What Causes Fatty Liver in Women? MASLD, Explained

What causes fatty liver? A common health issue, fatty liver happens when extra fat builds up inside liver cells, most often because of insulin resistance, excess weight—especially in the abdomen—and related metabolic problems. 

You may have heard that this condition is linked to alcohol (a common misconception), which is why you might be surprised if your recent blood test showed elevated liver enzymes, especially if you don’t drink much or feel fine and healthy. 

Here’s something that may surprise you: Women who have gone through menopause are more than twice as likely to have early fatty liver disease than women who haven’t gone through menopause yet. Estrogen protects a woman’s metabolic health, so when estrogen levels start to go down, you’re more at risk of metabolic dysfunction—and that includes fatty liver.

The upside: When identified early, fatty liver is highly manageable. Here’s what you need to know about the main causes of fatty liver, how it’s diagnosed, why the risk rises after menopause, and how a clinician trained in women’s midlife health—like one at Midi—can help you find the support you need. 

What Is Fatty Liver? MASLD, Formerly NAFLD, Explained

The official name for fatty liver is metabolic dysfunction-associated steatotic liver disease (MASLD). It happens when there’s extra fat in the liver that’s not caused by chronic alcohol consumption. 

MASLD was formerly called nonalcoholic fatty liver disease (NAFLD). The name change was agreed to by global liver societies because its previous name didn’t accurately reflect the cause of the condition, and it was stigmatizing. People didn’t like a disease with “fatty” in the name and that used alcoholic and nonalcoholic designations. So it was changed for the benefit of diagnosis and treatment.

There’s also a new category called MetALD, which is used for people who have MASLD but also consume more than 10 (women) or 15 (men) alcoholic drinks per week. With this liver disease, you have metabolic dysfunction and drink more than people with MASLD. It’s considered a “worse” disease than MASLD alone, because there’s a higher likelihood of progression and a greater risk of cancer and cardiovascular disease.

Two more acronyms to know about in the liver disease world: MASH and NASH. What used to be referred to as nonalcoholic steatohepatitis (NASH) is now known as metabolic dysfunction-associated steatohepatitis (MASH). 

If MASLD advances in severity, it’s called MASH. This is when the disease moves from excess fat in the liver to liver swelling/inflammation and damage. Eventually, you can develop fibrosis (scarring), cirrhosis, and even liver cancer. So, to recap the current acronyms: MASLD can progress to MASH.

MASLD is a huge concern worldwide: About 1 in 3 people have it, an increase of 50% over the last few decades, according to global data. Higher rates of obesity and type 2 diabetes are believed to be behind the spike.

What Causes Fatty Liver? The Main Drivers

At the heart of MASLD is metabolic dysfunction. When it comes to what causes a fatty liver in women, there are three main drivers that all work together:

• environmental factors, such as an unhealthy diet and sedentary lifestyle
• metabolic factors, including Insulin resistance, type 2 diabetes, obesity, high lipid (cholesterol, triglycerides) levels
• genetics

If you chronically eat more calories than your body needs, your liver can’t process it all. Those excess carbs and fats are then stored in the liver as triglycerides (a type of fat in your blood). Eventually, though, your liver can’t keep up, and its storage capacity reaches its peak. This can lead to fatty buildup in the liver and damage to liver cells, inflammation, and—over time—possibly fibrosis and more. 

This process can occur at any weight—lean MASLD is a real category of the condition, when people with a normal BMI have fatty liver. In fact, 10% to 20% of people with MASLD have a normal BMI. Some research suggests that females are more likely to have lean MASLD, as well as people of Asian or Hispanic descent. 

It can be more difficult to diagnose MASLD if you’re lean, though you’ll typically still have: 

• insulin resistance
• elevated fasting blood sugar
• high blood cholesterol
• more visceral (belly) fat 

Why Fatty Liver Risk Rises for Women After Menopause

Hormonal and metabolic shifts start happening as you go through menopause. 

First, let’s talk about the loss of estrogen. It’s been (accurately) dubbed your metabolic shield. Estrogen helps your body use sugar for energy and respond well to insulin, the hormone that moves sugar out of your blood. A reduction in estrogen means you lose some of this protective factor and are more at risk of conditions like diabetes in menopause.

There’s also hormonal belly fat to contend with. With estrogen’s decline, body composition changes: Waistlines often get bigger due to increasing visceral fat—which is fat that’s stored deep in your belly, around your organs. Visceral fat is a dangerous, inflammatory fat, and it boosts the risk of insulin resistance and liver fat. And yes, it happens even in lean people.

Fatty liver can speed up and progress in women due to this decline in estrogen and increased visceral belly fat, insulin resistance, and inflammation, according to research. So there isn’t just one thing going on—multiple factors are at play, all converging at once to conspire against your liver’s health. 

Other Causes and Risk Factors of Fatty Liver

Overall, the risk factors of MASLD include:

• being overweight or obese (a BMI of 25 or higher)
• having high triglycerides
• having high cholesterol
• having hypertension
• having prediabetes or diabetes
• being age 40 or over

Along with those factors, it’s important to mention polyendocrine metabolic ovarian syndrome (PMOS, formerly PCOS). If you have PMOS—and 1 in 8 women do—your risk of MASLD increases. Some research shows that up to 70% of women with PMOS have MASLD, about double the rate of women who don’t have PMOS. 

Alcohol and medications can cause liver injury, including pain relievers like NSAIDs and acetaminophen; certain antibiotics, antivirals, and antifungals; and some immunosuppressants, among others.

Finally, liver inflammation (hepatitis) can be caused by a virus, such as hepatitis A, B, or C. You can be screened or tested for these to rule them out.

What Are the Symptoms of Fatty Liver in Women?

MASLD is often considered a silent condition because liver damage doesn’t make itself known until it’s far advanced. If you’re searching for fatty liver symptoms in females, unfortunately, you won’t have clear, definitive signs that fat is building up in your liver. 

Most people with MASLD have no symptoms. However, some may have symptoms of fatigue or vague pain in the upper part of their stomach, though those are vague and nonspecific (meaning they can have many other causes, especially in midlife). 

That said, there are signs of insulin resistance, and we know that there’s a strong tie between poor insulin function and fatty liver:

• Acanthosis nigricans: These are areas of dark, thick, velvety skin in body folds and creases, typically affecting the armpits, groin, and neck.
• Visceral weight gain: This often looks like an increased waistline, but you can also have excess visceral fat with a normal BMI.
• Excess body hair, hair thinning, hormonal acne: These are signs of higher levels of androgens (“male” hormones), which are often more pronounced in women who have PMOS.

How Is Fatty Liver Diagnosed?

The first step in diagnosing MASLD is blood testing. Your clinician will check for liver enzymes (AST and ALT), blood sugar, a complete blood count, a comprehensive metabolic panel, and a lipid panel. If lab work points to MASLD, your clinician will recommend additional tests to rule out other causes of liver disease (such as hepatitis, hemochromatosis, and celiac) as well as a liver ultrasound. The diagnosis of MASLD is typically based on ultrasound imaging when there’s no other causes of liver injury. 

However, sometimes you may need a referral to a specialist, especially if treatments like lifestyle changes aren’t effective or liver disease is more advanced. At that point, you might be referred to a gastroenterologist or hepatologist for a FibroScan, which measures liver fat and scarring, or a biopsy. 

Is Fatty Liver Dangerous?

Yes, fatty liver is dangerous. Although early-stage MASLD is highly manageable and, in many cases, can be reversed, it may also progress when left unchecked. Fat inside the liver acts as a source of chronic inflammation. 

MASLD can progress to MASH. Again, this is the stage of disease where there is liver swelling and inflammation and liver cells are damaged. The next steps in the disease are fibrosis (scarring) and then cirrhosis (severe scarring). Cirrhosis increases your risk of developing liver cancer and cardiovascular disease, the latter of which is the most common cause of death for people with MASLD.

One study found that the risk for cardiovascular disease was nearly three times higher for people with MASLD than for a control population. And when women received a MASLD diagnosis between ages 40 and 60, their life expectancy was nearly 4 years shorter than that of the general population. 

Those are frightening stats. But if you receive a MASLD diagnosis, you can do something about it. 

Can You Reverse Fatty Liver?

Yes, you can reverse fatty liver. MASLD is highly treatable—and it start with lifestyle changes. Weight loss is the primary treatment.The liver is so resilient that when MASLD is caught early, you can return the organ to its normal function. 

Here’s how healthcare professionals generally recommend starting with treatment:

• Change your lifestyle: Eat a reduced-calorie diet (decrease calories by 500 to 1,000 per day) and get exercise in the form of aerobic and strength workouts. 
• Avoid or minimize alcohol: Even moderate amounts of alcohol can speed up inflammation and scarring.
• Lose weight: Aim for a weight loss of 5-7% of your body weight.
• Consider medications when needed: Medications to treat diabetes, weight loss, high cholesterol, and high blood pressure can help. 
• Immunizations: Vaccination for hepatitis A and hepatitis B virus are recommended, as is the pneumovax vaccine.

What you eat is a huge component of treatment. Cut way back on: 

• foods rich in saturated fats or refined carbohydrates 
• added sugars, especially sugary beverages
• processed meats (like bacon, sausage, and deli meats) 
• highly processed foods

These foods are typically packed with calories and are inflammatory. A healthier way to eat is to follow the Mediterranean-style or DASH diet—both are liver-friendly eating patterns because they focus on whole foods and healthy fats. Plus, they’re plant-based and rich in antioxidants. 

Fatty Liver Treatment Options for Midlife Women

There’s no single pill or cure for fatty liver. When you have MASLD, you need to put the emphasis on metabolic health and weight loss.

If your condition has advanced to MASH, certain medications can help. Wegovy, a GLP-1 medication, is FDA-approved to treat adults with MASH with liver scarring (alongside lifestyle strategies like increased physical activity and a reduced calorie diet). Rezdiffra (resmetirom) is an FDA-approved oral medication that also treats MASH. No matter which medication you’re prescribed, each is designed to be taken alongside diet and exercise changes and is indicated for people with moderate to advanced fibrosis but no cirrhosis. 

Hormone therapy is prescribed for menopause symptoms—not as a fatty liver treatment—but hormonal health can support metabolic health. Hormone therapy may fit into an overall care plan, especially if managing menopause symptoms (like sleep-disrupting night sweats) makes it easier for you to adopt and maintain new healthy habits. 

Some supplements, like milk thistle (silymarin), may support liver cell health. But talk with your clinician before taking it to make sure it fits and complements your treatment plan.

Protecting Your Liver in Midlife: When to See a Clinician

Given that the liver silently takes its hits, you’ll have to be a little proactive in its care. If any of the following apply to you, ask your doctor for lab work to analyze your metabolic health and liver enzymes:

• You have prediabetes or diabetes.
• You have high triglycerides.
• You’ve received a diagnosis of PMOS.
• You have a family history of liver disease.

A visit with a Midi Health clinician can help you piece together menopause hormonal changes, metabolic problems, and liver stress. And you can get on a comprehensive treatment plan that includes lifestyle changes that can make a difference in your overall health. 

Your Midi clinician might discuss nutrition and movement, a GLP-1 or other weight management medications if appropriate, hormone therapy for menopause symptoms, and a referral to a liver specialist when needed. 

Fatty liver in its early stages is a treatable diagnosis. When you need support along the way, your clinician can be there by your side to support your care.

Key Takeaways

• Fatty liver is when excess fat builds up inside liver cells, often due to metabolic dysfunction like insulin resistance—not only because of alcohol. 
• Women in menopause have more than a twofold higher risk of developing MASLD due to the metabolic changes associated with estrogen loss.
• Fatty liver in the early stages is highly treatable and can be reversed. Lifestyle changes and weight loss are cornerstones of managing the condition.
• A comprehensive care plan is often the best way to tackle metabolic problems during perimenopause and menopause. It may include diet and exercise support, medications for weight loss or more advanced fatty liver, treatments for high cholesterol and triglycerides, and menopause symptom management with hormone therapy.

Frequently Asked Questions (FAQs)

How do you fix a fatty liver?

There are several stages of fatty liver. When fatty liver is in its earliest stage, called MASLD, lifestyle shifts—including changing your eating habits, getting more exercise, and losing weight—are the cornerstone of treatment to reverse the condition. 

What are 5 signs of a fatty liver?

Fatty liver typically does not come with symptoms, so you won’t necessarily feel different if you have it. Any symptoms are nonspecific, such as weakness and fatigue. Some people may feel abdominal discomfort or pain. 

How quickly can fatty liver be reversed?

There isn’t a specific timeline on how quickly fatty liver can be reversed. It depends on how much the liver disease has progressed. By focusing on eating a nutrient-rich, reduced-calorie diet and regularly exercising, you can lose the 3% to 5% of your body weight recommended to reverse fatty liver in its early stages.

Does fatty liver cause pain?

Fatty liver typically doesn’t cause any symptoms. It’s largely considered a silent disease. However, abdominal discomfort or pain can be one feature of the condition, though that might not appear until it’s more advanced. 

Does milk thistle help fatty liver?

Milk thistle, or silymarin, may help fatty liver because it contains active flavonoids that may help repair damaged liver cells and help protect liver health. Taking a supplement will not be enough to treat fatty liver. Ask your clinician whether milk thistle fits into your treatment plan, which should be built on healthy lifestyle changes and medication if appropriate.