Heart; Women's Health; Your Pregnancy Matters
Pregnancy, statins, and high cholesterol: What women need to know
January 5, 2021
The majority of our patients who take statin medications to lower their cholesterol are age 50 and older. However, some younger women can also benefit from taking statins – particularly those with familial hypercholesterolemia (FH), a genetic condition that causes extremely high cholesterol, despite the patient's best efforts with diet and exercise.
Approximately one in 250 people has FH. Statins can help reduce their risk of having a first heart attack by blocking an enzyme the body uses to make cholesterol. While statins are proven to save lives, women who want to become pregnant must consider certain risks regarding statin use.
Statin use during the first trimester has been associated with an increased risk of pregnancy loss. So, we typically recommend that patients go off their statin when trying to conceive, during the pregnancy, and while breastfeeding.
For some women, this break is a year or longer, depending on the patient’s wants and needs. However, taking this much time off the statin may not be safe for all patients. Women's cholesterol levels rise dramatically in pregnancy – up to 50% between the 18th and 36th week of pregnancy – to create functional hormones. Levels may remain elevated up to four weeks after delivery, further increasing an FH patient's cardiovascular risks.
Before becoming pregnant – or as early in pregnancy as possible – it's important to create a heart- and pregnancy-friendly care plan with your cardiologist and Ob/Gyn. I've invited my colleague, Rina Mauricio, M.D., a cardiology fellow at UT Southwestern, to discuss this important topic further.
Dr. Mauricio on statin use and pregnancy
Young women may benefit from taking statins if their low-density lipoprotein (LDL, or bad cholesterol) is consistently higher than 190 mg/dL, or is consistently higher than 160 mg/dL and they have clinical presentation of FH.
Patients and providers may be concerned that statin use in pregnancy might increase the risk of abnormal fetal development. However, the limited available research suggests that miscarriage may be the greater risk.
A study that reviewed data from thousands of women, approximately half of whom took statins during their first trimester of pregnancy, showed that babies were not at increased risk of birth defects due to statin use. However, patients who did take statins in the first trimester had a higher rate of miscarriages.
Nearly half of all U.S. pregnancies are unplanned, and a woman may not know she is pregnant until several weeks into the first trimester. In these cases, we recommend stopping the statin as soon as the pregnancy is confirmed to reduce the risk of pregnancy loss.
Current guidelines recommend working with your doctor to stop taking your statin for at least three months prior to becoming pregnant. The doctor will likely recommend that you stay off the statin for the duration of pregnancy (approximately 40 weeks) and for as long as you choose to breastfeed.
For most women, this equates to at least one year off the statin. However, many women will not get pregnant right away after ceasing birth control. Some patients may require artificial reproductive therapy (ART) to conceive, which can sharply increase cholesterol levels.
In those cases, it's particularly important to work with your heart and Ob/Gyn care team to determine the safety of your chosen fertility method in conjunction with your other treatments and heart health. Certain ART medications and hormones may increase your LDL or total cholesterol levels.
Related reading: 10 truths about statins and high cholesterol
Heart health during the statin break
During this time, you'll need to be extra vigilant about your diet and exercise habits. While neither diet nor exercise alone is a long-term plan to manage FH, changes in your routine may reduce the impacts of your short-term break from taking statins.
Being careful about how much saturated fat and cholesterol you consume in your diet will be important. Your doctor may recommend the Mediterranean diet, which is a globally accepted nutrition plan that minimizes processed foods and red meat while emphasizing vegetables, fruits, lean meats, whole grains, and legumes. This eating plan is doable on any budget and can help support lifelong health, regardless of whether you have high cholesterol. A registered dietitian can help you create the optimal meal plan for your nutritional needs.
Getting enough aerobic exercise can also help control cholesterol levels. Make sure you are getting at least 30 minutes a day of pregnancy-safe exercise, such as walking, running, or swimming. Most women can safely continue their pre-pregnancy exercise routines up to and sometimes through the third trimester of pregnancy. Talk with your heart doctor and Ob/Gyn about what exercises are safe during your pregnancy.
Other cholesterol medications
While there are other cholesterol medications besides statins, many are contraindicated for or have not been studied in pregnant or lactating patients. One is bile acid sequestrants, which are not systemically absorbed – meaning the drugs do not pass into other tissues, such as the fetus or breastmilk. However, these drugs are known to affect absorption of fat soluble vitamins (A,D,and K) and folic acid, so talk with your provider about whether you should take specific supplements as well during pregnancy.
Unfortunately, bile acid sequestrants can cause extensive side effects, such as heartburn and constipation, which already plague some pregnant patients. Bile acid sequestrants also can significantly increase a patient's triglycerides, a type of fat in the body that is associated with heart disease – and that already increases 200% to 400% during pregnancy.
PCSK9-inhibitors are another advanced drug patients often ask about. UT Southwestern researchers identified the protein PCSK9, which the drug targets to lower cholesterol. There are currently no data to support safe use of PCSK9-inhibitors during pregnancy. However, data from a recent clinical trial registry may provide safety data we can use to help guide patients in the future.
Treating Generations of FH
Genetic testing confirmed that Zoe Allen has familial hypercholesterolemia – a condition stretching at least three generations back in her family. Over the years, UT Southwestern has helped great-grandmother, grandmother, mother, and daughter all cut their cholesterol in half and advance the treatment of the condition.
This is another individualized discussion to have with your provider because breastfeeding also requires taking a break from statins. Work with your provider to decide whether it is safe for you to go off your medication to breastfeed and for how long.
Remember, a fed baby is a happy baby. If you and your doctor decide that you need to resume your statin shortly after giving birth, formula feeding will give your baby the nutrition it needs.
Planning for the baby's heart health
Patients with FH have a 50/50 chance of passing the condition on to their baby. The risk increases if your partner also has FH. Children with a family history of FH should have their cholesterol checked by age 2, and all children should be checked between ages 9 and 11 to catch FH as early as possible. Guidelines suggest checking adults starting around age 20 and every four to six years thereafter.
Research focusing on solutions for the future
Navigating pregnancy and breastfeeding can be stressful, especially if you have a complex medical condition such as FH. However, a safe, healthy pregnancy is possible with proper planning and care from a team of cardiology and Ob/Gyn experts.
Ongoing studies are examining the safety profiles of statins in pregnancy, including a 12-year study to determine whether taking pravastatin, a type of statin medication, might reduce the risk of preeclampsia in high-risk pregnancies.
We hope that more focused research will lead to specific guidelines to help patients safely navigate pregnancy and their own heart health. Until then, having individualized conversations with your doctors is the best place to start.