Alcohol and Women’s Health: From Fertility to Menopause

Welcome to the second half of my miniseries on alcohol and women's hormonal health.

In part one, which you can find here, I focused on how alcohol metabolizes differently in women than in men and how this increases women's alcohol-related health risks. I also talked about how alcohol can effect puberty, our hormones, and menstrual cycles.

In this installment, I discuss how alcohol can impact fertility, PCOS, endometriosis, menopause, and breast cancer, giving you food for thought on whether and if so how much drinking is okay for YOU, and also tools for smarter alcohol intake should you decide you do want to continue to enjoy some alcohol in your lifestyle.

You'll learn:

• How alcohol may impact fertility and how to approach drinking while trying to conceive
• How inflammation caused by alcohol consumption can enhance symptoms of PCOS and endometriosis, and how to approach drinking if you have either condition
• The role of alcohol in menopause, hot flashes, and sleep problems, and why, in this stage of our lives, alcohol may increase our risks while decreasing our tolerance for drinking
• The role of alcohol in breast cancer: risks, susceptibility, genetics, and more
• How alcohol may impact methylation and DNA – and what you can do about this
• The top tips for drinking in a way that mitigates the risks of alcohol, while still being able to enjoy light intake should you want to.

Whether you're trying to conceive, are currently pregnant, going through menopause, struggling with PCOS or endometriosis, or simply want to learn more about the potential long-term effects of alcohol on your health, – even just light drinking – this series as a must-refer-back-to one for various cycles of your life.

So read or listen, save and share!

Alcohol and Your Fertility 

So alcohol and fertility, what's the deal? Well, interestingly, most studies, and this is great news if you like to have a drink now and then find that light drinking. Now remember, moderate drinking is a drink or so a day, no more than seven drinks a week, no more than three drinks at a time. Light drinking, I'm defining as one to three drinks a week at the most, and really not even every single week. So most studies find that light drinking just a few drinks per week, for example, does not impact fertility. Mic drop. So if you're reading on some wellness website or some fertility website that you should never have a drink if you wanna get pregnant, that's really not what the data supports. A 2009 study published in the journal Epidemiology followed 18,555, married women without a history of infertility for eight years as they attempted to become or became pregnant.

Most studies find that light drinking, just a few drinks per week, for example, does not impact fertility. For example, a 2009 study, published in the journal Epidemiology, followed 18,555 married women without a history of infertility for 8 years as they attempted to become (or became) pregnant. Diet was measured twice during this period and prospectively related to the incidence of ovulatory disorder infertility. There were 438 reports of ovulatory disorder infertility during follow-up, and alcohol Intakes were found to be unrelated to the risk of ovulatory disorder infertility.

And in a study of 567 women seeking fertility care at the Massachusetts General Hospital who participated in the Environment and Reproductive Health Study, published in the medical journal Fertility and Sterility, low-to-moderate intakes of alcoholic beverages were unrelated to ovarian reserve, as measured by antral follicle count (AFC), a well-accepted biomarker of ovarian reserve, in a cohort of women seeking fertility care. So if a glass of wine is part of your getting warmed up for sex ritual, there should be no harm in that. 

However, heavier drinking and binge drinking are another story, as may be heavier drinking just after ovulation. A study, published in Reproduction in 2017, looked at alcohol and fecundability  – the chance of becoming pregnant in a single menstrual cycle. It analyzed data from 413 women, ages 19 to 41 ( mainly white, non-Hispanic, and married with some college education) who completed daily diaries on alcohol intake, including the number of drinks and type (beer, wine, or liquor) for a maximum of 19 months of follow-up. During this time the women’s  monthly cycle phases were calculated with a calendar-based method and they provided monthly urine samples to assess pregnancy status. Over the course of the study, 133 women became pregnant. 

Data comparing the outcomes between drinkers and non-drinkers showed that the greater a woman’s alcohol consumption, the lower her chance she had of conceiving. Non-drinkers had a 41.3% chance of conceiving, light to moderate drinkers around a 32% chance of conceiving, versus  27.2% in heavy drinkers.. Further, the researchers discovered that moderate and heavy drinking in the post-ovulation phase decreased the likelihood of conceiving by  44% and 49%, respectively..

This same study also found some evidence that heavy drinking prior to ovulation may also have an impact on fecundability, and that each additional day of binge drinking around ovulation and in the luteal phase  was associated with a 19% decrease in conception, whereas this impact was not found with heavier drinking earlier in the menstrual cycle. Nor was menstrual cycle length changed by drinking at any time during the menstrual cycle. Rather, the interference with fertility has to do with an alcohol-triggered surge in estradiol levels, which may affect conception or implantation, suggest the authors. The authors also state that one limitation of their study is that, unlike in the large aforementioned study, where women were actively trying to get pregnant, in this study, women were not actively trying to conceive. 

The extent to which moderate to heavy drinking, and binge drinking, currently, or when we were younger, may have an impact on our fertility down the road is less clear. Some studies have found that long-term, moderate alcohol consumption may lead to diminished ovarian reserve, a marker of fertility, in childbearing age women. In one study moderate alcohol consumption was associated with significantly decreased ovarian volume and number of ovarian antral follicles. 

Further, binge, heavy, and even chronic moderate alcohol intake may deplete important nutrients, for example folic acid, needed for healthy ova, and also influence ovulation – which has been shown in short term studies, and studies done over 6 months. 

My recommendation for anyone trying to conceive is that there is compelling evidence to suggest cutting back on alcohol before you start trying to conceive. I feel it is important to keep drinking to 1-2 servings/week at most, making sure to also take a prenatal vitamin as it contains folic acid which may be protective against some of the harmful impact of alcohol on cellular function, DNA, and methylation. 

All forms of alcohol should absolutely be avoided in pregnancy. While some may consider there to be controversy around this because in some countries, some women may continue to drink during pregnancy, or you might hear ‘well, our grandmothers drank and our mothers were fine.” Fetal Alcohol Syndrome (FAS) is a very real phenomenon. The expression ‘better safe than sorry’ is nowhere better applied than here. If you’ve had alcohol before you realized you were pregnant, it’s important to just exhale. Make sure you’re taking your folic acid – your prenatal vitamin should contain enough of it to provide the neural tube protection your baby will need. 

What if You Have PCOS or Endometriosis 

When it comes to PCOS, no causative correlations have been clearly found to date, but as with other aspects of alcohol and our hormones, the data is also limited. Insulin resistance and blood sugar imbalances play a major role in the etiology of PCOS for the majority of women with this condition, leading to the increases in testosterone that cause many of the condition’s hallmark symptoms. The studies I mentioned in the first part of this series  on blood sugar suggest that from a strictly blood sugar perspective, low to moderate alcohol intake may not be harmful for women with PCOS, but this does not address the separate potential hormonal impacts of alcohol on menstrual cycle length, estrogen and testosterone levels, gut health, and inflammation, all of which independently and collectively impact women with PCOS. 

Some studies, though the data is limited and contradictory, have shown an increase in testosterone; in one study this was seen in premenopausal women with the consumption of  0.5g/kg of alcohol. That may increase androgenization and should be explored more in women with PCOS or at high risk for developing it, which I talk more about in my book Hormone Intelligence. There is also new research into what is being called EAFLD – endogenous alcohol fatty liver disease as a possible root cause of PCOS. We also definitely know that heavier drinking is associated with increased depression, diabetes, liver, and heart disease – all of which are increased risks in women with poorly treated PCOS.

Endometriosis is a complex and chronic  condition in which there is dysregulation in the interactions between the endocrine and immune systems. It is now recognized to have  multifactorial genetic and environmental causes; possibly lifestyle factors may mediate or exacerbate the condition – alcohol being one of these. 

As we’ve established, alcohol, particularly in moderate to higher amounts, can increase inflammation and oxidative stress through a variety of pathways; it may alter the gut microbiota composition and cause dysbiosis, and may increase estrogen levels, particularly if they are already elevated – all of which which play a role in endometriosis – which is aggravated by high estrogen levels. Endometriosis is also commonly accompanied by digestive symptoms, systemic inflammation, pain, and depression, all of which may also be exacerbated by alcohol intake. Alcohol may also be  part of a vicious “pain-stress-infammation” cycle for women with endometriosis.  Of note, a 2021 study found that one of the effects of the COVID-19 pandemic was an increase of alcohol consumption for 29.2% endometriosis patients. 

Data on endometriosis and alcohol intake is sparse and contradictory. A meta-analysis did find an increased risk of endometriosis among any alcohol users, but the authors concluded that the finding was only of borderline statistical significance and  was lower than their previous study estimated. 

My recommendations for women with PCOS or endometriosis? See how it feels to you – and monitor your symptoms – ideally over three months of completely abstaining; three months gives you a good beat on your symptoms over several consecutive menstrual cycles and allows time for your body to reset a bit. If  you notice symptom improvements or resolution, then make your decision on whether/ how much to drink accordingly. And regardless, keep drinking light – even 1-3 drinks a week is more than ideal with these conditions in my opinion, but certainly no more than that. 

Alcohol and Menopause 

The hormonal hallmark of menopause is a shift from the potent form of estrogen, estradiol, that has been our companion from the time we entered puberty, to a less potent form called estrone. As this shift occurs, not only do we stop ovulating and menstruating, but we lose some of the lubrication and tissue plumpness that estrogen provides – literally – in our skin, vaginal tissue, breast tissue, joints, and tendons, and more. We are also more likely to experience sleep disturbances, mood swings, headaches and migraines, hot flashes, and other symptoms that can be minor or major, and our risks for heart, bone, and metabolic diseases go up, as do risks of many forms of cancer. So it’s important that we be extra tender to ourselves during these years, nourishing ourselves optimally, and avoiding lifestyle choices that may negatively impact our health. 

Many women notice that as they enter their late 40s, just when they feel they’ve earned that glass of wine (or three!) in the evening, their alcohol tolerance has plummeted, and even a half glass of wine leads to headaches, disrupted sleep, depressed mood, and a hangover.  And they’re exactly right. 

After we go through menopause, we metabolize alcohol differently than when we were younger, and the gender gap in alcohol metabolism becomes even wider, making us less able to drink the amount we could previously, and making us more susceptible to alcohol-related problems than men or premenopausal women. Women are also at greater risk for alcohol-related health problems such as liver or heart disease as compared to men.

Why do all of these changes occur? And what does this mean for drinking in our menopausal years? 

We don’t tolerate alcohol as well as we age for a number of reasons. One is that muscle mass is replaced by fat tissue, which happens starting in our menopausal years, and the amount of water in our body also goes down with age. This leads to a higher blood alcohol concentration (BAC) when we drink. Additionally, your liver’s ability to metabolize alcohol also declines, as does the rate of elimination of alcohol from the body. I also suspect that changes in the microbiome that occur with menopause may impact our hepatic alcohol metabolism and elimination and our microbiotal response to alcohol intake may also unfavorably shift leading to the production of more inflammatory cytokines and microbial-produced chemicals that make us feel unwell.

Add to this the poor sleep and cognitive and emotional changes from depression to questioning one’s self-identity that we’re going through at this major life juncture, and it’s easy to see why a glass of wine or a gin and tonic sounds especially appealing after a full day. But there’s more than even that going on – at the same time that our tolerance goes down, our desire to drink goes up, as does the immediate pleasure from having a drink. A 2017 study found that binge drinking rates remained stable for men 60 years and older between 1997 and 2014. But women 60 years and older binge drank at steadily higher rates over that same time period; their rates increased by an average of 3.7 percent each year. 

Hot flashes, also called vasomotor symptoms (VMS), is the most common symptom of the menopause transition, with 60 to 80% of women experiencing them. They often begin in late perimenopause, when we’re in our mid-to-late 40s, and peak early in menopause, when we’re in our mid-50s. For some women they’re a short-lived annoyance that generally eases over time, unless triggered by something specific like stress or spicy foods. But for some women, they start early and last for as many as 15 years – and for a subset of women they are bothersome or even severe. Hot flashes also commonly occur at night – called night sweats – and can dramatically impact one’s amount and quality of sleep. 

But the data on hot flashes, like so much of the data on women’s reproductive health and menopause, is conflicting. and does appear to be both individually variable and dose-dependent – that means based on how much you drink.

Some studies have found that light drinking is associated with a lower risk of hot flashes, night sweats, and even bone density loss, as well as having positive effects on blood sugar, insulin, and triglyceride levels. For example, a study of 732 women (age range, 45 to 54 years) in the US found that current, moderate, or severe hot flashes were less frequent in women who consumed one drink per day or more compared with nondrinkers. A cohort study of 647 women found that those who drank > 12 drinks or more in the precedent year experienced a shorter duration of hot flashes than that women who drank < 12 drinks in the past year, and a study of 755 peri-menopausal women showed a favorable effect of light alcohol intake (defined as 1 to 5 drinks per week) on the frequency of hot flashes compared with non-drinkers, suggesting a potential protective benefit of moderate drinking thought to be due to alcohol- related increased estrogen levels. 

On the other hand,  one study found that moderate and heavy consumption of alcohol may lead to earlier onset of vasomotor symptoms, and that the effect was both dose dependent and more likely to contribute to night sweats compared to daytime hot flashes. Several studies have concluded that alcohol can act as an acute hot flash trigger, which many of us know from experience, and that women who drink more over time are more likely to be troubled by hot flashes. Most of the studies found that excessive drinking was more likely to be associated with hot flashes. For example, a Finnish study of 1427 women who drank 192 g of pure alcohol per week, and another a population-based study of  African American and Caucasian premenopausal women found that a higher number of alcoholic beverages per week was linked to significantly higher odds of hot flashes.

The mechanisms thought to be related to alcohol increasing hot flashes include stimulation of the release of the neurotransmitter serotonin (5-HT) as a stress response to alcohol, which then disturbs the body’s thermoregulatory system in the hypothalamus, other alterations in the body’s temperature regulatory centers in the hypothalamus causing us to both feel hotter and have a lower threshold for sweating, and disruption of thermoregulation by acting on the peripheral vasodilation and the central nervous system. 

The reason for conflicting results may be due to different study populations, the fact that alcohol intake and hot flashes wasn’t the primary reason for the study, or variation in individual responses to alcohol. Bottom line: if alcohol increases your hot flashes, use that as a message to moderate your intake  – or forego it altogether. 

Bone health is so important as we get older. Fractures, particularly hip fractures, pose a terrible risk for women, and are not only one of the most common reasons we become dependent on others or are forced to live in care facilities, but we have a 50% increased risk of mortality in the first year after a hip fracture. Osteoporosis is characterized by a substantial loss of bone mass and, consequently, increased risk of fractures. It affects 4 million to 6 million Americans, especially women after menopause. Alcohol can interfere with calcium and bone metabolism in several ways. Acute alcohol consumption can lead to a transient PTH deficiency and increased urinary calcium excretion, resulting in loss of calcium from the body. Studies in alcoholics also have shown that alcohol is directly toxic to bone-forming cells and inhibits their activity. Chronic heavy drinking can disturb vitamin D metabolism, resulting in inadequate absorption of dietary calcium. Liver disease in heavy drinkers  also affects bone metabolism.

However, as with practically every area we’ve discussed, the data is mixed. While heavy alcohol intake definitely appears to predispose to both osteoporosis and increased risk of falling – the biggest risk for fractures – moderate and light intake was  associated with increased bone mineral density in several studies, and some studies show no or few associations between moderate and low alcohol  intake and fractures. 

We’ll talk more about bone health in another episode, but one thing you can do for yourself, in addition to regular exercise, calcium-rich foods, and a calcium supplement, is to eliminate or at least reduce alcohol intake to no more than 1 to 3 drinks per week. And some good news is that studies  have found that even alcohol-induced changes in bone metabolism in alcoholics, including toxic effects on bone-forming cells, are at least partially reversible with cessation of drinking 

Heavy drinking, on the other hand, is unequivocally problematic in menopause. It can wreak havoc on our health, dramatically increasing our risks of breast cancer, heart, disease, liver disease, and osteoporosis, as well as affecting brain health – all of which are at higher risk for disease after our estrogen levels naturally decline in menopause. 

It’s incredibly important  for your overall health plan  to moderate alcohol consumption during and after-menopause, finding other ways to relax in the evening and on weekends and holidays, and to really observe the upper limits for moderate drinking as I’ve established with you. You can thank me later for better sleep and better moods, too! And yes – more to come on how to get good sleep in menopause – and anytime! 

Alcohol and Breast Cancer Risk

Breast cancer. It’s a scary set of words. And the reality is that most of us will never experience it directly. But it is a major risk for women, and of course we all want to do everything we can to reduce our risk. 

Not drinking alcohol is one of the most important things we can do, whether or not we have family risk of cancer, but especially so if we do. 

The evidence is really incontrovertible. In extremely large studies with collectively tens of thousands of women, over 3 millions person years, published in respected publications including JAMA, Journal of the National Cancer Institute, and the British Medical Journal, and the American Journal of Epidemiology, alcohol intake has been definitely associated with increased risk of both ER and PR positive breast cancers, and this risk is higher for individuals consuming as low as three drinks per week. The greatest risk is consistent, cumulative alcohol intake throughout adult life, and intake in both earlier and later in adult life. But it’s not just heavy drinking this time – even 1-3 drinks per week increase risk, and for every 10 gm of alcohol consumed, the risk may be increased by anywhere from 4 to 13%. Yes, that’s a lot. 

The mechanisms of action increased breast cancer risk secondary to alcohol use include alcohol’s ability to increase estrogen and androgen levels, increased mammary carcinogen DNA damage, and altered gene expression and methylation.

Susceptibility to the breast cancer-enhancing effect of alcohol may also be affected by other dietary factors (such as low folate intake), lifestyle habits (such as use of hormone replacement therapy), or biological characteristics (such as tumor hormone receptor status). Combination of alcohol and hormone therapy is an added risk. Per the Nurses' Health Study, compared with women who neither took hormones nor drank alcohol, the risk of breast cancer was twofold higher in those who drank more than one alcoholic drink per day and used hormones for five or more years. 

In short, there’s no amount of alcohol that’s considered safe when it comes to breast cancer prevention, and if you are at higher risk, I’d absolutely advise not drinking much at all. But there are ways you might be able to mitigate some risk, to reduce the risks of other symptoms and conditions we’ve discussed today, and to drink a bit more protectively for your overall health. 

Is There a Healthier Way to Drink?

So is there a way you can protect and support your hormone health if you still want to enjoy a drink or two per week?  Several things are clear: The amount, type, and timing definitely seem to make a difference, as does how often you drink does make a difference, and while they don’t compensate for drinking more than low to moderate amounts, nutritional status and lifestyle, may make a difference in mitigating some of the risks of light to moderate drinking. 

While none of these tips eliminates all of the risks, they are smarter ways to drink that may offset some of the impact the next day – and long-term. They are not meant as carte blanche to get your drink on – they are meant to help you support your optimal health if and when you do choose to imbibe. 

• Eat food first and start out and stay well-hydrated.  It doesn’t matter so much what you eat; drinking alcohol after meals reduces the peak blood values of ethanol due to delayed gastric absorption and emptying. The difference between the fasted and the fed state varies by person but can be as much as 65-70% of alcohol bioavailability.. 
• Stick to clear alcohols. When it comes to alcohol risk, most studies show no difference in the types of alcohol one drinks, but a few studies have shown – and many women corroborate this in how they feel, myself included – that clear alcohols like vodka and tequila have a lower effect on mood and sleep. Whenever possible, steer toward one of these if you are going to have a drink and pay attention to whether you notice a difference. 
• Avoid mixed drinks. They increase our sugar load, we knock them back faster and drink more than we meant to, and they raise our blood alcohol level too fast. 
• Don’t exceed guideline amounts and avoid binge drinking. While limited alcohol use appears to confer little overall health risk in otherwise healthy folks, alcohol intake above recommended limits is clearly associated with increased mortality and other medical morbidities. 
• Dilute. Divide the alcohol over two drinks 
• Consider taking folic acid. As I mentioned earlier, one of the mechanisms of action of breast cancer is through its impact on methylation and gene regulation – and the risk is higher in those who are low in folate/folic acid. In the Nurses' Health Study, consumption of one or more drinks per day was associated with a nonsignificant 5% increase in risk of breast cancer among females who consumed at least 300 micrograms of folic acid per day. By contrast, alcohol use was associated with a 32% increased risk of breast cancer in those with lower folate. Taking folic acid or methylfolate may partially mitigate, though does not eliminate, breast cancer risk in those who drink. The Iowa Women's Health Study found that folate intake can modify the higher risk of breast cancer in females who drink alcohol though this may be limited to ER-negative cancers for unclear reasons. 
• Nourish your gut and microbiome. Various studies also show that nutrition can modify alcohol-induced gut inflammation and, as a result, systemic inflammation and damage.  You can learn to do this in Hormone Intelligence, The 28-Day Gut Reset, and via other On Health Podcasts and articles on my website. 
• Consider post-drink support. The herb milk thistle, due to a compound called silybin, when taken after heavy alcohol consumption may help to protect/repair short-term alcohol induced damage to the liver cells (it’s considered a hepatoprotective herb), but it must be taken after drinking – and before bed or the next morning to work, and not prior to drinking when it may increase harm. 

Dr. Aviva's Bottom Line on Alcohol and Women's Health

• Alcohol may have a small positive effect on a limited number of conditions.
• Alcohol appears to have a largely negative effect on many aspects of women’s health.
• Some of this varies by individual, some by age and hormonal life cycle (puberty, reproductive years, perimenopause, menopause), and some by amount and frequency of alcohol intake. 
• No alcohol is probably better than any alcohol, but light drinking of 1-2 servings per week – true servings – not a big pour – is probably not going to significantly impair your health, though any alcohol does increase breast cancer risk and all alcohol should be avoided in pregnancy.
• Heavy drinking and binge drinking are absolutely risk factors for a wide-range of chronic and preventable diseases and conditions including breast cancer, other cancers, diabetes, osteoporosis, heart disease, cognitive decline, and more. 
• Lifestyle factors, including nutritional status, may impact your risk if you do drink.

And look, my dear, no matter what your age, heavy drinking is just a bad idea, binge drinking at any age can wreak havoc, and as we get older we really need to consider how alcohol is affecting our well-being and our health. Even the guidelines for moderate drinking don’t mitigate all risks – so if you are going to drink, keep it to the special occasion, even if that’s a glass of wine on Friday night or a G&T with a girlfriend on your birthday. 

Awareness of how alcohol affects your personal well-being, and reducing alcohol consumption or kissing it goodbye, can be an important part of your overall vote in favor of your long-term health – hormonal, reproductive, and overall. And really, it’s all about making the best choices for you, which I hope this episode has helped you to consider.