Q. I am a 70 year old woman. My cholesterol has always been between 206 and 220 with high HDLs and a good ratio. Last summer, my doctor said 214 is no longer acceptable and put me on simvastatin. My HDL was 65.
My cholesterol has now dropped to 145. Since I’ve read that low cholesterol may be linked to strokes I am concerned. My mother died of a massive stroke and my father of a cerebral hemorrhage.
My weight and blood pressure are normal and I exercise daily. When I see my doctor again, should I question the need for simvastatin?

A. Low cholesterol has been linked with bleeding strokes. Scientists hypothesize that cholesterol helps strengthen the small arteries that feed the brain. Without it, they become more vulnerable to breakage under stress, which happens when blood pressure rises. That might help explain research findings showing that very low cholesterol poses problems too.
Evidence comes from the Honolulu Heart Program. Scientists at the University of Hawaii studied 3,500 Japanese-American men born between 1900 and 1919. The volunteers’ total cholesterol levels were measured when they were middle-aged and again in the early 1990s, when they were elderly. Then the scientists kept tabs on who survived and who died.
To their surprise, the men with the lowest cholesterol levels had the highest risk of dying over the next several years. Those with cholesterol levels between 188 and 209 fared the best. Even men with elevated cholesterol, over 209, were less likely to die from any cause than were those with the lowest cholesterol readings. The investigators confessed their confusion: “We have been unable to explain our results. These data cast doubt on the scientific justification for lowering cholesterol to very low concentrations (less than 4.65 millimoles per liter) [less than 180 milligrams per deciliter] in elderly people.”
I. J. Schatzt and colleagues wrote in The Lancet in 2001:
“Our data accord with previous findings of increased mortality in elderly people with low serum cholesterol, and show that long-term persistence of low cholesterol concentration actually increases the risk of death. Thus, the earlier that patients start to have lower cholesterol concentrations, the greater the risk of death.”
This may be especially true for older women. With your family history of bleeding strokes, you should certainly discuss this issue with your physician. Your ratio of total cholesterol to good HDL cholesterol was great even before you started on simvastatin. Many experts now believe that this ratio is more important than cholesterol levels alone.
If you have no symptoms of heart disease you may want to ask your doctor why he is so gung ho about getting your cholesterol levels so low. There are no data to show that a woman of your age will benefit from statins in the primary prevention of heart disease. Someone who has had a heart attack or has been clearly diagnosed with heart disease may need such drugs. That is not obvious in your case from what you have described.
Although it often comes as a shock to physicians and patients, there are actually data to suggest that low cholesterol is associated with worse outcomes in older women. European researchers have discovered that elderly women have the lowest risk of death when their cholesterol levels are around 270.
• Forette, Bernard, et al. “Cholesterol as Risk Factor for Mortality in Elderly Women.” Lancet 1989; 1:868-870.
• Isles, C. G., et al. “Plasma Cholesterol, Coronary Heart Disease and Cancer in the Renfrew and Paisley Survey.” Br. Med. J. 1989; 298:920-924.
• Editorial. “Low Cholesterol and Increased Risk.” Lancet 1989; 298:920-924.
To learn more about risk factors and heart disease beyond cholesterol and a variety of other ways to improve your chances of living a long and healthy life we suggest our book, Best Choices From The People’s Pharmacy. It deals with the pros and cons of many cholesterol-lowering drugs and offers non-drug approaches you may find worthwhile.
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  1. BRC
    Reply

    HJL,
    I appreciate all the information and feedback- sometimes one feels a bit like a deer in the headlights with all the information overload about FC and cholesterol in general. Between yours and B’s response, I feel as though I am armed with a good foundation to jump off from and educate myself before my follow up appointment with my internist. I will definitely look into the Cholesterol Myth and additionally do some research about omegas and vitamins along with diet and my exercise program to move along this statin free path I am on.
    Thanks again,
    BRC
    PEOPLE’S PHARMACY RESPONSE: Be sure to listen to next week’s radio show: The Great Cholesterol Myth with Drs. Stephen Sinatra and Jonny Bowden.

  2. BRC
    Reply

    Thanks so much for you reply.
    I have been off all statins now for 3 weeks and I do not seem to have any residual muscle pain, weakness or that constant urge to stretch out my arms and legs to relieve muscle tension. Thinking back on this, I realize now in retrospect that a host of muscle symptoms dating back 6 years ago when I was on Lipitor and added a policosonal supplement were caused by this overload of statins to my system.
    I had 6 months of nighttime muscle symptoms where I would waken 4 to 5 times a night with an uncontrollable urge to stretch. I ended up going to a well known medical center to their neuromuscular clinic, and had every test in the book including muscle biopsies which of course showed nothing. Who knew back then that my symptoms were statin induced?
    You offer a lot of good information and suggestions. Thank you again for your input.
    BRC

  3. HJL
    Reply

    I was intrigued by your post because you said you were diagnosed with FH with
    a TC of only 286. This is how WIKI defines FH:
    Familial hypercholesterolemia (abbreviated FH, also spelled familial hypercholesterolaemia) is a genetic disorder characterized by high cholesterol levels, specifically very high levels of low-density lipoprotein (LDL, “bad cholesterol”), in the blood and early cardiovascular disease. Many patients have mutations in the LDLR gene that encodes the LDL receptor protein, which normally removes LDL from the circulation, or apolipoprotein B (ApoB), which is the part of LDL that binds with the receptor; mutations in other genes are rare. Patients who have one abnormal copy (are heterozygous) of the LDLR gene may have premature cardiovascular disease at the age of 30 to 40. Having two abnormal copies (being homozygous) may cause severe cardiovascular disease in childhood. Heterozygous FH is a common genetic disorder, inherited in an autosomal dominant pattern, occurring in 1:500 people in most countries; homozygous FH is much rarer, occurring in 1 in a million births.
    Based on the foregoing it is only LDL which is relevant to a diagnosis of FH. So I would see a real lipid specialist to see what you have or don’t have. No heart attacks in the family is counter to the diagnosis.
    More thoughts: 100 MG of CoQ10 is not enough. Most experts recommend at least 200. Your numbers are so good now, that maybe a lower dose would be effective with less side effects. You should have your LDLs analyzed to see if you have the bad kind. If not, your lipid specialist may conclude you don’t need a statin. Statins have not been proven to be effective for women and TC above 230 is consistent with longer life. Read the Cholesterol Myth by Drs. Sinatra and Bowden to learn more about this.

  4. B
    Reply

    BRC, you have my sympathy. Your doctor, in an attempt to make your system conform to a “medical norm” has actually made you unwell. You are not alone! Familial cholesterol is actually the only one that can be consistently reduced with statins. Unfortunately, that is the very cholesterol that is most effectively (and necessarily) utilized by your body. If you do not already have full blown Rhabdomyelitis, I suggest getting off the statins. High cholesterol is not a death sentence and by itself does not cause heart attacks.. If you want to control FC without the nasty side effects, do some research and find some natural supplements. The COQ10 is a good idea, but, given the problems, you describe, 100Mg may be a bit low.
    From experience with friends who took statins, it takes a while for the muscle pain to go away. The true bottom line is that I have never known anyone who took statins that did not have one or more side effects.
    Research and statistics aside, the majority of patients with heart attacks have normal cholesterol. Note, normal, not high. Recent research has revealed that seniors with total cholesterol over 250 have fewer heart attacks.

  5. BRC
    Reply

    I am a 57 year old woman, very fit, do spin class and eat mainly healthy diet with some minor slip ups. Besides having been blessed with the great family genes of looking 10 years my junior, I have also been “blessed” with familial hypercholestolaemia. (Everyone in family has high cholesterol,ranging ages 40s to late 80s, most are on statins. No one in my family has ever had a heart attack)
    14 years ago I was put on Lipitor 10 mg for total cholesterol of 286, after trying diet and exercise changes to no avail.This has kept my cholesterol at under 200, averaging 180.
    Now I am having muscle pains, involuntary muscle constriction and increased need to stretch out and relieve muscle tightness and constriction. I have taken CoQ10, just around 100 mg to see if it works. I was just changed to Zocor after stopping Lipitor and within a week I was having muscle symptoms. Last labs in September were Total 180, Triglycerides 96 HDL 78 LDL 83.
    I also have reacted to polycosinal but was taken in conjunction w/ Lipitor.
    I haven’t read many options that are available to those of us with a family genetic tendency for high cholesterol. What are our options when we are reacting to statin drugs and statin type supplements?
    Thanks.

  6. condoline
    Reply

    Good for you! Your skeptical nerve is your greatest protection; as a nurse friend once said to me, ” Watch out for doctors. They can kill you”. Iatrogenic illnesses are right up there with cancer and heart attack as causes of death in the US.
    There is no evidence that the benefits of statins even equal, let alone exceed, the risks for seniors. Not only that, but people with extremely low cholesterol have a high mortality rate, people with high cholesterol have relatively low mortality rates, most heart attacks occur in people with normal cholesterol, the cholesterol guidelines are the ” armchair” creations of a committee of nine men seven of whom have close financial ties to the drug industry…shall I go on?
    In other words, take 400 – 1000 mg of CoQ10 (no drug interactions with anything except maybe with anticoagulants), stay away from anything that fools with your cholesterol level, and enjoy life.

  7. HJL
    Reply

    I tried to make sense of what you are saying. I don’t buy the liability mentality argument. That may be true for high risk procedures but it just isn’t applicable to what we are talking about which is the management of chronic health issues. Additionally, the doc can put in the file, offered statin therapy which was declined. Additionally to prove an alternative approach cause or hastened death in an old person is difficult and damages if proven would be minimal. It just isn’t a “sexy” case for a lawyer.
    Additionally, the government regulatory agency does not forbid any doctor from doing anything they want. Doctors often prescribe medicines for “off label use” which are not approved by the FDA but often illegally shilled by the pharmaceutical cos. There is probably more liability for a doc doing that than
    using “alternative” approaches.

  8. DS
    Reply

    I have never heard “moderate” in the sense that you use it. I am not sure what you mean by “conservative approach” either. I disagree that the conventional and FDA approaches are “safest.” THEY are the ones pushing chemical dependence.

  9. RLB
    Reply

    Since I am a moderate, I feel strongly both ways regarding People’s Pharmacy and the medical profession. In defense of People’s, the conservative approach is probably the more correct option. In defense of the medical profession, the FDA and conventional treatment options are the safest.
    Given the liability mentality of the public, the only sane option for a doctor to follow is the accepted treatment protocols. Never mind that they may not work, and, in many cases do more harm than good. Since they are recognized and approved, they remove the liability aspect “I was only following orders”. To alter the nutritional, chemical, and autonomic processes is to sentence a patient to a lifetime of life sustaining chemicals that never cure.
    As long as the medical profession is driven by rote and the initiative to provide genuine cures is regulated, and for the most part, forbidden by a government regulatory agency, we will be a nation of chemical dependent wind up toys.

  10. HJL
    Reply

    Sorry to disagree with the People’s Pharmacy on this but I do. Ignorant and stupid are 2 entirely different things. To make it through med school and get licensed you can’t be stupid. Ignorant means you just don’t know something.
    The simple fact is that doctors are woefully ignorant as a generalization respecting nutrition and supplements and generally are clueless on the research respecting total cholesterol, triglycerides, HDL, and particularly the fact that only some LDL is bad. We can discuss forever the reasons for this, but it is a fact on these things too many docs are ignorant.

  11. HJL
    Reply

    Did you take or are you taking meds to drive your total and LDL numbers so low? If yes, discuss why and dosage with your doc. Are you a vegan or do you have any other specialized eating habit? Your cholesterol is so low that you are endangering all the good things cholesterol does: basis for testosterone and other hormones, vitamin D, bile salts and neuro transmitters.

  12. SM
    Reply

    to clarify my own earlier post, I meant that my mother in law had similar articles about high cholesterol in her own home. Apparently she thought this meant that high cholesterol was “ok” and she didn’t need to worry about it. The result was a low quality of life due to her developing vascular dementia.
    PEOPLE’S PHARMACY RESPONSE: Thanks so much for making this clear to all.

  13. jeffreywp
    Reply

    Get this … I’m 46, male and was reading an article about depression, AD and autism and ties to low serum cholesterol. My total is presently 131 (lowest 123, highest 148 in 2007). My HDL is now 50 (lowest 40, highest 58). My triglycerides and LDL have all been low: 70s-80s. When I go to my doctor’s this week I’m going to check my records to see if there is anything prior to 2007 to see how far back my low cholesterol goes.
    I was diagnosed with Major Depressive Disorder last year (which also came with major insomnia problems). Frankly, I want off of the meds (Trazadone, 100-150mg) b/c 1) I don’t remember having occasional burning urine before being on it and 2) I don’t like being on meds. period. FYI, my psa is .9 up from .8 at last check. I’m going to check in with my urologist again.
    Overall, my low cholesterol has been making me think about my depression, my insomnia and my thyroid since I did a little research and all of those can be tied to low cholesterol. Of course, it also freaks me out to think about low cholesterol being tied to AD.
    My family doesn’t have heart disease in our history (nor prostate or AD). My parents both died due to complications from smoking.
    Thoughts anyone?

  14. GU
    Reply

    I had a hemmoragic stroke in Aug. 2000.I have low cholesterol 155 HDL 58 LDL 86 I have never taken any cholesterol lowering drugs. I do take Forteo for Osteoporasis. You are basing your info on 1989 Data which is 24 years ago! Is there more recent data that confirms the Data?

  15. DH
    Reply

    I am thoroughly confused about what optimum cholesterol is. There is a strong history of cardiovascular disease in my family and my cardiologist wants my LDL’s at 70 or below. I take 40 mg. of Lipitor to achieve this result. Although my cardiologist wants me to maintain this level, I wonder if this is too low based on the recent studies.
    PEOPLE’S PHARMACY RESPONSE:
    Each person’s treatment must be individualized. That is why it is impossible to generalize from large-scale studies to each person.
    You and your physician must work out a program (in partnership) that produces the best possible outcome with the fewest possible side effects. A strong family history of heart disease and other signs and symptoms of cardiovascular problems could well signal the need for aggressive treatment.

  16. RLB;
    Reply

    SM, you are absolutely correct. Although the studies are accurate, they, as does the research done by the statin pushers, never tell the complete story. A history of dietary excesses and improper or inadequate nutrition is usually the culprit. The use of a chemical or a substance that crutches the natural balance of the digestive system in most cases does more harm than good. There are many natural and holistic supplements that provide the same results without the dangerous side effects. After seeing some of my friends suffering side effects of statins, I am definitely not a fan of any chemical intervention as a means of life support. I do not advocate a healthy life style, adequate and balanced nutrition, a regimen of sensible supplements, and regular exercise and social interaction to any one—-unless they wish to feel better and not suffer with colds and sniffles a few times a year. As with any other aspect of your life, your health is yours. Take control of it!.

  17. SM
    Reply

    It is possible for most people to lower their cholesterol by changing their diet so that they don’t need to suffer the possible side effects of the statin drugs.
    It would be too bad if people used the information from these studies as an excuse to continue eating foods that raise their cholesterol levels. My mother in law died recently from heart disease. She had high cholesterol and suffered from vascular dementia due to the heart disease for quite a few years before her death. After her death her daughter found articles similar to the studies mentioned in your post.
    PEOPLE’S PHARMACY RESPONSE: We are so sorry to hear about your mother-in-law. We absolutely agree that diet can be used to lower cholesterol out of the danger zone, and we believe that it is preferable to drug treatment if the drugs are causing side effects. Our remarks above about elderly women refer to those who DO NOT already have heart disease. The benefit of the statin drugs is clear for people who have heart disease (even though it is clearer for men than for women).

  18. RLB
    Reply

    Rew,
    I took the massive panel. I also have small particle size, total cholesterol 199, HDL 73. What was the answer?
    Statins will fix it all!. Fix what?
    I am 84 years old. What needs to be fixed has pretty well been fixed.
    My skeptical nerve, however, still functions.

  19. DS
    Reply

    The test is expensive. You can tell if your LDL is big and fluffy (desirable) by checking your triglycerides. If they are low and HDL high, I think you are okay.

  20. BBT
    Reply

    Interesting.
    Low cholesterol and statins have also been linked to depression. Is there a correlation between statins, strokes and depression?

  21. RLB
    Reply

    DS; I have often wondered the same thing. Is it that they are too busy to read updates? Are they so brainwashed that anything that contradicts what they learned in medical school is quackery?
    Because of the liability mentality, they are certainly risk averse. They have become safe within the cocoon provided by the current medical “facts” as advanced by the FDA and are protected when the outdated treatment and “facts” cause them to harm their patients.
    The majority of the current research regarding cholesterol indicates that most doctors do not understand all they “know” about cholesterol. Although it has been clinically proven that individuals over 65 live longer with cholesterol above 200, the medical profession as a whole is still trying to drive levels as much as possible below 200.
    They are elated when they see a really low total level even though, statistically, a patients’ risk of death from adverse effects increases at very low levels.
    PEOPLE’S PHARMACY RESPONSE: We don’t think doctors are ignorant, but we do think it is difficult to rearrange long-standing beliefs. It is a shame that cholesterol numbers have such a high profile as a stand-alone risk factor. They should be used as part of a bigger picture. For people with heart disease or a family history of heart disease, a high cholesterol is scarier and deserves more attention than for people with healthy hearts and no other risk factors.

  22. HJL
    Reply

    Dorothy, low HDLs together with high triglycerides are classic symptoms of over consumption of carbohydrates particularly sugar. My guess is your glucose and long term sugar test are both high. A high protein high fat diet will cause your HDLs to rise dramatically and your triglycerides (if no underlying problem) to plummet. My triglycerides use to be in the 400s and are now around 50 and it is w/o meds and totally attributable to the above-described diet.

  23. DS
    Reply

    I’d like to see you repeat this column every month until everyone has read it. Sometimes I wonder if doctors DO read.

  24. Dorothy R.
    Reply

    I, too, have been taking the statin drug even though my total cholesterol isn’t that high. My good cholesterol is low — also, I took the test measuring particle size a few years back. My particle size is small – and it tends to clump together (so I was told) and that is the reason I was advised to take the statin drug.
    I also take krill oil, omega 3 and more recently, Carlson’s cod liver oil. The reason for the cod liver oil is that I have high triglycerides – for which I take Tricor – or perhaps I should say even though I take Tricor I still have high triglycerides. Anyway, a cardiologist advised someone I know to try the Carlson’s and it worked for him. So I am going to try it for awhile and see if it really brings my triglyceride level down.

  25. Rew
    Reply

    I recently heard that some doctors think it is the SIZE of your cholesterol particles that determines whether you are at risk. There is a particle blood test available. What do you think of this?
    PEOPLE’S PHARMACY RESPONSE: This is based on real research, and it does make a difference. But it is not clear how much it helps doctors determine therapy:
    http://www.ncbi.nlm.nih.gov/pubmed/23257303

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