menopause and metabolic dysfunction-associated steatotic liver disease (MASLD)

If your doctor has ever said the words "fatty liver" after a routine blood test or ultrasound, you're far from alone, and the timing may not be a coincidence. Researchers have found that women after menopause have about twice the odds of having fat build up in the liver compared with women who haven't reached menopause yet. Here's what that condition is, why the drop in estrogen seems to matter, and what to ask your doctor about.

What is MASLD?

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the new name for what used to be called non-alcoholic fatty liver disease (NAFLD). The name changed in 2023, when liver societies from around the world agreed on new terms. Under the new definition, MASLD means fat has built up in the liver and you also have at least one of five cardiometabolic risk factors, such as a larger waistline, higher blood sugar, higher blood pressure, or higher triglycerides.

A liver is considered "fatty" when fat makes up about 5 percent or more of it. For many people it stays at that stage and never causes harm. In some, the fat comes with inflammation and cell damage. That more serious form is now called metabolic dysfunction-associated steatohepatitis (MASH), which used to be called NASH. Over time MASH can lead to scarring (fibrosis), and in some cases to cirrhosis, liver failure, or liver cancer.

What raises the risk?

MASLD is closely tied to how your body handles sugar and fat. Things that raise the risk include:

• carrying extra weight, especially around the middle
• insulin resistance or type 2 diabetes
• high triglycerides or high cholesterol
• high blood pressure
• a mostly sedentary day
• a diet high in added sugars and highly processed foods
• some medications, including corticosteroids
• very rapid weight loss

Read about menopause and high cholesterol

What are the symptoms of MASLD?

Most of the time, there aren't any. That's why so many women only find out when a blood test shows raised liver enzymes (ALT or AST) or an ultrasound done for something else picks it up. When symptoms do show up, they're often vague:

• tiredness that doesn't lift
• a dull ache or feeling of fullness under the right ribs

See a doctor right away if you notice yellowing of your skin or the whites of your eyes, dark urine, a swollen belly or swollen legs, vomiting blood or black stools, or new confusion or drowsiness. These can be signs of advanced liver disease and need to be checked urgently.

Why is MASLD more common after menopause?

A 2023 meta-analysis in the journal Menopause, led by Dr. Aunchalee Jaroenlapnopparat, pooled 12 studies comparing women before and after menopause. Postmenopausal women had about 2.4 times the odds of having fatty liver disease. When the researchers looked only at the six studies that adjusted for age and metabolic factors like body weight, blood sugar and blood fats, the odds were still about 2.2 times higher.

The authors point to the drop in estrogen as a likely reason. Estrogen helps decide where your body stores fat, how much fat travels from fat tissue to the liver, and how your body handles blood sugar. When estrogen falls, fat tends to shift toward the belly, insulin sensitivity often dips, and the liver can end up holding more fat. If you've felt like your body started storing weight differently in perimenopause, this is part of the same picture.

One important note: these studies show an association. They don't prove that menopause itself causes fatty liver, and they can't tell you your personal risk.

What does the research say about diet and movement?

Liver specialists agree that lifestyle is the foundation. None of this replaces your doctor's advice, and if you already have a diagnosis, your care team should guide the plan.

Weight, if you have extra to lose. The American Association for the Study of Liver Diseases reported that in people who already have the condition, losing at least 3 to 5 percent of body weight appears necessary to reduce liver fat, and 7 to 10 percent is needed to improve most of the inflammation and scarring seen on biopsy. Slow and steady is the goal here, since very rapid weight loss is itself a risk factor.

Read about perimenopause, menopause and weight loss: the fiber connection

A Mediterranean-style way of eating. A review in the Journal of Hepatology called the Mediterranean diet the most recommended dietary pattern for this condition. Think vegetables, legumes, whole grains, fish, olive oil and nuts, with less red meat and fewer ultra-processed foods.

Less added sugar. The same review links high intake of added sugars, especially fructose from sweetened drinks and processed foods, with more fat in the liver. Swapping sugary drinks for water or unsweetened options is one of the simplest places to start.

Moving your body. Both everyday movement, like cleaning, gardening and walking to the store, and structured exercise, like brisk walking, strength training or intervals, are linked to less liver fat, even when weight doesn't change much. Aiming for at least 150 minutes of moderate activity a week is a common recommendation.

Keeping an eye on alcohol. Even though MASLD isn't caused by alcohol, drinking puts extra load on a liver that is already working hard. Ask your doctor what's reasonable for you.

What will a doctor check?

If you have risk factors like type 2 diabetes, a larger waistline or high triglycerides, it's worth asking about your liver at your next checkup. The 2023 AASLD practice guidance recommends that doctors use a simple score called FIB-4, calculated from your age and routine blood work, to estimate the risk of liver scarring. Depending on the result, you may be sent for a specialized ultrasound scan, such as FibroScan, or to a liver specialist. Prescription treatments now exist for some people with MASH and scarring, which is one more reason to get properly assessed instead of guessing.

Questions women ask about MASLD

Is fatty liver disease more common after menopause?

Yes. A 2023 meta-analysis in the journal Menopause, led by Dr. Aunchalee Jaroenlapnopparat, pooled 12 studies and found postmenopausal women had about 2.4 times the odds of fatty liver disease compared with premenopausal women, and about 2.2 times after adjusting for age and metabolic factors. That shows a link, not proof that menopause causes it.

Can you have MASLD and not know it?

Yes. Most people have no symptoms. It is usually found when a blood test shows raised liver enzymes or an ultrasound done for another reason picks it up. When symptoms do show up, they tend to be vague, like tiredness or a dull ache under the right ribs.

What is the difference between NAFLD and MASLD?

They describe the same condition. In 2023, liver societies agreed to rename non-alcoholic fatty liver disease (NAFLD) as metabolic dysfunction-associated steatotic liver disease (MASLD). The new definition requires fat in the liver plus at least one cardiometabolic risk factor, such as a larger waistline or higher blood sugar, blood pressure or triglycerides.

How do doctors check for MASLD?

The 2023 American Association for the Study of Liver Diseases practice guidance recommends a score called FIB-4, worked out from your age and routine blood work, to estimate the risk of liver scarring. Depending on the result, your doctor may order a specialized ultrasound scan such as FibroScan or refer you to a liver specialist.

When should I see a doctor right away?

Get checked urgently if you notice yellowing of your skin or the whites of your eyes, dark urine, a swollen belly or legs, vomiting blood, black stools, or new confusion or drowsiness. These can be signs of advanced liver disease.

Bottom line

Fatty liver disease is more common after menopause, and falling estrogen appears to play a real part. It usually has no symptoms, so the best thing you can do is know your risk factors, ask your doctor about your liver numbers, and lean on the everyday habits the research supports: a Mediterranean-style plate, less added sugar, regular movement, and steady weight loss if you have extra to lose.