Alcohol consumption in peri- and postmenopausal women: differences in hormonal, bone, and cardiometabolic health outcomes between the United States and Europe

Background: Historically, women have been underrepresented in medical and scientific research causing significant gaps in the evidence base for women’s health across the lifespan. This is especially apparent in peri- and postmenopause, a midlife stage characterized by major hormonal, skeletal, and cardiometabolic changes. Despite its effect on all women at some point in life, research surrounding menopause remains underfunded and therefore underrepresented in current analyses, and the effects of alcohol consumption during this stage are not yet fully understood. Aim: This thesis aims to review the relations between alcohol consumption and hormonal, bone, and cardiometabolic health outcomes in peri- and postmenopausal women - including estradiol and vasomotor symptoms, bone mineral density, osteoporosis and fractures, and cardiometabolic markers such as adiposity, lipid profile, blood pressure, and inflammation- with a particular focus on uncovering any correlations between different cultural drinking habits between the United States of America (USA) and European Union (EU). Methods: A systematic search was conducted in PubMed and Scopus to identify studies examining alcohol consumption and relevant hormonal, bone, and cardiometabolic outcomes in peri- and postmenopausal women. Eligible studies included human research on peri- or postmenopausal women published between 2000 and 2026 which measured alcohol consumption and reported hormonal, bone, metabolic, and/or cardiovascular outcomes. Studies were screened according to predefined inclusion and exclusion criteria and grouped by geographic setting (USA vs EU), and alcohol exposure was harmonized into grams of ethanol to allow comparison across the two regions. Results: This review synthesized evidence from 17 studies (9 USA and 8 EU) across three health domains. The USA evidence derived almost entirely from large longitudinal cohorts, whereas the EU evidence relied more on smaller beverage-specific intervention trials. Regional differences appeared to reflect study design and measurement conventions (a USA standard drink ≈14 g vs an EU unit ≈10 g ethanol) rather than a clear biological divergence, and a comparable ~14–15 g/day risk threshold emerged in both settings. Findings suggested a threshold effect rather than a linear dose-response, with biological risk tending to increase above approximately 14-15 g of ethanol per day mark, while lower intake was associated with neutral or, for some outcomes, favourable results. In the hormonal domain, heavy consumption (>98 g/week) was associated with increased vasomotor symptom frequency (OR = 1.24), whereas moderate perimenopausal intake (14-70 g/week) was associated with a 48% reduction in the odds of bothersome symptoms. Bone-metabolic outcomes demonstrated that moderate consumption (5-14 g/day) is associated with a 12-25% reduction in fracture risk, potentially driven by non-alcoholic bioactives in beer and wine. Cardiometabolic results showed consistent lipid benefits (increased HDL-C) at moderate levels, though ethanol was found to counteract the blood pressure-lowering benefits of non-alcoholic polyphenols. Conclusion: Alcohol appears to act as a powerful endocrine modifier during the menopause transition, with its effects heavily moderated by dose, beverage type, and menopausal stage; apparent USA–EU differences appeared to stem largely from measurement conventions and study design rather than underlying biology once exposure was standardized in grams of ethanol. While low-to-moderate consumption may provide specific skeletal and lipid protection, these benefits are easily eclipsed by physiological risks to blood pressure and symptom severity as intake exceeds moderate limits. Moreover, although cancer outcomes were outside this review's scope, the WHO notes that no level of alcohol intake is safe with regard to cancer risk.