Metabolic-associated steatotic liver disease (MASLD) is a leading indication for liver transplantation in women. Menopause may influence disease severity, as MASLD and fibrosis prevalence rise after menopause. Historically, women experienced higher waitlist mortality under Model for End-Stage Liver Disease (MELD) allocation. MELD 3.0 introduced a female sex coefficient and albumin to improve equity, but its effect remains unclear.

We conducted a retrospective cohort study of women listed for liver transplant (UNOS 2013–2024). Menopausal status was estimated using National Health and Nutrition Examination Survey (NHANES)-derived logistic regression model incorporating age, body mass index (BMI), diabetes, and ethnicity. Primary outcomes were deceased-donor transplant and waitlist death/delisting, assessed with cumulative incidence functions and Cox and Fine–Gray models, adjusted for menopause, MASLD, MELD, BMI, diabetes, and MASLD-menopause interaction. Analyses were stratified by MELD 3.0 era (pre- vs post-July 2023).

Among 28,139 women (median age 56), 41% were premenopausal and 26% had MASLD. MASLD patients had a 21% higher adjusted risk of waitlist death/delisting vs non-MASLD. Postmenopausal MASLD women were 15% more likely to undergo transplant (sHR 1.15) and had 22% lower sHR hazard of death/delisting compared to premenopausal women (sHR 0.78). Cox models suggested high baseline mortality risk, but Fine–Gray models showed lower observed mortality, indicating successful prioritization. Favorable outcomes persisted after MELD 3.0 implementation.

Menopausal status modifies MASLD-related waitlist outcomes: younger women remain at elevated dropout risk, whereas postmenopausal women benefit from higher transplant rates and lower mortality, reflecting improved equity under current allocation.