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No one goes to Hank's for spreadsheets. They go for a darn good pizza. Lately, though, the shop's been quiet, so Hank decides to bring back the $1 slice. He asks Copilot in Microsoft Excel to look at his sales and costs and help him see if he can afford it. Copilot shows Hank where the money's going and which little extras make the dollar slice work. Now Hanks has a line out the door. Hank makes the pizza. Copilot handles the spreadsheets. Learn more@m365copilot.com Work.
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So good, so good, so good.
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Well. Podcast Family there's always something changing, and that's why we do this show. Because medicine moves fast. Yep. In March of 2026, the American College of Cardiology and the American Heart association published new guidelines on the management of dyslipidemia that came out in the Journal of the American College of Cardiology. Now, this actually was a big, pivotal change regarding screening for lipids in adults. Now, as primary care providers remember that we do well women's healthcare, of course we do well woman visits. And now this is where the change lies because traditionally we did, you know, fasting cholesterol or regular cholesterol, ldl, hdl, triglycerides, we get all that. But there was a shift in lipoprotein hormones, a screening. Now, traditionally, because that's more of a genetic issue that was left traditionally for patients who had high family history or high risk family history of like cardiovascular disease early on or early mis, you're like, oh my gosh, all of your family takes cholesterol medicine? Maybe we should look for lipoprotein A, the genetic form of hypercholesterolism, or one form of it. But this is where the 2026 guidance changed, because now, as of March of 2026, their recommendation is that every adult at least once in their lifetime, so it doesn't tell you how frequent, but at least once in their lifetime should have lipoprotein A levels checked because it is intimately tied to cardiovascular inflammation, cardiovascular disease, and even thrombotic events. Oh, okay, now here's where we get into some ob GYN stuff. Now this actually Comes from one of our podcast family members who had some great questions regarding this. Like, hey, according to these new guidelines, I'm supposed to check lipoprotein A at least once. But isn't this thing like anti. I'm sorry, not anti, pro, thrombotic. And so what we do in women's health, we do surgery, we give birth control pills. These women are getting pregnant. What does this have to do? How do we relate this lipoprotein A result if it's high, with things like ob GYN and women's health care, specifically birth control pills, periop care for maybe a C section or in a time of gin surgery. And what do we do with this in pregnancy? It is true. Lipoprotein A has been linked by association, and that's the key word, guys. It's been linked by association to some bad pregnancy things like fgr, preeclampsia, preterm birth. So she even asked this other question besides the birth control issue and periopath lovenox, is that an issue? The other question is, does this require aspirin? If I find that she has high lipoprotein A levels and that's it. Phenomenal, phenomenal question. So here's what we're going to hit. We're going to do this in kind of rapid fire because there's lots to cover. In light of the New March of 2026, American College of Cardiology and American Heart association guidance on checking lipoprotein A. If we find lo and behold, it's at moderate elevation, does that mean that low dose aspirin is required solely for that indication? What about TXA in patients with heavy menstrual bleeding? What about periop and post op care? Do these patients require anticoagulation? And we're gonna talk about oral contraceptives. Is that a risk in patients with moderate or high lipoprotein A levels? There's answers to all of these guys. And we're do this one after another, boom, boom, boom. We're gonna do this in question and answer, question and answer and question and answer and be done. So thank you to our OBGYN military physician who brought this to our attention. It's a great, great subject. Yes. I actually saw when they came out in March, I'm like, are we gonna do it? I don't know. It's kind of broad. But by breaking it down to these specific questions, as our podcast family member asked, we are absolutely going to answer this question. If I find that this level is high or at Least moderately elevated. What now? What now? What now? Let me tell you what now. So that's what we're gonna do. Thank you very much, Pulp Fiction from that weird scene. But we're gonna cover this and I'm gonna tell you what now. When you find out your lipoprotein A is mildly or moderately or severely elevated, what do we do with this in ob GYN care? I think I've set it up enough. We will be right back. We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OB GYN no Spin podcast. Is that the best kind of movie quote that we could come up with on what now? Really? The weird scene from Pulp Fiction, if you don't remember which one that is, it was for Butch and Vince. Ryan's kind of get into a little weird thing in the back room of a pawn shop. What now? What now? Let me tell you what now. Was it a pawn shop? I don't know what that was. Was it a gun shop? Who knows? Anyway, yeah, that was a weird, weird movie. Not a sponsor. Well, so what now? We are told by the American Heart association and the American College of Cardiology to at least once in adults, so 18 and up screen for lipoprotein A. And lo and behold, we find that the level is moderately elevated, let's just say. And because of its prothrombotic effect, remember, this is an association that key. That word is key, guys. It's an association. Well, how does that affect what we do in women's health? Because some of the things that we do can be considered kind of pro thrombotic, like birth control pills. So we're gonna answer some of these questions. We're gonna answer all of these questions one after another in categories. All right, this is a great, again, great topic suggestion from one of our podcast. Start first with general OB implications. All right, because this has been linked, as I said in the intro to preeclampsia, preterm birth. It's been linked to in some studies by association. Remember, associations are hard because there's a lot of confounding in there. A lot of things can find associations one with the other. Association does not prove what. We've covered this many times before. Causation or those are different things. But there has been an association in some studies with high liver protein A and stillbirth. That freaks people out. And it should. So what do we do with this? If you find your patient has elevated lipoprotein A and then becomes pregnant because she's reproductive age. I mean, this is not in menopause. This is just in an adult, not necessarily postmenopausal. These are premenopausal women. What do we do with this? Well, yes, it is true lipoprotein A is associated with some adverse pregnancy issues, including fgr, preterm delivery, preeclampsia, maybe some stillbirth, as we discussed, but here it is. Guys, you need to hear me very clearly. This does not prove causation. It does not prove causation. Now, for low dose aspirin, there's currently insufficient data, according to the best expert opinions here, that routine aspirin in pregnancy, solely based on elevated lipoprotein A in the absence of other classic preeclampsia risk factors, is warranted. Now, this gets into risk factor stratification versus universal use. This is why. Now, you know, I've said it many times before. This is why I'm a fan of universal aspirin. Anyway, unless you have some weird contraindication, I'm going to give you low dose aspirin. And if you are particularly high risk, I'm going to give you two tablets of 81mg 162. And remember that aspirin works best at night. It's not about taking aspirin anytime, whenever you want to. It seems to work best at night. And I have an episode on that because of circadian rhythms and catecholamine flares throughout the day and cortisol elevations. This works best at night, I think after the episode called Best time to take aspirin or something. And the answer is yes, for pregnancy, it's at night. Okay? So I would offer it as a general intervention. Anyway. Now, outside of pregnancy, secondary analysis of the woman's health study and the Asprey trial. Remember, that's asp R E E aspirin, preeclampsia, which we've talked about, that showed that it could reduce cardiovascular events when we're outside of pregnancy. And that showed that aspirin can reduce cardiovascular events in individuals with genetically elevated lipoprotein A. But that's outside of pregnancy. So once she delivers, I would say definitely continue your aspirin and you can drop back down to 81 milligrams, because that is cardio protective in patients with elevated genetic levels of lipoprotein A. All right, but in pregnancy, there's nothing that says check your lipoprotein A. And if it's high, we're gonna consider that a high risk factor. And. And Then definitely give her aspirin. Because I don't do risk factor based anyway. I do universal. And as Of June of 2026, lipoprotein A is not considered part of the triage algorithm for low dose aspirin use for preeclampsia prevention. Right. It's just not. So yes, lipoprotein A is associated, but it's not proved causation. That's why it's not enough to earn it aspirin designation in and of itself if you're doing risk based protocol. All right, now also since we're talking about pregnancy, if somebody comes in and says, hey, I'm reproductive age, I've got my lipoprotein A level, it's kind of moderately elevated and I want to get pregnant, your first thing to say is, well, do healthy dietary interventions. Take care of yourself. Maybe take an antioxidant as a vitamin supplement. That's controversial as well. But just take care of yourself. Obviously stop doing other things that put you at cardiovascular risk like smoking or excessive alcohol. And you've got to stop medication. If you're taking a cholesterol, cholesterol medication, ideally you should stop that like two months prior to conception and they should not be used in pregnancy. I think I've covered this in the past. There have been some case reports where they've used it because of other weird issues and it seems to be okay. But in general, any anti cholesterol medication is not endorsed in pregnancy. You don't want to do that. Right. Because the baby needs certain cholesterols for cell membrane formation and cell growth. So as of right now, you cannot use any pharmacolog method for this. So the first question having to do with pregnancy is does lipoprotein A level elevation require low dose aspirin? The answer is no, because even though there's an association with preeclampsia, association is different than causation. All right, that checks the box there. We're keeping moving on, guys, really quickly. Remember our job here is to tell you what now? Well, what about if your adult patient, let's say she's 30, she's had her once in a lifetime check of lipoprotein A. And again, moderate to mild to moderately elevated and she wants birth control pills. What do we do with that? And now the concern of course is that lipoprotein A levels could be linked to a pro thrombotic state. And there is some legitimacy to that that that is true. There was a 2026 this year, guys, a UK Biobank study looked at close to 400,000, actually 373,430,000ish patients and found that lipoprotein A levels when it was above 125. All right, so above 125 actually was associated. There's a word again, associated with a hazard ratio of 1.32. See, it's not a big association. Right? 1.32 is above 1, but definitely not 2. Not a double risk. 1.32 risk of VTE in premenopausal women. But here's the catch. You're like, oh, wait a minute, Lipoprotein A is associated with an increased risk of VTE. That's what you get if you just read the abstract. But when you read this UK Biobank study, here's what's in the fine print. Those women who took oral contraceptive pills, they did not have an increase above what lipoprotein A does by itself in that population. In other words, birth control pills didn't do anything. That's a big clinical pearl. And the reason is, unlike pregnancy, where you get supraphysiologic levels obviously of estrogen, remember that birth control pills, even though they contain estrogen in them, like a 35 microgram pill, it is still under what, a normal cycle, peaks of estradiol at mid cycle. Okay, so these women are still relatively hypoestrogenemic. We've got plenty of episodes on this that even though a patient is on estrogen containing birth control, they may still complain of vaginal dryness, you know, lack of lubrication during sex, because compared to a regular cycle, they are hypoestrogenemic. So because lipoprotein A may be estrogen related, where they rise in pregnancy, because lipoprotein A definitely rises in pregnancy with high estrogen levels, but with birth control pills, they're actually hypoestrogenemic. That's why the risk was not any higher. All right, so yeah, birth control pills, no problemo. Even with lipoprotein A. Also remember that the current, Again, June of 2026, the current CDC US medical eligibility criteria, while it does classify known thrombogenic mutations, it only considers those thrombogenic mutations as factor 5 Leiden, prothrombin mutation, protein C or S deficiency and antithrombin deficiency. Those are the thrombogenic mutations. Those are category four. It does not list lipoprotein A as part of that. Okay? Now if a patient has multiple risk factors for cardiovascular disease, like she's 40 years of age, she smokes, she's obese, she's hypertensive, then that is considered category three or four. So if there is a conglomerate burden of harm, then just don't give her birth control pills anyway. But that's not just because of the isolated lipoprotein A. That's because she's got multiple morbidities and that raised her risk. And that should not surprise anybody over the age of 35, especially if they smoke. Consider a non estrogen form of contraception. That's been a thing since I was in medical school. Because of the higher risk. Okay, so older age, smoking, diabetes, hypertension, obesity, dyslipidemia, where you put. That's where you put lipoprotein A in that patient. Then consider it category three or four, which is in accordance to the US medical eligibility criteria. Okay, so birth control pills with lipoprotein A. Absolutely. If that's the only factor and they're not obese or not hypertensive, they're not, you know, over the age of 35, that's not a problem at all. Again, I'll put the reference to the 2026 UK Biobank study, of course, in our show notes, but that most people consider a severe elevation to be greater than 125. And even with that, the association of the odds ratio of the hazard ratio rather was 1.32. Not. Not all that impressive. Okay. That's why there's a difference between association and causation. But remember, in that study, birth control pills did not augment risk.
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Venmo stash bundle terms and exclusions apply. See terms@venmo me stashterm venmo checkout not available at all merchants. Venmo MasterCard is issued by the Bancorp Bank NA. All right, so we tackled birth control pills. The point is, yes, knock yourself out. It's better than being pregnant with the supraphysiological levels of estrogen. So, yes, no problem at all. The question is, should you check the lipoprotein A levels after? Maybe. I mean, there's no guidance for that. Neither national or international. I think it's fine. Just. Why not just see what it's doing? Maybe it drops. Actually, for reasons we just discussed, and I've done that in the past when patients in the handful that I've had with this in my gin clinic, usually grad students or older students who come in through the university. Yeah, sure. You know what? I'll check in maybe six months later or definitely in a year, part of the World Women exam, just to see where they're at. Mainly out of academic curiosity, but we don't have any formal guidance for that. So I think that takes care of the issue with birth control pills and lipoprotein A. And I think we're good. Oh, one more thing. One more thing. There is. There's actually one more data reference for this that I think is helpful, and that's the nla. Okay, nla, you all know what that is. Okay? We're not medicine folks or family medicine, but it is a big thing. It's the National Lipid association and they actually did mention in 2024. Listen, this is a big deal. 2024, two years ago, the National Lipid Association. Michael just remembered me. It was in my show notes and I totally forgot. The national lipid Association in 2024 did not list. Y' all get this. Did not list elevated lipoprotein A as a condition to restrict combination hormonal contraceptive. How about that? So even the national lipid Association in 2024 said elevated lipoprotein A give them combination birth control because it's still safer than, say, a gestation, relatively in terms of estrogen levels and the possible reaction of lipoprotein A to those higher estrogen levels in pregnancy compared to lower with birth control pills. All right? So best practice, just follow the MEC medical eligibility criteria from the cdc. But as of right now, it is definitely not any guideline that says before you give a patient birth control pills, you need to check for their lipoprotein A status. Not at all. If they want birth control pills and they don't have an official traditional contraindication, knock yourself out. So we've covered the medical eligibility criteria, the UK Biobank study, and the National Lipid association from 2024 in their consensus statement. Thank you, Michael. All right, now that we've done that, let's talk about periop care. We're in our third bucket. We're almost done, guys. Okay, a lot of info coming. And just as a quick refresher as we take a breath, we're talking about Lipoprotein A. All this happened just because of March of 2026, where the American Heart Association, American College of Cardiology said, you should check this at least once. And then a podcast family member said, well, what do we do with this if it's elevated? And some of the things that we do that are potentially pro thrombotic? How do we relate these two? How do we marry these two? How do we negotiate these two, balance these two things together? So that brings us now to Periop care or the need for Lovenox. Is that a thing? All right, so Periop care and the need for Lovenox. But before I get into the Lovenox issue, which is a very, very good question, if you find value on this show, please give a wor out because we're always looking to grow. We're very thankful that month after month we are still growing. It's one of the few women's healthcare podcasts that's still experiencing growth. Thank you. And this is why people have found value in our podcast and that's why they partner with us for sponsorships. So speaking of that and value, we're very thankful to Tona T o n a Tona Activewear because they are one of our sponsors. And speaking of value, whoever goes through Tona and order through our website with the link in our show notes, you can get 16% off anything on the website. 16% off, that's 1. 6. Just because you're part of the podcast family. So that is Tona Activewear using the link. It has to be with the link in our show notes or it won't work. All right. You don't get the 16% discount. Just go through the link and then order anything the link and the discount is automatically applied. You'll see that at checkout. 16% just for being part of the no Spin OBG podcast. So thank you, Tona, for your partnership. The link is in our show notes. If you're driving and you can't look at the link, it's very easy. It is tonaactive.com that's T O N A active.com discount chopanospin obg altogether tonaactive.com discount chopanospinobg so now that we've said that back to Lovenox. No, you do not need Lovenox just for elevated lipoprotein A levels. You don't. It does not affect Virchow's triad. It's a whole other issue of inflammation. So here's a take home message. The relationship between lipoprotein A and VTE is very complicated and is an association. Thankfully most meta analysis show a very modest one. Not a huge association with an odds ratio of about 1.5 at max maybe 1.8. And here's the catch guys. Even genetic studies published through the lipidemiology folks, epidemiology and dyslipidemia. Boy, I combined those two things together. Sorry. Between epidemiology and dyslipidemia, genetic studies have found that there is not a likely direct causation. In other words, lipoprotein A probably causes the association with VTE by other inflammatory changes of the vascular wall. It's not that lipoprotein A in and of itself is thrombogenic. Does that make sense? So it's an IND correct pathway. All to say no, you do not need to use Lovenox just because they have elevated lipoprotein A levels. What you do need is to follow standard periop care scds, follow SMFM's Console Series 51 on using lovenox for obesity and use the fixed dose split regimen of 40mg sub QBAD especially in morbid obesity. We've talked about that before, so just follow standard protocol. Now here's another thing guys, I'm telling you this. Whatever I'm saying to back up even the 2022, the 2022 European Atherosclerosis Society, that's the the ones who deal all only with blood vessels and high cholesterol. All right, so the 2022 European Atherosclerosis Society, their consensus statement explicitly states. Here it is guys, here it is. And everybody can rest assured, quote, Current findings do not support lipoprotein A as a risk factor for venous thromboembotic events alone. End quote. Meaning it's not it by itself. It's the pro inflammatory changes that it leads to. It's a domino effect that can increase VT El but not the lipoprotein A by itself. So no, it is not necessary to give Lovenox just for this. Plus last year a 2025 review also stated that the association with VT EL is actually limited to other prothrombotic events like immobility and increase in Berchaus triad rather than just the lipoprotein A concentration by itself. This is why guys, here it is and we're gonna wrap this one up real quick and then we're touch on TXA and then we're done. This is why acog, the American College of Chest Physicians SMFM the Royal College. None of them, none of them include lipoprotein A as a standalone risk factor for the use of anticoagulant regulation periop. It doesn't. So it's interesting. Wow, you've got this factor. But even According to the 2022 European Atherosclerosis Society, the current findings do not support LPA as its own standalone risk factor for VTE. It's complicated and is an association, not causation. Last thing that we're going to do is to tackle the question that our podcast family member had, which is on txa and for the very same reason that we just mentioned, that it's not thrombogenic in and of itself. Yes, absolutely. TXA can be used in patients with heavy menstrual bleeding, even though there's no specific guideline. Be very clear, guys, we don't have any specific guideline that specifically talks about TXA use with elevated lipoprotein A. I can't pull one out that says, oh, in patients who have a lipoprotein a level of 130, TXA may be contraindicated. We don't have that because it's not considered a traditional hypercoagulable state. So would I use TXA in these patients? 100%. No question. Absolutely. And even though you can use TXA Listida transodenic acid of 1300 milligrams TAD for up to five days just to buffer it, Let me just show you what I would do. This is a chop of brain. I would only give it for the first 72 hours, for three days, just to balance that out, just to be conservative, because again, we don't have any good data on this. But can you give TXA in a patient with lipoprotein A? Absolutely. Do we have best practice for this? No. Do we have any guideline that specifically says three days is safer than five? No. But does that make sense to be conservative? Absolutely. So, yes, TXA is the usual dose, 1300 milligrams TID for up to five days, if you like. I only do it for 72 hours for only three days, but yeah, that is not a contraindication in patients with elevated lipoprotein A. So, podcast family, we've covered lipoprotein A, the American Heart association new guideline and obg. So what now? Well, not a lot. This is mainly a non pregnancy issue and a non thrombogenic issue in and of itself as it relates to what we do in obgyn. These patients should be on aspirin they should be working with their family medicine physician. They should be working with their a metabolic physician or the wellness physician to try to do healthy lifestyle changes because unfortunately Lipoprotein A is genetic and sometimes dietary factors are not enough here and there's not one specific medication that's FDA approved and well studied to go. This one only is going to work on LP better than a general statin. We just don't really have that and so they require just continued follow up evaluations and warning sign education to catch problems early. Podcast Family as always, we're thankful for you, Michael. Thank you for your help with this episode and thank you to our family member who brought this podcast family member who brought this to our attention. Lipoprotein A. Aha. And OB gyn. What now? I think we've covered that and now that we've done all that, Michael, come on, let's take it home.
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This is Dr. Chapma's obgyn no spin podcast. Sam.