HRT and Liver Disease: What 7 Current Labels and the Guidance Actually Say

Seven current hormone-therapy labels we audited—the FDA's six products updated in February 2026 plus one current twice-weekly estradiol patch—all list hepatic impairment or disease as a contraindication. AASLD's published guidance names three no-use conditions, while The Menopause Society separately lists liver disease broadly for systemic oral and transdermal HRT. The gap is real. It is not permission.

A quick safety note before anything else: do not start, stop, or switch a prescription based on this page. If you have new yellowing of the skin or eyes, new confusion or unusual sleepiness, vomiting blood, black tarry stools, or rapidly increasing belly swelling, stop reading and get urgent medical care. Those are signs of a liver problem that needs a person, not an article.

Best for

• You have MASLD, hepatitis, cirrhosis, PBC, a liver lesion, or a transplant history and want to understand why HRT was refused or delayed.
• Your liver tests changed while you were already using HRT.
• Someone told you a patch “bypasses the liver,” and you want the precise version of that claim.
• You need the exact questions and records that turn a vague no into a diagnosis-specific discussion.

Not for you if

• You want a website to give you a personal yes or no. This page cannot do that, and no page should.
• You have any of the urgent symptoms above. That is an urgent medical assessment, not an online-care decision.
• You do not yet know what your liver diagnosis is. The first useful step is getting the diagnosis and stage—not choosing a hormone route.

The HRT Index is the independent decision resource for online menopause and HRT care — comparing telehealth providers on clinical legitimacy, care quality, medication fit, price transparency, and access, with every claim verified and dated, so women can choose the path that fits their situation before their first consult.

The 30-second version

Your situation	The bottom line
Decompensated liver function, Budd–Chiari syndrome, or hepatocellular adenoma	AASLD's published guidance says menopausal hormone therapy should not be used. A patch does not change that.
Fatty liver / MASLD without known advanced fibrosis	Not a self-serve green light. Recent observational data is reassuring about some outcomes, but product labels and The Menopause Society remain broad, and HRT is not a fatty-liver treatment.
Compensated cirrhosis	Not named in AASLD's three-condition sentence, but still covered by broad product-label and Menopause Society contraindication language. This belongs with hepatology and a menopause clinician, not a quick intake form.
“The patch bypasses the liver”	It avoids first-pass metabolism. It does not make the liver irrelevant or remove the patch label's contraindication.
High liver enzymes without a diagnosis	A number is a clue, not a verdict. The pattern, symptoms, trend, medications, and underlying cause matter.
Vaginal estrogen	Product-specific. Estring has low systemic exposure but still carries a liver contraindication; do not assume every vaginal product has identical labeling.
Nonhormonal treatment	Not automatically liver-safer. Veozah and Lynkuet both have specific liver-testing rules, and Veozah is contraindicated in known cirrhosis.

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Why did my doctor say no to HRT because of liver disease?

Answer capsule: A clinician who declines systemic HRT because of liver disease can point to both current product labels and The Menopause Society's contraindication language. AASLD's liver-specific guidance is narrower, naming three conditions where menopausal hormone therapy should not be used. Those sources do different jobs, and the narrow list does not cancel the broad rule.^[1][2]

Here is what often happens. You mention menopause symptoms. Someone sees “liver disease” in the chart, and the conversation ends in about four seconds.

That refusal may feel lazy. It may also be exactly what the label and a major menopause guideline tell the clinician to do.

But a second problem remains: “liver disease” is not one disease. Mild steatosis, chronic hepatitis with no fibrosis, compensated cirrhosis, decompensated liver failure, Budd–Chiari syndrome, a hemangioma, and a hepatocellular adenoma do not carry the same biology or the same risk. A broad no may be label-faithful and still leave you without the explanation you need.

The Three-Source Gap

Three respected sources address this question. They do not say the same thing because they are not answering the same question.

Source	What it actually says	What that source can—and cannot—resolve
Current product labels in our seven-label audit	Every audited label lists hepatic impairment, liver impairment, or liver dysfunction/disease as a contraindication. None gives a disease stage, Child–Pugh class, fibrosis cutoff, or liver-enzyme threshold.	Product-specific and legally important, but broad. This audit covers seven labels, not every menopause product sold in the United States.
The Menopause Society	Its 2022 position statement lists liver disease among contraindications for systemic oral and transdermal hormone therapy. Its current patient page also says, in general, women with liver disease should not use hormone therapy.	Broad systemic-HRT guidance. The same position statement discusses observational liver findings, but says randomized trials are needed before firm liver-disease conclusions.
AASLD Reproductive Health and Liver Disease guidance	Menopausal hormone therapy should not be used in women with decompensated liver function, Budd–Chiari syndrome, or hepatocellular adenomas.	A diagnosis-specific specialist statement, but not a complete permission list. AASLD's page dates this guidance to September 2020; the journal publication appeared in 2021.[2]

The broad rule is real. The narrow list is real. The gap is not permission.

The original mistake on pages like this is to treat absence from AASLD's three-item sentence as clearance. It is not. Compensated cirrhosis, MASLD, viral hepatitis, PBC, hemangioma, and focal nodular hyperplasia are not named in that sentence, but The Menopause Society's systemic-HRT contraindication and the audited labels still exist.

The useful question is not, “Which document can I use to win?” It is:

What is my exact diagnosis and stage, what does the label for the exact product say, and which clinician is prepared to own the decision?

The right online HRT provider isn't the same for every woman — it depends on your symptoms, your age and whether you have a uterus, your medication route preference (patch, pill, gel, or vaginal estrogen), your risk history, your insurance or cash-pay situation, and your state. Some situations belong with an in-person clinician first. Because a general answer can't resolve those for you, use The HRT Index's Find My HRT Path tool to match your situation to the right provider — and to flag when online care isn't the right starting point — before your first consult.

On this page, that safety flag matters more than the provider match. The tool takes about 90 seconds, requires no email, labels FDA-approved and compounded options separately, and is for education and routing only. A licensed clinician makes every treatment decision.

You cannot ask a good question with a vague diagnosis.

→ Sort out whether online care is a sensible starting point

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What can this page not tell me about HRT and liver disease?

Answer capsule: This page cannot tell any individual woman that HRT is safe for her. No large randomized trial resolves menopausal hormone therapy across the full range of liver diagnoses and disease stages, and the labels we audited do not establish a safe threshold. What this page can do is replace a vague refusal with the exact documents, distinctions, and questions a real assessment requires.

Let's get the disappointing part out of the way early, because everything after it is more useful once this is clear.

There is no route, formulation, or provider that makes liver disease irrelevant. Not the patch. Not the gel. Not a vaginal ring. Not a compounded cream.

If you came here hoping we would hand you permission, we cannot. Honestly, you should not take it from a website if we did.

Here is what we can hand you:

• The exact liver line from seven current product labels, with dates and links so you can check us.
• The difference between broad systemic-HRT guidance and AASLD's three named no-use conditions.
• The evidence that route changes pharmacology without erasing contraindications.
• The condition-specific questions for MASLD, cirrhosis, viral hepatitis, PBC, transplant, and liver lesions.
• The liver rules for two nonhormonal prescription options, because “hormone-free” does not mean “liver-free.”
• A records-and-questions checklist for the appointment where this actually gets decided.

And if you are in one of AASLD's three named groups—decompensated liver function, Budd–Chiari syndrome, or hepatocellular adenoma—we would rather lose a conversion than turn a specialist no-use statement into a route-shopping exercise. Your menopause symptoms still deserve treatment. The route forward is a clinician-led nonhormonal or local-symptom discussion, not a clever way around the warning.

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When should I stop reading and get urgent medical help?

Answer capsule: New jaundice, new confusion or marked drowsiness, vomiting blood or coffee-ground material, black tarry stools, or rapidly increasing abdominal swelling require urgent medical assessment rather than online research. These can occur with serious liver decompensation or internal bleeding, and an article cannot safely separate them from a medication reaction or another emergency.

Get urgent medical help for:

• Yellowing of your skin or the whites of your eyes
• New confusion, unusual sleepiness, or a personality change other people notice
• Vomiting blood or material that looks like coffee grounds
• Black, tarry stools or another clear sign of internal bleeding
• Belly swelling that is increasing quickly
• Severe weakness with fainting, chest pain, or trouble breathing

This is not a complete emergency-symptom list. If something feels seriously wrong, act on that.

Different from an emergency, but still prompt: new itching, dark urine, pale stools, persistent nausea, or newly abnormal liver tests deserve contact with your clinician—not weeks of watchful waiting without a plan.

There is deliberately no button in this section.

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What do FDA labels say about HRT and liver disease?

Answer capsule: On August 6, 2026, we opened seven current menopause hormone product labels and transcribed the liver contraindication from each. All seven carry broad liver wording, none gives a severity or laboratory threshold, and two explicitly state that hepatic-impairment pharmacokinetics were not studied. This is a seven-product audit—not proof about every hormone product on the market.^[3][4]

This is the page's original evidence block: the same fields, checked across the FDA's first six February 2026 relabeled products plus one current twice-weekly estradiol patch.

The Liver Line Ledger

Product	Route	Exact liver contraindication	Label revision checked	What the label says about hepatic-impairment study data
Divigel (estradiol gel)	Skin gel	“Hepatic impairment or disease”	February 2026	No dedicated hepatic-impairment pharmacokinetic result stated in the label
Cenestin (synthetic conjugated estrogens A)	Oral tablet	“Hepatic impairment or disease”	February 2026	Not stated
Enjuvia (synthetic conjugated estrogens B)	Oral tablet	“Hepatic impairment or disease”	February 2026	Not stated
Bijuva (estradiol and progesterone)	Oral capsule	“Hepatic impairment or disease”	February 2026	Not stated
Prometrium (progesterone)	Oral capsule	“Known liver dysfunction or disease”	February 2026	Effect of hepatic impairment on pharmacokinetics has not been studied
Estring (estradiol vaginal system)	Vaginal ring	“Known liver impairment or disease”	February 2026	No pharmacokinetic studies were conducted in women with hepatic impairment
Estradiol transdermal system, twice-weekly (Mylan label checked)	Skin patch	“Hepatic impairment or disease”	June 2025	Not stated

Verification scope: current FDA-hosted prescribing information for the six products on the FDA's February 2026 update page, plus the current Mylan twice-weekly estradiol patch label on DailyMed. Checked August 6, 2026.^[3][4]

Three facts fall out of that ledger.

1. Seven labels, three phrasings, zero thresholds

“Hepatic impairment or disease.” “Known liver impairment or disease.” “Known liver dysfunction or disease.”

None of the seven names a fibrosis stage, a Child–Pugh score, a bilirubin level, an ALT cutoff, or a distinction between an incidental fatty-liver scan and decompensated liver failure. Within these seven labels, very different liver situations receive the same broad stop sign.

That does not prove the contraindication is wrong. It proves the label does not answer the individualization question.

2. The February 2026 boxed-warning changes did not remove the liver contraindications

On February 12, 2026, the FDA announced approved labeling changes for six menopausal hormone products: Prometrium, Divigel, Cenestin, Enjuvia, Estring, and Bijuva. Selected cardiovascular, breast-cancer, and probable-dementia statements were removed from boxed warnings. All six current labels still contain their liver contraindication.^[3]

If you saw the 2026 headlines and thought they erased the liver issue, they did not.

A boxed warning and a contraindication are not interchangeable. A boxed warning highlights a serious risk. A contraindication identifies a situation in which the label says the product should not be used. Removing selected boxed-warning statements is not the same as deleting a liver contraindication.

3. A low-dose vaginal ring still has the line

Estring releases about 7.5 micrograms of estradiol per day over 90 days. Its label reports that about 8% of the amount released by the ring is absorbed systemically unchanged and that steady serum estradiol levels are approximately 7 to 8 pg/mL over later measurement periods. The label also says vaginal delivery avoids first-pass metabolism and that no pharmacokinetic studies were conducted in women with hepatic impairment.^[5]

It still lists “known liver impairment or disease” as a contraindication.

That does not prove every low-dose vaginal product has the same exposure or identical liver wording. It proves that “local” and “zero systemic exposure” are not synonyms, and that the label for the actual product matters.

Why the labels can still feel internally confusing

The draft version of this page called parts of the labels contradictory. That went too far. The sections are doing different jobs.

A contraindication can say not to use a product in current hepatic impairment or disease, while a warning section separately tells a prescriber what to do with a history of cholestatic jaundice or what to do if jaundice recurs. Those are not necessarily opposing instructions.

Divigel's warning says estrogens may be poorly metabolized in women with hepatic impairment, advises caution in women with a history of cholestatic jaundice associated with past estrogen use or pregnancy, and directs discontinuation if cholestatic jaundice recurs. The current Mylan patch label carries similar warning language.^[4]

The patient leaflets can still feel maddening. One section says not to start if you have liver problems; another tells you to tell your clinician about liver problems. That is not permission. It is the difference between a patient screen and the information a clinician needs to know.

If you read your leaflet and felt as though it gave you two different messages, that confusion is not imaginary. The accurate conclusion is not “the label contradicts itself.” It is: the label is broad, and it does not give a severity threshold that a patient can apply alone.

Check our work

We would rather you verify the ledger than trust a summary:

1. Open the FDA's Menopausal Hormone Therapies with Updated Prescribing Information page.
2. Open the label for the product you actually use or are considering.
3. Search the label for hepatic, liver, and cholestatic.
4. Read both the Contraindications and Warnings and Precautions sections.
5. Check the revision date. A label from 2022 is not a substitute for a current label in August 2026.

Bring the sentence, not the summary. Print or save the current label page for the product under discussion. That does not force a clinician to prescribe it. It does stop the appointment from floating on a vague memory of what “all HRT” supposedly says.

→ Use Find My HRT Path to decide whether online care belongs in your next step

The tool does not pull product labels or decide whether HRT is safe. It routes by symptoms, treatment preference, safety history, budget, and state, then flags when a clinician—not an online match—is the real next step.

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Does an estrogen patch bypass the liver?

Answer capsule: A patch or gel avoids first-pass metabolism: estradiol enters the bloodstream through the skin instead of passing from the gut through the liver at high concentration before reaching the rest of the body. That is a real pharmacologic difference. It does not mean the liver is uninvolved, and it does not remove the contraindication in the patch label.^[4]

This is where the internet gets loud and imprecise.

Swallow oral estrogen and it travels from the digestive tract through the portal circulation to the liver before reaching the wider bloodstream. A transdermal patch or gel enters through the skin and avoids that first high-concentration hepatic pass.

The liver still metabolizes circulating hormones afterward. “Avoids first-pass metabolism” is accurate. “Never affects or reaches the liver” is not.

Claims you will hear online—and what is missing

Claim	What is accurate	What is missing
“The patch bypasses the liver.”	It avoids the first hepatic pass after oral absorption.	The liver remains involved in metabolism, systemic exposure remains, and the audited patch label still lists hepatic impairment or disease as a contraindication.
“Transdermal is always safe when oral estrogen is not.”	Route can change coagulation, triglyceride, gallbladder, and metabolic effects.	“Different risk profile” is not the same as “safe for every liver diagnosis.” Disease stage and product labeling still matter.
“Vaginal estrogen is only local.”	Low-dose vaginal products generally produce much less systemic exposure than systemic therapy.	Exposure is not necessarily zero, products differ, and Estring's current label retains a liver contraindication.
“Compounded bioidentical hormones are gentler on the liver.”	Compounding may meet a specific clinical need in some patients.	Compounded drugs are not FDA-approved, and FDA does not verify their safety, effectiveness, or quality before marketing. No FDA-reviewed liver label is not evidence of liver safety.[6]

What the route genuinely changes

First-pass exposure. This is the central pharmacologic difference, and it is real.

Gallbladder risk. The Menopause Society's 2022 statement concludes that estrogen therapy increases the risk of gallstones, cholecystitis, and cholecystectomy. Observational evidence suggests transdermal therapy may carry less gallbladder risk than oral therapy, but that route difference has not been confirmed in randomized trials.^[1]

Some metabolic markers and observational fatty-liver outcomes. In a 12-month retrospective study of 368 postmenopausal women receiving menopausal hormone therapy, the prevalence of NAFLD changed from 24.0% to 17.3% in the transdermal group and from 25.3% to 29.4% in the oral group. The transdermal group included 75 women; the oral group included 293. This was not a randomized liver-safety trial, so it supports a route hypothesis—not a guarantee.^[7]

What the route does not change

• It does not eliminate systemic exposure.
• It does not identify your liver diagnosis or fibrosis stage.
• It does not erase the current product label.
• It does not override The Menopause Society's systemic-HRT contraindication language.
• It does not make decompensated liver function, Budd–Chiari syndrome, or hepatocellular adenoma appropriate for menopausal hormone therapy.
• It does not convert a short online questionnaire into hepatology review.

The biggest recent cohort in women with established MASLD could not cleanly answer the route question because the underlying medication coding did not reliably separate all formulations. So the route argument is plausible, biologically coherent, and supported by smaller observational data—but not settled for every liver condition.

What about compounded or “bioidentical” hormones?

Do not let the missing label fool you.

Compounded preparations are not FDA-approved. The FDA does not verify their safety, effectiveness, or quality before they are marketed. A compounded product may be appropriate when a patient's needs cannot be met by an approved product, but it does not inherit approval, therapeutic-equivalence status, or FDA-reviewed safety labeling from an approved drug.^[6]

That means:

• No FDA-reviewed liver contraindication on a compounded cream is not evidence that the cream is safer for the liver.
• “Bioidentical” does not erase the need for a prescription, clinical assessment, and product-specific sourcing discussion.
• A compounded product should never be presented as equivalent to an FDA-approved product.
• A page or clinic that calls a compounded product “FDA-approved,” “generic,” “the same as,” or “clinically proven to work like” an approved product is blurring a regulatory line the FDA explicitly tells telehealth marketers not to blur.^[6]

The absence of a printed warning can mean the absence of FDA premarket review—not the absence of risk.

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Can you take HRT with fatty liver or MASLD?

Answer capsule: MASLD without advanced fibrosis is not the same clinical situation as decompensated liver disease, but it is not an automatic HRT clearance either. A 2026 matched cohort associated HRT use with fewer coded liver and cardiometabolic outcomes in women who already had MASLD. It was retrospective, could not prove causation, and does not override labels or systemic-HRT guidance.^[8]

Fatty liver is where the gap between the broad rule and the diagnosis-specific evidence becomes most frustrating.

First, the terminology changed

MASLD means metabolic dysfunction-associated steatotic liver disease. It replaced NAFLD in current nomenclature. The populations overlap heavily, but the definitions are not perfectly interchangeable: MASLD requires hepatic steatosis plus at least one cardiometabolic risk factor. MASH is the inflammatory form that replaced the older term NASH.^[9]

If an older report says NAFLD, do not assume the diagnosis disappeared. Ask how your clinician maps it to the current classification and, more importantly, whether fibrosis has been assessed.

The Two-Question Split

Two questions are constantly mashed together:

1. What happens when a woman who already has MASLD uses HRT for menopause symptoms?
2. Can HRT cause new steatotic liver disease?

They are not the same question, and the evidence does not support one sweeping answer.

What the 2026 established-MASLD cohort found

A 2026 Liver International study used the TriNetX research network to compare women aged 40 to 65 with pre-existing MASLD who initiated HRT with matched women who did not. After matching, each group contained 21,639 women. Over five years, HRT use was associated with lower rates of several coded outcomes:^[8]

Outcome	Hazard ratio (95% CI)	What that association means
Major adverse liver outcomes, combined	0.80 (0.71–0.90)	About 20% lower observed hazard in the HRT group
Cirrhosis	0.75 (0.63–0.90)	About 25% lower observed hazard
Ascites / spontaneous bacterial peritonitis	0.78 (0.64–0.95)	About 22% lower observed hazard
Type 2 diabetes	0.90 (0.84–0.96)	About 10% lower observed hazard
Major cardiovascular events	0.90 (0.83–0.98)	About 10% lower observed hazard
Breast cancer or venous thromboembolism	No increased association reported	Not proof of zero risk; this was not a randomized safety trial

Those numbers are useful. They are not permission.

The study looked backward through health-record data. Diagnoses depended heavily on coding. Matching can reduce measured differences between groups, but it cannot remove healthy-user bias, prescribing selection, missing variables, or unmeasured differences in access to care. The study also did not provide a clean, complete patch-versus-pill answer.

The honest conclusion is narrow:

In this matched cohort, women with established MASLD who received HRT did not have worse coded five-year liver outcomes and had lower observed hazards for several outcomes. That is reassuring enough to justify better research and a real clinical discussion. It is not enough to declare HRT a MASLD treatment or universally safe.

Does HRT cause fatty liver in the first place?

The evidence is not settled. Observational studies vary by population, route, timing, metabolic risk, and how liver disease was defined. The 2023 route study found opposite prevalence changes in transdermal and oral groups, but it was retrospective and nonrandomized. The 2026 cohort began with women who already had MASLD, so it cannot answer whether HRT causes new disease.^[7][8]

Anyone who turns those studies into “HRT prevents fatty liver” or “HRT causes fatty liver” has skipped the study-design question.

The line we will not cross

HRT is not an FDA-approved treatment for MASLD, MASH, fibrosis, cirrhosis, or any other liver disease. The menopause products in this article are approved for specific menopause-related indications, not for treating liver disease.

The data can support a clinician asking better questions. It cannot support a clinic marketing estrogen as a fatty-liver therapy.

What changes the MASLD conversation

The label “fatty liver” is not enough. Bring these distinctions:

• Was steatosis seen only on an incidental ultrasound, or is there a confirmed hepatology diagnosis?
• Is there a fibrosis estimate, elastography result, or biopsy stage?
• Are bilirubin, albumin, INR, and platelets normal?
• Is there diabetes, high triglycerides, hypertension, obesity, or significant alcohol exposure?
• Is the proposed therapy oral, transdermal, or local vaginal treatment?
• Is the clinician treating symptoms, or making an unsupported claim that HRT treats the liver disease itself?

Fatty liver and cirrhosis are different conversations. Your intake should not collapse them into one checkbox.

→ Use Find My HRT Path to see whether your safety history points away from online-first care

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What about cirrhosis, hepatitis, PBC, a transplant, or a liver lesion?

Answer capsule: These conditions cannot be collapsed into “liver disease,” and choosing a different route online does not resolve them. AASLD specifically says menopausal hormone therapy should not be used with decompensated liver function, Budd–Chiari syndrome, or hepatocellular adenoma. For other diagnoses, the labels and The Menopause Society remain broad, while disease activity, fibrosis, clot risk, and drug interactions change the clinical question.^[1][2]

The three AASLD names directly

Decompensated liver function. Decompensation means the liver can no longer maintain normal function without complications. Ascites, variceal bleeding, hepatic encephalopathy, and jaundice are common examples. AASLD's published guidance says menopausal hormone therapy should not be used. Route is not the rescue plan here.

Budd–Chiari syndrome. This involves obstruction of the veins draining the liver, often in a clotting context. AASLD names it directly. This is not a “try the patch” problem; it needs specialist ownership, often involving hepatology and hematology.

Hepatocellular adenoma. This is a benign liver tumor with a recognized relationship to exogenous hormones in some patients. AASLD names hepatocellular adenoma directly in its no-use statement. The exact lesion on the radiology report matters enormously.

If you are in one of those three groups, do not use the narrower AASLD list as a reason to shop for a different route. Use it as a reason to ask for a symptom-treatment plan that respects the liver condition.

Compensated cirrhosis

Compensated cirrhosis means substantial scarring is present, but the liver has not developed the classic complications of decompensation.

The AASLD sentence does not name compensated cirrhosis. That silence is not approval. The Menopause Society still lists liver disease among systemic oral and transdermal HRT contraindications, and every product in our seven-label audit uses broad liver wording.

We did not find adequate menopause-specific safety evidence that turns compensated cirrhosis into an online prescribing decision. The correct next step is not “Which patch company will accept me?” It is: which hepatology and menopause clinicians will review the same record and document who owns the decision?

Primary biliary cholangitis and other cholestatic disease

PBC creates a genuine two-sided problem. Bone loss matters, and estrogen labeling also treats cholestatic history as a real concern.

The narrative discussion inside AASLD's guidance says topical, oral, and parenteral estrogen-containing hormone therapy appear to be safe in women with PBC, while also acknowledging concern about estrogen's cholestatic effects.^[2] That is more permissive than the broad product-label and Menopause Society contraindication language. It rests on small, older studies—not on the kind of large randomized safety trial that would erase the uncertainty.

A 24-month double-blind randomized placebo-controlled trial in 31 postmenopausal women with PBC found femoral-neck bone density fell 3.76% with placebo and rose 0.21% with transdermal estrogen/progestin; the between-group result was borderline at p=0.058. Two new fractures occurred in the placebo group and none in the treatment group. The authors also reported that individual data suggested hormone therapy might worsen cholestasis.^[10]

That is the uncomfortable truth: the bone signal and the cholestasis concern exist in the same small trial.

Small studies cannot carry a broad safety claim. They are enough to show why a four-second refusal is not the same thing as a full risk-benefit discussion with hepatology involved.

Chronic hepatitis B or C

Viral control, fibrosis stage, current antiviral therapy, medication interactions, and other clot or cancer risks all matter.

The Menopause Society's 2022 position statement notes observational findings of slower fibrosis progression in women with hepatitis C who used hormone therapy, while stating that randomized trials are needed before conclusions about benefits and risks in liver disease.^[1]

Read that exactly as written: it is neither a reason to start HRT nor a reason to pretend the evidence is empty. It is an observational signal inside broad contraindication guidance.

After a liver transplant

There is a small, old prospective study rather than a modern clearance rule. Thirty-two postmenopausal women at least six months after liver transplant received transdermal estradiol 50 micrograms, with a progestogen for women with a uterus, for six months. The investigators reported no adverse change in measured liver or hemostatic parameters.^[11]

That is an existence proof, not a guarantee: small sample, short follow-up, older care era, and no randomized control group.

A transplant team also has to account for graft function, immunosuppressants, clot risk, cancer history, and interactions. An online menopause intake cannot own those variables by itself.

Liver lesions: the exact name on the report changes the question

Radiology or pathology term	Why the name matters
Hepatocellular adenoma	Named by AASLD as a condition in which menopausal hormone therapy should not be used.
Hemangioma	A different benign lesion. Several estrogen labels warn that estrogens may exacerbate hepatic hemangiomas, so the lesion still belongs in the discussion; it should not be treated as interchangeable with an adenoma.
Focal nodular hyperplasia (FNH)	Different from an adenoma. Guidance written for contraception or pregnancy should not be silently converted into a menopausal-HRT clearance rule.
Simple cyst	A different finding again. Size, symptoms, imaging certainty, and the rest of the liver matter.
Hepatocellular carcinoma or another suspected malignancy	Oncology and hepatology lead. This page does not.
“Liver lesion,” unspecified	Not enough information to apply any hormone rule. Get the actual report and final diagnosis.

“They found something on my liver” is not a usable diagnosis. Bring the report, not the memory of the phone call.

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My liver enzymes are high. Should I stop HRT?

Answer capsule: Do not stop, start, or change a prescription solely because of one lab result and a webpage. Liver enzymes can rise for many reasons, timing alone does not prove HRT caused the change, and none of the seven hormone labels we audited sets a universal ALT or AST stopping threshold. A raised result should trigger review of the pattern, trend, symptoms, medicines, supplements, and underlying diagnosis.

First, the phrase “liver function tests” hides two different categories.

Test	What it mostly tells you
ALT and AST	Enzymes that can rise with liver-cell injury or irritation. They do not directly measure how well the liver performs every job. AST can also come from muscle.
ALP and GGT	Can support a bile-flow or cholestatic pattern, but neither is specific enough to interpret alone.
Bilirubin	Can rise when processing or bile flow is impaired; the direct/indirect pattern matters.
Albumin and INR	Closer to liver synthetic function—what the liver makes—though other conditions can affect them too.
Platelets	Can provide clues in chronic liver disease and portal hypertension, but are not a liver-specific diagnosis.

“My ALT is up” and “my liver is failing” are not the same sentence.

A mildly raised ALT with normal bilirubin, albumin, INR, and platelets is a different pattern from rising bilirubin, prolonged INR, falling albumin, and new symptoms. Only a clinician with the full panel, history, and trend can tell you what the pattern means.

What else can move the numbers?

The list includes:

• Alcohol
• Viral hepatitis
• MASLD and metabolic change
• Gallbladder or bile-duct disease
• Prescription medicines and over-the-counter products
• Acetaminophen exposure
• Supplements marketed for menopause, sleep, weight loss, bodybuilding, or “liver detox”
• Thyroid disease
• Muscle injury or strenuous exercise, particularly for AST
• Infection or another acute illness

That is not a diagnostic checklist. It is why “the HRT did it” and “the HRT could not have done it” are both guesses before review.

What do the audited estrogen labels actually say about stopping?

They do name stop conditions. They do not give a universal mild-ALT cutoff.

Several estrogen labels direct discontinuation if cholestatic jaundice recurs. They also direct discontinuation if pancreatitis occurs in the setting of severe hypertriglyceridemia. Those instructions are different from a rule that every isolated enzyme increase requires abrupt self-discontinuation.

The useful questions are:

1. Which values changed—ALT, AST, ALP, GGT, bilirubin, albumin, INR, or platelets?
2. How high are they compared with the laboratory's upper limit and with your baseline?
3. Did the pattern begin before or after a medication or supplement change?
4. Are there symptoms such as jaundice, itching, dark urine, pale stools, nausea, right-upper-abdominal pain, confusion, bleeding, or swelling?
5. What is the repeat-testing or workup plan?
6. Does the clinician want the medicine continued, held, or stopped while that workup happens?

Get the pattern, not just the headline.

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Does the same liver rule apply to vaginal estrogen?

Answer capsule: It depends on the exact vaginal product. Estring's current label lists known liver impairment or disease as a contraindication even though it is a low-dose vaginal ring with much lower systemic exposure than systemic HRT. That does not prove every cream, tablet, insert, or ring has identical exposure or wording. Check the label for the product actually being considered.^[5]

If your main problem is vaginal dryness, painful sex, urinary burning, or recurrent urinary symptoms, this distinction matters. Local vaginal treatment is not the same therapeutic exposure as a systemic patch or pill.

The Menopause Society's position statement describes low-dose vaginal estrogen products as producing minimal systemic absorption. Minimal is not zero, and “low-dose vaginal” is a category containing different formulations.^[1]

Estring's label numbers

• Releases approximately 7.5 micrograms of estradiol per day over 90 days
• Reports that about 8% of the amount released is absorbed systemically unchanged
• Reports later steady serum estradiol values around 7 to 8 pg/mL
• States that vaginal administration avoids first-pass metabolism
• States that no pharmacokinetic studies were conducted in women with hepatic impairment
• Still lists known liver impairment or disease as a contraindication^[5]

The accurate question is not, “Is vaginal estrogen always safe with liver disease?”

It is:

For this exact vaginal product, at this exposure, with my exact diagnosis and stage, how does the label apply—and is a nonestrogen local option preferable?

Do not transfer Estring's numbers to estradiol cream, vaginal tablets, softgel inserts, or another ring. Use our vaginal estrogen guide for the product differences and using vaginal estrogen with systemic HRT for the combination question.

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If hormones are off the table, are nonhormonal options safer for the liver?

Answer capsule: Not automatically. Veozah is contraindicated in known cirrhosis, has a boxed warning for hepatotoxicity, sets a two-times-upper-limit laboratory gate before treatment, and requires scheduled liver monitoring. Lynkuet also requires baseline liver tests, uses the same two-times-upper-limit initiation gate, requires testing at three months, and is not recommended with moderate or severe hepatic impairment.^[12][13]

This is one of the most useful facts on the page: “nonhormonal” is a mechanism category, not a liver-safety guarantee.

Audited hormone labels vs Veozah vs Lynkuet

Liver question	Seven menopause hormone labels audited	Veozah (fezolinetant)	Lynkuet (elinzanetant)
Liver contraindication	Broad hepatic/liver impairment, dysfunction, or disease wording	Known cirrhosis	No liver-specific contraindication; pregnancy is the listed contraindication
Before-treatment liver gate	No numeric initiation threshold printed in the seven audited labels	Do not start if ALT or AST is ≥2× ULN or total bilirubin is ≥2× ULN	Do not start if ALT or AST is ≥2× ULN or total bilirubin is ≥2× ULN
Scheduled monitoring	No universal schedule printed in the seven audited labels	Baseline; monthly for first 3 months; month 6; month 9; additional testing for symptoms or abnormalities	Baseline and 3 months after initiation; additional evaluation as clinically indicated
Hepatic warning or restriction	Product-specific contraindication and cholestatic-jaundice warnings	Boxed warning for hepatotoxicity; postmarketing serious liver injury reported	Hepatic transaminase warning; not recommended in moderate or severe hepatic impairment
Label revision checked	February 2026 for six; June 2025 for patch	February 2026	August 2026

Veozah. The current label reports ALT or AST elevations above three times the upper limit of normal in 2.3% of women receiving Veozah versus 0.9% receiving placebo in clinical trials. Postmarketing drug-induced liver injury has been reported, with cases occurring within about 40 days of starting. The label tells patients to stop immediately and contact the prescriber for symptoms including unusual fatigue, reduced appetite, nausea, vomiting, itching, jaundice, pale stools, dark urine, or abdominal pain.^[12]

Lynkuet. The August 2026 label requires baseline ALT, AST, ALP, and bilirubin testing, bars initiation at the same two-times-ULN ALT/AST or bilirubin threshold, and calls for follow-up hepatic transaminase testing at three months. It says use is not recommended in moderate or severe hepatic impairment.^[13]

So the sentence “you cannot take hormones, so the nonhormonal prescription is automatically safer” is not reliable. The exact drug and exact liver condition matter more than the category label.

Other symptom-matched paths

The Menopause Society's nonhormone guidance supports several evidence-based approaches for vasomotor symptoms, including certain SSRIs/SNRIs, gabapentin, oxybutynin, cognitive behavioral therapy, and clinical hypnosis; product choice depends on other medicines, side effects, and comorbidities.^[14]

Main problem	Discussion worth having
Hot flashes and night sweats	FDA-approved nonhormonal options and off-label evidence-based prescriptions, each checked against liver function and drug interactions
Vaginal dryness or painful sex	Moisturizers, lubricants, pelvic-floor care, and product-specific local therapies rather than assuming systemic treatment is required
Sleep disruption	Treat the hot-flash trigger when present; also assess insomnia, restless legs, mood, alcohol, medications, and sleep apnea
Mood symptoms	A proper mental-health and medication assessment rather than assuming every symptom is estrogen deficiency
Bone protection	Fracture-risk assessment and osteoporosis treatments that do not require systemic estrogen

One more damaging admission: “natural” is not a liver-safety category. Herbal and dietary supplements can cause liver injury or interact with prescription medicines. Put every menopause, sleep, weight-loss, bodybuilding, and “liver support” product on the list you bring.

See our nonhormonal menopause treatments guide for the broader treatment comparison.

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What should I bring to the appointment where this gets decided?

Answer capsule: Bring the exact diagnosis, the newest liver panel and prior comparison values, any FibroScan or elastography report, imaging or biopsy summaries, your full medication and supplement list, and a short symptom record. The goal is not to argue past a contraindication. It is to give hepatology and menopause care enough information to make—and document—a diagnosis-specific decision.

Bring these records

• Your exact diagnosis as written in the chart. Not “liver trouble.” Not “a spot.” The actual wording and date.
• Your most recent liver panel and at least one prior panel so the trend is visible.
• Any elastography, FibroScan, MRI, ultrasound, CT, or biopsy report. Bring the report itself, not only “they said it looked okay.”
• Your latest hepatology, gastroenterology, transplant, or oncology note, when relevant.
• Every prescription, over-the-counter medicine, vitamin, and supplement. Include products you take only occasionally.
• Your history of jaundice, including jaundice during pregnancy or with prior estrogen use.
• Your clot, cancer, gallbladder, triglyceride, and cardiovascular history.
• Whether you still have a uterus. Systemic estrogen planning changes when endometrial protection is required.
• Two weeks of symptom frequency. Count hot flashes, night sweats, wake-ups, urinary symptoms, and pain rather than bringing only “it is awful.”

Ask these six questions

1. What exactly is my liver diagnosis, and is my liver function compensated or decompensated?
2. Has fibrosis been assessed? If yes, what did the result show? If not, does it need to be assessed before this decision?
3. Does my condition fall into AASLD's three named no-use groups—or another contraindication in the exact product label?
4. What does the current label for the exact product say, and which part of that wording drives your recommendation?
5. Would transdermal or local vaginal treatment change your assessment? If yes, what risk does the route change—and what risk does it not change?
6. Who owns the final decision, and can menopause care and hepatology communicate directly instead of sending me back and forth?

Name the handoff trap out loud

Gynecology says, “Ask your liver doctor.”

The liver doctor says, “That is a gynecology question.”

You leave with nothing.

Break the loop by asking one clinician to send the other a chart message containing the exact question. Not “the patient is asking about hormones.” Ask for something answerable:

“Does this patient's current diagnosis and stage make systemic menopausal hormone therapy inappropriate, and would product-specific transdermal or low-dose vaginal therapy change that assessment?”

One clinician may still say no. The improvement is that the reason now exists in the chart.

Why the care format matters

A brief asynchronous questionnaire can screen for a liver history. It cannot examine you, interpret a complex trend, reconcile conflicting specialist notes, or coordinate a transplant or hepatology plan by itself.

A video visit can allow more follow-up than a form, but it still does not create records the clinician has not received or replace an in-person assessment when symptoms, disease stage, or decompensation risk require one.

If a form keeps screening you out, stop trying to beat the form. You may need a person, records review, and specialist coordination—not a more permissive checkbox.

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What if I do not know my liver stage yet?

Answer capsule: If you have an incidental fatty-liver finding but no recent liver panel, fibrosis assessment, or clear diagnosis, that missing information comes before the HRT route decision. Stage often changes the clinical meaning more than the words “fatty liver” do. A normal-feeling day does not establish that fibrosis or impaired function is absent.

You cannot ask a precise hormone question about a condition nobody has described precisely.

A staging conversation may include:

1. Confirming the diagnosis and cause. Steatosis, viral hepatitis, alcohol-related disease, autoimmune disease, cholestatic disease, drug-induced injury, and vascular disease do not share one pathway.
2. Reviewing routine bloodwork. ALT, AST, ALP, bilirubin, albumin, INR, and platelets provide different pieces of the picture.
3. Using a noninvasive fibrosis score when appropriate. Scores such as FIB-4 use routine variables as a triage tool; they do not replace diagnosis or specialist interpretation.
4. Adding elastography or imaging when indicated. Liver stiffness can help estimate fibrosis without a biopsy in many situations.
5. Escalating to hepatology when results, symptoms, or diagnosis require it.

The sequence matters:

Diagnosis → stage → symptom priorities → product and route → clinician-owned decision.

Not:

Choose a patch → hope “bypasses the liver” is enough → discover the missing stage later.

→ Use Find My HRT Path only after you know what information is missing

The tool can help route an online-care decision. It cannot diagnose liver disease, calculate a safe hormone threshold, or replace hepatology.

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How did The HRT Index verify this page?

Answer capsule: Every label claim in the Liver Line Ledger was checked against current FDA-hosted or DailyMed prescribing information on August 6, 2026. Medical interpretation was anchored to The Menopause Society, AASLD, FDA materials, and peer-reviewed literature. Where the evidence does not settle the question—especially compensated cirrhosis—we say so instead of manufacturing certainty.

We use The HRT Index Verification Standard. It evaluates online-care information through five pillars, always in this order: clinical legitimacy, care quality, medication fit, price transparency, access.

This is a documented process, not a numeric score. We do not invent per-provider ratings or turn a complex safety question into a leaderboard.

What we verified firsthand on August 6, 2026

• Opened the current labels for Divigel, Cenestin, Enjuvia, Bijuva, Prometrium, Estring, and one current Mylan twice-weekly estradiol transdermal system.
• Transcribed the liver contraindication and checked the label revision date for each.
• Confirmed that all six products on the FDA's February 2026 menopause-label update page retained liver contraindication wording.
• Confirmed Estring's release rate, systemic-absorption figure, serum estradiol values, first-pass statement, and lack of hepatic-impairment pharmacokinetic studies.
• Confirmed The Menopause Society's broad systemic oral and transdermal contraindication language and its more cautious observational discussion of liver outcomes.
• Confirmed the AASLD three-condition statement and that AASLD's public page dates the guidance to September 2020.
• Confirmed Veozah's cirrhosis contraindication, baseline laboratory gate, monitoring schedule, and hepatotoxicity boxed warning.
• Confirmed Lynkuet's August 2026 baseline laboratory gate, three-month follow-up testing, and hepatic-impairment restriction.
• Rechecked the 2026 MASLD cohort's design, matched sample size, hazard ratios, and limits.
• Rechecked the 2023 route study and the small PBC and transplant studies quoted here.
• Opened the live Find My HRT Path page and confirmed the roughly 90-second, no-email, educational-routing description.

What we did not verify—and will not pretend we did

• A universal safe ALT, AST, bilirubin, fibrosis, or Child–Pugh threshold for menopausal HRT. The audited hormone labels do not provide one.
• Adequate menopause-specific safety evidence for systemic HRT in compensated cirrhosis.
• A modern randomized trial that settles HRT across MASLD, viral hepatitis, PBC, transplant, and cirrhosis.
• That every marketed patch, gel, pill, cream, insert, and ring has identical liver wording. It does not follow from a seven-label audit.
• That absence from AASLD's three-item sentence means a condition is approved or safe for MHT.
• Any individual reader's diagnosis, stage, eligibility, or treatment decision.

Why there are no success stories here

A testimonial on this page would do one of two bad things: imply HRT was safe because one woman used it with liver disease, or imply one woman's diagnosis predicts yours.

Neither is evidence. We did not add a customer quote, anonymous patient story, or first-person treatment claim to create emotional permission where the medical evidence cannot.

This page is editorial research. It has not been reviewed by a clinician. Read our medical review policy and editorial team page for how that status is disclosed.

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Frequently asked questions

Answer capsule: The questions below close the most common follow-ups about patches, fatty liver, cirrhosis, vaginal estrogen, abnormal liver enzymes, compounded hormones, and non-hormonal medicines. The same boundary applies throughout: broad contraindications are real, route differences are real, and a personal decision requires the exact diagnosis, stage, product, and clinician review.

Can you take HRT if you have liver disease?

Not from a website's yes or no. The Menopause Society lists liver disease among contraindications for systemic oral and transdermal HRT, and every product in our seven-label audit carries broad liver contraindication wording. AASLD separately names decompensated liver function, Budd–Chiari syndrome, and hepatocellular adenoma as no-use conditions. Your exact diagnosis, stage, product, route, and other risks require clinician review.

Is an estrogen patch safe for the liver?

A patch avoids first-pass metabolism, which is a meaningful difference from oral estrogen. It does not eliminate systemic exposure or make the liver irrelevant, and the current twice-weekly patch label we audited lists hepatic impairment or disease as a contraindication. “Lower first-pass impact” is not the same claim as “safe with liver disease.”

Does HRT cause fatty liver?

Current evidence does not establish one simple causal answer. A 2023 retrospective route study found NAFLD prevalence decreased in a transdermal group and increased in an oral group over 12 months, while a 2026 cohort in women with existing MASLD associated HRT with lower five-year adverse outcomes. Neither study randomized women to answer whether HRT causes new MASLD.

Can HRT treat or reverse fatty liver disease?

No menopause hormone product is FDA-approved to treat MASLD, MASH, fibrosis, or cirrhosis. Observational associations can justify research and a better risk discussion; they do not turn HRT into a liver treatment.

Do I need liver tests before starting HRT?

The seven menopause hormone labels we audited do not set a universal baseline-testing schedule or numeric initiation threshold. A clinician may still order tests because of your history, symptoms, other medicines, or diagnosis. Nonhormonal Veozah and Lynkuet do have explicit baseline liver-testing rules in their current labels.

Does HRT raise liver enzymes?

Liver enzymes can change for many reasons, and a rise after starting a medicine does not prove causation by timing alone. None of the seven audited hormone labels gives a universal ALT or AST stopping threshold. New abnormalities need review of the full pattern, trend, symptoms, medicines, alcohol, supplements, and underlying liver condition.

Can you use vaginal estrogen with liver disease?

Check the exact product. Estring's current label lists known liver impairment or disease as a contraindication despite low systemic exposure. That should not be silently generalized to every vaginal cream, tablet, insert, or ring; each product has its own exposure profile and prescribing information.

Can you take HRT with cirrhosis?

AASLD says menopausal hormone therapy should not be used with decompensated liver function. Compensated cirrhosis is not named in that three-condition sentence, but The Menopause Society's systemic-HRT contraindication and broad product-label wording still apply, and adequate menopause-specific safety evidence is missing. This is a hepatology-led decision, not an online route choice.

Is HRT safe with hepatitis B or C?

There is no universal answer. Viral control, fibrosis stage, antiviral treatment, interactions, and other risks matter. The Menopause Society notes observational findings of slower fibrosis progression in women with hepatitis C using hormone therapy, while stating randomized trials are needed before conclusions about liver-disease benefits and risks.

Can you take HRT with PBC?

PBC is not named in AASLD's three-condition MHT sentence, but cholestasis and prior cholestatic jaundice are genuine label concerns. A small randomized PBC trial found a bone-density signal alongside concern that treatment might worsen cholestasis. Both sides belong in a hepatology-led discussion.

Did the FDA's 2026 label changes remove the liver contraindication?

No. The FDA's first February 2026 update covered Prometrium, Divigel, Cenestin, Enjuvia, Estring, and Bijuva. The update removed selected cardiovascular, breast-cancer, and probable-dementia statements from boxed warnings; all six current labels retained liver contraindication wording.

Is compounded or “bioidentical” HRT gentler on the liver?

There is no FDA-reviewed basis for that claim. Compounded drugs are not FDA-approved, and FDA does not verify their safety, effectiveness, or quality before marketing. The absence of an FDA-reviewed liver label is the absence of FDA premarket review—not evidence that a compounded product is safer or equivalent to an approved drug.

Are nonhormonal hot-flash medicines safer for the liver?

Not automatically. Veozah is contraindicated in known cirrhosis, carries a hepatotoxicity boxed warning, and requires extensive scheduled liver testing. Lynkuet requires baseline and three-month liver testing and is not recommended in moderate or severe hepatic impairment. The exact medicine matters more than the word “nonhormonal.”

What if I have a liver lesion?

Get the exact radiology or pathology name. Hepatocellular adenoma is specifically named by AASLD as a no-use condition for menopausal hormone therapy. Hemangioma, focal nodular hyperplasia, simple cysts, and malignancy are different diagnoses with different implications. “Liver lesion” alone is not enough information.

Can an online HRT provider handle liver disease?

Sometimes online care can start the conversation, but unclear diagnoses, abnormal trends, cirrhosis, transplant history, Budd–Chiari syndrome, hepatocellular adenoma, or signs of decompensation require more than a fast intake. The provider must be able to review records and know when to defer to hepatology or in-person care. Online care is not the right starting point for urgent symptoms or unresolved advanced disease.

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Where do I go from here?

Answer capsule: Get the exact diagnosis and stage, bring the current label and your liver trend, and make one clinician own the documented decision. If online care cannot review the record or coordinate with hepatology, it is not the right starting point for this question.

Your diagnosis name is not your personal answer. Neither is a four-second no with no explanation.

The broad contraindication is real. The narrower liver-specialist statement is real. Route differences are real. The observational MASLD evidence is real. None of those facts, alone, gives you permission.

The next correct move is concrete:

1. Get the exact diagnosis and stage.
2. Bring the current label for the exact product.
3. Bring the liver trend, imaging, medication list, and symptom count.
4. Ask the six questions.
5. Make one clinician own the documented answer and coordinate with hepatology when needed.

If the answer is no, your symptoms still deserve treatment. If the answer might be more nuanced, the nuance has to come from your records and clinicians—not from pretending a patch erases the liver.

Still not sure whether online HRT care is the right starting point?

Find My HRT Path takes about 90 seconds and requires no email. It routes by symptoms, treatment preference, safety history, budget, and state; keeps FDA-approved and compounded options clearly separated; and flags when online care is not the right starting point. It does not diagnose liver disease or tell you whether you can take HRT.

→ Find the next care route that fits your situation

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Sources

¹ The Menopause Society. The 2022 Hormone Therapy Position Statement of The North American Menopause Society; and Hormone Therapy patient education. Accessed August 6, 2026.

² American Association for the Study of Liver Diseases. Reproductive Health and Liver Disease practice guidance page, updated September 2020; Sarkar M, Brady CW, Fleckenstein J, et al. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;73(1):318–365. doi:10.1002/hep.31559.

³ U.S. Food and Drug Administration. Menopausal Hormone Therapies with Updated Prescribing Information; FDA Approves Labeling Changes to Menopausal Hormone Therapy Products, February 12, 2026; current FDA labels for Divigel, Cenestin, Enjuvia, Bijuva, Prometrium, and Estring. Checked August 6, 2026.

⁴ DailyMed. Estradiol transdermal system, twice-weekly, Mylan prescribing information, revised June 2025. Accessed August 6, 2026.

⁵ U.S. Food and Drug Administration. Estring prescribing information, revised February 2026.

⁶ U.S. Food and Drug Administration. Compounding and the FDA: Questions and Answers; FDA to Telehealth Companies: What to Know When Promoting Compounded Drugs. Accessed August 6, 2026.

⁷ Kim SE, Min JS, Lee S, Lee DY, Choi D. Different effects of menopausal hormone therapy on non-alcoholic fatty liver disease based on the route of estrogen administration. Scientific Reports. 2023;13:15461. doi:10.1038/s41598-023-42788-6.

⁸ Henney AE, Wilson J, Riley DR, Alam U, Cuthbertson DJ. Effect of Hormone Replacement Therapy on Liver and Cardiometabolic Outcomes in Peri-Menopausal MASLD. Liver International. 2026;46(4):e70562. doi:10.1111/liv.70562.

⁹ American Association for the Study of Liver Diseases. New MASLD Nomenclature. Accessed August 6, 2026.

¹⁰ Boone RH, Cheung AM, Girlan LM, Heathcote EJ. Osteoporosis in primary biliary cirrhosis: a randomized trial of the efficacy and feasibility of estrogen/progestin. Digestive Diseases and Sciences. 2006.

¹¹ Safety and efficacy of transdermal estradiol replacement therapy in postmenopausal liver transplanted women. PMID 9688245.

¹² DailyMed. Veozah (fezolinetant) prescribing information, revised February 2026. Accessed August 6, 2026.

¹³ DailyMed. Lynkuet (elinzanetant) prescribing information, revised August 2026. Accessed August 6, 2026.

¹⁴ The Menopause Society. The 2023 Nonhormone Therapy Position Statement. Menopause. 2023;30(6):573–590.