Symptoms of Hepatitis C in Women

The symptoms of hepatitis C in women are similar to those in men. However, the disease can progress differently in people who are biologically female. Hepatitis C is a potentially fatal viral infection that can cause long-term damage to the liver. A biological female with hepatitis C faces unique challenges, including the risk of transmission to a fetus during pregnancy.

This article will go over the symptoms of hepatitis C in women who are biologically female. You will also learn how hepatitis C may affect people who are biologically female differently than people who are biologically male.

Hepatitis C Symptoms In Women

Hepatitis C symptoms in women who are biologically female are similar to those that biological males experience.

After a woman is infected with hepatitis C virus (HCV), they enter an acute phase of infection in which symptoms may or may not develop. If acute symptoms of hepatitis C appear, they may include:

• Severe fatigue
• Abdominal pain
• Nausea or vomiting
• Poor appetite
• Yellowing of the eyes or skin (jaundice)
• Dark urine
• Clay-colored stools

In many cases, the body's immune system will be able to clear the acute infection on its own with no long-lasting consequences.

For some people, however, the infection can persist and become chronic, causing progressive injury to the liver. Over the course of years or decades, chronic hepatitis C can progress silently, leading to liver fibrosis (scarring), cirrhosis (liver damage), liver failure, and liver cancer. For many, the disease will only become apparent in the advanced stages of infection.

The symptoms of hepatitis C are the same for women and men. Where the disease differs is in the rates of infection and disease progression in women versus men.

According to a 2014 review of studies in the Journal of Infectious Diseases, the characteristics of hepatitis C differ in women in several key ways:

The review further details that women usually experience a sudden increase in disease activity in later, post-menopausal years, whereas men have steadier, albeit more rapid, disease progression.

Death rates are not only lower in women with chronic hepatitis C but are significantly so.

Hepatitis C Infection Rates In Women

Women account for fewer hepatitis C infections than men—more specifically, around 45% of all cases in the United States, according to the Centers for Disease Control and Prevention (CDC). The ratio between female and male infections has remained more or less steady for many years and is similar to what is seen in other countries.

The differences in infection rates are believed to be linked to behaviors that increase the risk of HCV transmission rather than any innate biological defense or vulnerability. As a blood-borne disease, hepatitis C is mainly associated with injecting drug use, the practice of which is four times more common in men than in women.

Other factors can contribute to the disparity between sexes, including the increased potential for sexual transmission of hepatitis C among men who have sex with men. The sexual transmission of HCV among women and heterosexual men, by comparison, is considered rare with a reported incidence of one out of every 250,000 sexual acts.

This is not to suggest that all women are less likely to get hepatitis C. Even though fewer females inject drugs, those who do are 27% more likely to get HCV than their male counterparts, according to a 2017 study published in the Journal of Viral Hepatitis.

Hepatitis C Clearance In Women

The rate of clearance of hepatitis C in women who are biologically female can also be different. It is believed that 20% of all hepatitis C infections clear spontaneously without treatment. The rates of clearance, however, differ dramatically between sexes.

Ongoing surveillance data from the United States suggests that 37% of women with acute HCV will experience clearance compared to only 11% of men. The female hormone estrogen is believed to play a central role in this phenomenon.

A 2017 study published in Liver International reported that estrogen directly interferes with the virus's ability to replicate, mainly in the latter stages of its life cycle when the virus is making "copies" of itself. Without the means to replicate aggressively, the virus is more likely to be eradicated by the immune system.

Progression In Women

Women with hepatitis C who are biologically female may experience a different course of disease progression than biological males.

Estrogen also appears to have a blunting effect on chronic HCV infection in females, meaning that the disease tends to progress much slower in women than in men.

Men generally have estrogen levels ranging between 15 to 60 picograms per milliliter (pg/mL). Premenopausal women will have fluctuating levels based on the stage of the menstrual cycle, ranging from as low as 30 to 120 pg/mL during the follicular stage to as high as 130 to 370 pg/mL during the ovulatory stage. These higher levels appear to have a protective benefit for women.

The same does not hold true for postmenopausal women in whom hepatitis C can suddenly (and often rapidly) progress due to steep drops in estrogen production. By this stage in a woman's life, estrogen levels will be more or less the same as men's. This can accelerate the speed by which compensated cirrhosis (where the liver is still functional) becomes decompensated, leading to acute liver failure.

There is evidence that estrogen replacement therapy (ERT) used in some postmenopausal women can also slow the rate of HCV progression and the degree of liver fibrosis.

Alcohol and Cirrhosis

Women who have hepatitis C and use alcohol may notice that the behavior contributes to disease progression. Most studies have shown that heavy alcohol use is linked to the rapid development of cirrhosis of the liver. As a group, men are more likely to be heavy drinkers and are generally able to consume more alcohol than women.

Research has shown a direct correlation between the amount of alcohol consumed daily and the degree of liver fibrosis. In women, however, it takes far less alcohol to render the same harm.

This suggests that heavy alcohol use in women with chronic HCV may undercut the protective benefits of estrogen.

^{Note: A standard-size alcoholic drink in the United States contains 14 g (0.6 fluid ounces) of pure alcohol. Examples of standard drinks include a 5-ounce glass of wine, a 12-ounce beer, and a 1.5-ounce shot of 80-proof distilled spirits.}

Complications and Death

Once a biologically female woman is in her postmenstrual years, the annual increase in her risk of cirrhosis and liver cancer more or less mirrors that of their male counterparts. Even so, women tend to live longer with hepatitis C (due, in part, to the delayed onset of severe disease) and have a significantly lower risk of death compared to men.

A 2017 study in the Journal of Viral Hepatitis reported that, in men, the 15-year mortality rates of HCV-associated cirrhosis and liver cancer hover around 27% and 4%, respectively. By contrast, these rates are closer to 11% and 1%, respectively, for women. Similarly, after 15 years, around 27% of men with chronic hepatitis C will die compared to only 15% of women.

The one area in which women may be at greater risk is when liver transplantation is needed, either because of decompensated cirrhosis or non-metastatic liver cancer. (Today, cirrhosis related to chronic hepatitis C is the leading indication for liver transplants in the United States.)

According to a 2011 study in the journal Hepatology, being female is an independent risk factor for graft rejection and death in people who undergo liver transplantation. Statistically, 26% of women who undergo a liver transplant will experience organ rejection compared to only 20% of men. Death is a common consequence.

While the reasons for this are not entirely clear, the researchers suggest that older age plays a part given that women tend to experience hepatitis C complications later in life. Moreover, older recipients tend to get organs from older donors, another risk factor for organ rejection.

Hepatitis C In Women: Special Considerations

Beyond the differences in disease expression in women with hepatitis C who are biologically female, there are certain considerations that women have to think about if diagnosed with the disease.

Pregnancy and Breastfeeding

A woman with hepatitis C who can conceive will have to think about how having the disease may complicate a pregnancy.

The transmission of hepatitis C from mother to child during pregnancy is a less common mode of transmission, but it still affects between 2% and 8% of mothers with HCV. Certain factors can increase the risk, including a high HCV viral load at the time of delivery and a co-existing HIV infection.

Studies suggest that around 5% of adults with hepatitis C in the United States are coinfected with HIV. Among injecting drug users, coinfection rates hover closer to 90%.

Women with HCV and HIV have a two-fold increased risk of HCV transmission during pregnancy compared to women with HCV alone. It is important, therefore, that the diagnosis of HCV be followed by an HIV test. If positive, HIV therapy can be started to completely suppress the virus. A decrease in HIV activity is typically associated with a drop in the HCV viral load.

Some healthcare providers endorse the off-label use of direct-acting antivirals (DAAs) during pregnancy to reduce the risk of mother-to-child transmission. Since their introduction in 2013, DAAs have transformed the face of hepatitis C therapy, affording cure rates of over 95% in as little as eight to 12 weeks.

Breastfeeding is not contraindicated in women with HCV, except when they have cracked, damaged, or bleeding nipples. It's also contraindicated if a person has HIV.

Birth Control Failure

Women with hepatitis C who use contraception will need to know how their birth control might be affected by the disease and its treatments.

Studies have shown that HCV-associated fibrosis can lead to the failure of hormonal birth control. This is because hormonal contraceptives are broken down by the liver so that the active drug, ethinyl estradiol, can be released into the bloodstream. Ethinyl estradiol, the synthetic form of estrogen, is found in birth control pills, intravaginal rings, and hormonal patches.

Some hepatitis C drugs may also interact with hormonal contraceptives, although it is unclear how significant the interactions are. Most studies suggest that the risk of birth control failure is low.

Speak with your healthcare provider if you use hormonal birth control and have hepatitis C. In some cases, they may advise you to use alternate or combined forms of contraception, including condoms, diaphragms, or non-hormonal IUDs like Paragard.

Summary

Even though hepatitis C tends to progress slower in women who are biologically female than in men who are biologically male, that doesn't need women to need to worry less. There are things that can accelerate HCV progression in women or anyone else—including alcohol abuse, obesity, and coinfection with hepatitis A or hepatitis B.

To protect your liver, reduce your alcohol intake (and seek alcohol treatment if you can't), achieve/maintain a healthy weight with a low-fat diet and exercise, and get immunized for hepatitis A and hepatitis B if you haven't already. More importantly, work with your hepatologist or gastroenterologist to monitor the status of your liver until HCV treatment is approved.