High cholesterol, a risk factor for heart disease, affects nearly 1 in 5 American women at least 40 years old. Although heart disease is the No. 1 cause of death in women, there is little agreement about managing cholesterol.
A recent Centers for Disease Control and Prevention report found that 17.7 percent of women ages 40 to 59 had high cholesterol, as did 17.2 percent of those 60 and older. That’s higher than middle-age men (16.5 percent) and dramatically higher than older men (6.9 percent).
The report didn’t address why women have more cholesterol. Women take cholesterol-lowering medications (mostly statins) at somewhat lower rates than men: 26.2 percent vs. 30.1 percent, according to the CDC.
Some experts think cholesterol is a reason to raise women’s awareness of heart disease risks; others think cholesterol gets too much attention.
“More women die of heart disease than all cancers put together,” says Carl Pepine, a cardiologist at the University of Florida and co-chair of the American College of Cardiology’s Cardiovascular Disease in Women Committee. Yet, women are more worried about breast cancer.
Heart disease accounts for 1 in 4 deaths in women, according to the National Heart, Lung and Blood Institute. However, cholesterol is not the only risk factor for heart disease. High blood pressure plays a larger role, and age is a big factor.
“In the hierarchy of things that contribute to cardiovascular risk, I’d put cholesterol way at the bottom,” says Rita Redberg, a cardiologist at the University of California at San Francisco. “You can have high cholesterol and low cardiac risk.” Also, “you can have low cholesterol and high cardiac risk.”
Cholesterol is a component of plaques that build up inside blood vessels, narrowing and stiffening them. This condition, called atherosclerosis, increases the chance of a clot blocking blood flow, which can result in heart attack or stroke.
Cholesterol is a term for several types of fat in blood. There’s LDL cholesterol (low-density, “bad” cholesterol) HDL cholesterol (high-density, “good” cholesterol) and triglycerides. A blood test for cholesterol usually lists all three, in addition to total cholesterol.
The American Heart Association describes it like this: “Think of LDL cholesterol as being like a family member who carries stuff all through the house and drops it along the way. HDL cholesterol is like someone who picks up the dropped stuff and puts it away (and) helps keep the house from becoming impassable.”
In the past, people were encouraged to keep their total cholesterol under 200 milligrams per deciliter. Current thinking considers the ratio of LDL and HDL levels. Guidelines for using cholesterol-lowering drugs take into account overall risk for heart disease, including whether someone already had a cardiac event such as heart attack or stroke. Doctors disagree about whether people with risk factors but no history of cardiac events should take statins at all.
People can use different calculators to gauge their risk for heart disease. Pepine recommends the Reynolds Risk Score because it includes a measure of inflammation called high sensitivity C-reactive protein. Inflammation plays a role in atherosclerosis.
Redberg recommends the Framingham calculator because it includes HDL cholesterol.
“HDL cholesterol is generally higher in women,” Redberg says. She adds that guidelines for treating high cholesterol tend to focus on HDL (bad) cholesterol, in part because that’s what the drugs target. Statins also lower LDL cholesterol, which is associated with heart protection.
People can lower their cholesterol if they quit smoking, get regular exercise, eat a healthy diet and maintain a healthy weight. The American Heart Association’s Life’s Simple recommendations also include knowing your numbers for blood pressure, cholesterol and blood sugar.
Pepine says diet and exercise come first, before considering drugs. Statins are effective at lowering LDL cholesterol, but they also can cause side effects, such as muscle pain and diabetes. Even if you take statins, it’s important to exercise and eat healthfully.
A 2014 study examined nationwide surveys over a 10-year period, when overall statin use doubled. In the first year studied (1999-2000), statin users ate fewer calories and less fat than other people, but by the last year (2009-2010), statin users were eating more calories and fat on average. The researchers speculated that statin use makes people think they needn’t work at a healthy diet.
There are good reasons to address heart disease risk in women, but, cholesterol may not be the best way to do so, Redberg says. As always, consult your doctor.