MASLD is not just a man's disease

Metabolic dysfunction-associated steatotic liver disease now affects around 30 to 40% of adults worldwide. Although it’s usually more common in men, this advantage for women diminishes with type 2 diabetes. After menopause, women's rates can match or exceed men's. The review suggests we should assess women's risk at various reproductive stages, not just as one number.

The clearest example is polycystic ovary syndrome, now called polyendocrine metabolic ovarian syndrome. It affects about 10-13% of women of reproductive age. This condition roughly doubles the risk of MASLD and triples the risk of type 2 diabetes. Hyperandrogenism, along with insulin resistance, is the likely cause.

Elevated free testosterone roughly doubles the risk of steatohepatitis and fibrosis in premenopausal women with fatty liver. Women with advanced fibrosis often have higher androgen levels, regardless of age. Interestingly, this link shows up even in women without obesity or clear diabetes, the very group least likely to be screened.

Pregnancy is another window. MASLD during pregnancy raises the risk of gestational diabetes by about three times. It also leads to higher rates of pre-eclampsia, preterm birth, and Caesarean delivery. Since around one in three women with gestational diabetes develop type 2 diabetes later, the review recommends checking for MASLD after such pregnancies. This could enhance predictions for future diabetes risk, beyond BMI and family history. Menopause changes this balance. When oestrogen decreases, it leads to more visceral fat, dyslipidaemia, and advanced fibrosis. It also means losing the cardiovascular benefits of premenopause.

Two practical threads run through all of this. MASLD is often missed in women, especially younger ones and those with PCOS. Current risk tools don’t consider sex or menopausal status. The EASL-EASD-EASO guidelines recommend liver checks for those at metabolic risk, such as people with type 2 diabetes. However, the evidence for younger women and female-specific issues is limited. Also, treatment options are starting to improve. Only two agents are licensed for MASH with fibrosis: a thyroid hormone receptor beta agonist (resmetirom) and a GLP-1 receptor agonist (semaglutide, now licensed in the UK). Phase 3 trials showed similar responses in men and women. A sustained weight loss of 5 to 10% is still the first-line treatment for MASLD, PCOS, and type 2 diabetes.

This is a narrative review, not new trial data. So, the associations have the usual warnings about confounding factors like obesity and metabolic risk.

What it does well is join up conditions we tend to manage in separate boxes. A woman with PMOS, a history of gestational diabetes, or recent menopause might need more attention regarding her liver health.