Women & Pregnancy with FH

There’s not one absolute answer to this question, but there are several likely reasons.

The first is puberty. As young men go through puberty, their HDL (the “good” cholesterol) tends to fall. This does not happen to young women, and low HDL is an additional risk factor for early heart disease.

There is also some evidence to suggest that women are protected from the symptoms of heart disease before menopause, probably because of estrogen.

Plus, in the past (not as much of an issue today) more men than women smoked. Smoking is poison for everyone, but for those with FH, smoking is doubly poisonous.

As long as your partner doesn’t have FH, each child you have has a 50% of having FH.

Another important risk factor to check is  lipoprotein(a), also known as Lp(a). The only way to know if your Lp(a) is elevated is to have it measured with a simple blood test.

Studies show that approximately 1 in 5 people around the world have high Lp(a), so it is very common. Those living with FH who also have high Lp(a) are at even higher risk for early heart disease than those who only have a high LDL level.

This question can’t be answered precisely, but there is research to show that women with FH can expect their first heart attack in their early fifties.

Thankfully, this is not a common problem, but if you have “statin intolerance” it can be miserable.

Studies show statins reduce chances of a future heart attack by 30%. For every 40 mg/dL LDL is reduced, cardiac risk falls by about 20%.

Before stopping your statin, it’s important to consider if another underlying condition is causing your pain. For example, those with an underactive thyroid are significantly more likely to experience pain from statins.

Certain medications can also contribute to these side effects. These include drugs used to treat HIV or certain antibiotics. These medications should not be taken with statins and should be discussed with your healthcare provider.

It’s also important to note that not all statins are created equal. Some are stronger than others and some react differently within the body. Discuss trying different statins, one at a time, with your healthcare provider to see if any reduction in side effects.

This is a personal choice and something you need to discuss with your partner and your health care team. It is important to know that if your cholesterol rises dramatically during pregnancy, there are options.

One option is LDL-apheresis. This is a dialysis-like procedure that physically removes LDL-cholesterol from the blood stream on a weekly or bi-weekly basis. This 3-hour procedure involves removing blood from one arm, extracting the LDL cholesterol, then returning the blood to the other arm. LDL-apheresis has been successfully performed on many young pregnant women with very high cholesterol levels.

Other women successfully manage their pregnancies with diet and bile acid sequestrants.

It’s also important to remember there are many ways to create a family. Some people choose to adopt, and others create a family with the help of a gestational surrogate.

Again, this is a very personal choice. Many infertility medications can increase cholesterol dramatically. If you’re thinking about infertility treatments, you should consult a lipidologist. They can work closely with your infertility specialist to monitor your cholesterol and make a plan for the number of cycles to go through.

New Food and Drug Administration guidance says you can take a statin until you know you are pregnant.

If you become pregnant, stop taking your statins immediately. In fact, you should stop taking all cholesterol-lowering medications except for bile acid sequestrants.

In animal studies, some statins have been found to cause birth defects, so we don’t recommend them during pregnancy, but again, new FDA guidance suggests that it is safe to continue statins until pregnancy is confirmed.

Cholesterol increases significantly during pregnancy by about 25-50%. Women with FH experience the same increase, but since they are starting out at a much higher baseline, they can get extremely high cholesterol during pregnancy.

Women with FH must stop taking cholesterol lowering medications (except bile acid sequestrants) during pregnancy so cholesterol will go up immediately.

Then between the 18 and 36th week of pregnancy cholesterol can increase by as much as 50%.

Eating a low fat, low cholesterol diet during pregnancy is extremely important. You could also consider taking a bile acid sequestrant. This medication is not absorbed into your blood stream, so it is safe during pregnancy. It can lower your LDL cholesterol by about 15%, so it seems worth the eff­ort.

This is another personal choice. Everyone must decide what is best for their family.

Most lipid specialists would advise limiting breastfeeding to 6 months so you can then go back on your cholesterol-lowering medications.

Page written and reviewed by Mary P. McGowan, MD, FNLA

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