7 Surprising Facts Midlife Women Should Know About Alcohol

And a brief history, too

Photo by Kelsey Knight on Unsplash

Midlife women get confusing messages about alcohol. They hear drinking can worsen hot flashes and raise the risk of breast cancer. Alcohol has even been called "poison" and "toxic."

But wasn’t moderate drinking once considered heart healthy?

Although excess alcohol is no doubt harmful, these messages leave out big chunks of information. They don’t acknowledge that giving up drinking may not be right for everyone.

It also ignores the large body of observational data showing moderate drinking may help reduce cardiovascular disease and mortality. In fact, one of the key elements of the Mediterranean diet is moderate wine consumption.

So I took a deep dive into the research while keeping a midlife woman’s needs in mind. I came up with 7 surprising facts women need to know about.

But first, let’s go back to the 1970s, when the complicated relationship between alcohol and health first began.

The history behind alcohol and heart health

In 1974 a group of researchers discovered something odd. Alcohol abstainers had the highest number of heart attacks in their cohort.

This led to research showing that light to moderate alcohol intake had cardioprotective effects, while excessive consumption showed the opposite.

Even though abstainer bias was a concern, researchers began to control for it by accounting for the overall health of ex-drinkers.

By 2000, data from two national health interview surveys in the US population supported the following consensus:

In large populations, excess alcohol intake had been found to be associated with excess death, liver cirrhosis, some cancers, hemorrhagic stroke, cardiomyopathy, and hypertension. On the other hand, clear evidence exists for a protective effect of moderate alcohol intake against coronary artery disease.

A change of mind and the trial that wasn’t

During the early 2000s, a group of researchers re-evaluated the data, claiming that the healthy drinker bias negated any potential benefits to moderation drinking.

The years to follow were a constant back and forth between the opposing camps. The only way to get answers was to conduct a large, long-term randomized control study, which people had been talking about for years.

And in 2018, it was finally going to happen. The National Institute of Alcohol Abuse and Alcoholism’s Moderate Alcohol and Cardiovascular Health trial (MACH) began in February 2018.

This study was unfortunately cut off in May because of criticism of its funding from the alcohol industry.

However, The European Research Council is funding a large randomized controlled trial (RCT), which started last June.

The four-year study involves 10,000 people, with half receiving counseling on the Mediterranean diet with wine, and the other half receiving counseling on the diet with alcohol abstinence.

Hopefully, this will bring more clear answers.

Where we are now: The Precautionary Principle

Because of the doubts placed on old data, alcohol’s link to cancer, and new studies casting further doubt on the heart health connection, updated drinking recommendations reflect the precautionary principle.

For example, the World Health Organization says there is no safe level of alcohol. As of 2023, Canadian guidelines recommend only two drinks per week.

The 2020 Dietary Guidelines for Americans still recommend drinkers keep it to one drink a day for women and two for men. But this didn’t come without criticism.

It’s worth noting another issue found with epidemiological studies: the under report bias. In one Canadian study, drinkers under reported their alcohol intake by about half.

“Systematic under reporting of alcohol use could result in overestimating the association between a low amount of alcohol consumption and the risk of adverse health outcomes," wrote Vance and colleagues in this 2020 piece in JAMA Internal Medicine. “especially given evidence that heavy drinkers under report their true levels of alcohol consumption by up to 40% to 65%.”

My head was spinning at this point in my research, which is why I dug deeper to include controlled studies, revealing 7 surprising facts.

1. Nitric oxide is at the heart of it

I kept wondering: what is the mechanism that might make alcohol heart healthy?

Researchers who isolate animal and human tissues from endothelial cells that line blood vessels find that low doses of alcohol increase nitric oxide, a vascular dilator, while larger alcohol amounts decrease it.

I’ve written about the importance of nitric oxide and endothelial health for midlife women before. It matters because endothelial dysfunction, which results in reduced nitric oxide, is the starting event of heart disease.

“It is evident that low concentrations of ethanol are beneficial to endothelial cells,” wrote Toda and Ayajiki in the 2010 Alcohol and Alcoholism Journal. “Whereas high concentrations impair endothelial functions and cell viability.”

Excessive alcohol increases substances that lower nitric oxide, like homocysteine and oxidative stress. But why do low doses increase nitric oxide?

While we don’t know for sure, a randomized crossover trail gives us clues. Thirty-six postmenopausal women were given either white wine (25g of alcohol) or a cup of grape juice to have with dinner over six weeks.

The moderate drinking group had higher levels of adiponectin and an improved insulin sensitivity and lipid profile. Adiponectin is an adipokine produced from fat tissue known to increase nitric oxide and decrease inflammation.

Another intervention study with 40 men showed that 30g of daily alcohol of wine or gin had anti-inflammatory effects. But the wine had the additional effect of decreasing hs-CRP, an acute inflammatory marker.

Red wine provides additional benefits mostly due to its polyphenol content, including resveratrol, anthocyanins, and catechins working as powerful antioxidants. The wines with the highest resveratrol according to one study is Pinot noir and St. Laurent red wines.

Of course, these studies are small and not the last word on alcohol and cardioprotective benefits. But they agree with epidemiological studies revealing that in small doses, alcohol–especially red wine–may have heart health benefits.

2. Low to moderate drinking supports glycemic control

According to a meta-analysis of 14 trials, moderate alcohol significantly reduced fasting insulin and glycated hemoglobin, and insulin sensitivity in women only.

“Although these trials were generally short-term,” wrote Mukamal and Beulens in a 2022 editorial in the American Journal of Clinical Nutrition. “every existing trial among adults with diabetes that has spanned months to years has also demonstrated significant improvements in insulin resistance and/or glycemia.”

In a two-year trial, 224 people, 41-74 with type 2 diabetes, were given either 150ml mineral water, white wine, or red wine to drink with meals.

Between the three groups, there were no differences in blood pressure, weight, liver function, symptoms, or quality of life, except the wine groups reported better sleep quality. The wine drinkers had increases in HDL, with red wine showing the most increase, and improvements in fasting blood sugar and insulin.

This adds to the observational research suggesting that moderate drinking helps reduce the risk of type 2 diabetes. One theory is that increases in adiponectin, helps to increase insulin sensitivity and aids glycemic control.

3. Hormone therapy + alcohol = increased breast cancer risk 

According to the National Cancer Institute, alcohol causes 4% of cancers worldwide. Although heavy drinking increases this risk, light to moderate drinking is not benign.

The types of cancers linked to alcohol include cancers of the esophagus, head and neck, colon, and rectum and breast cancer for women. In fact, half of alcohol-related cancers are breast cancer. 

How does alcohol increase cancer risk? It could be the breakdown of alcohol to acetaldehyde (a known carcinogen), drinking-induced oxidative stress, or lower absorption of B vitamins such as folate.

But for breast cancer, experts believe estrogen plays a role. In fact, drinking has been found to increase estrogen at intakes of 15-30g per day, mostly through parent estrogens (which are precursors to make estrogen), lowering of sex hormone binding globulin (SBHG), and decreasing estrogen’s clearance from the body.

Higher estrogen levels may raise the odds of estrogen receptor positive (ER-Positive) breast cancer.

Here’s the kicker: menopausal hormone therapy (MHT) boosts this risk.

A 2015 study pooled two cohorts of 30,789 women aged 50 and older. Weekly alcohol consumption of >7 drinks per week resulted in 72 additional breast cancer cases per 100,000 compared to abstainers.

But for those on MHT, this number more than doubled to 180 additional cases.

Then there’s the Copenhagen City Heart Study revealing MHT users who reported over two drinks a day had five times the risk of breast cancer compared to those who did not drink or use hormones.

This isn’t new either as studies as early as the 90s showed this.

For instance, MHT users drinking alcohol increased their estrogen three-fold for about five hours, with no increases seen in women not taking hormones. And a review back in 1999 concluded: “Alcohol and hormone exposure together may act synergistically to create increased breast cancer risk.”

Every paper I could get my hands on showed an increased risk of combining alcohol and MHT than either one alone.

Why isn’t this talked about more? And why was the most current study on the subject done nearly a decade ago?

4. Alcohol’s effect on menopausal symptoms is a mixed bag (but not beer)

I kept hearing about how no amount of alcohol was good for common menopause symptoms like hot flashes. But that’s not what I found.

In 2005, researchers divided women ages 45-54 into two categories based on their experience of hot flashes: those who experienced them and those who didn't. The results showed that current alcohol intake of at least once per month was associated with less frequent and severe hot flashes.

In a 2015 study with 732 women aged 45 to 54 years revealed moderate, daily drinking was significantly associated with lower odds of experiencing hot flashes.

But another study with 293 women of the same age showed daily alcohol consumption significantly increased the risk of hot flashes. The research on hot flashes and alcohol is mixed.

Beer is another story because it contains isoxanthohumol (IX), which, during the brewing process, is turned into xanthohumol (XN). Once metabolized, it transforms into 8-prenylnaringenin (8-PN), a powerful phytoestrogen.

Thirty-seven postmenopausal were assigned to drinking alcoholic beer, non-alcoholic beer, and a control group. Both beer groups had reductions in hot flashes by over 40% while in the control group it was 10%.

A 2017 review of the literature states: 

There is evidence that regular and moderate intake of the polyphenols commonly found in hop and beer may help to relieve many common symptoms presented by women undergoing menopause.

5. Alcohol can disrupt sleep

People have used alcohol as a sleep aid for centuries, but official research on it didn't begin until the 1930s.

Initially, alcohol depresses the nervous system, which helps people relax and fall asleep. Yet alcohol can negatively affect sleep quality, particularly decreasing rapid eye movement (REM) and causing wakefulness the second half of the night.

“Evidence now suggests the deeper sleep of alcohol is also associated with an increase in frontal alpha waves, markers of wakefulness, and sleep disruption,” said Dan Ford, sleep psychologist and founder of the Better Sleep Clinic in this article on CNET. “Thus the deep sleep of alcohol is likely not to be restorative.”

Dose and timing are important. For instance, alcohol given close to sleep allows people to fall asleep but compromises sleep quality. One experiment measured the effect of moderate doses of alcohol on sleep at four different circadian phases, making the following conclusion:

Our data indicate that alcohol consumption near one’s circadian trough and when one has been awake for at least 13.33 hours (i.e., relatively high homeostatic load) is the worst time to consume alcohol in regards to disrupting sleep.

The higher the dose, the more sleep disruption, although even moderate drinking can increase sympathetic nervous system activity, potentially disrupting sleep. One review found circadian alterations following intake of higher than .5g/kg. For a 150-pound woman, that would be 34g of alcohol.

6. The pattern of drinking matters

We’ve talked about the dose and timing of alcohol, but there’s also the pattern of drinking. Do we drink with dinner? On an empty stomach? Right before bed?

A 2016 review in Food and Function, shares evidence that drinking wine with meals provides additional benefits than drinking alone.

For starters, when a person takes alcohol with food, the stomach begins metabolizing it with the enzyme alcohol dehydrogenase (ADH). This puts less of a burden on the liver, allowing a gradual rise in blood alcohol levels.

Drinking wine with meals may lower the risk of food borne illness as it helps kill pathogenic bacteria.

There is potential for maximizing other benefits. A study with 312,388 adults from the UK Biobank without type 2 diabetes were followed for over 10 years. Consuming alcohol with meals was associated with 12% lower risk of developing diabetes, but drinking outside meals wasn’t.

And last is the Mediterranean diet, which includes red wine with meals. Research from the PREDIMED trial shows the Mediterranean diet with nuts or olive oil decreased the risk of cardiovascular disease and breast cancer, compared to a low-fat diet.

Wine has been a strong risk-lowering factor of the Mediterranean diet. Researchers estimate that removing wine could decrease the benefits by 12-24%.

So, enjoying wine, or another alcoholic beverage, with a meal may be a superior pattern of drinking. Of course, we need more research to say for sure.

7. Alcohol affects everyone differently

The last thing to remember is that we all react differently to alcohol, with some people unable to control their intake. According to the National Institute on Alcohol Abuse and Alcoholism, the misuse of alcohol is linked to increased chronic disease, sleep problems, certain cancers and accidents.

For instance, consuming 200g of alcohol over one to two days — binge drinking — increases the risk of a coronary event 3-6 times compared to distributing the alcohol over the week.

A 2022 study in the Health Promotion International interviewed 50 women from South Australia (ages 45-64). They found women’s relationship with alcohol varied depending on social class.

Identifying the reason women drink is important, as many drink to numb or avoid feelings. One woman said:

Loneliness is definitely a factor for me, and I think it is for a lot of women. And I think once you start having a drink, it becomes a habitual. I’d like to see more done in terms of the loneliness because I think it is a real thing.

Of course, using alcohol in this way can be unhealthy both by drinking too much and not finding a long-term solution for loneliness.

Another factor is that we all metabolize alcohol differently depending on our genes. Although not the scope of this post, differences in metabolism may be at least partially responsible for how we feel in response to alcohol, risk of cancer, menopausal symptoms, and alcohol use disorder, and its ultimate effect on health.

Conclusion: The SMART way to drink

While the science on alcohol is evolving, it’s clear that the choice is deeply personal and dependent on individual factors like health, lifestyle, and preferences.

As for any of the potential health benefits, drinking is not the only way to gain them, thankfully. So, it’s never advised to start drinking if you don’t drink.

But if you choose to drink, there’s a way to do it that helps stack the benefits in your favor. So based on this research, I used the smart acronym to help you drinker smarter.

Stop drinking over 3 hours before bed to ensure good sleep. Drink earlier in the afternoon/evening and try a favorite herbal tea later in the night.

And if drinking is not working for you, stop for a period (or for good) and see how it makes you feel.

Make it low to moderate and skip days. Pick a favorite cup that meets the moderate guidelines. For help with skipping days, try the Mindful Drinking app which has strategies for reducing drinking during the week.

If you are on hormone therapy, talk with your health care provider about how much alcohol to drink. 

Always have alcohol with food or enjoy a drink socially. Drinking with meals helps maximize the benefits and slow the absorption of alcohol. Drinking moderately with friends can increase social bonding, another benefit to health.

Remember your B vitamins, including folate which, as research shows, may help decrease the risk of breast cancer. Sources of folate include asparagus, Brussels sprouts, bread, lentils, leafy greens, broccoli, and citrus fruits.

Try the “Mediterranean way of drinking” which includes red wine alongside a Mediterranean-style diet which has shown benefits in PREMED study. A Mediterranean diet is rich in fruits, vegetables, whole grains, olive oil, nuts, legumes, with moderate fish, dairy and poultry, and less often red meat.

To drink or not to drink—you decide!

The next time you hear you must cut out alcohol, remember there’s another side to it.

Midlife is a good time to reflect on your drinking habits. Maybe you can track your drinking to see where you stand. Does alcohol add to your life or is it a crutch or worse, harming your health?

Every woman needs to decide for herself what is best for her. That may be to quit, take a break, or keep enjoying it with some tweaks.

All are perfectly acceptable.

What’s your experience been with alcohol at this stage of life?