Liver enzymes creeping up in your forties, and it is not the wine
Your ALT was 22 five years ago. Then 28. Then 34. Every result was called normal, and somewhere along the way a doctor asked how much you drink. You said a glass or two on the weekend, which is true, and the conversation ended there.
For most of the women I see, it is not the wine. It is the same story that moved the cholesterol in Issue 010 and the insulin in Issue 012, arriving at the liver. I want to explain what those two numbers are, why they creep in the forties, what the newest guidance says the normal line should be, and what to ask for while the number is still small enough to turn round.
What ALT and AST are
ALT and AST are enzymes that live inside liver cells. When liver cells are stressed or damaged, some spill into the blood, and the number rises. ALT is the more liver specific of the two. AST is also in muscle and heart, which is why a hard workout the day before a draw can push it up on its own.
So a creeping ALT is not a diagnosis. It is a signal that liver cells are under strain. The job is to find out why, and in a woman in her forties who is not a heavy drinker the answer is usually fat in the liver, with a few other causes that need ruling out.
The range, and the word normal
Most labs print an upper limit for ALT somewhere between 35 and 55, and some go higher. Those ranges were built from populations where fatty liver is common, so the top of the range is set by people who already have it. In 2017 the American College of Gastroenterology recommended that a healthy ALT is 19 to 25 in women and 29 to 33 in men, and that anything above that should be assessed rather than watched. Most labs never changed their printouts.
That is the gap. A woman with an ALT of 34 has a number the lab calls normal and the specialists call worth investigating. If your ALT has doubled over five years while staying inside the range, the direction is the information, and the flag is not.
Why the liver in your forties
The liver in a woman under fifty is protected in a way that it stops being. Estrogen helps the liver handle fat, keeps it sensitive to insulin, and dampens inflammation inside it. As estrogen falls across perimenopause, the liver stores more fat and clears less. In the studies that compare women before and after menopause, the risk of fatty liver roughly doubles after the transition, even after allowing for age and weight, and it is higher again after the ovaries are removed surgically.
Behind that sits insulin. High insulin tells the liver to make fat and to keep it. That is why a rising ALT so often arrives with the triglycerides up, the HDL down, the waist growing and the fasting glucose still normal. It is one process seen from four angles. Read the folder one page at a time and you get four small flags nobody comments on. Read it at once and you get a liver that is quietly filling with fat because the body stopped hearing insulin.
Fatty liver was called non-alcoholic fatty liver disease for years. In 2023 the name changed to metabolic dysfunction associated steatotic liver disease, MASLD, because the drivers are metabolic: insulin, weight around the middle, blood pressure and blood fats. Roughly a third of adults have it and most do not know. It is the same problem as the cholesterol and the insulin, treated by the same things, and it is one of the few conditions where early damage clearly reverses if it is caught while the enzymes are creeping rather than climbing.
Alcohol still counts. For a woman, more than about one to one and a half drinks a day on average moves you into a category where alcohol and metabolism are both doing damage. Below that, in a woman with the metabolic pattern, alcohol is a contributor and rarely the cause.
The other causes that need ruling out
Fat is the usual answer and it is not the only one, which is why a rising ALT should be worked up and not watched. Thyroid that is under or overactive moves liver enzymes. Iron overload, which some people carry genetically, shows up as raised ferritin with a raised ALT. Celiac disease can present as nothing more than a creeping liver enzyme. Autoimmune liver disease is more common in women. Hepatitis B and C are worth a one time screen. Medicines matter, including statins, some antibiotics, some antidepressants, and daily acetaminophen for a sore back. So do supplements. Green tea extract, high dose turmeric, kava and many weight loss products have all been tied to liver injury, and the bottle does not say so.
What I ask people to get
I do not order tests. I tell you what to ask for by name, and I ask you to get the printout going back as far as it goes, because the trend is the finding.
ALT, AST, GGT and the whole liver panel. GGT is the one most often missed. It rises with alcohol and with fat and it helps tell the two apart.
Fasting insulin with fasting glucose, HbA1c and a lipid panel. This is where the cause usually is. Issue 012 covers why.
A full thyroid panel, ferritin with transferrin saturation, and hs-CRP. Thyroid and iron are the two easy things to rule out, and the inflammation marker tells you how hot the process is.
A hepatitis B and C screen if never done, and celiac antibodies. One time tests that close doors.
A FIB-4 score. Your doctor can calculate it from your age, AST, ALT and platelet count, all of which are already on the page. It estimates whether there is any scarring and it decides whether you need a scan.
A liver ultrasound or elastography if the enzymes stay up. The ultrasound shows fat. Elastography, a painless scan, shows stiffness, which is scarring, and it is the test that tells you where you are on the road.
What I would do first
None of this waits for a scan, and all of it helps whatever the scan shows.
Thirty grams of protein at breakfast, and something to slow every meal. The liver fills with fat on the back of high insulin. Everything that lowers insulin lowers liver fat, and this is the change people feel fastest.
Cut the sugar you drink. Fructose goes straight to the liver and is turned into fat there. Juice, soda, sweetened coffee, the smoothie that felt healthy. This is the single food change with the most evidence for liver fat, and it usually matters more than the wine.
Walk after your biggest meal, and lift twice a week. Muscle takes up glucose without insulin, and muscle lost in the forties is one reason the liver takes the load. Exercise reduces liver fat even before weight changes.
Coffee, if you drink it, is on your side. Two to three cups a day is repeatedly linked to lower liver enzymes and less scarring, as long as it is not the sugared kind.
Stop the supplements you cannot account for. Anything with green tea extract, high dose turmeric, kava or a weight loss claim comes off the shelf until the enzymes are explained. Bring the bottles to the appointment.
Count the drinks for two weeks. If it is more than you thought, that is information. If it is what you thought, put the question down and look at the insulin.
When to push harder with your doctor
Push harder if your ALT is above 25 and rising across more than one result, whatever the flag says. If ALT or AST is more than twice the top of the range, or up with a raised bilirubin, a low platelet count or a raised GGT, do not wait for the next annual. If a FIB-4 has never been calculated, ask for it. If you have type 2 diabetes, PCOS, high triglycerides or a waist above 35 inches, guidelines say fatty liver should be actively looked for. Yellowing of the skin or eyes, dark urine, pain under the right ribs, or swelling of the legs or belly are urgent and need a doctor that week.
If you take a statin, do not stop it over a mildly raised ALT. Statins are usually safe in fatty liver and that is your prescriber's call. If hormone therapy is on the table for hot flashes, it is the most effective treatment for them and a conversation for a menopause trained doctor, who can also tell you what the route of estrogen means for the liver.
I do not diagnose and I do not treat. I read these numbers next to your insulin, your waist, your sleep, your thyroid and your life, and tell you what I see as one picture. If it needs clinical care I say so and I send you.
Questions I get asked
What does a slightly high ALT mean in a woman in her forties?
Most often it means fat in the liver driven by insulin resistance, made worse by falling estrogen. It can also be thyroid, iron overload, celiac disease, a medication or a supplement, which is why a rising number should be worked up rather than watched.
What is a normal ALT for a woman?
Most labs print an upper limit between 35 and 55. The American College of Gastroenterology says a healthy ALT for a woman is 19 to 25 and anything above that deserves assessment. If your ALT has risen across several years while staying inside the lab range, the trend is the finding.
Can a fatty liver be reversed?
Yes, in the early stage, and it is one of the few conditions where the liver clearly recovers. Lowering insulin through protein, fiber, cutting sugary drinks, walking after meals and building muscle reduces liver fat within months. A loss of even a small share of body weight makes a measurable difference, and scarring caught early can stop progressing.
Does one glass of wine a night cause fatty liver?
On its own, at that level, rarely. For a woman, more than about one to one and a half drinks a day on average moves alcohol from a contributor to a cause. Below that, in a woman with high insulin and a growing waist, the metabolic picture is usually doing more damage than the wine, and cutting sugary drinks often does more than cutting the wine.
Which supplements can raise liver enzymes?
Green tea extract, high dose turmeric or curcumin, kava, and many weight loss and bodybuilding products have all been linked to liver injury. If your enzymes are rising and you take anything from that list, stop it, tell your doctor, and retest.
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This is general wellness education and not medical advice, diagnosis or treatment. Talk to a qualified professional, especially if you are pregnant, nursing, taking medication or managing a condition.