The American College of Obstetricians and Gynecologists

Women’s Health Care Physicians

Committee Opinion
Number 496 • August 2011
Committee on Health Care for Underserved Women
This information should not be construed as dictating an exclusive course of treatment or
Reaffirmed 2013 procedure to be followed.

At-Risk Drinking and Alcohol Dependence: Obstetric

and Gynecologic Implications
ABSTRACT: Compared with men, at-risk alcohol use by women has a disproportionate effect on their health
and lives, including reproductive function and pregnancy outcomes. Obstetrician–gynecologists have a key role in
screening and providing brief intervention, patient education, and treatment referral for their patients who drink
alcohol at risk levels. For women who are not physically addicted to alcohol, tools such as brief intervention and
motivational interviewing can be used effectively by the clinician and incorporated into an office visit. For pregnant
women and those at risk of pregnancy, it is important for the obstetrician–gynecologist to give compelling and
clear advice to avoid alcohol use, provide assistance for achieving abstinence, or provide effective contraception
to women who require help. Health care providers should advise women that low-level consumption of alcohol in
early pregnancy is not an indication for pregnancy termination.

The National Institute on Alcohol Abuse and Alcoholism white non-Hispanic women (5.6%), black non-Hispanic
defines at-risk alcohol use for healthy women as more than women (3.5%), and Hispanic or Latino women (3.8%)
three drinks per occasion or more than seven drinks per (3). In 2009, 25.6% of individuals aged 18–24 years
week and any amount of drinking for women who are reported binge drinking (4). Of those individuals, the
pregnant or at risk of pregnancy. Binge drinking is defined majority were white non-Hispanic, college graduates who
as more than three drinks per occasion. Almost 50% of had an average household income greater than $50,000
binge drinking occurs among otherwise moderate drink- per year (4). Among women aged 18–34 years who binge
ers (1). Moderate drinking is defined as one drink per drink, approximately one third (31.4%) report drink-
day (2). When evaluating a patient’s drinking habits, it is ing eight or more drinks per occasion (5). In 2008, 61%
important to verify the description of “a drink” to deter- of full-time college students were current drinkers and
mine the actual amount of alcohol consumed (Box 1). 40.5% reported binge drinking (3). Binge drinking is
National surveys indicate that American Indian and associated with a sudden peak in the level of alcohol in the
Alaska Native women (13.7%) were the most likely race blood, resulting in unsafe behavior and the risk of more
to have an alcohol use disorder. This is compared with reproductive and organ damage than sustained high levels
of alcohol consumption (6).
For many people, alcohol use can be a pleasant
Box 1. What Is a Drink? experience as a method of relaxation and social connec-
One standard drink is equal to 15 mL of pure ethanol
tion. It also offers some beneficial cardiovascular effects
(7). However, women are particularly vulnerable to the
• Beer or wine cooler – 12 oz physical and psychosocial health risks of at-risk alcohol
• Table wine – 5 oz (25-oz bottle = 5 drinks) use. Alcohol-related mortality represents the third lead-
• Malt liquor – 8–9 oz (12-oz can = 1.5 drink) ing cause of preventable death for women in the United
• 80-Proof spirits – 1.5 oz (a mixed drink may contain 1–3 States (8). As indicated in Box 2, at-risk alcohol use results
or more drinks) in multiple adverse health effects. Of note, data indicate
that women who drink between two and five drinks
per day have up to a 41% increased incidence of breast Obstetrician–gynecologists have important oppor-
cancer, and the risk increases linearly with consumption tunities for at-risk alcohol use intervention in three key
throughout this range (9, 10). areas: 1) identifying women who drink at risk levels, 2)
encouraging healthy behaviors through brief intervention
and education, and 3) referring patients who are alcohol
dependent for professional treatment.
Box 2. At-Risk Alcohol Use: Secondary
Consequences Affecting Women Identification of At-Risk Drinking
Increased medical and physical risks The U.S. Preventive Services Task Force recommends
• Unplanned pregnancy that all adult patients in a primary care setting be
• Sexually transmitted diseases*
screened for alcohol misuse and provided counseling
for identified risky or harmful drinking. Referral for
• Altered fertility †, ‡
specialist treatment may be appropriate for those with
• Menstrual disorders§ alcohol abuse or dependence (11). All women seeking
• Injuries obstetric–gynecologic care should be screened for alcohol
• Seizures§ use at least yearly and within the first trimester of preg-
• Malnutrition§, || nancy. It should be noted that women who drink at risk
• Cardiomyopathies¶
levels are less likely to maintain routine annual visits, and
screening should be considered for episodic visits if not
• Cancer of the breast, liver, rectum, mouth, throat, and
completed within the past 12 months. Screening can be
esophagus§, #, **
accomplished using a variety of simple validated tools,
Increased risk of psychosocial problems like TACE with additional questions about the quantity
• Loss of primary relationships and frequency of alcohol use, within the context of the
• Sexual assault routine visit (Box 3). Although the CAGE mnemonic
• Loss of income screening tool has been taught in most medical schools
• Child neglect or abuse and loss of child custody and residency programs, it has not proved to be sensi-
tive for women and minorities (12). Using a validated
• Domestic violence
screening tool decreases false-positive and false-negative
• Driving under the influence responses. Women may fear disclosure of their alcohol
• Altered judgement use will result in the loss of employment, their children,
• Bartering sex for drugs or their relationships. Therefore, it is crucial that the cli-
• Depression and suicide nician assure the patient before screening that the infor-
mation disclosed is privileged and confidential. Seeking
*Nicoletti A. The STD/alcohol connection. J Pediatr Adolesc obstetric–gynecologic care should not expose a woman
Gynecol 2010;23:53–4.
to criminal or civil penalties or the loss of custody of her
†
Rossi BV, Berry KF, Hornstein MD, Cramer DW, Ehrlich S,
Missmer SA. Effect of alcohol consumption on in vitro fertiliza- children (13).
tion. Obstet Gynecol 2011;117:136–42. Women who develop alcohol or substance use
‡
Grodstein F, Goldman MB, Cramer DW. Infertility in women dependence are often more likely than men to deny
and moderate alcohol use. Am J Public Health 1994;84:1429–32. that they have a problem and to minimize the problems
§
Corrao G, Bagnardi V, Zambon A, La Vecchia C. A meta-anal- associated with their use. However, when they do seek
ysis of alcohol consumption and the risk of 15 diseases. Prev help for the problem, it often is from their primary care
Med 2004;38:613–9.
providers (14). Importantly, most women who use alco-
||
National Institute on Alcohol Abuse and Alcoholism. Alcohol
and nutrition. Alcohol Alert No. 22 PH 346. Bethesda (MD): hol at risk levels have no signs on physical examination.
NIAAA; 1993. Available at: [Link] A detailed medical history obtained by a trusted clinician
tions/[Link]. Retrieved April 18, 2011. remains the most sensitive means of detecting alcohol
¶
Urbano-Marquez A, Estruch R, Fernandez-Sola J, Nicolas JM, abuse (15).
Pare JC, Rubin E. The greater risk of alcoholic cardiomyopathy
and myopathy in women compared with men. JAMA 1995;274: Encouraging Healthy Behaviors and
149–54.
#
Ferrari P, Jenab M, Norat T, Moskal A, Slimani N, Olsen A, et al.
Early Intervention Strategies
Lifetime and baseline alcohol intake and risk of colon and rectal Many women may be surprised to learn that their drink-
cancers in the European prospective investigation into cancer ing exceeds a safe level of alcohol consumption. They may
and nutrition (EPIC). Int J Cancer 2007;121:2065–72.
live or associate with others who drink similar amounts
**
Kuper H, Tzonou A, Kaklamani E, Hsieh CC, Lagiou P, Adami HO,
et al. Tobacco smoking, alcohol consumption and their interac- of alcohol and consider their alcohol use as “normal.”
tion in the causation of hepatocellular carcinoma. Int J Cancer Offering compassionate education, exploring practical
2000;85:498–502. strategies to reduce use, and requesting a follow-up
appointment is a successful strategy for many women

2 Committee Opinion No. 496

 “As your obstetrician–gynecologist, I am con-
Box 3. Alcohol Use Screening Tools cerned that your menstrual irregularities or
other clinical findings may be associated with
TACE your drinking. This level of drinking also puts
you at risk of unplanned pregnancy and inju-
• T – Tolerance ries. Are you willing to try and reduce your
How many drinks does it take to make you feel high? drinking? I can offer you resources to help.”
(More than 2 drinks = 2 points)
(Wait for her response.)
• A – Annoyed
Have people annoyed you by criticizing your drinking? “Getting pregnant at this time could be very
(Yes = 1 point)
harmful for you and your baby. I want you to
consider using a more effective contraception
• C – Cut down method while you are working on reducing
Have you ever felt you ought to cut down on your your alcohol intake.”
drinking?
(Yes = 1 point) (Wait for her response.)
• E – Eye-opener At the conclusion of the brief intervention, it is
Have you ever had a drink first thing in the morning to important to assist the patient in setting a goal (eg, “I
steady your nerves or get rid of a hangover? will not have more than three drinks at the Friday happy
(Yes = 1 point) hour”), record the goal, and let her know that there will
be a follow-up discussion at the next visit. If she does not
A total score of 2 points or more indicates a positive consistently meet her goal, restate the advice to quit or cut
screening for at-risk drinking back on drinking, review her plan, and encourage her to
Alcohol Quantity and Drinking Frequency Questions seek additional support. A failed attempt is a motivating
moment toward seeking help.
• In a typical week, how many drinks do you have that
contain alcohol? Referral
(Positive for at-risk drinking if more than 7 drinks) Women who continue to drink or use alcohol at risk
• In the past 90 days, how many times have you had levels and women who exhibit signs of alcohol depen-
more than 3 drinks on any one occasion? dence require referral to a substance abuse specialist. This
(Positive for at-risk drinking if more than one time) referral is best made while the patient is in the clinician’s
office so that she is involved in making the appointment
Data from Sokol RJ, Martier SS, Ager JW. The T-ACE ques-
tions: practical prenatal detection of risk-drinking. Am J Obstet with the encouragement of her health care provider.
Gynecol 1989;160:863–8; discussion 868–70 and National Local substance abuse treatment programs can be found
Institute on Alcohol Abuse and Alcoholism. Helping patients through the Substance Abuse and Mental Health Services
who drink too much: a clinician’s guide. Updated 2005 edition. Administration treatment locater (19). If the patient
Bethesda (MD): NIAAA; 2005. Available at: [Link]
[Link]/publications/practitioner/CliniciansGuide2005/Guide_
refuses treatment, the health care provider should respect
[Link]. Retrieved April 18, 2011. her decision, make a short-term follow-up appointment
with her, and assure her that she will be welcomed back
in the clinician’s office. It may take a number of offers
before the patient is ready to accept a treatment referral.
The patient’s trust in her medical provider may be key in
who are not physically or psychologically dependent on taking the step toward treatment.
alcohol. There are effective alcohol educational materials
available for patients that are free or offered at a very low Alcohol Use and Pregnancy and
cost (see Resources). Breastfeeding
Brief, motivation-enhancing interventions are asso- Alcohol is a teratogen. Fetal alcohol syndrome is the most
ciated with a sustained reduction in alcohol consumption severe result of prenatal drinking. Fetal alcohol syndrome
(16–18). Following is an example of a brief intervention: is associated with central nervous system abnormalities,
“You indicated that you are drinking five or six growth defects, and facial dysmorphia. However, for
drinks one evening a week and that you often every child born with fetal alcohol syndrome, many more
do not feel drunk when you drink that amount. are born with neurobehavioral defects caused by prenatal
This is considered at-risk drinking. What do alcohol exposure. Alcohol-related birth defects include
you think about that?” growth deformities, facial abnormalities, central nervous
system impairment, behavioral disorders, and impaired
(Wait for her response.) intellectual development. Alcohol can affect a fetus at any

Committee Opinion No. 496 3

stage of pregnancy, and the cognitive defects and behav- be monitored at the postpartum and follow-up visits
ioral problems that result from prenatal alcohol exposure (27). It is important to educate the at-risk patient about
are lifelong. In early pregnancy during organogenesis and pregnancy prevention and offer and provide effective,
perhaps before the patient’s recognition of pregnancy, long-term reversible contraception until at-risk alcohol
the fetus may be particularly vulnerable to maternal use has been curtailed.
binge or heavy alcohol use. Alcohol-related birth defects Contrary to cultural folklore, alcohol consump-
are completely preventable (20). Even moderate alcohol tion does not enhance lactational performance. There is
consumption during pregnancy may alter psychomo- consistent evidence showing that when lactating mothers
tor development, contribute to cognitive defects, and consume alcohol, there is reduced milk consumption by
produce emotional and behavioral problems in children, the infant (28). Alcohol consumption during lactation
although patient denial and underreporting make it dif- is associated with altered postnatal growth, sleep pat-
ficult to quantify these effects (21). There is evidence of terns, and psychomotor patterns of the offspring (29).
varying susceptibility to alcohol’s effect on the developing After breastfeeding is well established, a mother should
fetus. Although alcohol consumption may have negative be encouraged by her health care provider to wait 3–4
consequences for any pregnant woman, the effects of hours after a single drink before breastfeeding her infant.
alcohol may be more potent in mothers who are older, in By doing so, the infant’s exposure to alcohol would be
poor health, or who also smoke or use drugs (22). negligible (30).
The U.S. Surgeon General advises that pregnant
women should not drink any alcohol. Women who have Coding for Screening and Assessment
already consumed alcohol during a current pregnancy and Brief Intervention
should stop in order to minimize further risk, and those There are two Current Procedural Terminology codes
who are considering becoming pregnant should abstain to report for alcohol abuse structured screening and
from drinking alcohol. Recognizing that nearly one half brief intervention services. Report Current Procedural
of all births in the United States are unintended, women Terminology codes 99408 (alcohol abuse structured
of childbearing age should discuss with their clinicians screening and brief intervention services; 15 to 30 min-
steps to reduce the possibility of prenatal alcohol expo- utes) and 99409 (greater than 30 minutes) for screen-
sure (20). Health care providers should advise women ing and brief intervention services for patients without
that low-level consumption of alcohol in early pregnancy Medicare. These codes are only reportable for structured
is not an indication for pregnancy termination. screening using a validated screening tool, such as TACE,
A recent study indicated that the highest prevalence and brief intervention. They are not reportable when
of late-pregnancy alcohol use was reported by women physicians ask patients about their alcohol use as part
who were white non-Hispanic, college graduates, and of a comprehensive medical history. The services under
aged 35 years or older (23). However, these same women these new codes may be conducted as part of a periodic,
were those who reported the least screening and counsel- scheduled, preventive care office visit or in an acute
ing for alcohol use by their health care providers. There setting.
is strong evidence that brief behavioral counseling inter-
ventions with women who engage in at-risk drinking Resources
reduce the incidence of alcohol-exposed pregnancy (24,
25). Pregnant women are generally motivated to change American College of Obstetricians and Gynecologists. Alco-
their drinking behavior, and alcohol dependence is rela- hol, tobacco, and other substance use and abuse. Guide-
tively rare (24). In one multicenter project, nearly 70% of lines for Adolescent Health Care [CD-ROM]. 2nd ed.
women who were drinking at risky levels and not using Washington, DC: ACOG; 2011.
effective contraception reduced their risk of alcohol- National Institute on Alcohol Abuse and Alcoholism
exposed pregnancy 6 months after a brief intervention (NIAAA), has free brochures on women and alcohol
because they stopped or reduced their drinking below as well as pregnancy and drinking available in English,
risky levels or they started using effective contraception Spanish and for American Indians. They also have video-
(26). Randomized studies report significant reductions taped screening and brief intervention interviews to guide
in alcohol use and improved newborn outcomes after physician–patient interaction.
interventions with women who are already pregnant.
National Institute on Alcohol Abuse and Alcoholism. Help-
Women who are alcohol dependent need intense special-
ing patients who drink too much: a clinician’s guide and
ized counseling and medical support during the process
of withdrawal. They should be given priority access to related professional support resources. Available at: http://
withdrawal management and treatment (24). If a woman [Link]/Publications/EducationTraining
continues to use alcohol during pregnancy, harm reduc- Materials/Pages/[Link]. Retrieved April 18, 2011
tion strategies should be encouraged (24). Postpartum, Substance Abuse and Mental Health Services Admin-
many women who were abstinent during pregnancy istration. Substance abuse treatment locator. Available at:
rapidly resume at-risk levels of alcohol use and should [Link] Retrieved May 18, 2011.

4 Committee Opinion No. 496

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Committee Opinion No. 496 5

 29. Mennella JA, Garcia-Gomez PL. Sleep disturbances after Copyright August 2011 by the American College of Obstetricians and
acute exposure to alcohol in mothers’ milk. Alcohol Gynecologists, 409 12th Street, SW, PO Box 96920, Washington,
2001;25:15– 8. DC 20090-6920. All rights reserved. No part of this publication may
be reproduced, stored in a retrieval system, posted on the Internet,
30. Little RE, Northstone K, Golding J. Alcohol, breastfeeding, or transmitted, in any form or by any means, electronic, mechani-
and development at 18 months. ALSPAC Study Team. cal, photocopying, recording, or otherwise, without prior written per-
Pediatrics 2002;109:E72–2. mission from the publisher. Requests for authorization to make
photocopies should be directed to: Copyright Clearance Center, 222
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ISSN 1074-861X
At-risk drinking and alcohol dependence: obstetric and gyneco-
logic implications. Committee Opinion No. 496. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2011;118:383–8.

6 Committee Opinion No. 496