Why High Cholesterol Is So Dangerous in Women
A woman’s “bad” LDL can rise as her estrogen levels drop, upping her risk for cardiovascular disease.
Cholesterol. You’ve heard of it, you know it’s important, and you think it has something to do with your heart. So far, you’re on the right track. But what if we told you that both gender and aging play a role in determining your cholesterol profile—and thus, your overall cardiovascular risk throughout your life? Umm, say what?
New research in the journal Circulation examines the role of menopause in heart disease risk and reveals something pretty astounding: This midlife transition marks an increase in LDL levels in the body, ultimately contributing to an elevated heart disease risk for women. What’s more, this is true no matter the age you go through menopause—your 50s (as the majority of women do), your 40s, or even your 30s.
In the last decade, “there has been a lot of excitement and interest looking at menopause as a risk factor for heart disease and looking at the mechanisms behind it,” says Malissa Wood, M.D., co-director of the Corrigan Women’s Heart Health Program at Massachusetts General Hospital in Boston. “Even menopause [that] occurs in young women has a profound increase in cardiovascular risk.”
Heart disease accounts for one in five female deaths in the U.S., and women are at higher risk than men for severe heart failure or death following a heart attack. Clearly, this is something worth paying attention to. And perhaps the best way for women to keep cardiovascular risk down is by monitoring cholesterol levels closely, especially during the menopausal years.
Cholesterol Levels in Women Versus Men
Cholesterol is a fatty substance that circulates in your blood. The body needs some cholesterol and actually makes enough on its own, but foods like meat, eggs, and dairy contain dietary cholesterol—and more crucially, they are high in saturated fat. This type of fat causes your body to produce more LDL cholesterol (so-called “bad” cholesterol). And, if LDL increases while HDL (the “good” kind of cholesterol that's responsible for sweeping excess LDLs away) decreases, fat deposits can build up along the walls of your arteries. These excessive plaque buildup can spell trouble.
“Risk of heart disease goes up directly as LDL levels go up,” Dr. Wood explains. The more your arteries become clogged with fat deposits, the more susceptible your vessels are to blood clots—which cause blockages that can trigger a heart attack or stroke.
A multitude of risk factors can lead to an unfavorable cholesterol profile: lack of exercise, a diet high in saturated fats, smoking, or extreme stress. But as a general rule, men and women have slightly different cholesterol levels to begin with. The estrogen produced by women’s bodies before menopause is believed to help boost the levels of HDL cholesterol, meaning younger women are less likely than younger men to have a cardiovascular event. Then menopause, yep, changes things.
The Menopause Effect
Menopause is associated with a significant drop in the estrogen your body produces. This can mess with the cholesterol levels in your body, causing HDL to begin to decrease. Add to that the myriad other uncomfortable side effects of menopause: weight changes, sleeplessness, hot flashes, night sweats, and anxiety, all of which can add the stress on your body that contributes to rising bad cholesterol.
“We know that many women have more anxiety, gain weight around the midline, and have difficulty with insomnia with they go through menopause,” Dr. Wood says. “Each and every one of those isolated downstream effects of menopause may have some degree of contribution to the unfavorable lipid numbers we see.” One study in the Scandinavian Journal of Public Health found that people who were more stressed at work tended to have higher cholesterol levels, suggesting that chronic stress can take a toll on your heart health. Not to mention, when you’ve only been sleeping five hours per night due to hot flashes, you might not be too motivated to eat healthy or work out.
Triglycerides (a type of fat in your blood from excess calories) can go up, too, when estrogen levels plummet, says Nieca Goldberg, M.D., director of the NYU Center for Women’s Health in New York City and an American Heart Association volunteer expert. “The HDL cholesterol either stays the same or goes down.” Women who are generally healthy—those who eat a balanced diet, exercise regularly, watch their weight, and abstain from smoking—are significantly less likely to have a cardiovascular event than those who already presented lifestyle-related risk factors.
Dr. Goldberg refers to a 2017 study in the Journal of the American Health Association, which found that healthier lifestyles among older adults contributed to a significantly lower number of heart-related hospitalizations. “People who had healthier lifestyles even as they got older had a healthier profile and were less likely to develop a heart attack,” she explains. What this shows is that even though your biology may be working against you, you do have the power to fight back.
That’s not to say older women are the only ones who need to stay diligent. Research in JAMA has shown that premature menopause (menopause in women younger than 40) also contributes to an increased risk for heart disease because of how the drop in estrogen influences a woman’s cholesterol profile—in this case, over the course of additional years. “That data takes age out of the equation,” Dr. Wood notes. If a woman goes through menopause early, she needs to be extra diligent to monitor her cholesterol throughout the rest of her life. “We need to be even more aggressive about other risk factors when premature menopause is present,” she explains. That means seeing your doctor regularly, living a healthy lifestyle, and getting on medication as needed to address any risk factors that arise.
Protecting the Female Heart
Of course, menopause isn’t the sole driver for poor heart health. “Not every woman who goes through menopause has a heart attack,” Dr. Goldberg says. (Phew, half the population says!) Those whose risk levels are higher before menopause have a significantly elevated risk—that’s anyone with a family history of heart disease, who is overweight or obese, physically inactive, has high blood pressure, or is a smoker. The time to address these isn’t after menopause, but before estrogen loss occurs, she adds.
Dr. Wood suggests to her patients that they try to go into menopause “armed for battle,” prepared for the changes that will come. “That means trying to be in as good shape as possible when we go into menopause,” she says. Adopt a workout regimen, eat a diet high in fruits and vegetables and low in saturated fat, and try your best to keep your stress levels in check. These adjustments help reduce your bad cholesterol before menopause, so it will be that much easier to keep your lipid profile in a good range as your body changes.
Keep up with your annual visits to a healthcare provider, too. “You can keep track of your cholesterol by getting a yearly cholesterol test and following that with your doctor,” Dr. Goldberg suggests. If your negative cholesterol levels are on the rise, talk to your doctor about what treatment plan might be best for you. “It needs to be a continuous conversation,” she says—one that can be done with either a cardiologist or with your primary care provider. Depending on your age or overall risk level, your doctor may choose either a cholesterol-lowering medication or a lifestyle-based approach.
Screening saves lives, and for heart disease, it isn’t done nearly often enough—particularly in women. “Women get screened with pap smears, women get screened with mammograms, but women do not always get the same scrutiny paid to their cardiovascular risk factors,” Dr. Wood says. “It’s really important.” Heart disease is common, but it’s also largely preventable. That starts by having all the facts in front of you to understand the factors at play.
Menopause Increases CVD Risk: Circulation. (2020.) “Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association.” ahajournals.org/doi/10.1161/CIR.0000000000000912
Menopause & Heart Disease: America Heart Association. (n.d.) “Menopause and Heart Disease.” heart.org/en/health-topics/consumer-healthcare/what-is-cardiovascular-disease/menopause-and-heart-disease
Gender Differences in Cholesterol Levels: Indian Journal of Endocrinology & Metabolism. (2016.) “Gender differences in 7 years trends in cholesterol lipoproteins and lipids in India: Insights from a hospital database.” ncbi.nlm.nih.gov/pmc/articles/PMC4792023/
Heart Disease in Women: Centers for Disease Control and Prevention. (n.d.) “Women and Heart Disease.” cdc.gov/heartdisease/women.htm
Cholesterol Basics: American Heart Association. (n.d.) “What is Cholesterol?” heart.org/en/health-topics/cholesterol/about-cholesterol
Chronic Stress & Cholesterol: Scandinavian Journal of Public Health. (2013.) “The relationship between job stress and dyslipidemia.” journals.sagepub.com/doi/abs/10.1177/1403494812470400
Older Adults & Healthy Lifestyle: Journal of the American Heart Association. (2017.) “Cardiovascular Health and Healthcare Utilization and Expenditures Among Medicare Beneficiaries: The Reasons for Geographic And Racial Differences in Stroke (REGARDS) Study.” ahajournals.org/doi/10.1161/JAHA.116.005106
Premature Menopause & Heart Disease Risk: JAMA. (2019.) “Association of Premature Natural and Surgical Menopause With Incident Cardiovascular Disease.” jamanetwork.com/journals/jama/fullarticle/2755841
Women Higher Risk of Heart Attack Death: Circulation. (2020.) “Is There a Sex Gap in Surviving an Acute Coronary Syndrome or Subsequent Development of Heart Failure?” ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.048015