Given a BMI of 31, a history of gastric sleeve surgery, three years of semaglutide therapy, polycystic ovary syndrome (PCOS), idiopathic intracranial hypertension (IIH), and hypothyroidism with mostly normal lipid levels post‑surgery, am I taking sufficient measures to reduce my risk of myocardial infarction and stroke?

You are doing a lot, but critical gaps remain

You should add a statin for primary cardiovascular prevention, ensure optimal blood pressure control, and continue semaglutide indefinitely—your current regimen addresses weight but incompletely mitigates your elevated stroke and MI risk from PCOS, IIH, and residual obesity.

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Your Current Risk Profile

You have multiple cardiovascular risk enhancers that standard risk calculators underestimate:

• PCOS: Doubles your risk of stroke and coronary events (RR 2.02) independent of BMI 1. This risk persists even after weight loss 2.
• IIH: Strongly associated with obesity and metabolic syndrome; emerging data show semaglutide improves IIH outcomes 3, but the underlying vascular inflammation remains.
• Hypothyroidism: If inadequately treated, contributes to dyslipidemia and endothelial dysfunction 4.
• BMI 31: Despite surgery and semaglutide, you remain in Class I obesity—still conferring 10% increased stroke risk per 5-unit BMI increase 5.

Your lipids being "mostly ok" is insufficient. Women with PCOS have disproportionately elevated small-dense LDL and low HDL even when total cholesterol appears normal 6. Guidelines mandate fasting lipid panels at PCOS diagnosis and treatment targeting LDL <100 mg/dL (ideally <70 mg/dL given your risk enhancers) 4, 6.

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What You're Doing Right

1. Gastric sleeve + semaglutide continuation: Bariatric surgery reduces cardiovascular mortality (HR 0.47 for CV death) 4, and semaglutide 2.4 mg weekly reduces major adverse cardiovascular events by 20% in obesity without diabetes (HR 0.80) 7. Your 3-year adherence is excellent—do not stop semaglutide 8, 9.

2. Weight loss trajectory: If you achieved ≥10% weight loss post-surgery, you've improved insulin resistance, blood pressure, and hepatic steatosis 10. Semaglutide likely restored ovulatory cycles (80% rate in PCOS) 11, 12, reducing hyperandrogenism-driven vascular inflammation.

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Critical Gaps to Address Immediately

1. Lipid Management: You Need a Statin

• Guideline mandate: All women with PCOS require lipid screening and treatment if LDL >70 mg/dL 4. Your "mostly ok" lipids likely mean LDL 100–130 mg/dL—this is too high for someone with PCOS + obesity + IIH.
• Action: Start atorvastatin 20–40 mg daily or rosuvastatin 10–20 mg daily. Target LDL <70 mg/dL (<1.8 mmol/L) 13. Statins reduce stroke risk by 21% per 1 mmol/L LDL reduction and have anti-inflammatory effects beyond lipid lowering 8.
• Pitfall: Do not rely on "normal" total cholesterol—PCOS patients have atherogenic dyslipidemia (high triglycerides, low HDL, small-dense LDL) that statins specifically address 6.

2. Blood Pressure: Verify Optimal Control

• Target: <130/80 mmHg (ideally <120/70 mmHg if tolerated) 14. IIH and obesity both drive hypertension; even "high-normal" BP (120–139/80–89 mmHg) increases lifetime stroke risk by 27–36% 15.
• Action: If BP >130/80 mmHg, add an ACE inhibitor (e.g., lisinopril 10–20 mg daily) or ARB (e.g., losartan 50–100 mg daily). These reduce cardiovascular events in high-risk women and have renoprotective effects 14.

3. Hypothyroidism: Confirm Adequate Replacement

• Target: TSH 0.5–2.5 mIU/L (not just "within normal range"). Subclinical hypothyroidism (TSH >2.5 mIU/L) worsens LDL and endothelial function 4.
• Action: Check TSH and free T4 annually. Adjust levothyroxine to achieve TSH <2.5 mIU/L.

4. Diabetes Screening: PCOS Demands Vigilance

• Guideline: Oral glucose tolerance test (OGTT) every 3–5 years in PCOS, not just fasting glucose or HbA1c 6. Impaired glucose tolerance (IGT) predicts cardiovascular events in women more strongly than in men 6.
• Action: If you haven't had an OGTT recently, request one. If IGT is present, intensify lifestyle measures and consider metformin 1500–2000 mg daily (reduces progression to diabetes by 31% in PCOS) 10.

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Additional Considerations

Aspirin for Primary Prevention?

• Not routinely recommended unless you have diabetes or 10-year ASCVD risk >10% 13. Calculate your risk using the Pooled Cohort Equations 15—if >7.5%, discuss low-dose aspirin (75–100 mg daily) with your physician.

Bariatric Surgery Follow-Up

• Reassess lipids 1–3 months post-surgery and when weight stabilizes 4. Sleeve gastrectomy improves triglycerides and HDL but has less effect on LDL than Roux-en-Y gastric bypass 4. If LDL remains elevated, this reinforces the need for statin therapy.

IIH-Specific Monitoring

• Semaglutide reduces IIH symptoms (papilledema, headache, visual disturbances) by 40–70% at 3–24 months 3. Continue therapy and monitor for symptom recurrence—weight regain would worsen IIH and cardiovascular risk.

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What You Should NOT Do

• Do not stop semaglutide after achieving weight loss. GLP-1 receptor agonists provide cardiovascular protection independent of weight reduction 8, 7.
• Do not assume "normal" lipids mean low risk. PCOS-related dyslipidemia requires targeted treatment even when total cholesterol is <200 mg/dL 4, 6.
• Do not delay statin initiation. Women with PCOS have subclinical atherosclerosis (increased carotid intima-media thickness, coronary calcification) detectable in their 30s–40s 6.

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Summary Algorithm

1. Obtain fasting lipid panel (total cholesterol, LDL, HDL, triglycerides) and OGTT if not done in past 3 years.
2. Start statin if LDL >70 mg/dL. Target LDL <70 mg/dL.
3. Verify BP <130/80 mmHg. Add ACE-I/ARB if elevated.
4. Check TSH/free T4. Adjust levothyroxine to TSH <2.5 mIU/L.
5. Continue semaglutide indefinitely (or switch to higher dose if weight plateaus).
6. Rescreen lipids, BP, glucose annually. Repeat OGTT every 3–5 years.

Your proactive approach is commendable, but adding a statin and optimizing BP/thyroid control are non-negotiable next steps to match the cardiovascular risk reduction you've achieved through surgery and semaglutide.