Kelly, 49, eats a plant-based diet and abstains from processed foods. So, after a recent routine blood test revealed that she had high cholesterol, “I was shocked and upset,” she says, “since it never has been [high] in the past.”
It’s not just Officer. As women enter menopause, cholestrol levels jump—by an average of 10-15%, or about 10 to 20 milligrams per deciliter. According to the National Library of Medicine, a healthy range for adult cholesterol is between 125 and 200 milligrams/deciliter.
In the midst of physical symptoms, and all that goes with it, this change is often overlooked. But, says Dr. Erin Michos, director of women’s cardiovascular health at Johns Hopkins Medicine, “we need women to get screened and know their numbers.” High cholesterol is a leading risk factor for heart disease, which kills more women in the U.S. than any other cause, including all forms of cancer combined. High cholesterol can lead to heart attacks or strokes if it is not controlled.
There are many factors that can increase cholesterol, including a more sedentary lifestyle and a less healthy diet. The unavoidable, sudden drop in estrogen levels during menopause is the main driver for this change. Unlike other issues that begin in perimenopause—mood changes, hot flashes, fatigue—the rise in cholesterol tends to happen fairly suddenly, typically in the year before through the year after menopause.
Scientists are discovering more about the causes of this mutation, as well as how to better screen for it and what treatment options for women. First, acknowledge the change. “This is a normal transition,” Michos says. Women should be aware that menopause is a crucial time to assess their health.
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Big cholesterol changes
The average age at which women experience menopause is 51, in the U.S. This advantage is lost with menopause. When people are in their 70s and 60s, cardiovascular disease rates almost equal between the sexes. Women have a higher risk of developing this condition than the men. Even more so, women who experience menopause in their twenties are at greater risk.
Estrogen’s protective effect on cholesterol is apparent even before menopause, as cholestrol levels rise and fall slightly with estrogen level fluctuations throughout each menstrual cycle. Researchers are still teasing out the details about how estrogen influences cholesterol, but much of it can be traced back to the liver, where estrogen receptors help to dictate a person’s lipid profile.
It is clear that if the body does not produce as much estrogen, overall lipid profiles become more dangerous. Levels of “bad” cholesterol (low-density lipoproteins, or LDL) and triglycerides rise, and “good” cholesterol (high-density lipoproteins, or HDL) falters.
Samar El Khaudary, associate professor at University of Pittsburgh School of Public Health, suggests that even the HDL may become less protective. She found that HDL was a sign of a decreased risk for developing heart disease, but the reverse might hold after menopause. So it’s not just the quantity and balance of these particles, but also that “the quality of these particles changes as women transition through menopause,” she says.
Assess and test
Only way to know your cholesterol level around menopause, is to have them tested. It is not easy to predict the time. Menopause is usually only apparent once it’s over and a person has already gone a year without a period.
The current recommendation is that people with low cardiovascular risk should have their cholesterol measured every five years. This could start at the age of 20. Children and teenagers should receive baseline cholesterol screenings. Experts recommend additional testing for anyone with a history of high cholesterol.
High cholesterol is a risk factor for heart disease. It’s important to have regular tests. And cholesterol can be a quiet killer: “If you don’t check, you don’t know,” says Dr. Samia Mora, a cardiovascular specialist and director of the Center for Lipid Metabolomics at Brigham and Women’s Hospital and associate professor at Harvard Medical School.
High cholesterol does not necessarily mean that all women go through menopause have high levels of cholesterol. If someone’s baseline cholesterol has been healthy, and if their other risk factors for heart disease are low, an average rise in cholesterol levels is usually not immediately worrying.
If cholesterol and other risk factors such as smoking or high blood pressure are present, additional testing might be required. Doctors might also recommend a calcium scan to measure plaque buildup around the heart, or an examination for lipoprotein (a), a type of LDL which can provide more information about your cardiovascular risk.
El Khoudary and others say that doctors should also start looking beyond standard lipid panels for more details about a person’s cholesterol, including particles’ size, shape, and composition. For example, studies have shown that smaller LDL particles are less harmful than those with larger sizes. Such tests exist—El Khoudary and others use them in research—but they are harder to get through standard clinician visits. These details could help women transition from menopause to better health in the future.
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Success is in the treatment
Lifestyle changes are often the best option for women with high cholesterol. “We can’t avoid aging, we cannot avoid our genetics, but we can change our lifestyle to counteract these effects,” Mora says.
Cholesterol can be affected by diet alone, ranging from 20-30 milligrams per deciliter. Michos loves to remind her patients that even though diet alone is unlikely to get them into a healthy range of cholesterol Michos also likes the reminder that extra work would make their cholesterol worse. Michos sees many women in menopause, who even on vegan diets, still need medication to lower cholesterol.
High cholesterol patients, even those during menopause, can take statins as their standard of care. Because women have fewer options for statins than men, this is due to both lower rates of recommendation from their health care providers and less willingness to consent to taking them. This trend is unfortunate because women can get a greater benefit from statins than men do, says Dr. Patricia Best, a cardiologist at Mayo Clinic and the Women’s Heart Clinic and an associate professor at Mayo Clinic College of Medicine and Science.
Best sees people get discouraged when their lifestyle efforts fail to generate healthy cholesterol levels—and many then avoid medications because taking them makes them feel like they’ve failed. “It’s really important to understand that sometimes even if you do everything right, you’re still going to end up needing a medication,” Best says. She says that this isn’t a failure. Starting on medication to manage high cholesterol is a success: “The most important thing is to keep yourself healthy over the long haul.”
Experts warn doctors that many physicians base their calculation of the need to take statins and other cholesterol treatments on the 10-year likelihood of suffering a serious event such as a stroke or heart attack. These risk-scoring systems don’t account for the cumulative risk over the years, especially for midlife women. “You don’t want to wait until 65 to start instituting all of these preventive [measures] that are going to help for quality of life throughout the rest of her years,” Mora says.
A drop in estrogen can cause an increase in cholesterol. What about hormone replacement therapy, which adds estrogen to the body. Hormone replacement therapy is often prescribed to treat hot flashes, and other signs of menopause. Many women who take the hormone replacement therapy see an improvement in their cholesterol. However, it’s not recommended solely as a cholesterol drug, in part because estrogen also increases the risk for blood clots.
Preventing is best, as with many aspects of your health. “It’s not just how high your cholesterol is now, but how long it has been high,” Mora says. “All of the years exposed to high cholesterol are cumulative. On the plus side, lifestyle interventions are also cumulative.”
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How—and why—to prioritize cholesterol
Menopause often coincides with a potentially stressful and busy time in women’s lives, when their careers are still in full swing, and they may be providing care for their offspring as well as their parents. Amid these pressures, women often put their own health aside, foregoing exercise and healthy food—and missing routine health care, including cholesterol checks.
Best claims that this is a time when healthy behaviors are crucial. “A little bit more exercise, a little bit more thoughtfulness [about] diet can really make a huge difference—because it’s during the next decade that women are at a marked increased risk of heart disease.”
Best states that the hard truth is, with all of the metabolic changes occurring in middle age, it might no longer be enough to maintain your health. “Your body is changing, so you have to adapt.”
When a shift in hormones is coupled with weight gain, “that’s your one-two punch” that can lead to a high cholesterol reading—often for the first time in a woman’s life, Best says. These two patterns have become more frequent over the years. Officer was a regular runner, however, the epidemic disrupted her exercise routines. Officer now claims that she lost all of her healthy habits and has gained weight.
To help combat menopause-related cholesterol shifts, women don’t need to start running marathons or even going fully vegan, Mora says. A heart-healthy diet is recommended by Mora, which includes plenty of fresh fruits and vegetables as well whole grains, low levels of refined sugars and processed carbohydrates. Other often-overlooked lifestyle adjustments, she says, including getting enough sleep and managing stress—which can help not just cholesterol but overall cardiovascular and metabolic health.
Mora is in her mid-twenties and tries to live a smart lifestyle about 80-90%. This means she eats lots of fruits and nuts and takes the stairs instead of the elevator—but still eats the occasional dark chocolate bar. “We get overwhelmed with trying to change everything at once,” Mora says. “All you need to do is institute a moderate amount of healthful lifestyle behaviors that you do consistently most of the time.”
Best acknowledges the difficulty of making healthy choices every single day. She’s 53, the mother of two children, and married, and she holds multiple positions at the Mayo Clinic as well as with other professional groups. “So I fully understand my patients when they’re like, ‘Are you kidding me? How am I going to fit that in?’”
Best is a strong believer in incorporating healthy activities into daily life. She has included walking and cooking together as well as taking walks with her husband. Not only are these good for her own health, she says, “but it’s good for everyone else in the family.”
Despite these efforts—and her own clinical expertise—even Best’s cholesterol went up during menopause. “It’s always disappointing,” she says. She didn’t lose her resolve though. “Hormonal weight gain and having worse cholesterol are expected, but you can also fight through all of those things.”
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