Control of rising cholesterol

Take control of rising cholesterol at menopause

Here’s what the numbers mean — and strategies to lower your cholesterol if it’s too high.

For some women who’ve had normal cholesterol readings all their lives, that changes at menopause. “Going through menopause often results in lipid and cholesterol changes for the worse,” says Dr. Samia Mora, an associate professor of medicine at Harvard Medical School and a specialist in cardiovascular medicine the Brigham and Women’s Hospital. Drops in the female hormone, estrogen, are associated with a rise in total cholesterol levels due to higher amounts of low-density lipoprotein (LDL), the “bad” cholesterol, and another blood lipid (fat) known as triglyceride. Over time this can raise heart risks, which is a reason for concern, as cardiovascular disease is the No. 1 cause of death in postmenopausal women, says Dr. Mora.

“So, it’s especially important to track the numbers in perimenopause and the early years after menopause, as LDL cholesterol and total cholesterol tend to increase,” she says.

However, while you may face an elevated risk from high cholesterol after menopause, there are things you can do to reduce that risk. We asked Dr. Mora what you should know about cholesterol, how high is too high, and when and how to take action to lower your levels.

Q. What is cholesterol and how does it affect our health, particularly heart and brain health?

Dr. Mora: “Cholesterol is a fatlike substance made in the body or ingested in food,” says Dr. Mora. For the most part, cholesterol is carried in our bloodstream in packages called lipoprotein particles. There are many types of particles: small ones and large ones, with different densities and even different functions. They may contain different amounts of cholesterol or triglycerides.

When your doctor says that you have high cholesterol, she or he is likely referring to your total cholesterol, a measure that includes three different types of cholesterol: the “bad” LDL and VLDL (very-low-density lipoprotein), which together make up what’s called non-HDL cholesterol, and HDL (high-density lipoprotein), sometimes referred to as “good” cholesterol.

“In general, the higher the cholesterol — especially LDL or non-HDL cholesterol — the higher the chance a woman has of developing a heart attack or stroke in her lifetime,” says Dr. Mora. “Individuals with extremely high cholesterol levels can have heart attacks at very young ages, especially if they have a hereditary form of high cholesterol, such as familial hypercholesterolemia.”

But if your cholesterol reading isn’t high, that doesn’t mean you’re off the hook.

“Many women and men who have heart attacks and strokes have average or even low levels of cholesterol,” says Dr. Mora. “Usually these individuals have other risk factors.” For example, not all LDL is the same and a certain subtype of LDL is associated with a greater chance of heart disease. (A standard cholesterol test won’t catch this problem; rather, you’ll need a separate test called an apolipoprotein B blood test.) Or they can have other risk factors such as smoking or vaping, diabetes, high blood pressure, unhealthy diet, a sedentary lifestyle, or more. “Also, age is the strongest risk factor, so as we age, the chance of having a heart attack or stroke increases,” she says.

Q. What is a good cholesterol reading?

Dr. Mora: For most people who don’t have heart or vascular disease, the goal is to get total cholesterol below 200 milligrams per deciliter (mg/dL), non-HDL cholesterol (total minus HDL) to less than 170 mg/dL, and LDL cholesterol to less than 100 mg/dL.

“But for people with other risk factors for heart attack or stroke, then lower levels would be optimal,” says Dr. Mora. The people at highest risk should aim for LDL levels below 50 mg/dL. “In general, lower is better for cholesterol,” she says.

Problems due to high cholesterol occur over time. It’s a cumulative exposure effect, similar in that way to a smoker’s “pack-years” (a measure of how much and how long the person has smoked). The greater the “cholesterol-years” (or “particle-years”), the greater the risk.

If a woman has high HDL — the “good” cholesterol — does that help to protect against heart disease and stroke?

“Women, especially premenopausal women, tend to have higher HDL levels than men,” says Dr. Mora. “We used to think that having high HDL cholesterol was always protective, but we now know that it may be protective for some patients, while for others it may not be protective at all.” If a woman has other risk factors that put her at increased risk for a heart attack, stroke, and diabetes, high HDL might not reduce those risks.

Women should also know about other risk factors that are specific to women, such as

premature menopause (occurring before age 40)
certain pregnancy-related conditions, including pre-eclampsia, pregnancy-related hypertension, gestational diabetes, and preterm delivery.

“Calculators for estimating risk of heart attack and stroke do not often incorporate these women-specific factors in the equations, so these additional factors will put a woman at increased risk, even if her score by the typical calculator is not considered high,” says Dr. Mora.

Q. There are a lot of numbers involved with cholesterol readings. Is there an easy way to understand the numbers?

Dr. Mora: There are online risk calculators that are available for people to use to calculate their risk. They also provide recommendations regarding the optimal level for each individual depending on her particular risk factor profile. Examples include My Life Check from the American Heart Association (AHA) and the ASCVD Risk Estimator Plus from the American College of Cardiology and the AHA (also available as an app).

“I also like AHA’s Life’s Simple 7 recommendations, as those emphasize the multiple ways that cholesterol and other risk factors can interact and put someone at increased risk,” says Dr. Mora. In some cases, it may be helpful to ask your doctor if you should have a coronary calcium scan to better assess your risk.

Q. Should people with high cholesterol be concerned, and should they be proactive about treating it?

Dr. Mora: Yes. “People with LDL levels of 160 mg/dL or higher may have a genetic form of a cholesterol problem and often need a statin or other medication to lower the cholesterol and, importantly, to lower their risk of having a heart attack or stroke,” says Dr. Mora. The higher the level, and the older the individual, the greater the risk. “Having said that, everyone should be proactive to improve risk factors for heart attack and stroke, because these risk factors are very common in the adult U.S. population, for both women and men,” says Dr. Mora.

Q. Should people try to treat their high cholesterol through lifestyle interventions first, or should they consider other options as well?

Dr. Mora: It depends on how high the level is. “Everyone benefits from lifestyle interventions — and the great thing about lifestyle interventions is that if they are done consistently, day in and day out, they have a huge benefit,” says Dr. Mora. “In fact, we can prevent heart attacks, stroke, and diabetes in about 80% to 90% of the cases by practicing an optimal lifestyle. But practicing an optimal lifestyle is not easy, especially in our modern way of living.”

Lifestyle factors are also cumulative, as cholesterol is, so even small improvements matter. Lose a few pounds. Fitting in 15-minute walks a few times a day or eating more fruits and vegetables can have large benefits if done regularly and over a lifetime. “The more the better for heart-healthy lifestyle, and the lower the better for cholesterol and triglycerides,” says Dr. Mora.

Q. What are the benefits or drawbacks of statin medications to reduce cholesterol levels? Do statin medications have any benefits or risks beyond decreasing cholesterol?

Dr. Mora: Statins have been shown to reduce the total risk of having a heart attack or stroke, or dying from heart attack or stroke, by about 20% to 30%. Statin use has also reduced heart attack severity. “We see fewer of the ‘big’ heart attacks that used to occur more often before widespread use of statins,” says Dr. Mora

Some people who take statins do experience unpleasant side effects, primarily muscle discomfort or sometimes muscle weakness.

“In these cases, we look to see if another medication is causing an adverse interaction with the statin, or if the patient has certain conditions that put her at increased risk for not tolerating the statin, such as a family history of statin intolerance, a diagnosis of hypothyroidism, or another medical condition,” says Dr. Mora. “If there is no other cause for the muscle problems, we usually recommend the patient take a break from the statin for a few weeks and then restart it at a lower dose, take it less frequently, or both.” Typically, most people are able to tolerate the statin after this adjustment.

Statins may increase the risk of developing diabetes in people who have risk factors for the condition, such as a family history of diabetes, being overweight or obese, or having an abnormal fasting glucose level.

“These patients can be monitored more closely,” says Dr. Mora. Higher-risk patients are also typically encouraged to make lifestyle changes, such as losing weight, eating a more healthful diet, and increasing their daily activity level.

The good news, though, is that the vast majority of heart attacks and strokes can be prevented with lifestyle changes and by managing cholesterol and other various risk factors appropriately. It’s never too late or early to start, says Dr. Mora.


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