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Here’s a common scenario: A woman in her late 30s starts drinking a glass or two of wine every night. Ten years pass. She notices that she is more tired than usual, her stomach seems bloated, and her skin looks a little yellow. Finally, she goes to her doctor, expecting to be told that she is simply overworked. Instead, she is diagnosed with cirrhosis, or permanent scarring of the liver. She didn’t think she had drunk that much. She had no idea her liver was even in danger.
In recent years, more and more women have been diagnosed with serious liver diseases, including cirrhosis, which can be life-threatening. Much of the increase is related to increased alcohol consumption, which has led to rising rates of alcoholic liver disease (ALD) (formerly called alcoholic liver disease). Rising rates of steatotic liver disease (formerly called fatty liver disease) are also increasing the number of women diagnosed with liver disease, and this trend is expected to continue.
What is Cirrhosis?
The liver is one of your hardest working organs. It filters toxins from your blood, helps digest food, and makes proteins your body needs for blood clotting and fighting infections. When the liver is repeatedly damaged by too much alcohol, fat buildup, or an overactive immune system, it begins to scar. This scarring is called fibrosis. When enough scar tissue builds up, liver cirrhosis occurs.
People with cirrhosis of the liver can develop serious complications such as fluid buildup in the abdomen, internal bleeding, confusion, kidney failure, and even liver cancer. Some people with cirrhosis eventually need a liver transplant to survive.
The alcohol problem: Women bear a greater burden
One of the biggest causes of liver cirrhosis in women is ALD. It turns out that women’s livers are more easily damaged by alcohol than men’s, even if they drink less.
A review of research published in the European Medical Journal found that women have lower levels of a stomach enzyme called gastric alcohol dehydrogenase, meaning their blood alcohol levels rise higher than men’s after drinking the same amount. Women who consume 40 grams of alcohol per day (approximately three drinks) are more than three times as likely as men to develop liver cirrhosis.
One study found that women also develop liver cirrhosis more quickly than men, in about 13.5 years compared to 20 years, even when accounting for women drinking less overall. And even when women with cirrhosis stop drinking entirely, they tend to have lower five-year survival rates than men who do the same.
In addition, a large population-based study from Ontario, Canada, involving thousands of adolescents and young adults found that alcoholic hepatitis – inflammation of the liver caused by heavy drinking – is increasing much faster in women than in men, with the rate increasing by 11% per year in women compared to 8% per year in men. Women who developed alcoholic hepatitis (formerly alcoholic hepatitis) were about 50% more likely to develop liver cirrhosis over time than men, and the rate of liver-related deaths was almost twice as high over a 10-year period.
The metabolic connection: MASLD and women
Alcohol is not the only route to liver cirrhosis. A growing number of women are developing liver disease through a different pathway: MASLD, which stands for metabolic dysfunction-associated steatotic liver disease (formerly known as nonalcoholic fatty liver disease, or NAFLD). MASLD occurs when too much fat builds up in the liver, causing inflammation and, over time, scarring.
The risk factors for MASLD are related to metabolic health, conditions such as high blood sugar, high blood pressure, excess abdominal fat, and high triglycerides. Jennifer Dodge, MPH, an associate professor at Keck Medicine of USC who studies these connections, says the numbers are astonishing.
“Among women [in the U.S.]“69% have increased waist circumference, 41% have high blood pressure, 31% have type 2 diabetes or prediabetes, and 64% have at least two cardiometabolic risk factors,” Dodge explained. “This is a significant proportion of women at risk.”
Even more worrying, these risk factors appear to be more dangerous for women’s livers than men’s. Research by Dodge and her colleagues found that women with high waist circumference, type 2 diabetes or prediabetes have a higher risk of liver fibrosis than men with the same risk factors. “There is increasing evidence that women may have a lower threshold for metabolic liver damage,” she said, citing differences in the way women’s bodies handle fat, blood sugar and inflammation.
Why menopause is a hidden turning point
Unfortunately, menopause turns out to be a risk factor. The hormone estrogen appears to protect the liver, and when estrogen drops after menopause, the risk of liver disease in women increases significantly.
A review found that MASLD is more common and severe in men than women during childbearing years. But after menopause, cases of MASLD increase in women, who are also at higher risk of advanced fibrosis than men, suggesting that protection from estrogen is lost after menopause.
Dodge said the evidence for estrogen’s protective role is growing. She explained that estrogen is thought to protect the liver by controlling inflammation, insulin sensitivity and the body’s processes that lead to scar tissue formation. “Not just current estrogen exposure, but overall lifetime estrogen exposure appears to have a positive effect on liver health,” Dodge said.
A 2024 study in the journal Liver International found that MASLD is now the leading reason women need liver transplants, and that women over 50 are currently underrepresented in liver disease clinical trials, even though there are many women with the condition.
Autoimmune Liver Disease: Another Health Problem for Women
In addition to alcohol and metabolism, there is another category of liver disease that affects women more often than men: autoimmune diseases, in which the immune system mistakenly attacks the liver.
Women are ten times more likely than men to develop primary biliary cholangitis (PBC), a chronic disease that slowly destroys the bile ducts in the liver. You are four times more likely to develop autoimmune hepatitis, in which the immune system directly attacks liver cells. Both diseases can lead to liver cirrhosis if not detected and treated early.
What happens when women are diagnosed with cirrhosis?
Even if a woman has been diagnosed with liver cirrhosis, her journey through the healthcare system can be more difficult than that of a man.
Jessica Rubin, MD, MPH, a transplant hepatologist and public health researcher at the University of California, San Francisco, has spent years studying the gap between how women with liver cirrhosis actually get sick and how it is treated.
“Women tend to come with more complications, frailty and comorbid conditions,” she said. “Cirrhosis is a catabolic disease [when the body breaks down muscle and fat for energy]and women start out with less muscle mass, making them particularly vulnerable.”
Rubin pointed out that a scoring system commonly used to determine liver transplantation, called the MELD score, tends to underestimate women’s disease status. This means that women can be ranked lower on transplant waiting lists, even if they are actually sicker than their male counterparts. Their research has shown that women on transplant waiting lists are hospitalized at higher rates than men, likely reflecting the discrepancy between their actual disease severity and their MELD score.
Racial disparities: Some women face even greater risks
Liver disease does not affect all women equally. Rubin emphasized that race and socioeconomic status create additional disadvantages that are often not captured in research.
“Black women face real barriers from multiple directions, including structural racism in accessing health care, the MELD gap affecting women generally, and barriers to supporting resources,” she says. “Hispanic women bear a disproportionate burden of MASLD and often present with more advanced fibrosis,” she noted, noting that they often do not get the help they need because they face hurdles such as language barriers, documentation concerns and lack of insurance.
A 2025 analysis published in Scientific Reports found that rates of alcoholic liver cirrhosis are highest among women in lower-income regions, due to a complex mix of cultural, health and socioeconomic factors that increase susceptibility to the disease. Rubin explained, “The differences that we can actually measure are probably an underestimate.”
What you can do to reduce your risk of liver disease
Here’s the empowering part: Much of what leads to liver disease in women is manageable, and knowing your risk is the first step.
Dodge directly expresses the message she wants to convey to women. “Liver disease is common in the United States, and women are at risk due to cardiometabolic risk factors. This connection between liver disease and metabolic factors is not well recognized – but these risk factors can be treated, and how well they are treated impacts liver disease outcomes.”
This means talking to your doctor about your blood sugar, blood pressure, cholesterol levels and waist circumference. It means being honest about your drinking habits and knowing that even moderate alcohol consumption poses a higher liver risk in women than in men. It means understanding that menopause is a time when one should pay more attention to metabolic health, not less. And it means standing up for yourself when something feels wrong. Fatigue, bloating and jaundice are symptoms that deserve special attention.
Rubin, who sees patients with advanced liver cirrhosis every day, puts it succinctly: “The questions I face in the clinic are the most actionable. We need women and their doctors to start asking them sooner.”
This educational resource was created with support from Merck.
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