Menstrual function frequently ceases in women with advanced chronic liver disease and may be mistaken for menopause, despite often recovering after liver transplantation (LT). Whether post-LT menstrual recovery is associated with subsequent graft liver disease (GLD) has not been well characterized.

This is a single center retrospective cohort study of adult women undergoing LT between ages 18 and 55 years from 2014 to 2022. Women were categorized by post-LT menstrual status within 1 year (menses vs. no menses). The primary outcome was GLD, defined as ≥1 biopsy or ≥ 2 images with fibrosis and/or steatosis in the absence of alcohol.

Among 88 women with median follow-up of 1515 days (IQR 835–2807), 43 (48.9%) had documented menses within one-year of LT. The 5-year cumulative incidence of GLD was 28.2% (95% CI 15.7%–38.8%). GLD occurred more frequently among women without menses compared to those with menses (35.6% vs 9.3%, p = 0.004). In overlap-weighted Cox models, absence of menses was associated with higher hazard of GLD (HR 8.37, 95% CI 2.29–30.60). Findings were consistent in prespecified subgroup analyses, including women aged ≤45 years ( n = 31).

In this single-center cohort, absence of menses within one year of LT was strongly associated with subsequent risk of GLD. Prospective studies with standardized reproductive and graft surveillance measures are needed to validate menstrual recovery as a clinically useful risk marker after LT.