There are many areas where women and men face different health and medical issues. Now there is evidence that one area where they may differ is in a key part of our culture: how they respond to consuming alcoholic beverages.

For example, according to a recent study published in JAMA Health Forum, alcohol-related health issues rose faster among women than men during the pandemic. And surprisingly, women ages 40 to 64 experienced the fastest rate of increase. Another recent study found that women who binge drink are more likely to develop heart disease.

Timothy Brennan, MD, MPH

In this Q&A, Timothy Brennan, MD, MPH, Chief of Clinical Services for the Addiction Institute of Mount Sinai, discusses some of the ways alcohol can be harmful, including how alcohol can affect women differently than men and what you can do if you think you may have a drinking problem.

Why do women and men respond differently to alcohol?

People born biologically female or born with two X chromosomes, have a higher percentage of body fat and a lower percentage of water on average compared to men of the same weight. Alcohol is water soluble. So, if you’ve got a lower percentage of water, the alcohol concentration in a woman is higher after consumption of the same quantity of alcohol.

Here’s a scenario to illustrate: a biological XX person and biological XY person who have the same weight each consume three 12-ounce beers. The biological XX person will have a higher blood alcohol concentration compared to the other person and is therefore more impaired.

There’s also a difference in the way that women process alcohol. There’s an enzyme in our livers called alcohol dehydrogenase (ADH), that’s responsible for metabolizing alcohol in our bodies. Women have lower levels of ADH, meaning they have less ability to metabolize that alcohol. So bottom line, the alcohol hangs around longer and exerts more of an effect on women.

What amount is considered safe for a woman to drink?

Our understanding is evolving quickly, but what we now know is, no alcohol is best. Alcohol simply does not appear to convey any health benefit, whatsoever. There used to be some belief that drinking certain types of alcohol, red wine, for example, might lower your risk of cardiovascular disease. That doesn’t seem to be the case anymore. Different countries have looked at this question differently. The Canadian government has been much more emphatic than the United States that no alcohol is best.

However, if we’re defining “safe” as not being at risk to develop an alcohol use disorder, then we can look to the National Institute on Alcohol Abuse and Alcoholism for some general guidelines. They recommend that women have no more than seven drinks per week and no more than three drinks on any one day. By comparison, their recommendation for men is no more than 14 drinks per week and no more than four drinks on a single day. That means no more than a drink a day for a woman, which might strike the lay person as pretty low.

Isn’t it hard to limit drinks when we regard alcohol as a social lubricant and ingrained in our society?

Alcohol is pervasive in our cultures and in our social interactions. It’s ritualized across a variety of our holidays and traditions. It’s part of our everyday vernacular. It’s hard to even ask someone to do something in the evening without drinking being implied. Happy hour is a big component of our recreation.

But alcohol is technically a neurotoxin, which means that it is destructive to nerve tissue. I heard someone suggest that instead of using the term “alcohol,” we should use the term “neurotoxin.” It’s a provocative thought, but imagine someone saying, “Hey, would you like to get a couple neurotoxic beverages after work?” The response would most likely be, “Not really.” Just the way we talk about alcohol is very interesting.

A recent study found that women ages 40 to 64 were the fastest growing segment of people with alcohol related health problems during the pandemic. Why is that?

Most likely a lot of factors are involved. First, there’s the anxiety of society as a whole with the pandemic, so people turn to what they think are anxiety relieving products. However, the anxiety-relieving effects of alcohol diminish over time and actually promote anxiety. Someone may say, “Well, my wine is the only thing that helps,” and it becomes the thing that hurts the most with their anxiety in the long run. But on top of that, women tend to be responsible for the family, have the increased stress of children at home, and are managing an entirely new routine.

Plus, our social norms are that you really couldn’t drink on the job for the most part. But if you’re suddenly working at home, how would the boss know if you grab that glass of wine at 3 pm versus 6 pm? Nobody has any idea what you’re doing. And the normalization of drinking at home has been promoted with the advent of Zoom happy hours and social media memes.

Why is it important to discuss the health effects of alcohol?

It’s hard to find an organ system that’s not affected by alcohol. Classic examples that we talk about start off with the liver and liver damage. Types of liver damage can vary from what is called a fatty liver and advance to alcoholic hepatitis or alcoholic fibrosis. It can progress all the way to cirrhosis and liver failure, when the person will need a transplant.

Cardiovascular issues are pervasive among people who are heavy drinkers. Not only does it promote hypertension and high blood pressure, but heavy drinking also weakens the heart muscle and promotes arrhythmia, or irregular heartbeat, and stroke.

The gastrointestinal system or GI system can be irritated and develop ulcers or GI bleeds. The pancreas can frequently be acutely inflamed with alcohol and oftentimes people can develop pancreatitis. Alcohol is not safe for our brain, and long-term alcohol use can lead to cognitive impairment. It affects our psychiatric health and emotional health in many ways. Heavy alcohol use can interrupt our ability to metabolize certain vitamins and minerals such that people can develop chronic dementia. And alcohol can promote a variety of cancers. The way alcohol affects our body is very profound.

What is the difference between a heavy drinker and an alcoholic?

When we talk about alcoholism, the clinical term we use is alcohol use disorder. That’s a disease that’s been codified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or DSM-5. Alcohol use disorder is diagnosed by 11 different criteria. It’s not something you can diagnose with a blood test. If you’ve got two to three criteria, it’s mild. If you’ve got four to five, it’s moderate. If you’ve got more than five, that’s considered a severe alcohol use disorder. Heavy drinking is not defined in the DSM-5. But the guidelines from the National Institute on Alcohol Abuse and Alcoholism we discussed earlier define low risk drinking to high-risk drinking based on the number of drinks consumed in a week. Let’s say for example, a biological female has more than seven drinks per week. But a clinician goes through that DSM-5 criteria with them, and they have none of criteria. You can’t diagnose them with an alcohol use disorder. You wouldn’t call them an alcoholic, but technically, they’re a high-risk drinker. And I think it’s reasonable to classify high risk and heavy drinkers in the same way.

Now that the pandemic is over, would you expect less drinking-related health concerns?

It’s well established in our field that once a substance use disorder takes hold, it does not go away by simply changing one factor in our environment. Alcohol hijacks the reward pathway in our central nervous system. It’s very hard to break that cycle, without any treatment and without any actual abstinence.

What should people do if they think they have a problem with alcohol?

First, there are some patient-facing websites that allow a person to quantify their alcohol use and explore it. The National Institute of Alcohol Abuse and Alcoholism has a lot of great information and interactive tools. I also encourage people to talk to their doctor. Often, people don’t realize the damage alcohol is doing to their body. And they may be self-medicating because of some other issue, like struggling with sleep or anxiety. And revealing that to their doctor can address the primary issue.

If you think you have an alcohol use disorder, I encourage people to check out a meeting of Alcoholics Anonymous. You don’t need to be an alcoholic to go to an AA meeting—there are Open Meetings where anyone can attend. And if you determine that you do have an alcohol use disorder, I always recommend that people get formal addiction treatment. And by that, I mean finding someone who is board-certified in addiction medicine. I trained in pediatrics, and then followed that with an addiction medicine fellowship. Unlike addiction psychiatry, addiction medicine is a multi-specialty subspecialty so there are a lot of different paths into it. Mine was pediatrics, but others might be internal medicine or family medicine. The good news is, there is a lot of help and resources for people seeking help.

The approach of fall is when doctors normally begin reminding patients to think about getting the flu vaccine, and now they are also reminding patients about the new COVID-19 vaccines that were recently approved.

The new COVID-19 vaccines are recommended for everyone six months of age and older. The U.S. Food and Drug Administration approved the vaccines, from manufacturers Pfizer and Moderna, on Thursday, August 22. The annual influenza vaccine is also recommended for those six months and older.

You should think about getting both vaccines before the end of September, according to Bernard Camins, MD, MSC, Professor of Medicine (Infectious Diseases) at the Icahn School of Medicine at Mount Sinai and the Medical Director for Infection Prevention for the Mount Sinai Health System.

“The immune response from the COVID-19 vaccine can wane after a few months, so that’s why people should get the most current vaccine and be ready for the fall surge,” Dr. Camins says.

Those at risk for developing severe disease from COVID-19 should think about getting the new vaccines within the next month, according to Dr. Camins. This includes older adults, those with chronic medical conditions, such as diabetes, heart disease, chronic lung disease and those with reduced ability to fight infections, such as organ transplant recipients and those being treated for cancer.

You may find it easier to get your new COVID-19 vaccine and flu shot at the same time. However, if you want to get them one after the other, you should start with the COVID-19 vaccine, because the peak flu season usually occurs later than the COVID-19 surge, according to Dr. Camins.

Flu vaccines are important because the flu is contagious and can lead to serious illness, hospitalization, and even death, according to the U.S. Centers for Disease Control and Prevention (CDC).

Experts say getting the new COVID-19 vaccine is important now because the number of cases generally surges as colder temperatures arrive and people spend more time indoors, especially during the holidays.

In addition, the new COVID-19 vaccines have been developed to provide the best protection against the newest subvariants. The vaccines you may have gotten last year were developed for different strains. COVID-19 vaccines typically provide protection for up to 20 weeks before their effectiveness begins to decline.

Many private insurance plans, along with Medicare and Medicaid, cover the cost of COVID-19 vaccines.  You can find more information from the New York City Department of Health about where to get the new COVID-19 vaccines.

Based on last year’s data, the COVID-19 vaccines will prevent COVID-19 in about half of people. But more importantly, they are more effective in preventing serious illness and hospitalizations for those who do become infected. They can also help you avoid complications from long COVID.

For kids, it’s important to get the COVID-19 vaccine because younger people can also have complications if they get infected, plus they can bring home infections where they can affect other family members who may be more at risk.

Meanwhile, your best defense against a COVID-19 infection remains the same: Keep up to date with your vaccinations, consider taking steps to limit your exposure to large indoor crowds, wear a well-fitting mask at public gatherings or in tight spaces such as an airplane or public transportation, and talk with your health care provider if you are feeling sick.

There is a third vaccine that older adults should consider getting, and that is for RSV (respiratory syncytial virus). RSV is a common respiratory virus that infects the lungs, but can also affect the nose and throat.

RSV spreads in the fall and winter along with other respiratory viruses, like flu and COVID-19. RSV usually peaks in December and January, according to the CDC. The CDC recommends the RSV vaccine for adults 75 years and older, and for adults 60 to 74 who are at increased risk for getting severe infections. You do not need to get the RSV vaccine every year.