Bridging the gap: Alcohol use, menopause and mental health

From frontline to academia: First steps of the PhD journey 

Before returning to academia, I had the opportunity to work for the charity We Are With You, in Liverpool, supporting people who use drugs and alcohol. I quickly became aware that the majority of the service users were men, making me wonder: Where are the women? The very few on my caseload had to reschedule or cancel appointments, generally due to work or household priorities (looking after a child or caring for a loved one, for instance). Organising a stable follow-up proved challenging, and many dropped out of treatment.  

It was in this context that I came across a PhD offer to look at midlife women's alcohol use. This immediately resonated with me, as more needs to be done to support women in accessing information and treatment. And now, just over a year in, I am hoping that my research will lead to tangible improvement and be beneficial to women and the people around them. 

The big M, the second Spring, the change! 

Menopause has been a hot topic recently; thanks to the likes of TV host Davina McCall, creative Karen Arthur, MP Carolyn Harris, Dr Louise Newson and Dr Nighat Arif, the spotlight has been brought to focus on this phase of life. But what is it exactly? I realised that apart from my mother's and aunt's recollection of insomnia and hot flushes, my understanding of the menopause was nearly non-existent, and if that was the case for me, I'm willing to bet that it is for a lot of women. So here is what I have learned.

The World Health Organization (WHO) defines menopause as a fluctuation in sex hormone activity (the perimenopausal stage), a later decline in sex hormone production, and a gradual transition into a postmenopausal stage, when a woman's menstrual cycle has stopped for 12 months. It typically starts around the age of 45 and can affect women until around 55. However, variations exist, with some women experiencing perimenopause in their early 40s (occurrences before 40 are defined as 'premature' menopause) or until later than 55.  

Menopause causes various symptoms, differing in intensity, such as the infamous hot flushes, sleep disturbances, migraines, lack of concentration, the dreaded 'brain fog,' increased stress, and increased risk of depression and anxiety symptoms. The list is long, and no two women will have the exact same profile of symptoms. Menopause can have a significant impact on a woman's daily professional and social life; you might have heard about women having to take time off work or even quit their jobs, sparking the 'Menopause at work' initiative.  

Shifting trends: Women and alcohol  

In parallel, the NHS 2021 statistics on alcohol behaviours has observed that women of menopausal age, roughly between 45 and 64, increased their drinking and were more likely to drink above the NHS recommended guidelines of 14 units a week. This is more than their younger and older counterparts. We know that women in Western countries are drinking more, and that the historical drinking gender gap between men and women is closing. 

Traditional roles are changing, women drinking is more tolerated, and access to alcohol is made easier, via increased availability through off-licenses, feminisation of alcohol products and of venues. However, women are more vulnerable to alcohol harms, and more so as they age.  

Risks and vulnerabilities 

Biologically, women's body fat levels are greater than their body water levels compared to men, yet alcohol needs water to dissolve, causing greater concentrations of alcohol in women's bodies. Women also produce less dehydrogenase, the enzyme responsible for breaking down alcohol. Therefore, they are at greater risk of developing alcohol-related issues quicker such as liver disease and certain types of cancer.  

Another important mechanism involves sex hormones. The female neuroendocrine system - the network in charge of creating hormones - produces two main hormones essential to reproduction (among other functions), oestrogen and progesterone. 

These two hormones power important neurological pathways; the Hypothalamic-Pituitary-Adrenal (HPA) and Hypothalamic-Pituitary-Gonadal (HPG) pathways are responsible for stress-response and reproduction in our bodies. They work hand-in-hand, and may significantly be associated with the development and maintenance of alcohol use disorders. The HPA pathway, when dysfunctioning, can lead to stress-related cortisol overproduction, a risk factor for alcohol use disorder. The menopause transition, with its erratic production of oestrogen and progesterone, comes to disrupt the healthy functioning of these pathways.  

Research also shows strong associations between alcohol harm and mental ill-health in women, with women suffering from alcohol dependence more prone to also suffering from anxiety or depression. Women are more likely to use alcohol as a coping mechanism, and such motives to drink are strongly associated with more severe alcohol use. In other words, women could be self-medicating to cope with the severity of their psychological symptoms. 

The need for research 

Despite the known challenges faced by women regarding the menopause transition and alcohol use, and the established links between mental ill-health and drinking behaviour, research and knowledge bridging these topics is still too scarce. The 2022 Women's Health Strategy for England has called for a broad range of studies to address this lack of research. 

The recent spotlight on menopause has helped in gathering momentum for research in the broader field of women's health. It is in this context that this particular study has emerged. With the help of my supervisory team, Dr Abigail Rose, Dr Catharine Montgomery, Dr Andrew Jones & Dr Zetta Kougiali, we are asking: 'What are the associations between alcohol use, menopause transition, mental health and wellbeing?'.  

How I am delving into this 

To aid in answering this question, I am recruiting women aged 40 to 65 to complete fortnightly online surveys over six months (12 surveys in total), in which participants are asked about their menopausal/menstrual health, menopausal symptoms, drinking habits and motives, mental health, and wellbeing. I am currently in the recruitment and data collection stage and aim to start analysing by the end of 2024. 

I hypothesise that the more intense the menopausal and mental health symptoms are, and the more women evoke drinking to cope, the more likely they are to drink at harmful levels.  

We are hopeful that this study generates useful information to empower women into making informed choices regarding their alcohol consumption, and to support alcohol interventions tailored to midlife women's needs, as such interventions are currently nearly non-existent.  

If you are interested in participating, and you are a woman between 40 and 65, please email me at: [email protected]

We need as many women as possible to gather strong data and results. Thank you!