Low HDL Cholesterol: Symptoms, Causes, and What the Result Means

Low HDL cholesterol usually causes no symptoms. Learn the thresholds for men and women, common causes, and how a low result fits with LDL, ApoB, and triglycerides.

Published

September 29, 2026

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7 min read

Medically reviewed by

Rhonda Collins, FNP-C

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Low HDL cholesterol means an HDL result below 40 mg/dL for men or below 50 mg/dL for women, the cutoffs used by MedlinePlus, the MSD Manual, and the metabolic syndrome criteria. Low HDL itself usually causes no symptoms. You cannot feel the number. What people notice, if anything, are the conditions it tends to travel with, such as insulin resistance, high triglycerides, excess weight, or established heart disease. That is why low HDL is almost always found on a routine lipid panel.

The HDL cholesterol biomarker overview explains what HDL is and how it is measured. This page covers what a low result means and what usually sits behind it.

What Counts as Low HDL

HDL thresholds differ by sex because women tend to run higher HDL than men.

The adult cutoffs come from MedlinePlus and the MSD Manual. The same 40 and 50 mg/dL values are one of the five criteria for metabolic syndrome in the AHA and NHLBI statement. Some labs report HDL in mmol/L, where 40 mg/dL is about 1.0 mmol/L and 50 mg/dL is about 1.3 mmol/L.

Does Low HDL Cause Symptoms?

No. Low HDL does not produce fatigue, pain, or any other sensation at the levels most people have. MedlinePlus describes no symptoms of low HDL, and it is found on a blood test rather than by how you feel.

When symptoms appear in someone with low HDL, they come from a related condition rather than the HDL number:

• Heart and blood vessel disease. Chest pressure on exertion that eases with rest, or calf pain while walking, can be signs of atherosclerosis. These need prompt medical evaluation on their own terms.
• Insulin resistance and type 2 diabetes. Increased thirst, frequent urination, or darkened skin folds can point to blood sugar problems that often lower HDL.
• Very high triglycerides. Severe elevations raise the risk of pancreatitis. See high triglyceride symptoms.

Rare inherited HDL deficiencies are the exception. Tangier disease, for example, can cause enlarged orange tonsils and nerve problems, according to MedlinePlus Genetics. HDL in that condition is below 5 mg/dL, far lower than a typical low result.

Common Causes of Low HDL

Most low HDL results reflect metabolic health, habits, medicines, or inheritance rather than a single disease.

• Insulin resistance and metabolic syndrome. Low HDL is one of the defining features of metabolic syndrome, alongside high triglycerides, a large waist, raised blood pressure, and raised fasting glucose. Diabetes also lowers HDL.
• High triglycerides. Low HDL and high triglycerides often appear together, because the same metabolic shift that raises triglyceride-rich particles lowers HDL.
• Smoking. Cigarette smoking and secondhand smoke are listed causes of low HDL.
• Physical inactivity and excess weight. Both are associated with lower HDL.
• Genetics. Some people inherit lower HDL. Rare conditions such as familial apo A-I deficiency, LCAT deficiency, and Tangier disease cause very low HDL, in the MSD Manual’s reported ranges from under 5 to 30 mg/dL.
• Medicines. The MSD Manual lists anabolic steroids, beta-blockers, thiazide diuretics, progestins, retinoids, glucocorticoids, cyclosporine, tacrolimus, and some HIV antiretrovirals. MedlinePlus also lists benzodiazepines. An HDL result on its own is not a reason to stop a prescribed medicine.
• Other conditions. HIV infection and nephrotic syndrome can lower HDL.

How Low HDL Fits With LDL, ApoB, and Triglycerides

Low HDL is a marker, not usually the main target. In population studies, lower HDL is associated with higher heart disease risk. Trials that raised HDL with medicines did not show the same benefit:

• Adding niacin to statin therapy raised HDL but did not reduce cardiovascular events in the AIM-HIGH and HPS2-THRIVE trials.
• CETP inhibitors raised HDL substantially. Torcetrapib increased deaths and cardiovascular events, and dalcetrapib and evacetrapib did not reduce events.
• A 2012 mendelian randomisation study found that gene variants raising HDL alone were not linked to lower heart attack risk.

That is why the 2018 AHA/ACC cholesterol guideline centers treatment on LDL cholesterol and overall risk rather than on raising HDL. It is also why the HDL biomarker page treats ApoB as the stronger risk signal. ApoB counts every particle that can enter the artery wall, while HDL describes a different kind of particle.

Low HDL still carries useful information in context:

• With high triglycerides, it suggests an insulin-resistant pattern. The HDL vs triglycerides comparison explains how the two move together.
• As a TG/HDL ratio, it has been studied as a marker of insulin resistance. In overweight adults, a triglyceride to HDL ratio of 3.0 or higher (in mg/dL) identified insulin resistance in one 2003 study. See HDL vs TG/HDL ratio and the TG/HDL ratio biomarker.
• With normal LDL, low HDL can hide residual risk, because LDL cholesterol can look fine while particle number is high. ApoB measures that particle number directly.

When to Follow Up

Review a low HDL result with your clinician alongside the rest of your lipid panel, blood sugar, blood pressure, and family history. It is worth a closer look when:

• HDL is low together with high triglycerides, a large waist, raised blood pressure, or raised glucose, which together can meet the definition of metabolic syndrome;
• LDL or non-HDL cholesterol is also high, or you have a family history of early heart disease;
• HDL is very low, for example under 20 to 25 mg/dL. That range is uncommon from lifestyle alone and overlaps the inherited HDL deficiencies, so a clinician will usually look for anabolic steroid use, other medicines, kidney disease, or a genetic cause.

A standard lipid panel measures HDL, LDL, triglycerides, and total cholesterol, so it shows whether low HDL is part of a wider pattern. When LDL looks normal but other risk factors are present, an ApoB test adds particle count. Current pricing is on the lipid panel cost guide.

For the lifestyle factors associated with higher HDL, see how to improve your HDL cholesterol naturally.

Frequently Asked Questions

What if my HDL is 35?

An HDL of 35 mg/dL is below the low cutoff for both men (40) and women (50). It is not an emergency and causes no symptoms. It is a prompt to look at the rest of the panel: triglycerides, LDL or ApoB, fasting glucose or HbA1c, blood pressure, and waist size. Low HDL alongside high triglycerides points toward insulin resistance. A single result can also vary, so a repeat test may be reasonable.

Is low HDL worse than high LDL?

They answer different questions. High LDL and high ApoB reflect the particles that build plaque, and lowering them is the main goal in the 2018 AHA/ACC guideline. Low HDL is a marker of risk and often of metabolic health, but raising HDL with medicines has not been shown to reduce heart attacks.

Can you have low HDL and still be healthy?

Yes. Some people inherit lower HDL and have normal triglycerides, ApoB, blood sugar, and blood pressure. In that case the low HDL means less on its own. The full picture matters more than one number.

Does low HDL cause tiredness or chest pain?

No. Low HDL does not cause tiredness, chest pain, or any other symptom. Chest pain on exertion or persistent fatigue needs evaluation for its own cause, whatever your HDL is.

Why is HDL low but triglycerides high?

Insulin resistance is the usual common driver. The AHA and NHLBI metabolic syndrome statement describes high triglycerides and low HDL as parts of the same lipid pattern, so the two often move in opposite directions together. Smoking, inactivity, and excess weight can push both the same way.

References

• MedlinePlus: HDL, the “good” cholesterol
• MedlinePlus Genetics: Tangier disease
• MSD Manual Professional: Dyslipidemia
• Grundy SM, et al. Diagnosis and management of the metabolic syndrome. Circulation. 2005
• Grundy SM, et al. 2018 AHA/ACC guideline on the management of blood cholesterol. Circulation. 2019
• AIM-HIGH Investigators. Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. N Engl J Med. 2011
• HPS2-THRIVE Collaborative Group. Effects of extended-release niacin with laropiprant in high-risk patients. N Engl J Med. 2014
• Barter PJ, et al. Effects of torcetrapib in patients at high risk for coronary events. N Engl J Med. 2007
• Schwartz GG, et al. Effects of dalcetrapib in patients with a recent acute coronary syndrome. N Engl J Med. 2012
• Lincoff AM, et al. Evacetrapib and cardiovascular outcomes in high-risk vascular disease. N Engl J Med. 2017
• Voight BF, et al. Plasma HDL cholesterol and risk of myocardial infarction: a mendelian randomisation study. Lancet. 2012
• McLaughlin T, et al. Use of metabolic markers to identify overweight individuals who are insulin resistant. Ann Intern Med. 2003

Related Resources

• HDL cholesterol biomarker overview
• How to improve your HDL cholesterol naturally
• HDL vs triglycerides
• HDL vs TG/HDL ratio
• Understanding HDL for heart health and longevity
• High triglyceride symptoms
• High LDL symptoms
• Lipid panel cost guide

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