 2000).

Screening strategies for alcohol problems in women

Use these basic strategies to detect possible alcohol use problems:

• Incorporate questions about alcohol, tobacco and other drug use as a routine part of care.
• Start with simple quantity–frequency questions and asking about maximum number of drinks per occasion (to assess for binge drinking)
• Note medical conditions that may be possible indicators of alcohol use problems.

Screening tools

Screening tools are more sensitive if they are administered as part of an interview (Chang et al., 1999; Sokol et al., 1989; Waterson & Murray-Lyon, 1989).

Use the T-ACE and TWEAK screening tools to identify risky drinking during pregnancy.

The TWEAK, CAGE and AUDIT 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).

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

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. Periconception risk drinking is defined as two or more standard drinks per day (Russell, 1994).