High LDL cholesterol despite plant based diet

[Jebus]

a hysterectomy doesn't not necessarily mean the ovaries have been removed, since removing them (the ovaries) can increase disease risk they often don't remove them unless there is a good reason. So this would be an important detail.

Yes, ovaries were removed.

So I checked the old blood tests. One month before her hysterectomy her LDL was 3.0 mmol (116 mg). A bit high but still inside the range. At the same time her HDL was high 2.2 mmol (87 mg). A few months after the operation her LDL was up to 4.0 and now 11 months after it is up to 5.2. HDL and triglycerides have remained unchanged. Food habits were the same before and after the operation.

The hysterectomy definitely seems to have had an impact although genetics may have played a part as well. WIll the LDL continue to rise or is it likely to come back down at some point? Do you @DrDavid still recommend the medication? If the medication helps, will the LDL shoot up again once she stops taking the meds?

[brimstoneSalad]

Cholesterol lowering medication can have some pretty serious side effects. She should try to cut down on saturated fat first. Animal products are a major source so it should be easy for a mostly vegan by cutting down on coconut and palm oil, and possibly just eating lower fat in general (but make sure to continue consuming plenty of Essential fatty acids and particularly Omega 3; taking a DHA supplement would be optimal and should help reduce risk too given her levels).
Be sure to replace those fats with polyunsaturated fats or complex carbs (not sugar) for the best result.

I would also ask the doctor about more aggressive HRT. He or she may be giving a standard dose without making any attempt to match her pre-operation hormone levels, and estrogen levels vary a lot from person to person. It could be that she is now low relative to her normal levels, and that's what's doing it.
The correlation would be quite a coincidence if it's not causation, so as long as hormones are matched perfectly, it should correct cholesterol to pre-operation levels unless there's something else about the operation that could affect LDL that I don't know about.
A combination of that and some small dietary changes should hopefully be enough to avoid medication.

[carnap]

So I checked the old blood tests. One month before her hysterectomy her LDL was 3.0 mmol (116 mg). A bit high but still inside the range. At the same time her HDL was high 2.2 mmol (87 mg). A few months after the operation her LDL was up to 4.0 and now 11 months after it is up to 5.2. HDL and triglycerides have remained unchanged. Food habits were the same before and after the operation.

This wouldn't be a typical result of having your ovaries removed, estrogen helps keep LDL down but also keeps HDL up and the shifts aren't as dramatic.
But this really should be something she should discusses with her doctors, often when ovaries are removed they often do hormonal theories. What other medications are being taken, etc. There are a lot of details here and only someone looking at her medical history can give good advice.

But removing ovaries does increase heart disease risk so this would be the time for her to re-think her diet, what "worked" in the past may no longer work (she had high cholesterol prior to the hysterectomy). And even if the shift in cholesterol levels is primarily due to the operation that doesn't mean it cannot be addressed by diet and lifestyle.

[DrDavid]

I would also ask the doctor about more aggressive HRT. He or she may be giving a standard dose without making any attempt to match her pre-operation hormone levels, and estrogen levels vary a lot from person to person. It could be that she is now low relative to her normal levels, and that's what's doing it.

I agree, it should be looked into.

The hysterectomy definitely seems to have had an impact although genetics may have played a part as well. WIll the LDL continue to rise or is it likely to come back down at some point? Do you @DrDavid still recommend the medication? If the medication helps, will the LDL shoot up again once she stops taking the meds?

It normally takes a couple of months for LDL to fully adjust after any changes to lifestyle, hormones or medication. Her current level should be stable now, I don't believe it will come down unless she changes her lifestyle, or perhaps HRT. Since she isn't an overweight pizza/hamburger/fries eating person, I just don't think that any lifestyle changes alone will be enough reduce her LDL to recommended levels. She should still try to implement the changes recommended by others here, it will at least help to reduce dosage of any medication. If she does commit to change, then I would suggest 3-6 months before reevaluating her status.

Serious side effects of statins are extremely rare, and all the common side effects are reversible if she stops taking the meds. Unfortunately, the same goes for her cholesterol levels. If she does start taking a statin, she should have a blood test after 4-6 weeks to check for any adverse effects to liver or muscle tissue (ALA(T) + CK).

Thyroid function also affects cholesterol levels. Since her symptoms were weakness/dizziness, I have assumed that her thyroid function was checked, and that it was normal. I shouldn't assume - did she have normal TSH/T4?

[Jebus]

OK thanks. Please check this list and let me know if anything is missing (or if anything on the list is unnecessary).

Avoid saturated fats
Ask physician about thyroid function
Do a genetic cholesterol test
Take statins
Do hormonal replacement theory (if estrogen levels have changed dramatically)
Check pre operation estrogen levels (assuming that this was tested)
Increase Omega 3 intake

[DrDavid]

OK thanks. Please check this list and let me know if anything is missing (or if anything on the list is unnecessary).

Avoid saturated fats
Ask physician about thyroid function
Do a genetic cholesterol test
Take statins
Do hormonal replacement theory (if estrogen levels have changed dramatically)
Check pre operation estrogen levels (assuming that this was tested)

If she isn't on any HRT, or poorly adjusted HRT, then that, along with some minor lifestyle changes, might be enough to avoid statins. Check that first along with thyroid function.

[brimstoneSalad]

OK thanks. Please check this list and let me know if anything is missing (or if anything on the list is unnecessary).

Avoid saturated fats
Ask physician about thyroid function
Do a genetic cholesterol test
Take statins
Do hormonal replacement theory (if estrogen levels have changed dramatically)
Check pre operation estrogen levels (assuming that this was tested)

If she isn't on any HRT, or poorly adjusted HRT, then that, along with some minor lifestyle changes, might be enough to avoid statins. Check that first along with thyroid function.

Yes, in order of operation, I'd say:

Avoid saturated fats -- you can start that today, and it's harmless.
Ask the doctor about about thyroid function and check pre operation estrogen levels (assuming that this was tested)
Do hormonal replacement theory (if estrogen levels have changed dramatically) and address thyroid function if that's a problem.
Then if all else fails, take statins.

I don't think doing a genetic cholesterol test will tell you much that you don't already know. If it's cheap or covered, why not? But otherwise the same things as above would probably be a good idea regardless of the test results.

[Jebus]

[quote=brimstoneSalad post_id=40201 time=1533956705 user_id=106I don't think doing a genetic cholesterol test will tell you much that you don't already know. If it's cheap or covered, why not? But otherwise the same things as above would probably be a good idea regardless of the test results.
[/quote]

Good point.

Thanks to everyone who helped. I'll send an update after the next blood test.