Your thyroid has a impact direct impact on the heart. Thyroid hormones influence cholesterol metabolism, blood pressure, circulation, vascular inflammation, and overall cardiovascular risk.
Inna is joined by Dr. Sanjay Bhojraj, an integrative cardiologist who takes a root-cause approach to heart health. Together, they break down the relationship between thyroid function, estrogen, insulin resistance, inflammation, and plaque formation. They also discuss the labs and scans that provide a more complete view of cardiovascular risk and why personalized assessment matters so much more than simply following general population guidelines.
How Low Thyroid Function Raises Cholesterol
Dr. Sanjay explains that high cholesterol can happen for three main reasons. You may be making too much, absorbing too much, or not clearing it properly. In hypothyroidism, one of the most important problems is poor clearance.
The liver uses LDL receptors to remove LDL particles from circulation. Dr. Sanjay describes these receptors as Hungry Hungry Hippos that grab LDL out of the bloodstream. When thyroid function is low, the number of these receptors decreases. That means LDL stays in circulation longer instead of being cleared efficiently.
The longer LDL remains in the bloodstream, the more likely it is to become damaged or oxidized. This oxidized LDL is far more inflammatory and is one of the things that helps trigger the immune and inflammatory cascade involved in plaque formation. Low thyroid function can also slow gut motility, which gives the body more time to absorb cholesterol in the digestive tract and creates another way that cholesterol levels can rise.
When a Sudden LDL Increase Means More Than Diet
One of the most important clinical pearls in this episode is that a sudden jump in cholesterol should always prompt a deeper look. If someone has historically stable cholesterol and then sees a quick increase, Dr. Sanjay says that something has likely changed physiologically.
He highlights three reversible causes he considers first. The first is thyroid dysfunction. The second is perimenopause and declining estrogen. The third is kidney dysfunction, particularly nephrotic syndrome. Rather than assuming the patient must be eating poorly, he emphasizes the need to ask what changed and investigate accordingly.
This is especially important for people with Hashimoto’s because thyroid levels can fluctuate during flares, with medication changes, or when absorption changes. Those fluctuations can create surprisingly large shifts in cholesterol over a short period of time.
The Estrogen Connection and Cardiovascular Risk
Estrogen affects much more than fertility. Dr. Sanjay explains that estrogen receptors are found throughout the cardiovascular system and that estrogen helps maintain vascular youth. It supports nitric oxide production, helps blood vessels stay more flexible, and influences how cholesterol is processed.
As estrogen declines during perimenopause and menopause, nitric oxide declines as well. Blood pressure may begin to rise and LDL may start to creep up. The endothelium, the inner lining of blood vessels, also loses some of its protective function. This creates a more favorable environment for plaque formation and inflammation.
Dr. Sanjay points out that this hormonal shift is one of the most under-recognized cardiovascular risk factors for women. In some cases, when women are supported with estrogen replacement, their cholesterol markers improve relatively quickly. He emphasizes that this is not just about hot flashes or skin changes. It is also about protecting long-term cardiovascular health.
Why Standard Lipid Panels Miss So Much
A standard lipid panel includes total cholesterol, HDL, triglycerides, and LDL. While that provides some useful information, Dr. Sanjay explains that it is based on older technology and misses a large amount of what actually matters.
He recommends asking for ApoB, which gives a much better picture of the total number of atherogenic particles. ApoB captures not only LDL, but also the intermediate particles that can contribute to plaque and risk. This makes it much more informative than LDL alone.
He also discusses comprehensive lipid panels, which can show particle size, particle count, and additional details that help determine whether those particles are more or less likely to contribute to plaque formation. In some people, an HDL that looks high and reassuring may actually be made up of dysfunctional HDL particles that are not doing their job well.
Why You Cannot Look at Cholesterol in Isolation
Dr. Sanjay strongly emphasizes that cholesterol can never be evaluated by itself. Metabolic health matters. Inflammation matters. Hormones matter. Imaging matters.
He discusses hemoglobin A1C as a common screening tool for blood sugar, but explains that it tells only part of the story. Fasting insulin or C-peptide gives a much better sense of how hard the body has to work to keep blood sugar normal. This can reveal early insulin resistance long before blood sugar becomes obviously abnormal.
He also looks at inflammatory markers such as high sensitivity CRP, homocysteine, myeloperoxidase, and LP-PLA2 to better understand vascular inflammation. These markers help show whether the internal environment is calm or whether it is a powder keg, even in someone whose cholesterol looks acceptable on paper.
The Difference Between Calcified Plaque and Soft Plaque
One of the most eye-opening parts of this episode is Dr. Sanjay’s explanation of plaque. Calcified plaque is not the same as soft plaque. Calcification is often the body’s way of stabilizing an area of injury or inflammation by creating a shell around it. That makes calcified plaque more stable and less likely to rupture than soft plaque.
Soft plaque is the more active and inflammatory form. It is more likely to rupture and trigger a heart attack. The problem is that a standard calcium score only shows calcified plaque. Someone can have a calcium score of zero and still have a significant amount of soft plaque that is completely hidden.
This is why Dr. Sanjay does not rely only on calcium scores. He uses more advanced imaging to detect the plaque that actually carries more immediate risk.
Why a Calcium Score of Zero Does Not Always Mean You Are Safe
A calcium score is a CT scan that looks for calcified plaque in the arteries of the heart. It can be helpful, but it is not the whole story. Because it does not use IV contrast, it cannot show soft plaque.
Dr. Sanjay explains that younger patients or patients earlier in the disease process may not have calcified plaque yet, even though they already have significant soft plaque burden. That means they may be told everything is fine when in reality their cardiovascular risk is far from low.
For this reason, he often uses CT angiography, which involves IV contrast and can show the health of the blood vessel wall more clearly. This type of imaging can identify both calcified plaque and soft plaque, making it much more useful for precision cardiology and early intervention.
What to Do When Cholesterol Is High
Dr. Sanjay says the first step is always to look for reversible causes. That includes checking thyroid hormones, female hormones, testosterone, and other factors that could be driving the elevation.
From there, his first-line approach is diet and lifestyle optimization. This means eliminating processed foods, improving sleep, managing stress, building lean muscle, doing movement with a purpose, and reducing visceral fat. He emphasizes that lowering visceral fat can dramatically improve triglycerides, blood pressure, sleep, body aches, and overall metabolic health.
He also shares some of his favorite supplements for cardiovascular support. Fish oil is one of his top choices, especially high-quality formulas with a good EPA to DHA ratio. He also likes berberine for its support of LDL receptor recycling, glucose metabolism, and blood pressure. Nitric oxide support is another key area because it helps maintain endothelial health, vascular flexibility, and blood flow throughout the body.
When Medication Is Necessary
Dr. Sanjay takes a balanced view of medication. He is not anti-medication, but he is also not quick to prescribe when lifestyle and root-cause work have not yet been fully explored. He believes people need practitioners who are comfortable using both conventional and integrative tools.
There are cases where biology wins, such as familial hyperlipidemia or patients with significant existing cardiovascular disease. In those situations, medication may absolutely be necessary. But even then, diet, lifestyle, stress reduction, and targeted supplementation still matter and can often allow someone to use lower doses with fewer side effects.
He also notes that statins do not remove calcified plaque. In fact, statins often increase calcium scores because they stabilize plaque by reducing the angry soft core and promoting a more calcified, stable structure. His focus is not on removing calcium, but on stabilizing plaque, reducing inflammation, and preventing rupture.
Why Personalized Cardiology Matters
Throughout the conversation, Dr. Sanjay returns to the idea that population statistics are not enough for individuals. Conventional risk calculators can be helpful, but they often miss the nuances that matter most in real people.
Precision cardiology means looking at the individual. It means considering hormones, inflammation, metabolic health, imaging, exposome, lifestyle, and the person’s unique biology rather than relying only on general averages or isolated lab values.
For people with Hashimoto’s, this is especially important because the relationship between thyroid health and cardiovascular health is so strong and so often overlooked.
Connect with Dr. Sanjay
Website: www.lagunamedicine.com
Instagram: @doctorsanjaymd
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PLEASE NOTE
All information, content, and material on this podcast is for informational purposes only and is not intended to serve as a substitute for the consultation, diagnosis, and or medical treatment of a qualified physician or healthcare provider
