Can perimenopause cause gallbladder problems?

Yes. And it is one of the most under-explained parts of the whole transition.

Between 2004 and 2019, close to 780,000 gallbladders were removed in Australia. Women accounted for 69.4% of them.

What is striking is the trend sitting underneath that number. Over the same period, hospital admissions for gallbladder problems actually fell by around 10%, while the proportion of those patients who went on to have surgery rose from 67% to 75%. The surgeons who published that data titled their paper Are we over-intervening?

It is a fair question. And it is exactly why I would rather help you look after your gallbladder than watch you lose it.

Because the reason women dominate those figures is not bad luck. It is hormonal, and it is well described.

So many women arrive in my clinic somewhere in their mid-40s saying a version of the same thing: "I have never had a problem with rich food in my life, and now a creamy pasta or a takeaway curry has me awake at midnight."

Nothing has gone wrong with you. Your bile chemistry has changed.

What your gallbladder actually does

Your gallbladder is small, tucked under your liver, and does one job extremely well. It stores and concentrates bile.

Bile is made in your liver. It sits in the gallbladder getting steadily more concentrated until you eat something with fat in it, at which point the gallbladder squeezes and releases a dose into your small intestine.

That bile does four things:

• Breaks down fat so you can actually digest it
• Unlocks the fat-soluble vitamins A, D, E and K, which you cannot absorb properly without it
• Keeps things moving through the bowel, because bile is one of your body’s own stimulants for bowel motility
• Carries waste out, including used hormones, cholesterol and the by-products your liver has processed

That fourth one is the part almost nobody mentions. And it is the part that matters most in perimenopause.

The cholesterol connection

Most women in peri or post-menopause hear that their cholesterol is getting too high. But here's a critical point most of you never hear when you're being told you need to lower your cholesterol: bile is made from cholesterol. Sending bile out through your gut is actually one of the main ways your body disposes of cholesterol it no longer needs.

So when the loop slows and bile gets reabsorbed instead of leaving, you're not just recycling oestrogen. You're recycling cholesterol too. It's one of the reasons cholesterol often creeps up through perimenopause even when nothing about your diet has changed, and it's also why fibre does double duty here: it binds bile in the gut and escorts it out, taking both the used oestrogen and the cholesterol with it.

If your last blood test showed rising cholesterol, your gallbladder and your lipids are more connected than they look. I've written about what actually helps in another post.

The two-way loop between bile and your hormones

Here is where the gallbladder stops being "just a digestion thing."

Direction one: your hormones change your bile. Oestrogen increases the amount of cholesterol secreted into bile and reduces bile salt secretion, which makes the bile thicker and more likely to crystallise into stones. Progesterone and synthetic progestins do the other half of the job: they relax smooth muscle, which slows how forcefully the gallbladder contracts and empties. Thicker bile sitting still for longer is precisely the recipe for gallstones.

Oestrogen also interferes with the transporters your liver uses to physically pump bile out of its cells, so the effect is a genuine slowing of flow rather than only a change in what the bile contains.

In perimenopause, when both hormones are swinging unpredictably, you can get both effects inside the same cycle.

Direction two: your bile affects your hormones. Your liver takes used oestrogen, packages it up, and sends it out in the bile to leave via the stool. If bile flow is sluggish, or there is not enough fibre in the bowel to bind it, some of that packaged oestrogen gets unpacked and reabsorbed instead of leaving.

So you get a loop. Hormonal change slows the bile. Slow bile means slower oestrogen clearance. More circulating oestrogen thickens the bile again, and it can also mean more of the oestrogen-driven symptoms: heavy or flooding periods, sore breasts, irritability, fluid retention, that wired and puffy feeling in the week before a bleed.

This is why I never treat the gallbladder in isolation. Bile, bowels and hormones are the same conversation.

Why what you do in your 40s matters more than it feels like it should

Here is a question I get asked often, and it is a smart one. If oestrogen is driving this, and oestrogen falls after menopause, does the risk go away once you are through?

It is good reasoning. But the answer is no, and the reason is worth understanding.

Gallstone prevalence is around 8.8% in people over 50, compared with 3.4% under 50. It goes up after the transition, not down.

Four things explain the gap between the mechanism and the outcome:

• Stones do not dissolve when oestrogen falls. Perimenopause is the formation window. Once a stone is there, it is there. Falling oestrogen removes the mechanism that makes them, but not the stones themselves.
• The other risk factors accelerate after menopause. Higher body weight, visceral fat, insulin resistance, type 2 diabetes, high blood pressure and fatty liver are all confirmed gallstone risk factors, and all become more common after the transition. The hormonal driver eases while the metabolic drivers pile on.
• Many women reintroduce oestrogen through menopausal hormone therapy, at which point the mechanism resumes. More on that below.
• Age is a risk factor in its own right, quite apart from hormones.

So the picture looks like this. Perimenopause is when the stones tend to form. The decades afterwards are when they announce themselves.

Which means the work you do now, in your 40s, is not really about how you feel after dinner tonight. It is about whether you are having surgery in your 60s.

Symptoms to watch for

Gallbladder trouble does not always announce itself with dramatic pain. In perimenopause it usually starts quietly:

• Bloating, heaviness or nausea after fatty, creamy or fried food
• Discomfort or a dull ache under the right ribs, sometimes running through to the right shoulder blade
• Feeling uncomfortably full very quickly
• Burping or reflux after rich meals
• Pale, clay-coloured or unusually light stools, because bile is what gives stool its normal brown colour
• Floating or greasy stools, a sign fat is not being digested
• Constipation that has crept in over the last few years
• A new intolerance for foods you have always eaten happily, particularly red meat, eggs, cream and rich sauces

That last one is worth pausing on. If rich food and red meat have started sitting like a brick, the gallbladder is one of the first places I look. I have written more about that in why you do not tolerate meat anymore.

What if I have gallstones but no symptoms?

This is more common than most people realise. Around 80% of gallstones are found incidentally, meaning they turn up on a scan done for something else entirely.

The reassuring news is that most silent stones stay silent, at least for a good while. In a 2026 meta-analysis following nearly 26,000 people, the proportion who developed symptoms was:

• 10% at five years
• 19% at ten years
• 26% at fifteen years

So roughly three-quarters of people with silent stones still have no symptoms fifteen years later. Worth knowing if you have just been told about stones and are quietly panicking.

Two things shifted the odds in that analysis: alcohol intake and high blood lipids both increased the chance of becoming symptomatic. Being male was protective, which is another way of saying women with silent stones are more likely to end up with symptoms than men are.

If your cholesterol has crept up alongside everything else, that is not a separate issue. I have written about what happens to cholesterol in perimenopause.

Does MHT affect your gallbladder?

It can, and how you take it makes a real difference.

The Million Women Study followed just over one million postmenopausal women and found that those using menopausal hormone therapy were more likely to be admitted to hospital for gallbladder disease. But the route mattered a great deal. Compared with women who had never used it, risk was raised by 74% with oral tablets and by 17% with patches or gel.

That difference comes down to first-pass metabolism. Oestrogen swallowed as a tablet travels straight through the liver before reaching the rest of your body, so the liver sees a concentrated dose and responds by pushing more cholesterol into the bile. Oestrogen absorbed through the skin largely bypasses that, so the liver never gets the same hit.

Now the important part, because percentages like that can be alarming without context.

In absolute terms, over five years, gallbladder removal happened in roughly 1 in 100 women not using hormone therapy, 1.3 in 100 using patches, and 2 in 100 using tablets. So we are talking about one extra woman in a hundred, over five years. And the risk falls again after therapy stops.

The same study found that conjugated equine oestrogens carried slightly more risk than estradiol, and that higher doses carried more risk than lower ones.

None of this is a reason to avoid MHT, if it is something you wish to do. For a great many women the benefits are substantial, and this is one factor among many in a much bigger decision. But if you already have gallstones, a history of gallbladder trouble, or several other risk factors stacked up, it is a perfectly reasonable thing to raise with your prescriber when you are discussing patch versus tablet.

That conversation is much better had at the start of therapy, rather than after something goes wrong.

What makes bile sluggish

Hormones are the driver in perimenopause, but they rarely work alone. The usual companions:

• Not enough fat in the diet. This one surprises people. Bile is released when fat arrives. Chronically low-fat eating means the gallbladder rarely gets the signal to squeeze, so bile just sits there concentrating. Decades of low-fat dieting is a genuine risk factor.
• Not enough fibre. Fibre binds bile in the bowel and carries it out. Without it, bile and the oestrogen it is carrying get reabsorbed.
• Rapid weight loss or extended fasting. Both are well recognised triggers for stone formation, worth knowing if you are considering a very low-calorie approach in your 40s.
• Dehydration. Thicker bile flows more slowly.
• A diet built on refined and processed food, typically low in both the fibre and the quality fat bile needs.
• Higher body weight, insulin resistance and fatty liver, all confirmed risk factors.
• Chronic stress, which shifts you out of the rest-and-digest state where digestion actually happens.

Where GLP-1 medications fit

These deserve their own mention, because so many women in midlife are now taking one. GLP-1 medications such as semaglutide and tirzepatide do increase gallstone risk, and the mechanism is not mysterious. They slow gastric and gallbladder emptying, and they produce rapid weight loss. Both are established gallstone triggers, and you will recognise both from the list above.

A 2025 meta-analysis of placebo-controlled trials found GLP-1 medications increased gallstone risk by around 46%, which worked out at roughly 2 extra cases per 1,000 people. A larger analysis of 76 trials involving more than 103,000 people found the risk of gallbladder and biliary disease was more than twice as high when the medication was prescribed for weight loss rather than for type 2 diabetes, and higher again at larger doses and with longer use.

That is not a reason to avoid them, and it is not a judgement about using them. It is a reason to take the bile-supporting basics in this post seriously if you are on one. Enough quality fat at meals so the gallbladder keeps contracting, plenty of fibre, bitters before meals, and steady weight loss rather than the fastest possible weight loss.

How to support your gallbladder and keep bile moving

There are three levers, and they work together. Fats to trigger bile release. Fibre to bind it and carry it out. Bitters to stimulate the whole system.

1. Eat fat, deliberately

Do not skip fat to protect your gallbladder. Include a moderate amount of quality fat at meals so your gallbladder is prompted to contract and empty regularly. Extra virgin olive oil, avocado, oily fish, nuts and seeds, and a little butter or ghee if you tolerate it. What tends to trigger trouble is the enormous fatty hit after a long stretch of nothing, not fat itself.

2. Get serious about fibre

This is the piece most women are missing. Fibre binds bile in the bowel so it leaves the body rather than being reabsorbed, which keeps oestrogen clearance moving too.

• Oats, barley, psyllium and chia for soluble fibre
• Legumes: lentils, chickpeas, black beans, butter beans
• Freshly ground flaxseed, which supports both bile binding and oestrogen clearance
• Vegetables at every meal, not just at dinner
• Plenty of water alongside, because fibre without fluid makes constipation worse, not better

3. Bring in the bitters

Bitter foods stimulate bile production and flow. They have all but disappeared from the modern diet, and they are one of the simplest and cheapest things you can add back:

• Rocket, radicchio, endive, witlof, dandelion greens
• Chicory, artichoke, radish
• Lemon juice or apple cider vinegar in water before meals
• Bitter herbs such as globe artichoke, dandelion root and gentian, which I use often in clinic

A small bitter salad before a rich meal is not a garnish. It is a functional signal to your digestion that food is on the way.

4. The specific foods worth knowing

• Beetroot, for betaine, which supports bile thinning and liver function. Grated raw into salads is easiest.
• Brassicas: broccoli, cauliflower, cabbage, Brussels sprouts. They support the liver’s oestrogen clearance pathways, which is the upstream half of the loop.
• Eggs, for choline, a building block of bile itself.
• Oily fish: salmon, sardines, mackerel. Omega-3 fats improve bile quality.
• Coffee, one to two cups a day, which stimulates gallbladder contraction. A real benefit, provided your sleep and nervous system tolerate it.
• Turmeric and ginger, both traditionally used to encourage bile flow.
• Water, consistently, across the day.

5. Move your body and manage the stress load

Regular movement supports bile flow and bowel motility. And because digestion really only happens in a parasympathetic state, sitting down, putting the phone away and taking three slow breaths before you eat is not a soft suggestion. It genuinely changes how well the meal is digested.

If all of that sounds sensible but you are looking at it thinking "yes, but what do I actually cook on Tuesday", that is exactly what PerimenoGO is for. Four weeks of eating and living in a way that suits a perimenopausal body, with the nutrition plan and the recipes done for you.

What if your gallbladder has already been removed?

With close to 780,000 cholecystectomies performed in Australia between 2004 and 2019, and women making up nearly 70% of them, a good number of you reading this will not have a gallbladder at all. This section is for you, and it is not a consolation prize. There is a lot you can do.

Without a gallbladder, your liver still makes bile. What you have lost is the storage tank and the concentrated squeeze. Bile now drips continuously into the small intestine at low concentration, which means plenty is available for a light meal and not much for a rich one.

What that tends to look like:

• Loose stools or urgency, particularly after fatty meals
• Ongoing difficulty with rich food, sometimes years after the surgery
• Lower fat-soluble vitamin status over time, particularly vitamin D
• The same oestrogen clearance question, because that route still depends on bile and fibre

What helps:

• Spread your fat across the day rather than loading it into one meal. Smaller amounts more often matches the drip feed you now have.
• Keep fibre high. It matters more without a gallbladder, not less, for both stool form and oestrogen clearance.
• Bitters before meals to keep the liver’s bile production up.
• Check your fat-soluble vitamins, particularly vitamin D, and your iron and B12 if digestion has been poor for a while.
• Ox bile is sometimes used to support fat digestion after gallbladder removal. It is not right for everyone and dosing matters, so this is one to work through with a practitioner rather than self-prescribe.

Having your gallbladder out does not mean poor digestion for life. It means the way you eat needs to account for it.

The bigger picture

Your gallbladder is not a spare part. It sits right at the junction of digestion, cholesterol handling and hormone clearance, which is exactly why it starts complaining in perimenopause, and exactly why supporting it tends to improve more than just your digestion.

If rich food has become a problem, your bowels have slowed, and your hormonal symptoms have ramped up over the same period, those are not three separate issues. They are one system asking for help.

If you are reading this nodding along, and food that used to be fine suddenly is not, that is worth looking at properly rather than simply eating less of it.

My free Clarity Call is 20 minutes to talk through what is actually going on for you and what would help most. Book a Clarity Call here.

And if you have had gallbladder trouble in perimenopause, or you have had yours out, I would love to hear how it has been. Tell me in the comments.

References

1. Mollah T, et al. Gallbladder-associated hospital admission and cholecystectomy rates across Australia and Aotearoa New Zealand (2004 to 2019): Are we over-intervening? Ann Hepatobiliary Pancreat Surg. 2022;26(4):339-346. Read the study
2. Ning Q, et al. Estimating global prevalence of gallbladder stones in general population from 2000 to 2024: systematic review and meta-analysis. Ann Med. 2025;57(1):2570795. Read the study
3. Alzoubi M, et al. Asymptomatic gallstones: cumulative incidence proportion, incidence rate, and risk factors for symptoms development: systematic review and meta-analysis. PLoS One. 2026;21(3):e0345462. Read the study
4. Liu B, et al. Gallbladder disease and use of transdermal versus oral hormone replacement therapy in postmenopausal women: prospective cohort study. BMJ. 2008;337:a386. Read the study
5. Zu Y, et al. The pathological mechanisms of estrogen-induced cholestasis: current perspectives. Front Pharmacol. 2021;12:761255. Read the study

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