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Hosts are joined by Meena Bansal, MD, to discuss long-standing research gaps and what clinicians need to understand about sex-specific drivers of liver disease today.
In this episode of Liver Lineup, hosts Nancy Reau, MD, and Kimberly Brown, MD, are joined by Meena Bansal, MD, to examine how liver disease uniquely affects women across the lifespan. While conditions like metabolic dysfunction-associated steatotic liver disease (MASLD) are often discussed in broad terms, the trio highlights how risk, progression, and outcomes can differ significantly based on sex and hormonal status.
From reproductive years through menopause and beyond, physiologic changes play a central role in shaping liver health, but these distinctions have historically been underrecognized in both research and clinical care.
0:00:00 – Welcome & women’s liver health framework
0:03:17 – Menopause, estrogen loss, and fibrosis risk
0:10:57 – PCOS, young women, and high‑risk metabolic phenotypes
0:13:54 – Pregnancy, MASH, and maternal-fetal outcomes
0:18:45 – Screening strategy, menopause as a pivot, and intervals
0:28:03 – Practical toolkit: FIB‑4, second‑line tests, and who to test
0:31:27 – Management, GLP‑1s, resmetirom, and key takeaways
Bansal frames MASLD through the lens of a woman’s life course, emphasizing that risk is not static but evolves from reproductive years through menopause and beyond. While premenopausal women may have some degree of protection against liver disease, this advantage diminishes with the loss of estrogen.
As Bansal explains, the postmenopausal transition is associated with increased visceral adiposity and heightened fibrogenic activity, contributing to a rise in MASLD prevalence and severity that begins to parallel, and in some cases exceed, that seen in men. These physiologic shifts mirror patterns observed in cardiovascular disease and underscore the need for more tailored approaches to screening and monitoring in women.
The discussion also underscores critical gaps in the evidence base, with much of the existing literature historically extrapolating findings from predominantly male populations or failing to account for hormonal status among women. As Brown notes, even when women are included in studies, they are rarely stratified by life stage, limiting the ability to draw meaningful conclusions about disease behavior in specific subgroups such as those with polycystic ovary syndrome (PCOS), during pregnancy, or after menopause.
Pregnancy represents another key inflection point. Women with MASLD face increased risks of adverse maternal outcomes, including gestational diabetes and preeclampsia, as well as potential downstream effects on fetal health. Emerging data suggesting epigenetic influences further reinforce the importance of early identification and management. However, therapeutic decision-making in this population remains challenging, particularly given contraindications for commonly used agents such as GLP-1 receptor agonists during pregnancy and the lack of robust safety data for newer therapies.
Across the discussion, Bansal and the hosts repeatedly emphasize the importance of proactive screening and patient advocacy. Tools such as the FIB-4 index offer accessible, scalable approaches to risk stratification, but clinicians must remain attentive to timing and frequency, particularly during periods of hormonal transition. The group also calls for greater collaboration with obstetrics and gynecology providers, who often serve as primary care touchpoints for women, to improve early detection and intervention.
Ultimately, this episode highlights a critical shift in hepatology: moving beyond a one-size-fits-all model toward a more nuanced understanding of how sex and gender influence liver disease. As Bansal notes, empowering women with knowledge about their risk and encouraging clinicians to recognize these distinctions will be essential to improving outcomes in MASLD and beyond.
Editors’ note: Relevant disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal. Relevant disclosures for Bansal include Boeheringer-Ingelheim, Boston Pharma, Fibronostics, GSK, Madrigal, Merck, NOVO Nordisk, and The Kinetix Group.
