A divorce at 28 left Sara* in emotional turmoil. In search of a distraction from her personal life, she turned to Chicago’s lively bar scene. Drinking holes were judgment-free zones, and Sara found a bar for every activity: “You could go to watch a football game, read a book, drink with friends.”
Soon enough, imbibing became Sara’s private pastime too. She’d stock up on cheap grocery-store vodka, drinking up to a liter a day. At age 31, three years after ending her marriage, Sara was diagnosed with alcohol-related hepatitis and cirrhosis, according to Dr. Haripriya Maddur, her hepatologist at Northwestern Memorial Hospital.
The diagnosis came as a shock to Sara, who had no idea she’d put herself at risk for such serious diseases. “You don’t think it will happen to you,” she said. “You don’t realize the liver doesn’t flush everything out.”
In recent years, the same diagnosis has come as a shock to a growing number of patients in their 20s and 30s, as cases of alcohol-related cirrhosis rise among millennials. This alarming trend caught the attention of Dr. Elliot Tapper and Dr. Neehar Parikh, both hepatologists at the University of Michigan, in 2017. Given that alcohol-related liver disease has traditionally been concentrated in people over 65, the two doctors decided to investigate further.
Their subsequent study findings, published in BMJ in July, were surprising enough to garner national coverage: The greatest increase in deaths from alcohol-related cirrhosis between 2009 and 2016 was found in people aged 25 to 34. Within that age group, the rate of death had risen 13 percent in women, compared to 9 percent in men. In 2016, 209 millennial women died from cirrhosis, compared to 66 in 2008. Although we assume that those assigned female at birth have similar risks, we have no cirrhosis data about transgender men.
“More men are dying, but the increases are faster for women,” Tapper said, noting that the absolute number of cirrhosis deaths doesn’t reveal the full scope of the situation. While he and Parikh focused on cirrhosis in their study, a growing number of millennial women are also incurring other alcohol-related diseases. Alcohol consumption can cause a range of health problems, including pancreatitis, heart disease and three types of liver disease:
- Fatty liver disease is marked by a build up of fat cells in the liver. It’s an acute condition, meaning it can develop after days, weeks or months of heavy drinking. The damage is reversible with abstinence.
- Alcoholic hepatitis (unrelated to infectious hepatitis) is most often caused by prolonged alcohol misuse. Less commonly, it develops after a short period of extreme binge drinking. The severity of liver damage varies, but is usually reversible with permanent abstinence.
- Cirrhosis is severe scarring of the liver caused by conditions including hepatitis and chronic alcoholism. The liver becomes impaired while processing toxins like alcohol, but it can usually repair itself. When it has to process more alcohol than it can handle, however, it begins to scar, a process known as fibrosis. As hard scar tissue replaces healthy tissue, organ function is lost. The damage isn’t fully reversible.
For alcohol-related cirrhosis to strike someone in their 20s or 30s, consumption has to be exceedingly high. Cirrhosis in young women tends to surprise both patients and doctors, says Dr. Jessica Mellinger, another hepatologist at the University of Michigan. “That demographic doesn’t come to mind when you think of someone with alcoholism.”
Often, changes in appearance are what motivate young women with early-stage cirrhosis to see a doctor. “A lot of concern from the patient’s standpoint,” said Maddur, “is about why they’re losing their hair and why they’re getting skinnier.'”
Those were two of the symptoms Sara noticed before her diagnosis. She was also having trouble with her memory and balance, and itching all over her body as a result of peripheral neuropathy (nerve damage). And she had severe pain in her belly from built-up abdominal fluid, called ascites. By the time Sara took herself to the emergency room, her stomach was distended to the point where she looked pregnant.
“My symptoms built up,” she said, “and then overnight, my body just quit.”
Why the uptick?
Without a partner and with limited social support, Sara worried her future would be a lonely and difficult road. Drinking eased the stress.
She’s far from the only 30-something feeling stressed about the future. According to a Pew report, millennials have more student loan debt, higher poverty and unemployment levels, and lower income levels than any previous generation at the same stage of life. Generational stressors prompted by the recession, Parikh and Tapper surmise, may be a factor in climbing rates of deaths from cirrhosis. But they’re reluctant to blame the rise solely on an economic downturn, particularly because their patients vary in terms of income and education.
In fact, according to data from the National Emergency Department Sample, the Washington Post found that women from wealthier neighborhoods are much more likely to show up at the hospital for alcohol intoxication than lower-income women. Additionally, 31 percent of the women with a college degree reported drinking multiple days a week, compared to 21 percent of women with some college and 14 percent of women with a high school education or less.
A contributing factor, experts speculate, might be a lack of awareness around healthy consumption limits. “Maybe they don’t know what a glass of wine really means,” says Mellinger. “And if they have one drink a day, how big is that one drink?”
Those recommended limits are lower than you might think: no more than eight drinks per week for women, per the National Institute on Alcohol Abuse and Alcoholism. A standard drink contains 14 grams of alcohol, which is roughly equivalent to 12 ounces of beer with 5 percent alcohol, 5 ounces of wine with 12 percent alcohol and 1.5 ounces of liquor with 40 percent alcohol.
How to know if you’re at risk
The danger of alcohol-related liver disease is higher for women because of their heightened sensitivity to alcohol. A woman’s organs are exposed to more alcohol because, pound for pound, women have less water in their bodies than men. With higher alcohol levels in their blood, they are more vulnerable to resulting health problems.
The notion that drinking in moderation promotes heart health is only true for women over 55, according to the NIAAA. And a recent meta-study published in the Lancet linked alcohol consumption of any amount with health risks and no benefits.
Unfortunately, patients can’t assume that routine checkups will catch alcohol-related health issues. Currently there’s no standard practice for screening people who toe the line of unhealthy drinking. If women regularly cross the eight-drinks-per-week threshold, they should tell a doctor. (And if they’re having a hard time cutting back, there are alcohol cessation tools and programs to help.)
Maddur wishes doctors were more proactive. “It should start with first-line primary care doctors asking people how much they’re drinking,” she said. “If they’re exceeding the recommended limit, doctors should give them tools with which to minimize their drinking.”
Getting tested is smart even if you feel healthy; signs of cirrhosis often don’t show up during the early stages of the disease. Early symptoms include yellowed skin (jaundice), itching, loss of appetite and a swollen abdomen. If drinking continues and the disease advances, symptoms can include degeneration of the brain, severe bleeding, kidney failure and weakness. Diagnosing cirrhosis involves some combination of blood tests, imaging and liver biopsies.
The good news is that the liver has a high capacity to regenerate compared to other organs. After a year of sobriety, Sara’s liver is functioning again. Most of her hair is back, and she’s put on weight and regained her ability to walk. But she can’t resume drinking, ever, and must monitor everything that goes into her body. She also struggles with balance, takes medication for memory problems and sees a neurologist for peripheral neuropathy. Managing these issues, and protecting her liver from further damage, will be a lifelong effort.
*Name changed by request
I find this to be very true of many of my patients and friends. I’m not a drinker (other than the occasional get-together or ladies night) but i can see how circumstances might make it a daily thing. Before you know it, one drink turns into one bottle and women’s bodies simply cannot handle that.
I’m one of these cases. Army vet that thought drinking in large amounts was normal initially, then it became a med(kinda), also got in a serious relationship with another alcoholic. Before all was said and done I was drinking 2 fifths of vodka each weekend day and 1+ fifth every weekday. A lot has changed in my life over the last 2 years and I’m grateful but also uneasy about my future.