Closing the Gap in Alcohol Screening for Women’s Health

Despite how common risky drinking is among women, alcohol screening in most primary care and OB-GYN settings remains inconsistent and largely ineffective, according to Amy de la Garza, M.D. She explains why casual questioning about alcohol use falls short, what validated screening tools actually catch that informal conversation misses, and why OB-GYN visits represent an especially important, and often overlooked, opportunity to intervene.

De la Garza also addresses a diagnostic challenge specific to midlife: Many symptoms of problem drinking, including poor sleep, irritability, anxiety and fatigue, overlap almost entirely with symptoms of perimenopause and menopause, making it easy for both patients and providers to misattribute one for the other. She offers practical guidance for providers who aren’t addiction specialists but want to meaningfully help patients navigating this overlap.

What does standard screening miss, and what would better screening look like across a woman’s life?

Amy de la Garza, M.D.: The reality is that screening for risky alcohol use and alcohol use disorder in this country’s primary care and OB-GYN settings is dismal. Most physicians screen with casual questioning about use, which is not effective for identifying risky use or use disorders. Identifying risky use and alcohol use disorder meaningfully increases with a validated screening tool that is given to the patient in a paper or electronic form. Patients will answer more truthfully, and screening tools are more sensitive for identifying risk. The AUDIT-C and the Single Alcohol Screening Question (SASQ) are both short tools that can be easily implemented into clinical workflows. If a woman screens positive, further questioning using longer screening tools should be utilized to further assess for alcohol use disorder.

Brief interventions aimed at helping women understand the risks of their use, tying their current health concerns to their use and developing patient-centered goals to reduce use have been shown to reduce alcohol use as well as to provide opportunities for patients to obtain specialized substance use treatment if needed. The National Institute on Alcohol Abuse and Alcoholism has an excellent resource for providers to learn about screening and brief interventions for alcohol use. The Core Resource on Alcohol can be found here.

Why are OB-GYN visits an important entry point, not just primary care?

ADLG: For many women, the OB-GYN is their main, sometimes only, regular doctor across the reproductive years and into menopause. That makes these visits a natural and trusted place to talk about alcohol. OB-GYN providers should be utilizing the same evidence-based screening and brief intervention tools across the lifespan of their patients. Specific alcohol screening tools are available for the pregnant woman. The evidence supports that screening, brief interventions, and treatment of family members with risky use and use disorders not only improve outcomes for the patient but also improve medical outcomes for family members.

How do life-stage transitions complicate recognition or treatment? Does alcohol use disorder present differently in perimenopause or menopause?

ADLG: Yes, and the differences are part of why it goes unrecognized.

Poor sleep, low mood, irritability, anxiety, hot flashes and fatigue can all come from menopause, from drinking or from both. It’s easy for everyone, patient and clinician, to attribute alcohol’s effects to “just menopause,” or to treat menopause symptoms without asking about alcohol.

Midlife problem drinking often looks like a nightly increase at home to cope with stress, sleep or symptoms, rather than the obvious crises people associate with addiction.

Stigma and practical obstacles make it harder for women to access care and recover, so problems that are recognized still may not get treated.

The takeaway is that women are increasingly accessing care for perimenopausal and menopausal symptoms, as well as symptoms related to postpartum depression and premenstrual dysphoric disorder. Primary care physicians, hormone specialists and OB-GYNs, as providers to women, should all be implementing evidence-based screening tools, brief interventions to reduce use and trusted referral networks to specialty addiction providers. Additionally, and importantly, all front-line providers can prescribe evidence-based medications for reducing alcohol use and treating alcohol use disorder if identified. Oral naltrexone, Vivitrol (a long-acting injectable form of naltrexone), gabapentin and disulfiram (Antabuse) are all evidence-based medications that can be easily prescribed by any provider.

For a non-addiction-specialist provider who suspects a patient’s drinking has shifted during a transition, what should they know or ask?

ADLG: You do not need to be an addiction specialist to make a real difference. The evidence-based first steps are squarely within general practice. Screen for risky use with a validated tool, and follow up with additional screening if needed. A nonjudgmental, accepting discussion about use and a patient-centered plan to reduce alcohol use will provide a woman with a safe space to explore her use with a trusted provider.

Developing two trusted relationships with providers of substance use care in the community, including an addiction medicine or psychiatry provider and a trusted alcohol detox resource, is critically important. If you are going to screen, you must have a place to refer the patient who requires additional care. Familiarize yourself with resources for AA and other mutual help programs. SAMHSA’s Find Support resource provides a comprehensive list of recovery support organizations and links.

Lastly, become familiar with prescribing medications for reducing alcohol use. As trusted providers of primary care services for women, family medicine, internal medicine and OB-GYN providers are perfectly positioned to screen, intervene and treat their patients with whom they have developed trusting relationships. Reducing risky use and preventing the development of alcohol use disorder in women across the lifespan is our best hope of stemming the tide of alcohol-related comorbidity and death.

This transcript was edited for clarity.