Cholesterol levels, also known as the lipid profile, are one of the most helpful predictors of who will go on to have a heart attack or stroke. Even though most women reading this article will die from cardiovascular disease, a very small percentage know their total cholesterol and only a tiny minority know the levels of their good and bad cholesterol. Among women who take medications for abnormal cholesterol, most do not know which cholesterol is good and which is bad. It is important for women to understand the different types of cholesterol. After menopause, the lipid profile worsens.

Knowing your total cholesterol level is not helpful – it doesn’t tell you the amount of LDL (Low-Density Lipoprotein), HDL (High-Density Lipoprotein) and triglycerides. LDL blocks arteries and HDL unblocks the arteries. Triglycerides also contribute to artery blockage. The higher your LDL and triglycerides, the more likely you are to have a heart attack. The higher your HDL, the less likely you are to have a heart attack.
 
Atherosclerosis describes the state of blockage of the arteries. LDL, the bad cholesterol, is critical to the formation of these blockages. The blockages are caused by plaques consisting of mounds of LDL, white blood cells and scar tissue that grow larger every year. Not only do plaques narrow arteries preventing blood from flowing downstream, but they are sticky. Sticky plaques attract platelets in the blood, which clump together causing blood clots. Blood clots, in turn, further narrow the arteries. Plaques may grow in any artery in the body: if there are plaques in the coronary arteries feeding the heart, they may cause heart attacks, and if they are in the carotid arteries which feed the brain, they may cause a stroke. Plaques in the femoral arteries of the leg are common in smokers and diabetics, and cause poor circulation.  The decreased blood flow in the leg may cause gangrene in the lower leg and subsequent amputation.

Plaque formation starts at very young ages. Plaques go through several stages of growth. The first stage, present in most children in the United States, is when white blood cells in the lining of the artery fill with droplets of LDL. The second stage is the “fatty streak,” when even more LDL and white blood cells build up in the artery, causing a dirty yellow smear on the artery. Until fatty streaks were seen on autopsies of young soldiers who died in the Korean War, it was not known that plaques were present in teenagers. Over time, more and more LDL and white blood cells accumulate over the fatty streak until fully developed plaques, full of scar tissue and rotting cells are formed and protrude into the blood vessel. The more LDL cholesterol droplets are in the plaque, the more likely it is to rupture and cause a heart attack or stroke.

Even though you can’t develop plaques unless you have high levels of LDL cholesterol, some medical organizations recommend that the lipid profile not be measured in women until they are in their 40’s. The problem with this recommendation is that plaques develop in childhood because of our diet. By the time you are in your 40’s, fully developed plaques have formed, continue to grow, and put you at very high risk for heart attack. If you knew in your 20’s that you had abnormal lipids, you could do something about it.

Guidelines to treat abnormal lipid profiles emphasize lowering the LDL to protect your heart. The guidelines however, are based on research findings in men but not women. There is strong evidence that HDL and triglycerides are more important in women to predicting heart disease. Even though guidelines are based mostly on studies of men, the changes you make to improve your LDL cholesterol will improve your other lipid levels.

Nearly every woman reading this article has some degree of atherosclerosis that is progressing: the plaques are growing larger and more arteries are being affected. The process is not inevitable: there are lifestyle changes you can make that will improve all your lipids:

1. Lose weight. Every pound you lose will lower your LDL and triglycerides and raise your HDL.

2. Increase exercise. Even if you don’t lose an ounce, your LDL and triglycerides will decrease and your HDL will increase.

3. Stop smoking and avoid second-hand smoke. The biggest contributor to high LDL is smoking. High LDL leads to more plaques which is why smokers get heart disease at a young age.

4. Drink alcohol in moderation. Women who have one drink a day have high HDL levels.

5. Treat diabetes aggressively. Diabetes is associated with very high triglycerides and low HDL. The lower your glucose, the more your triglycerides and HDL normalize.

6. Treat high cholesterol aggressively. Take your medications regularly. Drugs like statins not only lower LDL cholesterol, but they also shrink plaques, make them less likely to rupture and make them less sticky. There are also specific drugs like niacin to raise HDL (especially important in women), and other drugs designed to lower triglycerides. Fish oil, which contains omega-3 fatty acids, is extremely effective in lowering triglycerides.

7. Eat more complex carbohydrates. Eat more whole grains (like oatmeal), whole-wheat bread and pasta, fruits and vegetables. Avoid refined carbohydrates like desserts, white rice, and cereals.