Menopause brings profound hormonal changes that extend far beyond reproductive health, influencing metabolism, body composition, and organ function throughout the body. One area of growing clinical interest is the relationship between menopause and non-alcoholic fatty liver disease (NAFLD), a common condition affecting up to 30% of UK adults. Whilst menopause does not directly cause fatty liver, research suggests that the decline in oestrogen during this transition may significantly increase metabolic vulnerability and liver fat accumulation. Understanding this association is vital for women navigating midlife, enabling informed discussions with healthcare professionals about risk assessment, prevention strategies, and the importance of maintaining liver and cardiovascular health during and after the menopausal transition.

Understanding Fatty Liver Disease and Menopause

Non-alcoholic fatty liver disease (NAFLD) is a condition characterised by excessive fat accumulation in the liver in individuals who consume little to no alcohol. It represents a spectrum of liver conditions, ranging from simple steatosis (fat accumulation) to non-alcoholic steatohepatitis (NASH), which involves inflammation and potential liver damage. NAFLD has become increasingly prevalent in the UK, affecting an estimated 20–30% of the general population, and is closely associated with metabolic conditions such as obesity, type 2 diabetes, and cardiovascular disease. You may also see NAFLD referred to as metabolic dysfunction-associated steatotic liver disease (MASLD) in newer literature, though UK NHS materials and services commonly continue to use the term NAFLD.

Menopause marks the permanent cessation of menstruation, typically occurring between ages 45 and 55, when ovarian function declines and oestrogen levels fall significantly. This hormonal transition triggers numerous physiological changes throughout the body, extending well beyond reproductive function. The menopausal transition is associated with alterations in body composition, metabolic rate, lipid profiles, and fat distribution patterns.

Observational research has increasingly highlighted a potential association between menopause and metabolic liver disease. Studies suggest that postmenopausal women experience higher rates of NAFLD compared to premenopausal women of similar age, raising important questions about the protective role of oestrogen in liver health. Understanding this relationship is crucial for healthcare professionals and women navigating the menopausal transition, as it may inform risk-based assessment strategies and preventive interventions.

The liver plays a central role in metabolic regulation, including glucose homeostasis, lipid metabolism, and hormone processing. When hormonal changes coincide with lifestyle factors and genetic predisposition, the risk of developing fatty liver disease may increase substantially during and after menopause. It is important to note that cardiovascular disease is the leading cause of death in people with NAFLD, making cardiovascular risk modification a central priority in management.

Does Menopause Cause Fatty Liver?

Whilst menopause does not directly cause fatty liver disease, observational evidence suggests that the hormonal changes associated with menopause may significantly increase the risk of developing NAFLD. The relationship is complex and multifactorial rather than simply causative, and other factors such as weight gain and reduced physical activity during this life stage may also contribute.

Oestrogen's protective role appears central to this association. Before menopause, oestrogen helps regulate lipid metabolism, insulin sensitivity, and fat distribution. Oestrogen influences hepatic lipid handling by modulating enzymes involved in fatty acid synthesis and oxidation. It also promotes subcutaneous rather than visceral fat deposition. When oestrogen levels decline during menopause, these protective mechanisms diminish, potentially leading to:

• Increased visceral (abdominal) fat accumulation

• Reduced insulin sensitivity and glucose tolerance

• Altered lipid profiles with elevated triglycerides and LDL cholesterol

• Changes in adipokine secretion affecting liver metabolism

• Increased hepatic fat deposition

Large epidemiological studies have demonstrated that postmenopausal women may have approximately 1.5 to 2 times higher prevalence of NAFLD compared to premenopausal women, even after adjusting for age and body mass index. Some research suggests that early menopause (before age 45) may confer even greater risk, though further studies are needed to confirm this association.

However, it is important to emphasise that menopause interacts with other established risk factors rather than acting in isolation. Obesity, insulin resistance, sedentary lifestyle, dietary patterns, and genetic factors all contribute significantly to NAFLD development. Women who maintain a healthy weight, engage in regular physical activity, and follow balanced diets may not develop fatty liver despite menopausal hormonal changes. The menopausal transition should therefore be viewed as a period of increased metabolic vulnerability requiring heightened attention to modifiable risk factors.

A note on menopausal hormone therapy (HRT): Some studies suggest that HRT may have beneficial effects on liver fat in certain women, but HRT is not licensed or indicated for the prevention or treatment of NAFLD. Decisions about HRT should be based on menopausal symptom control and overall risk–benefit assessment in line with NICE guidance on menopause management, not on liver health alone.

Symptoms and Diagnosis of Fatty Liver During Menopause

Fatty liver disease is often asymptomatic in its early stages, which presents a diagnostic challenge. Many women with NAFLD remain unaware of the condition until it is detected incidentally during investigations for other health concerns, through routine blood tests, or on imaging such as ultrasound. Importantly, liver blood tests (liver function tests or LFTs) are often normal in people with NAFLD, so normal results do not exclude the condition. When symptoms do occur, they are typically non-specific and may include:

• Persistent fatigue or general malaise

• Vague discomfort or fullness in the right upper abdomen

• Unexplained weight changes

• General feeling of being unwell

These symptoms overlap considerably with common menopausal complaints, making it difficult to attribute them specifically to liver disease. More advanced liver disease (cirrhosis) may present with jaundice (yellowing of the skin or eyes), ascites (fluid accumulation in the abdomen), confusion, vomiting blood, or black tarry stools—these are red-flag symptoms requiring urgent medical assessment.

Diagnosis and risk assessment in the UK follow NICE guidance. There is no routine population screening for NAFLD; instead, assessment is recommended for people with risk factors such as type 2 diabetes, obesity, or metabolic syndrome. The diagnostic pathway typically includes:

• Initial blood tests: Comprehensive metabolic assessment (fasting glucose, HbA1c, lipid profile), liver function tests, and full blood count. Exclusion of other causes of liver disease (viral hepatitis, autoimmune conditions, excessive alcohol consumption, certain medications) is essential.

• Non-invasive fibrosis risk scores: NICE recommends using the FIB-4 score (or NAFLD Fibrosis Score) as a first-line tool to assess the risk of advanced liver fibrosis. Age-specific thresholds are used: in adults under 65, a FIB-4 score below 1.3 suggests low risk, whilst a score above 2.67 suggests higher risk; in adults aged 65 and over, a score below 2.0 suggests low risk, and above 2.67 suggests higher risk.

• Enhanced Liver Fibrosis (ELF) test: If the FIB-4 or NAFLD Fibrosis Score is indeterminate or suggests increased risk, an ELF blood test is recommended in primary care to further assess fibrosis. An ELF score of 10.51 or above typically prompts referral to a liver specialist.

• Imaging: Ultrasound scanning is often the first imaging modality and can detect moderate to severe hepatic steatosis, though it may miss mild cases. Transient elastography (FibroScan) measures liver stiffness to assess fibrosis; where available, the controlled attenuation parameter (CAP) can estimate the degree of steatosis. Availability of FibroScan varies by locality. In selected cases, MRI-based techniques provide detailed assessment, whilst liver biopsy remains the gold standard for definitive diagnosis and staging, though it is reserved for cases where non-invasive methods are inconclusive or when advanced disease is suspected.

Referral to hepatology is recommended if non-invasive tests suggest advanced fibrosis, if there is diagnostic uncertainty, or if red-flag symptoms are present. Your GP will guide you through the appropriate pathway based on your individual risk profile and test results.

Managing Fatty Liver Risk After Menopause

Lifestyle modification remains the cornerstone of NAFLD management and prevention in postmenopausal women. There are currently no licensed pharmacological treatments specifically for NAFLD in the UK, making behavioural interventions paramount. Evidence-based strategies include:

Weight management is the most effective intervention. Studies demonstrate that losing 7–10% of body weight can significantly reduce liver fat, inflammation, and even fibrosis. For postmenopausal women, this may require adjusting caloric intake to account for reduced metabolic rate. A Mediterranean-style diet rich in vegetables, fruits, whole grains, legumes, nuts, and olive oil, with moderate fish consumption and limited red meat and processed foods, has shown particular benefit for liver health. NICE guidance on obesity management outlines options including dietary support, physical activity programmes, behaviour change interventions, and—where clinically appropriate—consideration of weight management medications or referral for bariatric surgery.

Regular physical activity provides benefits independent of weight loss. UK Chief Medical Officers recommend at least 150 minutes of moderate-intensity aerobic activity weekly (such as brisk walking or cycling), combined with muscle-strengthening activities on at least two days per week. Exercise improves insulin sensitivity, reduces visceral fat, and directly decreases hepatic fat content. For women new to exercise or with mobility limitations, starting with achievable goals such as daily walking and gradually increasing intensity is advisable.

Metabolic risk factor control is essential, particularly as cardiovascular disease is the leading cause of death in people with NAFLD. This includes:

• Optimising glycaemic control in women with diabetes or prediabetes

• Managing dyslipidaemia according to cardiovascular risk—statins are safe and beneficial in NAFLD when indicated for cardiovascular protection

• Controlling hypertension

• Regular medication review with your GP or pharmacist to ensure all medicines remain appropriate

Alcohol consumption should be kept within UK Chief Medical Officers' low-risk drinking guidelines: do not regularly exceed 14 units per week, spread drinking over three or more days, and avoid binge drinking. If you have evidence of significant liver fibrosis or cirrhosis, your doctor may advise complete abstinence from alcohol.

Monitoring and follow-up should be individualised based on disease severity and risk. NICE recommends that adults with low-risk non-invasive test results (FIB-4 or NAFLD Fibrosis Score) have repeat assessment approximately every three years, alongside ongoing management of cardiometabolic risk factors. Women with evidence of advanced fibrosis or NASH typically require specialist hepatology input and more intensive surveillance. Your healthcare team may also discuss vaccinations against hepatitis A and B if you have chronic liver disease.

When to seek medical advice: Women should consult their GP if they experience persistent fatigue, unexplained abdominal discomfort, or have risk factors including obesity, type 2 diabetes, or metabolic syndrome. Seek urgent medical attention if you develop jaundice (yellowing of skin or eyes), confusion, vomiting blood, black tarry stools, or rapidly increasing abdominal swelling. Postmenopausal women with metabolic risk factors should discuss whether assessment for NAFLD is appropriate with their healthcare provider. Early detection and intervention through risk-based assessment can help prevent disease progression and reduce long-term complications, particularly cardiovascular disease.

Frequently Asked Questions