How Hepatitis C Symptoms Differ in Females

Notable Ways This Liver Disease Affects Women Differently

Hepatitis C is a potentially fatal viral infection that can cause long-term damage to the liver. Although the symptoms of hepatitis C are similar in women and men, the disease can progress differently in females. Women also face unique challenges, including the risk of mother-to-child transmission during pregnancy.

Similarities and Differences

Once infected with the hepatitis C virus (HCV), people go through an acute phase of infection in which symptoms may or may not develop. If acute symptoms 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, 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:

Hepatitis C Statistic Women Men
More likely to become infected  
More likely to clear an acute infection  
Faster disease progression if chronically infected  
Lowest death rate from chronic HCV  

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.

Rates of Infection

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 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

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.

Studies suggest that estrogen, which persists at higher levels in premenopausal women than men, is able to inhibit HCV replication by as much as 67%. Progesterone and testosterone appear to have no effect on HCV replication.

Disease Progression

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 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 in 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. 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

Certain behavioral factors also contribute to disease progression. Most studies, for example, have shown that heavy alcohol use is linked to the rapid development of cirrhosis. 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.

According to research in the Journal of Infectious Diseases, women with hepatitis C who drink 20 grams of alcohol per day will often experience the same degree of liver damage as men who drink 30 grams per day.

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 woman is in her postmenstrual years, the annual increase in her risk of cirrhosis and liver cancer more or less mirrors that of her 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, in 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.

Special Considerations

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

Pregnancy and Breastfeeding

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 doctors 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.

Although DAAs have not demonstrated significant fetal toxicity in animal studies, they are currently not approved for use during pregnancy due to the lack of safety research.

Breastfeeding is not contraindicated in women with HCV, except when the mother has cracked, damaged, or bleeding nipples, or has HIV.

Birth Control Failure

Studies have shown that HCV-associated fibrosis can lead to 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 doctor 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.

A Word From Verywell

Even though hepatitis C tends to progress slower in women than men, that shouldn't suggest that women need to worry less. There are things that can accelerate HCV progression, 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.

Was this page helpful?
Article Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Cleveland Clinic. Hepatitis C. Updated April 11, 2019.

  2. Baden R, Rockstroh JK, Buti M. Natural history and management of hepatitis C: Does sex play a role?. J Infect Dis. 2014;209 Suppl 3:S81-5. doi:10.1093/infdis/jiu057

  3. Centers for Disease Control and Prevention. Hepatitis C prevalence estimates 2013-2016. November 6, 2018.

  4. Iversen J, Page K, Madden A, Maher L. HIV, HCV, and health-related harms among women who inject drugs: Implications for prevention and treatment. J Acquir Immune Defic Syndr. 2015;69 Suppl 2:S176-81. doi:10.1097/QAI.0000000000000659

  5. Lockart I, Matthews GV, Danta M. Sexually transmitted hepatitis C infection: the evolving epidemic in HIV-positive and HIV-negative MSM. Curr Opin Infect Dis. 2019;32(1):31-7. doi:10.1097/QCO.0000000000000515

  6. Terrault NA, Dodge JL, Murphy EL, et al. Sexual transmission of hepatitis C virus among monogamous heterosexual couples: the HCV partners study. Hepatology. 2013;57(3):881-9. doi:10.1002/hep.26164

  7. Esmaeili A, Mirzazadeh A, Carter GM, et al. Higher incidence of HCV in females compared to males who inject drugs: A systematic review and meta-analysis. J Viral Hepat. 2017;24(2):117-27. doi:10.1111/jvh.12628

  8. Magri A, Barbaglia MN, Foglia CZ, et al. 17,β-estradiol inhibits hepatitis C virus mainly by interference with the release phase of its life cycle. Liver Int. 2017;37(5):669-77. doi:10.1111/liv.13303

  9. Endocrine Society. Laboratory reference ranges. 2020.

  10. Iyer JK, Kalra M, Kaul A, Payton ME, Kaul R. Estrogen receptor expression in chronic hepatitis C and hepatocellular carcinoma pathogenesis. World J Gastroenterol. 2017;23(37):6802-6816. doi;10.3748/v23i376802

  11. Ulitzky L, Lafer MM, Kukuruga MA, Silberstein E, Cehan N, Taylor DR. A new signaling pathway for HCV inhibition by estrogen: GPR30 activation leads to cleavage of occludin by MMP-9. PLoS ONE. 2016;11(1):e0145212. doi:10.1371/journal.pone.0145212

  12. Centers for Disease Control and Prevention. Excessive alcohol use and risks to men's health. December 30, 2019.

  13. National Institute on Alcohol Abuse and Alcoholism. National Institutes of Health. Rethinking Drinking. What Is a Standard Drink?

  14. Kramer JR, El-Serag HB, Taylor TJ, et al. Hepatitis C virus-related complications are increasing in women veterans: A national cohort study. J Viral Hepat. 2017;24(11):955-65. doi:10.1111/jvh.12728

  15. Parrish NF, Feurer ID, Matsuoka LK, Rega SA, Perri R, Alexopoulos SP. The changing face of liver transplantation in the United States: The effect of HCV antiviral eras on transplantation trends and outcomes. Transplant Direct. 2019;5(3):e427. doi:10.1097/TXD.0000000000000866

  16. Lai JC, Verna EC, Brown RS, et al. Hepatitis C virus-infected women have a higher risk of advanced fibrosis and graft loss after liver transplantation than men. Hepatology. 2011;54(2):418-24. doi:10.1002/hep.24390

  17. Prasad MR, Honegger JR. Hepatitis C virus in pregnancy. Am J Perinatol. 2013;30(2):149-59. doi:10.1055/s-0033-1334459

  18. Bosh KA, Coyle JR, Hansen V, et al. HIV and viral hepatitis coinfection analysis using surveillance data from 15 US states and two cities. Epidemiol Infect. 2018;146(7):920-30. doi:10.1017/S0950268818000766

  19. U.S. Department of Health and Human Services: Special populations: Hepatitis C virus/HIV coinfection. Updated December 24, 2019.

  20. Kushner T, Cafardi J, Reau N. Considering direct-acting antivirals to cure hepatitis C virus during pregnancy: is this the last treatment frontier?. Ther Adv Infect Dis. 2019;6:2049936119838229. doi:10.1177/2049936119838229

  21. Mangia A, Losappio R, Cenderello G, et al. Real life rates of sustained virological response (SVR) and predictors of relapse following DAA treatment in genotype 3 (GT3) patients with advanced fibrosis/cirrhosis. PLoS ONE. 2018;13(7):e0200568. doi:10.1371/journal.pone.0200568

  22. American Association for the Study of Liver Disease. HCV in pregnancy. Updated November 6, 2019.

  23. American College of Obstetricians and Gynecologists. Hepatitis B and Hepatitis C in Pregnancy. FAQ093. Published September, 2019.

  24. Canadian AIDS Treatment Information Exchange (CATIE). Hepatitis C; An in-depth guide. Updated 2019.

  25. Geddawy A, Ibrahim YF, Elbahie NM, Ibrahim MA. Direct acting anti-hepatitis C virus drugs: Clinical pharmacology and future direction. J Transl Int Med. 2017;5(1):8-17. doi:10.1515/jtim-2017-0007