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Cardiovascular

HDL Cholesterol: Normal Values and What a Low HDL Means

HDL cholesterol is called the good cholesterol, but the value reads differently in women than in men. The lower limit sits at 1.2 mmol/l, against 1.0 mmol/l for men, because oestrogen naturally lifts your HDL. The same result can therefore be too low in you and normal in your partner.

Because HDL moves with oestrogen, the value is also sensitive to your life stage and to hormone use. The contraceptive pill raises it, pregnancy raises it substantially, and during the menopausal transition it is mainly the quality of your HDL particles that changes rather than the number itself. This page shows how to read your HDL value as a woman, and when a low value genuinely matters.

Doctor's Assessment Included

When is this value abnormal?

Decision limits per result, in mmol/l
Result Value (mmol/l)
Higher risk < 1,04
Moderate risk 1,04–1,55
Low risk ≥ 1,55

Deze grenzen gelden voor iedereen; de NVKC maakt geen onderscheid tussen mannen en vrouwen. Het zijn risicogrenzen, geen normaalwaarden: een HDL onder 1,04 mmol/l gaat samen met een hoger risico op hart- en vaatziekten. Let op: hoger is niet onbeperkt beter. Bij zeer hoge HDL-waarden neemt de sterfte weer toe: bij mannen vanaf ongeveer 2,5 mmol/l en bij vrouwen pas vanaf ongeveer 3,5 mmol/l. De laagste sterfte werd gezien rond 1,9 mmol/l (mannen) en 2,4 mmol/l (vrouwen) (Madsen, Eur Heart J 2017). De NHG-Standaard CVRM stelt zelf geen streefwaarde voor HDL. Bespreek uw uitslag met uw huisarts.

Source: NVKC Reference population: Nederlandse volwassenen (NVKC, geen onderscheid man/vrouw)

Reference ranges may vary between laboratories. When you order a test, a BIG-registered doctor assesses your personal results in context. For treatment decisions, discuss your results with your GP.

HDL Cholesterol: what this test measures

Your HDL result is the amount of cholesterol carried by the smallest and densest lipoproteins in your blood. Those particles collect cholesterol from your tissues and from the artery wall and deliver it to the liver. The test does not count how many of those particles you have and does not measure how well they do their job; it only weighs the cargo.

For women, reading that result starts with one number that often gets skipped: the lower limit. For HDL the laboratory prints no upper limit, only a minimum, and that minimum differs by sex. For women it is 1.2 mmol/l, for men 1.0 mmol/l. The difference is not an administrative choice but physiology. Oestrogen stimulates production of the main HDL protein and slows the breakdown of HDL particles, which leaves women on average roughly 0.2 to 0.3 mmol/l higher than men from puberty onwards. The bar sits higher for you, and a value of 1.1 mmol/l that is perfectly normal in your partner falls below your lower limit.

Because oestrogen is the engine behind that difference, your HDL moves with anything that changes your oestrogen level. Hormonal contraception, pregnancy, hormone therapy and the menopausal transition all leave traces in this value. That makes your HDL more informative than a man's, but also easier to misread: without knowing which life stage you are in and which agents you use, the number cannot be interpreted.

One relationship belongs with that. HDL moves inversely with triglycerides. A transfer protein swaps cholesterol out of your HDL particles in exchange for triglycerides from the fat-rich particles; the loaded HDL particle then loses cholesterol and is cleared faster. A low HDL is therefore rarely a stand-alone problem, but almost always the shadow of a raised triglyceride value and of the insulin sensitivity behind it. So never read your HDL without your triglycerides and your LDL beside it.

You do not need to fast. HDL barely shifts after a meal.

HDL Cholesterol: why this value matters

Most information about cholesterol is written with a male average in mind. With HDL that shows immediately, because this is the value where the difference between women and men is largest and where your hormonal life stage weighs most heavily.

The lower limit is not the same number. For you it is 1.2 mmol/l, for a man 1.0. In practice that means the following: if you and your partner both come out at 1.1 mmol/l, his result is normal and yours is not. That is the most common reading error on this value, and the reason a woman with a slightly reduced HDL is often wrongly reassured by a table calibrated on men.

Menopause does something other than what you have probably read. The persistent story is that HDL falls during the transition and that risk rises as a result. That is not correct. In long-running research following women through the menopausal transition, the HDL concentration stays flat or even rises slightly. What does change is the quality of the particles: they get smaller, take on more triglyceride and become less good at removing cholesterol from the artery wall. So the number holds while the function declines. In fact, an HDL that climbs across the transition went together in that research with more arterial change, not less. For you that means: a stable or rising HDL around menopause is no reassurance, and a conversation about your LDL, your non-HDL cholesterol and your ApoB is more useful in that phase than a conversation about your HDL.

What does measurably worsen around menopause are the other lipids. Total cholesterol, LDL and ApoB rise measurably around the final menstrual period, and that is the change that counts. Women who notice their cholesterol values worsening without anything changing in their lifestyle are therefore experiencing real physiology and are not imagining it.

And you can barely raise it. Drugs that raised HDL substantially did not reduce cardiovascular events, and people who naturally carry a genetic variant for a higher HDL do not have a lower risk because of it. HDL is a reflection of your metabolism, not a dial. A low HDL tells you something else is going on, usually raised triglycerides, abdominal fat or reduced insulin sensitivity, and those are the factors that carry the risk.

HDL Cholesterol: how to prepare

Nothing special is needed for these tests.

  1. No need to fast

    Good to know

    Eating beforehand makes little difference to these values. You can have breakfast.

  • Water is always fine. Drink as usual beforehand, it makes the draw easier.
  • Take your usual medication, unless your own doctor told you otherwise.

HDL Cholesterol: when is testing worthwhile?

HDL belongs in a full lipid profile, together with total cholesterol, LDL and triglycerides. Drawn on its own the value says too little.

The day of your cycle barely matters for HDL. Unlike oestradiol or the other cycle hormones, a lipid profile does not need to be drawn on a particular day; the variation across the cycle is small compared with the difference between life stages. Fasting is not required either, although your doctor may ask for a fasting repeat if your triglycerides come out high.

What does count is the life stage you are in when you test. During pregnancy your total cholesterol, your HDL and your triglycerides all rise substantially, as normal physiology. A lipid profile from that period cannot be compared with the ordinary reference values and says nothing about your usual situation. Wait to interpret until roughly six to eight weeks after delivery, and longer if you are breastfeeding.

Always report which hormonal agents you use. The pill, menopausal hormone therapy and hormonal coils affect your lipids in different ways, and without that information the result cannot be placed. Also postpone testing until a few weeks after an infection or an operation, because the whole profile dips temporarily then.

The table below sets the life stages side by side. These are directions, not cut-offs.

SituationWhat happens to HDLHow to read it
Lower limit, women1.2 mmol/lfor a man it is 1.0; do not compare one to one
Across the cyclesmall variationyou can be drawn on any cycle day
Combined pill with oestrogenrisesa higher number from the pill, not from a better metabolism
Contraception with an androgenic progestogenthe rise fails to appear or the value dips slightlydepends on the type of pill, not on you
Pregnancyrises substantially, as do triglyceridesnot interpretable; wait 6 to 8 weeks after delivery
Menopausevalue stays flat or rises slightly; particles get smallerthe number hides a loss of function here
Oral oestrogen therapyrisesthe first liver passage amplifies the effect
Oestrogen through the skinbarely risesan unchanged HDL is normal here
High triglyceridesfallstreat the triglycerides, not the HDL

A single measurement is a snapshot. Have an abnormal result repeated before drawing conclusions from it.

HDL Cholesterol: symptoms of a high or low value

Low Levels

A low HDL causes no symptoms. You do not feel it, it does not affect your energy, and there is no symptom that would bring you to this value. You find it only in a blood result.

For women the first thing that counts is whether the value is genuinely low. The lower limit sits at 1.2 mmol/l and not at 1.0, so a result of 1.15 that looks normal on a general cholesterol table falls below your limit. Conversely, it happens that a woman worries unnecessarily about a value that is only low relative to her own earlier result, raised at the time by the pill.

What usually stands around it matters more than the number itself. A low HDL generally travels with raised triglycerides, a growing waistline and reduced insulin sensitivity. In women that pattern can be associated with polycystic ovary syndrome, in which a low HDL and high triglycerides often occur together. That is an association, not a diagnosis: only a doctor can assess it, and not on the strength of your HDL.

So always discuss a low value with a doctor, together with your triglycerides, your LDL, your hormone use and your life stage. A low HDL on its own does not make a diagnosis and says nothing about the state of your arteries.

High Levels

A high HDL causes no symptoms either, and in women a high value is more common than in men. That is usually exactly what you would expect: oestrogen lifts HDL.

The three ordinary explanations for a clearly raised value in a woman are hormone use, alcohol and inheritance. A combined pill containing oestrogen raises HDL, oral oestrogen therapy during menopause does so too and more strongly than a patch or gel, because a hormone taken by mouth passes through the liver first. Alcohol raises the value as well, without any health gain to set against it. And some women naturally carry an inherited variant in the transfer protein that pulls cholesterol out of HDL particles.

None of those three makes a high HDL good news. At very high values the picture even reverses: in large population research the lowest mortality in women sat around 2.4 mmol/l, and above that it climbed again. An HDL above 3.5 mmol/l is therefore not an achievement but a reason to discuss the result with your doctor.

And finally the most important nuance for women around fifty: an HDL that stays stable or rises slightly across the menopausal transition is normal, and is no proof that your risk profile is staying favourable. The particles get smaller and function less well in that period, and you cannot see that in this number.

HDL Cholesterol: what to do about an abnormal value

Female

If Low

Low HDL increases cardiovascular risk. Consider more exercise and healthy fats.

If High

High HDL is protective and beneficial for heart health.

HDL Cholesterol: lifestyle and this value

Start with the honest message: HDL is not a value you should try to push up directly. The trials in which HDL was raised substantially with drugs did not reduce cardiovascular events. So direct your effort at the metabolism this number reflects, and treat a rising HDL as a by-product.

What demonstrably helps:

  • Lowering your triglycerides. In women this is the most productive route, because HDL moves inversely with triglycerides. Fewer fast carbohydrates and less alcohol lower your triglycerides, and your HDL comes up along with them.
  • Stopping smoking. Smoking lowers HDL and the value recovers after quitting. In women this weighs extra heavily, because smoking combined with an oestrogen-containing pill raises the risk of clot formation.
  • Endurance training. Regular aerobic exercise genuinely raises HDL, but modestly: roughly 0.05 to 0.1 mmol/l in meta-analyses, built up over months, with duration per session weighing more heavily than intensity.
  • Less abdominal fat. Visceral fat and reduced insulin sensitivity are the main reason HDL drops. Around menopause many women see their waistline grow even without gaining weight, and that shifts the whole lipid profile.

One thing not to do: drink alcohol in order to raise your HDL. The value does rise from it, but that is a cosmetic effect without health gain.

On hormones: never change anything about your contraception or your hormone therapy on your own initiative on the basis of an HDL result. Those agents are chosen on other grounds, and the HDL effect is incidental to them. If your lipid profile does play a part in that choice, that is a conversation with your doctor, in which the route of administration can also come up. The same goes for cholesterol-lowering medication: it targets LDL and ApoB, not HDL.

HDL Cholesterol: frequently asked questions

What is a normal HDL value for a woman?

For women the laboratory prints a lower limit of 1.2 mmol/l, against 1.0 mmol/l for men. No upper limit is given. That difference comes from oestrogen, which naturally keeps your HDL higher. A result of 1.3 mmol/l is therefore normal for you, while 1.1 mmol/l falls below your lower limit and would still sit within the reference range for a man.

Does the pill raise my HDL cholesterol?

A combined pill containing oestrogen usually does raise HDL. How much depends on the progestogen in it: variants with androgenic activity blunt that rise or reverse it. A higher HDL from the pill does not mean your metabolism has improved, and a drop after stopping the pill is not a deterioration. So always mention your contraception with a lipid profile.

Does my HDL change during menopause?

Less than is often claimed. In long-running research the HDL concentration stays flat or even rises slightly across the menopausal transition. What changes is the quality of the particles: they get smaller and clear cholesterol less well. Your total cholesterol, LDL and ApoB do rise measurably in that period, and those are the values you are best off following then.

I am pregnant and my cholesterol is high. Should I be worried?

Pregnancy raises total cholesterol, HDL and triglycerides substantially, and that is normal physiology belonging to the building of the placenta and the nourishment of your child. A lipid profile from that period cannot be compared with the ordinary reference values. Only assess the values roughly six to eight weeks after delivery, and always discuss a result from pregnancy with your midwife or doctor.

Does menopausal hormone therapy change my HDL?

Oestrogen you take as a tablet raises HDL, because it goes through the liver first. Oestrogen through the skin, as a patch or gel, skips that first liver passage and affects your lipids far less. A difference between two results can therefore come entirely from the route of administration. Never adjust your hormone therapy yourself on the basis of an HDL value.

My HDL is 1.15 mmol/l. Is that too low for a woman?

That falls just below the lower limit of 1.2 mmol/l that applies to women, while the same value would fall within the reference range for a man. A slightly reduced HDL is not a disease in itself and causes no symptoms. What counts is the pattern around it: have the value assessed together with your triglycerides, your LDL and your other risk factors, and repeat the measurement before reading anything into it.

Does it matter which day of my cycle I test on?

For HDL, not really. Unlike oestradiol, progesterone and LH, your lipid profile varies only slightly across the cycle, certainly compared with the difference between life stages. So you can be drawn on any cycle day. If you combine the lipid profile with cycle hormones, the hormone with the strictest timing decides when you go.

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HDL Cholesterol

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