Xanthelasma
Soft, flat, yellowish patches on or around the eyelids, usually near the inner corner.
Often associated with raised cholesterol, though it can occur with normal levels too. Worth a blood test either way.
Medically Reviewed By: Dr Paul Lim – MBBS, M.Med (Int Med), MRCP (UK), FAMS (Cardiology)
Cardiovascular Risk Factor
Dr Paul Lim Chun Yih
Senior Consultant Cardiologist & Electrophysiologist
High Cholesterol Signs & Symptoms
High cholesterol almost never causes symptoms — which is precisely why it goes unnoticed for years. Looking for signs you might have missed? Dr Paul Lim will go through your results with you, unhurried, and tell you what they mean for your heart.
Dr Paul Lim Chun Yih
Senior Consultant Cardiologist & Electrophysiologist
Basic Heart Check-Up — S$368 (NETT, incl. GST). Full lipid panel, plus ApoB and Lp(a) — which a standard cholesterol test does not measure. Consultation and results review included.
What You Can and Cannot See
Signs and Symptoms of High Cholesterol
Cholesterol circulates in the blood. It does not press on a nerve, stretch an organ or inflame a joint, so there is nothing for the body to report — high cholesterol does not usually cause symptoms.
Three things are worth separating: the visible signs that do exist, the symptoms of damage already done, and the things people wrongly attribute to cholesterol.
1. Visible signs — cholesterol you can actually see
When cholesterol is very high, or high for a long time, it can deposit in the skin and eyes. These are painless and harmless in themselves. Their value is as a flag: they are a reason to have a blood test, not a diagnosis on their own.
Corneal arcus
A pale grey or white ring around the outer edge of the iris.
Common and generally not significant over about 50. Under 45 it more often points to a genuinely raised level.
Get seen sooner
Tendon xanthomas
Firm thickening over the knuckles, the back of the hand, or the Achilles tendon.
Strongly associated with familial hypercholesterolaemia. This one warrants prompt assessment.
Eruptive xanthomas
Crops of small yellowish bumps, often on the buttocks, elbows or knees.
Usually reflects very high triglycerides rather than cholesterol, and can accompany poorly controlled diabetes.
Most people with raised cholesterol have none of these. Their absence is not reassurance — it is simply the normal state of affairs.
2. Symptoms that appear once the arteries have narrowed
These are not symptoms of cholesterol. They are symptoms of what cholesterol has already done — deposits building in artery walls over years, narrowing the vessels that supply the heart, brain and legs. By the time these appear, the process has been running quietly for a long time.
- Chest tightness, pressure or pain on exertion that eases with rest. This is angina, and it is more often described as a weight or a band than a sharp pain.
- Breathlessness. Climbing stairs or walking uphill becomes harder than it used to be.
- Cramping pain in the calf or thigh when walking that stops when you stand still. Known as claudication, it suggests narrowing in the leg arteries.
- Reduced exercise tolerance: a gradual, easily-rationalised decline in what you can comfortably do.
- Sudden weakness, numbness or difficulty speaking. This may be a stroke or a transient ischaemic attack. It is an emergency.
When to seek emergency care
Call 995 or go to the nearest A&E immediately if you have chest pain or pressure lasting more than a few minutes, chest discomfort with breathlessness, sweating or nausea, or signs of a stroke. Remember F.A.S.T.: Face drooping, Arm weakness, Speech difficulty, Time to call 995.
3. What high cholesterol does not cause
These come up often, and it is worth being direct about them. There is no good evidence that raised cholesterol on its own produces:
- Tiredness or fatigue — a very common symptom with many other explanations. See unexplained fatigue.
- Headaches
- Dizziness or giddiness
- Numbness or tingling in the hands and feet
- Neck or shoulder ache
None of this means those symptoms should be ignored — they should be investigated on their own terms. It means that treating cholesterol is unlikely to resolve them, and that a normal cholesterol result does not explain them away.
Already been given a cholesterol result you would like explained? Dr Paul Lim will go through it with you.
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Reviewed by Dr Paul Lim
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Dr Paul Lim is a Senior Consultant Cardiologist who assesses cardiovascular risk alongside his subspecialty in heart rhythm disorders. He reads a cholesterol result together with your blood pressure, family history, calcium score where relevant, and any symptoms. He completed advanced fellowship training at Barts Heart Centre, London under Singapore’s HMDP award.
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The Basics
What Is High Cholesterol?
Cholesterol is a waxy, fat-like substance your body needs. It builds cell walls, makes hormones and helps produce vitamin D. Your liver makes most of what you need; the rest comes from food. The problem is not cholesterol itself — it is having more of the wrong kind circulating than your body can clear.
Excess cholesterol works its way into the walls of your arteries and forms deposits called plaque. Over years the artery narrows and stiffens. If a plaque ruptures, a clot can form and block the vessel outright — which is what a heart attack or most strokes actually are. This is why the condition is taken seriously despite producing no symptoms: the damage is cumulative and silent.
What the different numbers mean
A cholesterol blood test, known as a lipid panel, reports several figures rather than one. In plain terms (what HDL, LDL and triglycerides each measure):
- LDL cholesterol is the one that deposits in artery walls, often labelled “bad”. Lower is generally better, and it is the figure most treatment decisions turn on.
- HDL cholesterol carries cholesterol back to the liver for disposal, often labelled “good”. Higher is generally better.
- Triglycerides are a different blood fat, closely tied to diet, alcohol, weight and blood sugar control. Often the number that moves fastest when habits change.
- Total cholesterol is a summary figure. Useful at a glance, but it can mask a poor LDL/HDL balance, so it is rarely read on its own.
What counts as high for you is not a single universal threshold. It depends on your age, blood pressure, whether you smoke, whether you have diabetes, and your family history. Two people can be handed the same LDL figure and reasonably be given different advice, which is why it is worth going through your report with a cardiologist rather than comparing it against a chart.
Why It Happens
What Causes High Cholesterol — and Who Is at Risk
It is usually a combination of what you inherit and how you live. Neither alone tells the whole story, which is why slim, active people are sometimes surprised by their results.
Lifestyle contributors
- A diet high in saturated fat: fatty and processed meats, full-fat dairy, coconut milk, palm oil, deep-fried food and many baked goods
- Physical inactivity, which lowers HDL as well as raising LDL
- Excess weight, particularly around the abdomen
- Smoking, which lowers HDL and damages artery walls directly
- Excessive alcohol, a strong driver of triglycerides in particular
Medical contributors
- Type 2 diabetes and insulin resistance (see HbA1c and fasting insulin)
- An underactive thyroid
- Kidney or liver disease
- Menopause, as levels commonly rise when oestrogen falls
- Certain medications, worth reviewing your full list at consultation
Inherited cause: familial hypercholesterolaemia
Some people are born with it. In familial hypercholesterolaemia (FH), an inherited change means the body cannot clear LDL cholesterol efficiently, so levels are high from childhood regardless of diet or fitness. It is passed directly from parent to child.
Consider it if any of the following apply:
- A markedly high cholesterol reading, especially at a young age
- A parent, sibling or child who had a heart attack or stroke before about 60
- Tendon thickening over the knuckles or the Achilles tendon
- Corneal arcus (the pale ring around the iris) under the age of 45
Tendon thickening makes FH very likely when it is there, but most people with FH never develop it, so smooth knuckles and clear eyes rule nothing out. The cholesterol reading and the family history carry far more weight than anything visible.
FH is worth identifying because it responds to treatment, and because a diagnosis has direct implications for your immediate family — each first-degree relative has roughly a one-in-two chance of carrying it.
Risk in Singapore
Raised cholesterol is common here and is not confined to any one group. Risk of coronary disease at a given cholesterol level differs across Singapore’s ethnic groups, and central obesity carries cardiovascular risk at a lower body mass index in Asian populations than the thresholds derived from Western data. In practice that means a normal-looking BMI is not by itself a reason to skip the test. There is a national overview of raised blood lipids in Singapore; our own summary of local figures is in heart health statistics for Singapore.
Finding Out
How High Cholesterol Is Diagnosed
Since there is nothing to feel and usually nothing to see, diagnosis rests on a blood test. It is quick, routine, and the results are straightforward to act on.
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1
A lipid panel — the standard test
One blood sample measures total cholesterol, LDL, HDL and triglycerides. Many modern panels no longer require fasting, though you may be asked to fast if other markers are being measured at the same time. It is included in every heart screening package, starting with the Basic tier.
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2
Assessment of your overall risk
Your result is read alongside your blood pressure, weight, smoking status, diabetes status, family history and any symptoms. This is the step that turns a number into a decision.
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3
Additional markers, where the picture is unclear
Two situations call for more than the standard panel: your results look unremarkable but your family history does not, or your numbers sit close to the line where the decision could reasonably go either way. These add information:
- Apolipoprotein B (ApoB) counts the actual number of cholesterol-carrying particles, which can be high even when LDL looks acceptable.
- Lipoprotein(a) is an inherited, largely fixed risk marker that a standard panel does not capture. Worth measuring once.
- hs-CRP flags low-grade inflammation in the blood vessels.
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4
Checking whether damage has already occurred
Cholesterol tells you about risk. Imaging tells you what has already happened. A CT coronary calcium score detects calcified plaque in the heart’s arteries and is often the single most useful test for someone weighing up whether to treat. Where symptoms are present, a treadmill stress test or CT coronary angiogram may be appropriate.
Costs for individual tests and consultations are listed on the cardiology fees page.
What Happens Next
If Your Cholesterol Is High
A raised reading is not an emergency and not a verdict. It is information, arriving early enough to act on.
Lifestyle comes first, and it does work
For many people this is enough on its own. The changes that move cholesterol most:
- Cut saturated fat. Less fatty and processed meat, full-fat dairy, coconut milk, palm oil and deep-fried food. Replace rather than simply remove: unsaturated fats from fish, nuts and vegetable oils help.
- Eat more soluble fibre. Oats, beans, lentils, barley, fruit and vegetables bind cholesterol in the gut.
- Move regularly. Around 150 minutes of moderate activity a week raises HDL and lowers triglycerides. See how to build a stronger heart.
- Lose excess weight around the middle. A modest loss often shifts the numbers more than expected.
- Stop smoking. This is among the most effective single changes for your arteries, and it raises HDL.
- Reduce alcohol, particularly where triglycerides are the raised figure.
Medication is a conversation, not a default
Cholesterol-lowering medication is well established and, where it is warranted, it works. But it is not the automatic answer to a single raised number. Whether it is worthwhile for you depends on your overall cardiovascular risk: your level, your age, your blood pressure, whether you smoke, whether you have diabetes, your family history, and what any imaging shows. That is then weighed against what lifestyle change alone is realistically likely to achieve in your case.
Some people can bring their numbers down without medication and should be given a fair chance to. Others will not get there on diet and exercise alone, particularly those with an inherited cause or existing arterial disease, and delaying is not in their interest. That judgement is what a consultation is for.
Treat what sits alongside it
Cholesterol rarely travels alone. High blood pressure, raised blood sugar, excess weight and smoking compound each other, and addressing them together achieves considerably more than treating any one in isolation. This is also why a cholesterol result is best read as part of a broader assessment rather than as a standalone score.
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Common Questions
High Cholesterol FAQ
The questions people most often arrive with about cholesterol symptoms, testing and treatment.
Does high cholesterol have symptoms?
In most people, no. High cholesterol does not cause pain, and you cannot feel it circulating in your blood. It is detected with a blood test, not by how you feel. The exceptions are visible cholesterol deposits in the skin and eyes, which appear mainly when levels are very high or inherited, and the symptoms of damage that cholesterol has already caused to the arteries — such as chest tightness on exertion.
Can you feel high cholesterol?
No. There is no sensation associated with a raised cholesterol level itself. People often describe feeling tired, heavy or foggy and wonder whether cholesterol is the cause — it usually is not. The only reliable way to know your level is a blood test.
What is the first sign of high cholesterol?
For most people the first sign is a number on a blood test result, not a physical symptom. When there is a physical sign, it is most often a visible deposit — a soft yellowish patch on the eyelid (xanthelasma) or a pale ring around the edge of the coloured part of the eye (corneal arcus). In some people the first sign is unfortunately a heart attack or stroke, which is the reason screening exists.
What are the signs of high cholesterol around the eyes?
Two signs appear near the eyes. Xanthelasma are soft, flat, yellowish patches on or around the eyelids, usually near the inner corner. Corneal arcus is a pale grey or white ring around the outer edge of the iris. Neither is painful and neither affects vision. Corneal arcus is common and generally not significant over the age of about 50, but under 45 it is more likely to point to a genuinely raised level and is worth a blood test.
Does high cholesterol cause tiredness, headaches or dizziness?
There is no good evidence that raised cholesterol on its own causes tiredness, headaches or dizziness. These are common symptoms with many other explanations. They are still worth investigating — but through a proper assessment of what is actually causing them, rather than assuming cholesterol is responsible.
Are high cholesterol symptoms different in women and men?
The condition itself is silent in both. What differs is the pattern of risk. Cholesterol levels in women often rise after menopause as oestrogen falls, so a reading that was normal in the forties can change in the fifties. When cholesterol has already narrowed the arteries, women are somewhat more likely than men to experience symptoms as breathlessness, unusual fatigue, nausea or jaw and back discomfort rather than classic central chest pain.
Can young adults and slim people have high cholesterol?
Yes. Being slim, young or physically active does not rule it out. A significant proportion of cholesterol level is inherited rather than eaten, and familial hypercholesterolaemia is present from birth. If a parent or sibling had a heart attack or stroke at a young age, that is a reason to check your own level regardless of your build or age.
How do I know if I have high cholesterol?
A blood test called a lipid panel measures total cholesterol, LDL, HDL and triglycerides. It is a routine test, takes a few minutes, and is included in every heart screening package at the clinic. Many modern lipid panels no longer require fasting, though you may be asked to fast depending on what else is being measured at the same time.
What causes high cholesterol?
It is usually a combination of what you inherit and how you live. Contributors include a diet high in saturated fat, physical inactivity, excess weight around the middle, smoking and excessive alcohol. Type 2 diabetes, an underactive thyroid, and kidney or liver disease can raise it, as can some medications. Familial hypercholesterolaemia is a genetic cause that produces markedly high levels from a young age.
Is high cholesterol dangerous?
It is not dangerous in the moment — there is no crisis to react to on the day you are told. The risk accumulates over years, as cholesterol deposits narrow and stiffen the arteries supplying the heart, brain and legs. That process is what leads to heart attack, stroke and peripheral arterial disease. Because it develops slowly and silently, it is also one of the more modifiable cardiovascular risks once identified.
Can high cholesterol be reversed?
Cholesterol levels respond well to change. Diet, regular activity, weight loss, stopping smoking and reducing alcohol all lower it, and for many people that is sufficient. Where the level is driven largely by genetics, lifestyle alone may not bring it far enough down and medication is considered. Arterial narrowing that has already formed is not simply undone, but its progression can be slowed considerably.
Will I have to take medication for the rest of my life?
Not necessarily, and it is not a decision made from one number. Whether medication is worthwhile depends on your overall cardiovascular risk: your level, your age, blood pressure, whether you smoke, whether you have diabetes, and your family history. That is weighed against what lifestyle change alone is likely to achieve for you. It is a conversation to have at a consultation, with your own results in front of you.
How often should I check my cholesterol in Singapore?
For most healthy adults, every few years from around the age of 40 is a reasonable starting point. Check earlier and more often if you have a family history of early heart disease, diabetes, high blood pressure, if you smoke, or if a previous reading was raised. If you are already on treatment, your doctor will set the interval.
What is familial hypercholesterolaemia?
Familial hypercholesterolaemia is an inherited condition in which the body cannot clear LDL cholesterol from the blood efficiently, so levels are high from childhood. It is passed directly from parent to child, and it substantially raises the risk of early heart disease if untreated. Clues include very high readings and a strong family history of heart attack or stroke before the age of 60. Tendon thickening over the knuckles or Achilles tendon is another clue, but most people with FH never develop it, so its absence does not rule the condition out. It is worth identifying because it is treatable and because a diagnosis has implications for close relatives.
Which cholesterol test should I ask for?
A standard lipid panel is the right starting point for almost everyone. Where the picture is unclear, such as a strong family history alongside an unremarkable panel, or borderline numbers where the decision could go either way, additional markers like apolipoprotein B, lipoprotein(a) or hs-CRP can add useful information. A CT coronary calcium score answers a different question: whether deposits have already formed in the heart’s arteries.