High cholesterol can sneak up on anyone, even you.
It’s a silent condition that usually has no symptoms, so you could have high cholesterol and feel just fine. If you’re a woman, it’s especially important to learn about risk factors, symptoms and cholesterol testing.
Your risk for high cholesterol can go up after menopause, when estrogen levels decline and LDL cholesterol levels rise. Other health conditions can also raise your cholesterol levels.
Since heart disease is still often thought of as a man’s problem, women’s risk is underestimated and high cholesterol in women is often overlooked. So how do you know if you have high cholesterol? A blood test is the only way to know for sure.
Why it is usually silent
Plaque (made of fat, cholesterol, calcium and other substances found in the blood) builds up in the arteries. This causes arteries to become narrowed and hardened. This results in less oxygen-rich blood getting to various tissues and organs of the body. Over time, atherosclerosis may develop. This disease can start early in life and worsen over time.
High cholesterol is often a silent condition, meaning there are no overt symptoms that something is wrong. LDL cholesterol enters the artery wall and triggers inflammation that then thickens the vessel lining. In the early stages, there are no obvious symptoms since you still have adequate blood flow.
There’s also no pain related to the plaque formation itself. Did you know that cholesterol’s damage to your body worsens in silence? That means that you often feel fine while damage is happening in the blood vessels. That’s because symptoms typically will only be felt when that damage gets severe enough to limit blood flow in the blood vessels. This is especially true upon exertion, such as walking or climbing stairs.
You may also notice symptoms when the plaque ruptures and a clot partially or even completely blocks the flow to the heart, brain, kidneys, or legs. Diseases linked to atherosclerosis are sadly the leading cause of death in the United States and even the world. That’s why when a condition is silent it doesn’t mean that it’s harmless.
The signs that can appear
Even though most high cholesterol conditions have no signs or symptoms, there are exceptions, and they usually point to inherited forms, not ordinary high cholesterol.
Familial high cholesterol is an inherited condition that’s passed down in families. It causes very high LDL cholesterol from birth as a result of your body being unable to clear LDL from the blood properly. That’s why it can sometimes show up as deposits in the skin, the eyes, and the tendons. It’s often treatable once it’s found, which is why the lipid panel and family screening keep coming up in each sign.
1. Cholesterol deposits around the eyelids — xanthelasma
Those living with the condition will note soft, yellowish, waxy deposits around their eyelids and often near the inner corner. It’s a sign of cholesterol deposits in the skin and can occur with high cholesterol, but it isn’t specific to familial high cholesterol.
It can also occur without high cholesterol levels, and you are more prone to the condition with age. Clinicians are unable to diagnose xanthelasma from appearance alone. They will likely order a blood test called a lipid panel and review your family history to determine if further evaluation is needed.
2. A pale ring around the cornea — corneal arcus
Corneal arcus, or arcus cornealis, is a gray-white or pale ring at the edge of the clear front surface of the cornea in your eye. This sign indicates that cholesterol is deposited at the corneal edge. Besides high cholesterol, aging is also a risk factor for corneal arcus.
You may see this symptom while living with normal cholesterol blood levels. But if you’re under the age of 45 with these symptoms, it is probably more likely that it is due to inherited high cholesterol. Clinicians aren’t able to diagnose the condition based on how the eye looks alone. What it does do is prompt them to order further testing and review your family history.
3. Thickening over the Achilles tendon — tendon xanthoma
A firm thickening or lump over the Achilles tendon is not a part of aging. If you notice it, possible redness at the back of the ankle where the calf muscle attaches to the heel it may be a sign of high cholesterol.
This is called a tendon xanthoma, and you may notice that the skin is inflamed at the site. This condition is the most specific physical sign for inherited high cholesterol. It’s often rarely seen in general practice but still considered a hallmark of the condition.
If you experience any local symptoms at your Achilles tendon, it’s best to get a lipid panel test right away. Your clinician will also review your family history of early heart disease and possibly ask about a referral to a lipid specialist and family screening since close relatives may also have it.
4. Thickening over the knuckles — tendon xanthoma
People living with high cholesterol may also notice thickening over their knuckles, also called tendon xanthoma. They notice that the knuckles are firm with sometimes fusiform or nodular lumps over the tendons on the back of the hands. These are easily missed when the fists are clenched but much easier to see with fingers extended.
The symptoms point strongly towards familial high cholesterol and also worsen with age when cholesterol stays extremely high. A clinician will likely again order a lipid panel, review family history, refer you to a lipid specialist, and also recommend screening for your close blood relatives.
When the symptoms are the consequences
What’s unique about having high cholesterol is that there are no symptoms associated with the condition. Instead the symptoms seen are from what happens when untreated cholesterol has already gotten so bad that it’s caused atherosclerosis or narrowed arteries and can no longer keep up normal blood flow.
Let’s take a look at an example. Chest pain is also known as angina and it is a common symptom of coronary heart disease. Heart disease is caused by the buildup of cholesterol into the blood vessels of the heart.
It is not a symptom of high cholesterol. The buildup of plaque caused from the excess cholesterol is what narrows the arteries carrying blood to the heart vessel. Chest pain will likely feel like pressing or squeezing discomfort under the breastbone.
People may also feel it in their shoulders, arms, neck, jaw, and even back. When the heart needs more oxygen than the blood vessels can normally supply, like with activity and exertion, it may ease within a few minutes of rest.
Pain that doesn’t go away with rest, or occurs while resting, can signal a heart attack. All chest pain should be checked by a healthcare provider.
Leg pain while walking is a symptom of peripheral artery disease. Plaque narrows the arteries carrying blood to the legs. It feels achy, heavy, or cramping when walking or climbing stairs, and eases after rest, most often in the calf, but also in the buttocks, thigh, or foot. This is not a cholesterol symptom; it is leg muscle not getting enough blood or oxygen during activity.
A stroke occurs when plaque narrows or blocks arteries to the brain, or a clot blocks blood flow there. Symptoms are sudden: numbness or weakness in the face, arm, or leg, especially on one side; confusion, trouble speaking or understanding speech; trouble seeing in one or both eyes; trouble walking, dizziness, or loss of balance; severe headache.
If you or a loved one is experiencing any of these symptoms, call 911 right away. Do not waste time driving to the hospital. Call for an ambulance so treatment can begin right away. Remember BE FAST: Balance lost, Eye changes, Face drooping, Arm drift, Speech slurred or strange, Time to call 911.
What changes for women
A woman’s risk for high cholesterol is often underestimated, and her levels can fluctuate when she’s not watching.
Women are typically screened and treated less aggressively. Furthermore, their heart symptoms are often more atypical, so cholesterol can be found later.
In menopause, the body has lower estrogen levels. That lower estrogen prevents the liver from being able to clear bad cholesterol (LDL) from your blood. The good cholesterol, also known as HDL, may also decline in menopause. The hormone and cholesterol changes may even occur without you making any changes in your diet or gaining or losing weight. In fact, a woman may have normal cholesterol levels before menopause but find they’ve elevated after it.
Hypothyroidism is a common condition caused by an underactive thyroid gland. It can lead to slowly and quietly rising cholesterol levels. That’s because lower thyroid hormone levels slow the body’s ability to clear LDL, and that’s why LDL and total cholesterol may rise.
Clinicians may find that treating the thyroid condition may also lower cholesterol levels without requiring separate and specific cholesterol treatment. However, diet and genetic factors may still keep it above optimal levels. It’s not uncommon for a clinician to rule out hypothyroidism if a patient’s labs show high cholesterol. They do so by ordering a blood test called thyroid stimulating hormone or TSH test.
Polycystic ovarian syndrome, or PCOS, is a condition in women that leads to insulin resistance, excessive androgen, and even chronic inflammation, among many other symptoms. It can also lead to high cholesterol. Women living with PCOS may be at a higher risk for having elevated LDL and triglyceride levels with lower HDL.
In fact, there’s as many as 50 to 70% of women living with PCOS that develop high lipids. That means even young women are at a higher risk for high cholesterol.
Another risk factor of high cholesterol in women is pregnancy. Women who’ve been pregnant may be at a higher risk of elevated cholesterol. Complications in pregnancy like preeclampsia and gestational diabetes and hypertension are also all linked to a higher risk of heart disease and stroke later in life.
Some recent research actually points to a twofold risk increase for negative cardiovascular outcomes with pregnancy. Preeclampsia, which is elevated blood pressure during pregnancy, is even linked to a fourfold risk of heart failure.
How you actually find out
The only way to know if you have high cholesterol is through lab testing of your blood.
A lipid panel is a common blood test and is also called a lipid profile. This blood test measures four things: total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. Your clinician may order the simple blood draw when high cholesterol is suspected or if you are at a higher risk.
LDL is often called bad cholesterol because it increases the risk of heart disease, stroke, and other conditions. On the other hand, HDL is dubbed good cholesterol since a higher level is associated with lower risk.
Triglycerides are a type of fat that can contribute to plaque buildup in the arteries. It’s important for a clinician to review all of the numbers together; each plays a part in assessing your overall cardiovascular risk and shouldn’t be seen as a single pass or fail number. They will also consider the results and compare them with your age, family history, blood pressure, diabetes, and other risk factors.
The American Heart Association recommends all adults 20 years or older to have their cholesterol checked every four to six years when they’re at low risk. However, if you have a family history of high cholesterol or heart disease, diabetes, high blood pressure, obesity, smoking, or if you are already on a cholesterol-lowering medication, they may check your cholesterol more often.
It’s not uncommon for a clinician to ask you to fast before the test. According to the 2018 ACC/AHA guidance, a non-fasting test can still accurately detect high cholesterol in adults over the age of 20 who aren’t taking lipid-lowering medications.
If you’re asked to fast, it’s usually to avoid eating or drinking anything other than water for nine to 12 hours before the test. Always make sure to follow the instructions your clinician or lab facility gives you for your specific test.
Your clinician may or may not ask you to fast before testing your cholesterol. Fasting may give them a better picture of your triglycerides and LDL levels with certain individuals.
The Bottom Line
Even if you’re feeling okay, it doesn’t mean that you should skip cholesterol testing. Remember that high cholesterol usually has no symptoms. The few visible signs that are possible usually only point to inherited forms and not the ordinary high cholesterol.
If you have any symptoms such as chest pain, leg pain, stroke signs, know that these are consequences of what untreated cholesterol produces and not cholesterol symptoms themselves.
Women, especially after menopause or an underactive thyroid, PCOS, or a pregnancy history of preeclampsia, gestational diabetes, or preterm birth, should understand they’re at a higher risk for high cholesterol. That risk is also high with a family history of high cholesterol or early heart disease.
Any of the symptoms above or if you’re exhibiting these risk factors, it’s important to speak with your clinician right away. The only way to truly know if you have high cholesterol is through a blood test called a lipid panel. If you’ve never been checked or you’re at a high risk, speak to your clinician about the test and if it applies to you.
You don’t have to have a medical degree to know if you’re healthy. Instead, just knowing your numbers can help make a silent condition turn into something you can actually do something about.
Stephanie Wright, RN, BSN, is a Registered Nurse with more than 15 years of experience in critical care, mental health, managed care, and clinical leadership.
Is your neighborhood healthy?
Get a free report on your tap water, air quality, walkability and more
