The liver is a curious organ – especially as women transition menopause.
According to traditional Chinese medicine, the expression “the liver stores the soul and controls the deliberations” indicates that the liver plays an important role in the process of regulating emotion. This is because the liver stores blood and blood stores the soul. Qi and blood are the material bases of emotional activities. Which is why, in Chinese medicine, you cannot understand stress, without understanding it’s effects on the liver. [Yu Wei et al., 2018].
It is hard to dispute that for millions of women today, stress is part and parcel of everyday life. I know myself and from the women who join me in my coaching community, that family, social and work obligations can easily overpower precious time and resources, causing both physical and emotional stress to take a greater toll on menopause symptoms and general health, especially fatigue levels.
Stress has been defined as any action or situation (stressor) that places increased physical or psychological demand on one’s state of internal balance, or homeostasis.
To meet these increased demands, the body must have the ability to cope, which means that there are also increased neural and endocrine (hormonal) demands on the Hypothalamus-Pituitary-Adrenal-Thyroid Axis (HPA-Thyroid Axis), in response to repeated or chronic stress.
For women who have had decades of stress, including the physical stress of training and competing in sports or participating in demanding exercise, this is where attention needs to be given to the health of the liver.
Researchers now understand that just one episode of stress messes up liver biochemistry.
Stress and Liver Health during Menopause
Inflammation in the liver can sit around for years. Especially if those years leading up to menopause, have been well, … ‘stressful’.
When chronic stress is present, so too are higher levels of cortisol. This is because the reaction to any given stressor, involves the stimulation of the pathways within the brain leading to the (over)activation of the HPA-Thyroid Axis.
As such, sympathetic nervous system drive increases, releasing larger amounts of cortisol into the circulation.
Higher levels of cortisol stimulates the liver to produce more glucose in response to the increased energy demands on the body, i.e. the ‘fight or flight’ response. In response to the need for more glucose, the liver produces it from stored glucose. This process is known as gluconeogenesis, which leads to increased blood glucose levels.
In response to these higher blood glucose levels, the pancreas releases insulin to carry the glucose to the brain and muscles. Which is why, over time, if stress continues and cortisol remains elevated, this can lead to insulin resistance.
‘Psychological stress is associated with a variety of pathological conditions resulting in liver injury through multiple systems, including the sympathetic nervous and adreno-cortical system.’ [Joung, Cho et al, 2019, p. 1].
Stress (both physical and psychological) leads to the reduction in hepatic (liver) blood flow. This is important to understand.
The resulting reduction in oxygen uptake in the liver, due to reduced liver blood flow, causes inflammation in the liver – mainly in the mitochondria, which are the cells that help to burn fats to turn into energy. This inflammation places a lot of strain on ageing liver cells, (Chandel et al, 2000).
Furthermore, when hepatic blood flow is reduced, then this also impacts the health of the gut, through the gut-liver axis.
The gut-liver axis refers to the bidirectional communication and interaction between the gut, its microbiome, and the liver, influencing gastrointestinal and liver health and disease. [Albillos et al., 2020].
Some of your clients may well be arriving in peri-menopause and menopause, with a tired, inflamed liver, not only from physical or emotional stress, but also from menopause-related insomnia. This places an additional burden on the health of the liver, contributing to Non-Alcoholic Fatty Liver Disease, (NAFLD) and/or Metabolic Associated Fatty Liver Disease (M-FLD). [Bagnato et al., 2024]
If your client’s blood work has shown that their liver enzymes are high (whether they drink alcohol or not), you might want to discuss the connection between their liver health and stress levels with them.
Peta was the same – as a competitive triathlete and coach, she was frustrated with not being able to lose weight and have the energy she needed to train and compete. As she mentioned,
“I’d lost all my mojo and drive to train. Getting out of bed was hard enough. All the reading I had done had told me that my oestrogen levels were dropping in peri-menopause, so I was stuffing myself with oestrogen products but Wendy’s programme told me I was feeding myself stuff that was making my liver health worse – and the stress o training and lack of sleep and everything plus feeding myself high protein (eggs etc) sports nutrition foods, had turned my body into a cocktail of hormones.”
The Demands of the Liver Increase with Training/ High Intensity Exercise:
Female exercisers and women who work in physically demanding jobs must remember that before, during and after exercise or when workloads are high, the liver has a lot of work to do.
When muscles are demanding more glucose (sugar) to function, e.g. as in exercise or sports participation, the liver is busy turning over glucose and lactic acid from its storage cells.
The muscles only store enough glycogen (stored glucose), to produce small amounts (up to 20 seconds) of ATP (the energy molecule) at the commencement of exercise – ATP is needed for muscle contraction.
The harder women train or exercise or the more stress that they experience daily, the more work the liver has to do to keep supplying both the muscles and brain with energy. To achieve this, the adrenal glands are producing cortisol, but it’s the liver that is playing a crucial role in the metabolism of cortisol and can produce it locally, converting cortisone to cortisol via the enzyme 11-beta-HSD1. [Thau, 2023).
The higher the production of cortisol, the more that it is also demanding cholesterol from the liver. For more and more cortisol to be produced, the liver is producing cholesterol to help the adrenal glands make cortisol.
The increased production of cortisol then becomes problematic for women in their menopause transition, because it uses up progesterone in the production pathway. When progesterone levels are low in comparison to oestrogen, menopause symptoms may become worse. The role of progesterone cannot be underestimated and if progesterone is low, then symptoms can become worse. The diagram below shows the numerous roles of progesterone in females.
This is why, you cannot help your clients manage their stress levels, without giving consideration to the role of the liver and the inflammatory changes that have occurred over many years. All this, at a time of life, when ageing changes are also impacting the liver’s function and size, including the role of enzymes. (Brady, 2015).
The role of the liver and the evidenced detoxification pathways are covered in both the Menopause and Lifestyle Practitioner Course and the Menopause Weight Loss Coach Course.
In these courses, I also talk about the impact of alcohol on an ageing and inflamed liver. Hepatic inflammation during menopause, reduces ALDH enzymes, which affects alcohol metabolism. As such, some women find that certain types of alcohol impact the severity of their hot flushes.
Alcohol aromatises into oestradiol, a form of oestrogen. In humans, oestradiol (E2) is the predominant circulating oestrogen. If women have breast cancer, then they may know all about this type of oestrogen already.
I hope you can join me on any of the certified MyMT™ Education courses. Please also reach out to the Course Convenor, Georgia, if you have any questions.
Georgia Sweet, Course Convenor
Dr Wendy Sweet, PhD/ Member: Australasian Society of Lifestyle Medicine
References:
Albillos A, de Gottardi A, Rescigno M. The gut-liver axis in liver disease: Pathophysiological basis for therapy. J Hepatol. 2020 Mar;72(3):558-577. doi: 10.1016/j.jhep.2019.10.003. Epub 2019 Oct 14.
Bagnato, C. B., Bianco, A., Bonfiglio, C., Franco, I., Verrelli, N., Carella, N., Shahini, E., Zappimbulso, M., Giannuzzi, V., Pesole, P. L., Ancona, A., & Giannelli, G. (2024). Healthy Lifestyle Changes Improve Cortisol Levels and Liver Steatosis in MASLD Patients: Results from a Randomized Clinical Trial. Nutrients, 16(23), 4225. https://doi.org/10.3390/nu16234225
Brady C.W. (2015). Liver disease in menopause. World J Gastroenterol. 7;21(25):7613-20.
Brown TM, Fee E. Walter Bradford Cannon: Pioneer Physiologist of Human Emotions. Am J Public Health. 2002 Oct;92(10):1594–5. PMCID: PMC1447286.
Chandel, N. S. , McClintock, D. S. , Feliciano, C. E. , Wood, T. M. , Melendez, J. A. , Rodriguez, A. M. , & Schumacker, P. T. (2000). Reactive oxygen species generated at mitochondrial complex III stabilize hypoxia‐inducible factor‐1α during hypoxia a mechanism of O2 sensing. Journal of Biological Chemistry, 275(33), 25130–25138.
Gerber LM, Sievert LL, Schwartz JE. Hot flashes and midlife symptoms in relation to levels of salivary cortisol. Maturitas. 2017 Feb;96:26-32. doi: 10.1016/j.maturitas.2016.11.001. Epub 2016 Nov 3. PMID: 28041591;
Joung JY, Cho JH, Kim YH, Choi SH, Son CG. (2019). A literature review for the mechanisms of stress-induced liver injury. Brain Behav. 9(3):e01235. doi: 10.1002/brb3.1235. Epub 2019 Feb 13. PMID: 30761781; PMCID: PMC6422711.
Thau L, Gandhi J, Sharma S. Physiology, Cortisol. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
Yu Wei, Tianfang Wang, Hao Wu, Yamei Huang, Mengying Wu, Min Zheng, Renlai Zhou, Qingguo Wang, Yan Zhao. Biological mechanisms underlying the liver’s regulation of emotions in women: A study using the Trier Social Stress Test. Journal of Traditional Chinese Medical Sciences, (5), 2, 2018, (110-118).
