Women, Cholesterol, and Heart Disease: Three of My Favorite Things

These are a few of my favorite thinnnngs.  Sorry, nostalgia.

Women are not men. That should be obvious to everyone. Women have a different balance of sex hormones than men do, they have a higher body fat requirement, they can grow a baby in their bellies for 9 months, and they really like romantic comedies. Despite their inexplicable love for Matthew McConaughey movies, however, the scientific research world likes to pretend these differences don't exist. Over my years of studying cholesterol and cardiovascular disease research, I've noticed a bias here. But it's time to wise up... the research on cholesterol and heart disease shows a stark difference between the sexes. If you're a woman, and there's a 50% chance that you are, then you've been fed a load of shit. Here's why.

Cholesterol Levels in Women
In men, there has historically been an association between cholesterol levels and risk of heart disease.  Take the MRFIT trial for example, one of the landmark studies in this area... (1)

If you're a middle-aged man, risk of heart disease and dying overall increases with your cholesterol level.  There's SO much more to it than just this, of course... there's HDL, LDL, triglycerides, and most importantly LDL particle number. All of these are more important markers than total cholesterol in my opinion, and each case should be evaluated on an individual basis.  Just because your cholesterol is a little high doesn't mean you're going to die.  But for the purposes of this article, you can't deny the relationship above.  It exists. 

It exists in men, that is. Women? Not so much. Take the Norwegian HUNT 2 Study, for example (2). The researchers followed 52,087 Norwegians aged 20-74 who were free of cardiovascular disease (CVD) for 10 years, then assessed the relationship of total cholesterol with total mortality, CVD mortality, and heart disease mortality. Most importantly to the purposes of this article, they studied both men and women, and they analyzed each of their data separately.  As you've probably already assumed, they each yielded very different results.

Note: Since this study comes from Europe, the units for blood cholesterol are shown in mmol/L, rather than the mg/dL that we are used to. The researchers classified the participants into four groups, based on their blood cholesterol. Here are the converted unit values in mg/dL for the four groups... <193, 193-229, 230-269, and >270.

This is the all-cause mortality data, the most important information from the study.  Just take a moment and compare these graphs to the MRFIT graph above.  Do it.  For men, we see a similar U-shaped trend, although this study shows a lesser risk with high cholesterol than with low.  But just look at the women... those with the highest total cholesterol, over 270, were least likely to die! And that's statistically significant. Of course there are other studies that show this gender difference as well (3).

The relationship between cholesterol and risk of imminent death clearly differs between men and women.

Women and Cholesterol-Lowering Drugs
I've written of cholesterol-lowering drugs (aka statins) a couple times, once about the potential side effects and once concerning their efficacy (4, 5).  The truth is, statins don't save any lives in women, and the potential side effects make these drugs a definite no-go.  I know it's hard to believe; these drugs are given out to women like candy, just like they are to men.  On top of that, your doctor likely isn't aware there's any difference between sexes.  That's why I provide evidence.  Prepare to be mindblown.

The most positive, statin-supporting study ever done is known as ASCOT-LLA (6).  It was a secondary prevention study, meaning that the study participants had pre-existing heart disease. In other words, taking statins in this case was more treatment than prevention.  The results were fantastic.  So fantastic, in fact, that the researchers ended the study early for ethical reasons; the drug supposedly saved so many lives that they thought it unethical to continue.  The drug did reduce heart-disease-related deaths dramatically... it even reduced all-cause death.  But there was one group in which the results weren't so peachy... women.

Effect of atorvastatin vs. placebo on risk of death from heart disease

Yup, sticks out like a sore thumb... the women who took the placebo fared better than those who took the drug!  And this is for heart disease only... the data for all-cause death would inevitably be skewed more to the placebo side.  Unfortunately there's no handy dandy chart for that.

Surely this an aberration Burn!! My doctor would have told me about this! Nope, sorry. It's real. Two major meta-analyses have confirmed this finding (7, 8). In women without pre-existing heart disease, the drugs have no benefit whatsoever and likely increase all-cause death.  And in women who do? Well statins tend to reduce their risk of dying of a heart attack, but don't change their risk of dying overall.  In other words, they increase the risk that you'll die of something else. I don't know about you, but I care more about overall survival than arbitrarily lowering my risk of just ONE mode of death.

It's clear that if you're a woman, regardless of whether or not you have heart disease, you're gaining nothing by taking statins. Except maybe an early grave. Or some wacko neuromuscular side effects. Don't do it.  And if your doctor insists on it? Send him/her here. Argument over.

Synthesis
Now, synthesize all of this information in your mind and what do you get??  Cholesterol levels in women just aren't an issue.  I don't think it's something we need to concern ourselves with. Again, each case should be evaluated on its own, but I've talked to far too many women with "high cholesterol" who are unnecessarily worried for their health.  They come back from the doctor with a cholesterol level of 230, thinking they have to change their entire life around to fix it. FIX WHAT?? PLEASE TELL ME. And if he/she wants to get you started on statins? Time to find a new doctor, Toots, because this one obviously doesn't have a frickin' clue.

I'll just leave you with this thought... Remember that time you heard you shouldn't eat saturated fat because it raises your cholesterol? Seems kind of irrelevant now, doesn't it? Don't fucking worry about it. Just don't.

Burn, out.