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To Your Good Health: About Good and Bad Cholesterol

Dear Dr. Roach: Although I’ve read that women should have an HDL cholesterol level of at least 60 to protect the heart, mine has always been higher than 100. The last time my cholesterol was checked, the total was 293, but the HDL was 108; the LDL was 171, and the triglycerides 72. My doctor is not concerned, due to the high HDL. My research into high HDL indicated that the risk of heart disease is less than half the average, even when the LDL is high, and that those with HDL of more than 75 may even be blessed with increased longevity. I would appreciate your comments on high HDL levels. — S.J.

Answer: There are several different subtypes of cholesterol; the most commonly discussed are total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol and triglycerides. There remains debate despite scores if not hundreds of studies about the relative importance of these. It’s also important to realize that studies that look at risk of heart disease based on cholesterol levels without medicine may not reflect the risk of heart disease while on medication. One promising drug that dramatically increased HDL actually slightly worsened heart risk. Older (non-statin) drugs that lowered cholesterol sometimes increased overall mortality risk.

So, for people on no medication, high levels of HDL cholesterol are associated with a lower risk of heart disease. (Think “H” for “healthy” cholesterol.) Unfortunately, even people with high levels of HDL cholesterol still can get heart disease, so it isn’t absolute protection.

Those who do usually also have A high level of LDL (think “L” for “lousy”) cholesterol. When I see someone with both high HDL and high LDL, I try to get more information in order to determine risk. Other risk factors — such as smoking, diet, blood pressure and especially family history — are important. If I’m still on the fence, I might test a C-reactive protein, a separate blood test that predicts heart disease risk independent of cholesterol.

I very rarely see blockages in the arteries of people with HDL levels over 100, and it would be exceedingly rare for me to recommend cholesterol-lowering medicine in such a person.

Dear Dr. Roach: I have a follow-up question regarding your answer about testosterone replacement. You say it should not be used in someone who has had prostate cancer. Does that apply even if this person had the surgery to remove the entire prostate? If so, why is that? — P.R.

Answer: Most prostate cancer is stimulated to grow through testosterone. The first effective treatment for prostate cancer was to remove the testes and therefore drop testosterone levels.

Testosterone is not recommended for people with a history of prostate cancer because if there are any residual cancer cells, they could be stimulated to grow. In the case of someone who has had the entire gland removed, many urologists and oncologists worry that any cancer cells that may have spread before surgery but which are currently not growing might be stimulated to do. In most people, the risk is only theoretical. But it’s a risk to be weighed against benefits in a discussion with your doctor.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or write to P.O. Box 536475, Orlando, FL 32853-6475.