A woman’s heart isn’t a smaller version of a man’s heart. It’s way more dynamic, and isn’t the same heart at 35, 55, and 75.
In the year around your final period, your LDL cholesterol and ApoB climb faster than at any other point in midlife, and the climb follows the menopause transition more closely than it follows your age.[1] Lp(a), the number many of us were taught never moves, runs about 27% higher in women after menopause.[2] Women are less likely than men to have calcified plaque in their coronary arteries, and when it does appear, it carries more risk of dying from heart disease than the same finding in a man.[3] Then you reach your 70s and the evidence thins out, because the big trials enrolled too few women your age to answer your questions.[4]
Men’s numbers don’t have a menopause. Ours move in chapters, so our care has to change by chapter too.
Few doctors were trained to see this. In a national survey of physicians, fewer than 1 in 5 knew that more women than men die of cardiovascular disease each year.[5] Nearly a decade later, only 39% of primary care physicians ranked heart disease as a top concern for their women patients, behind weight and breast health, and few felt extremely well prepared to assess a woman’s risk.[6] Women are still less likely to be offered cholesterol-lowering therapy, and more likely to stop it.[7] I’ve spent 30 years in the gap between what the research shows about women’s hearts and what happens in a typical insurance-based 15-minute visit. This post is my attempt to close the gap for women.
In my last post, I showed you two women and three cardiovascular biomarkers. Laura, a woman in my practice with identifying details changed, is 45. Her Lp(a) jumped 30% in three years, from 54 to 70 mg/dL. Her LDL climbed to 148 mg/dL while her ApoB sat at 86 mg/dL. Her numbers argued with each other.
Then there’s me. My LDL has never once been flagged. My ApoB hovered around 80 mg/dL for two years, then rose to 91 mg/dL within a year of my final period and crossed the 90 mg/dL line the National Lipid Association uses as a treatment threshold for people at borderline or intermediate risk.[8] Same chapter of life. Opposite patterns. That’s the point. Two women at the same stage of life can need entirely different plans, and a woman at 75 needs a different plan again.
My doctor suggested Zetia, the brand name for ezetimibe. I promised you I’d tell you what I decided.
This post is that answer, plus everything I do for a woman’s heart numbers, from the tests to the drugs, with the trials and the number most doctors skip, the number needed to treat. And because so many of you wrote to me from your 70s and 80s asking whether any of this still applies to you, there’s a section built for you. It does apply.
This is how I practice. It isn’t a prescription. Every drug here needs a clinician who knows your history.
Last month, my new labs posted to the portal. I scrolled past the green dots, straight to the number that had crossed the line in the spring. I’d made my choice about Zetia back then. This was the moment I’d find out whether I had chosen right, or whether menopause was going to keep moving my numbers no matter what I did.
