PART 2: HRT, LDL, LDL-P, ApoB & Triglycerides — What Really Predicts Heart Disease

If I had to choose one intervention to protect a woman’s cardiovascular system in midlife, my top choice is hormone replacement therapy (HRT).

Before we even talk about supplements, statins, or advanced lipid markers, HRT stands out because of its profound, physiologic effects on the arterial system itself. Estrogen improves endothelial function, arterial elasticity, nitric oxide production, metabolic health, inflammation, and—remarkably—has been shown to reduce existing plaque.

No other therapy impacts so many cardiovascular pathways simultaneously.

With that said, HRT is one part of a comprehensive evaluation. To truly understand cholesterol and cardiovascular risk, we must look much deeper than standard labs—and this is where LDL-P becomes essential.

LDL-C vs LDL-P: Why the Difference Matters

Most people are taught to worry about their LDL cholesterol (LDL-C). But LDL-C only measures how much cholesterol is inside LDL particles, not how many particles there are.

LDL-P (LDL particle number) measures the actual number of circulating LDL particles. This distinction matters because:

• You can have a perfectly normal LDL level

• Yet have a very high LDL-P

  
  

And it is particle number that drives plaque formation, endothelial irritation, and long-term cardiovascular risk.

LDL-P correlates very strongly with Apolipoprotein B (ApoB). Both are excellent markers of atherogenic particle burden, but LDL-P gives an even clearer understanding within an advanced lipid panel. This is the marker I rely on most to evaluate deeper dyslipidemia.

Why LDL-P Matters So Much

Many women are surprised to learn: Your LDL can look “pretty good,” but your LDL-P may be dangerously high.

This is one of the biggest blind spots in traditional cholesterol testing. A normal LDL level can be falsely reassuring in women who:

• Have a strong family history

• Have an elevated calcium score

• Are postmenopausal

• Have insulin resistance

• Have high inflammation or autoimmune conditions

  
  

LDL-P provides the missing clarity.

Optimal Targets

• LDL < 100

• LDL-P < 1000

  
  

Lower targets are used for anyone with known cardiovascular disease or high-risk features.

The Most Effective Ways to Lower LDL-P

Two non-prescription therapies have the strongest evidence for improving LDL particle number:

1. Niacin

Improves LDL-P, increases healthy HDL, and promotes safer LDL particle size.

2. Omega-3 fatty acids

EPA + DHA + GLA totaling 4,000–5,000 mg/day (in divided doses).

Omega-3s reduce inflammation, stabilize the vascular endothelium, improve LDL particle size, and directly lower LDL-P.

Together, niacin and omega-3s are powerful alternatives for women wanting to avoid statins or enhance their statin regimen.

What Statins Do—and Don’t Do

Statins lower LDL cholesterol effectively, but they do not reliably lower LDL-P.This is why someone with “perfect LDL” may still have progressive plaque.

Statins remain appropriate for:

• Very high LDL

• Strong family history

• High coronary artery calcium scores

• Prior heart attack, stroke, or TIA

• Severe or complex dyslipidemia

  
  

Patients on statins should also take:

• CoQ10

• A high-quality multivitamin

  
  

Several nutrients are depleted with higher-dose statin therapy and should be replaced.

A Personalized, Non–One-Size-Fits-All Approach

Many women come to me already on statins; many are strongly opposed to them. The truth is: There are many ways to manage cholesterol.From both a Western and functional medicine perspective, great results come from combining:

• Lifestyle

• Smart nutrition

• Exercise

• Supplements

• Prescription medications (when appropriate)

• Hormone replacement therapy

  
  

Each patient’s treatment must be individualized. Family history of heart disease or stroke, metabolic health, hormone status, inflammation, and personal risk tolerance all matter deeply.

When Avoiding Statins: An Effective Supplement Blend

For women who prefer non-pharmaceutical support or who cannot tolerate statins, I often recommend a targeted combination that supports multiple cholesterol pathways:

• Red yeast rice + CoQ10

• Phytosterols

• Garlic

• Berberine

• Tocotrienols

  
  

This blend helps reduce cholesterol production, prevent absorption, decrease inflammation, and improve particle behavior.

Why HRT Remains My Top Cardiovascular Therapy

Beyond lowering LDL-P or controlling cholesterol, HRT improves the vascular system itself, which no other therapy can fully replicate. Estrogen supports:

• Arterial elasticity

• Endothelial repair

• Nitric oxide (NO) production

• Glucose and insulin control

• Lower inflammation

• Healthier lipid patterns

• Stabilization — and even reduction — of plaque

  
  

This is why HRT sits at the top of my cardiovascular prevention toolkit for midlife women.

Don’t Miss These Key Contributors

• Triglycerides should ideally be < 75

• Always rule out thyroid disease, a common cause of elevated LDL, LDL-P, and triglycerides

Even mild hypothyroidism can dramatically shift lipid patterns.

The Bottom Line

LDL-P is one of the most accurate and important markers of cardiovascular risk. When it is evaluated alongside inflammation, thyroid function, hormones, metabolism, lifestyle, and family history, treatment becomes far more personalized—and far more effective.

And when appropriate, HRT can improve not just cholesterol values, but arterial health itself, making it the most powerful heart-protective intervention for midlife women.