Precision Medical Care Newsletter October 2025
Doctors Agarwal and Johnson representing Precision Medical Care at HerLongevity on World Menopause Day
From the desk of Dr Johnson
October was quite fulfilling with much networking at conferences while busy expanding our practice growth at the offices. Dr. Agarwal and I spoke at the inaugural HerLongevity conference in NYC on World Menopause Day, October 18th. We met many women’s health experts and had the chance to meet some of the people who are leading the movement in women’s health: Kayla Barnes (champion of the “millenopausal” health movement, Dr. Mary Claire Haver, Dr. Jessica Shepard, Dr. Heather Hirsch, Dr. Poonam Desai, Dr. Tara Scott, Dr. Cynthia Keller and so many other strong women advocates for women’s health who share our passion for longevity medicine. I was also at the Menopause Society Meeting last week in Orlando and thrilled to see that the Keynote address featured the importance of healthspan for women with an emphasis on advancing the practice of individualized and personalized care. For many years, I feel I have practiced proactive and personalized medicine in isolation as a clinical precisionist. These connections with fellow healthy longevity enthusiasts is truly expanding my personal healthspan. I feel invigorated and renewed to return to my offices and see the impact of proactive care on the health of our patients in the Precision Medical Community, thank you for the opportunity to learn with you and share the message of prevention. There has been quite a buzz on my phone when Dr. Peter Attia was speaking on 60 minutes about Medicine 3.0, too. HERE is the link for those who missed it.
Dr. Attia’s work has been in the spotlight and “trending,” but I can assure you that the mentors who have taught me precision medicine have been practicing for DECADES while highlighting the importance of tracking body composition data, laboratory data and performance in the context of lifestyle to optimize healthspan. Preventive and proactive health is not a trend, it is a science. Precision Medical Forecasting with targeted and proactive intervention changes our aging trajectory.
The data collected by Dr. Gordon when tracking mood changes in women during perimenopause!
The importance of differentiating longevity from healthspan while noting organ specific aging trajectories.
Annual Menopause Society 2025 Meeting: A few key takeaways
Mental stress ischemia is causal to risk of heart disease and stroke, these are validating advances in the study of women’s heart disease: Women’s heart disease is often micro vascular disease in women (compared to men who tend to have larger blood vessel atherosclerotic changes): INOCA is ISCHEMIA with NO Obstructive Coronary Arteries “the blood vessels are not acting as they should” coronary microvascular dysfunction occurs in 2/3 of women and 1/2 men with and no obstructive CAD and at least 50% have coronary microvascular dysfunction and contributes to functional disability. Stress (Cortisol) is increased which can cause increased blood pressure, increase heart rate and increase in blood sugar which can contribute to MENTAL STRESS ISCHEMIA which induces this microcirculatory coronary artery dysfunction. Women have inducible coronary ischemic changes with mental stress triggers and anger provocation… this is why it’s so important for healthy longevity to optimize our stress resilience, mental health and sleep.
White coat hypertension shouldn’t be minimized: trend and treat blood pressure to reduce cardiovascular disease risk with target treatment levels to achieve blood pressure of 120/80
Breast Cancer risk assessment is recommended for all women by age 25 with Tyrer Cuzic or Gail prediction tools Breast Cancer Risk Assessment Calculator - NCI. AI Risk Prediction tools with mammogram screenings are also very predictive: this is an example Clairity Breast - Clairity.
Our brain’s center for memory, emotion and our autonomic nervous system is the hippocampus. Research is showing us that the hippocampus is actually an endocrine organ, our hormones impact the health of this vital brain tissue.
Alcohol use and health: 5.4% of cancer cases in the US are attributable to alcohol and 4.1% of all deaths attributable to alcohol.
48% of women over age of 18 drank alcohol in last month, 19% report binge drinking (more than four drinks in two hours)
Overall, alcohol use is declining- especially noted in younger adults
9% drop 18-34 y/o
10% drop 25-54 y/o
5% drop 55 y/o
Alcohol is a carcinogen: especially to cancers of the mouth, throat, larynx esophagus, breast, liver colon and rectum
Alcohol and breast cancer: risk increase 9% for each 10g of alcohol consumed daily so risk of cancer is 14-20% increased for two drinks a day which creates an impact of an additional 2.5 cases of cancer per 100 women
The top three modifiable risks of cancer:
Cigarettes
Obesity
Alcohol
I will be sharing more insights from the Menopause Society meeting on a podcast with my friend Dr. Jila on her podcast "Her Time, Her Health".
From the desk of Dr. Agarwal: An Attitude of Gratitude
As autumn settles in and the season of gratitude begins, we’ve been reflecting on how fortunate we are at Precision Medical Care. Over the past few weeks, Dr. Johnson and I have had the opportunity to attend and represent PMC at incredible gatherings—from Vibrant Longevity to Menopalooza and most recently HERLongevity, each one reminding us why we do what we do.
We’re deeply grateful to spend our days talking about what we love, connecting with passionate clinicians from around the world, and working with patients who truly value proactive, personalized health. Every conversation, every shared story, every “aha” moment fuels our mission to bring the best of precision medicine back home to our PMC community.
Thank you for being part of this journey with us. Here’s to a season—and a mindset—of gratitude.
Elinzanetant FDA Approval Update
Announced at the Menopause Society meeting last week by many of the lead investigators and researchers who contribute to the research of these novel non-hormone therapies for treatment of Vasomotor Symptoms(hot flashes/night sweats) of menopause.
We are excited to share that the U.S. Food and Drug Administration (FDA) has approved a new medication, Lynkuet (elinzanetant), for the treatment of moderate to severe hot flashes and night sweats (also called vasomotor symptoms) related to menopause in adult women.
Elinzanetant is a non-hormonal, once-daily pill that can help reduce the number and severity of hot flashes and night sweats. In large clinical studies, women taking elinzanetant had fewer and less severe symptoms, often noticing improvement within the first week. Many also reported better sleep and improved quality of life. Most side effects were mild, such as headache or tiredness, and serious side effects were rare.
How is elinzanetant similar to Veozah (fezolinetant)?
Both Lynkuet (elinzanetant) and Veozah (fezolinetant) are non-hormonal medications approved by the FDA to treat moderate to severe hot flashes and night sweats due to menopause. They work by blocking certain signals in the brain (called neurokinin receptors) that are involved in causing these symptoms. Both are taken as a daily pill and have been shown to be effective and well-tolerated in clinical trials.
How is elinzanetant different from Veozah?
Mechanism: Veozah blocks one type of brain signal (the NK3 receptor), while Lynkuet blocks two (NK1 and NK3 receptors). This difference may help explain why some women experience additional benefits with Lynkuet, such as greater improvement in sleep quality.
Clinical effects: Some studies suggest elinzanetant may provide a slightly greater reduction in hot flash frequency and severity, and may be especially helpful for women whose symptoms disrupt sleep.
Side effects: Both medications are generally well-tolerated. Elinzanetant may have a lower risk of certain side effects, such as headache, compared to fezolinetant.
Who might benefit?
Elinzanetant and Veozah are good options for women who cannot or prefer not to use hormone therapy, or for those who have not found relief with other treatments. If you are experiencing bothersome hot flashes or night sweats, talk with your healthcare provider about whether one of these new medications may be right for you.
If you have any questions or would like to discuss your options, please contact our office.
Evolving role of biomarker testing for Alzheimer’s
Diagnostic Test Highlight: Coronary Artery Calcium screening
Up to 15% of zero scores might be concerning for false reassurance, especially in women.
Coronary artery calcium (CAC) scoring has changed the game for preventive cardiovascular care, giving clinicians a way to directly measure atherosclerosis burden and accurately estimate cardiovascular risk. With this technique, a simple, non-invasive CT scan produces a number that correlates tightly with risk of future major adverse cardiovascular events (MACE), helping to guide treatment decisions. The catch is that CAC only measures what it can see—calcification—leaving non-calcified, high-risk plaque invisible. This blind spot is especially problematic in women.
CAC scores 101
Long before it can be detected with CAC scoring, atherosclerosis is progressing in blood vessels. The process begins with the accumulation of apoB lipid particles in the artery wall, where they become oxidized and trigger an immune reaction. White blood cells rush in, engulf the lipids, and turn into “foam cells.” As inflammation and remodeling continue, these fatty streaks evolve into more complex lesions called plaques. Some plaques remain soft and lipid-rich, while others become more fibrous (tissue that is more scar-like). With time, they begin to calcify—the stage quantified with CAC scoring.
This calcification is quantified using non-contrast CT. Each calcified lesion in the coronary arteries is identified and scored based on its area and density. These values are then summed to create the Agatston score (named after Arthur Agatston, a cardiologist who, along with Warren Janowitiz, described the method in 1990). Scores are typically grouped into categories (0, 1–99, 100–399, ≥400) that track with increasing risk. In general, the higher the score, the greater the atherosclerotic burden, and the more compelling the case for aggressive therapy, such as with statins or other lipid-lowering medications, to prevent MACE.
But there’s an important problem with this system: it is actually the non-calcified plaques that are most likely to destabilize and rupture or erode, triggering heart attacks and strokes. Calcification is the body’s attempt at healingthe lesion. Laying down calcium stabilizes the plaque, thus reducing the likelihood of one of these rupture events. In fact, one of the mechanisms by which statins reduce cardiovascular risk is through calcification of the more vulnerable, non-calcified plaques. So while CAC is invaluable for quantifying calcified plaque, this measurement doesn’t capture the highest-risk plaque and is therefore only capturing the tip of the iceberg when it comes to cardiovascular risk. The bulk of the threat—the non-calcified, unstable plaque—remains unseen, and the impact of this oversight is not uniform across individuals.
Implications are more concerning in women
The inability of CAC scoring to capture non-calcified plaque is especially problematic in women, particularly in their pre- and perimenopausal years. During this period of a woman’s life, non-calcified plaques predominate, with calcification tending to appear about a decade later in women than in men.1 The sex difference in prevalence of calcium deposits is exemplified in the Multi-Ethnic Study of Atherosclerosis (MESA), in which 62% of women had a CAC of zero compared with 40% of men. As a result of these differences in calcification rates, men are more likely to have detectable calcium by midlife, while women often carry lipid-rich, non-calcified plaques through their 40s and 50s. The catch-up in calcification usually comes after menopause—creating a diagnostic blind spot during midlife, when risk may be rising but CAC still reads zero.
Pathology and imaging studies confirm these sex differences. Women are more likely to experience plaque erosion—a disruption of the endothelial surface over a non-calcified plaque—while men more often present with plaque rupture in lesions with fibrous caps and some calcium.3 Both mechanisms can trigger MACE, but only rupture reliably shows up on CAC. And when advanced imaging is used, the disparity is striking: high-risk plaque features predict events in both sexes but do so far more strongly in women (odds ratio 34.5 in women vs. 4.1 in men).4 In short, the plaques most likely to harm women are the very ones CAC cannot see.
Importantly, none of this means CAC is completely irrelevant in women. Once calcification is present, risk rises with CAC score just as it does in men. In fact, these scores may be even more indicative of risk in women: data from the CAC Consortium show that among people with detectable calcium, women are 30% more likely to die a cardiovascular-related death compared to men.1 In other words, CAC is still predictive in women—it just underestimates risk early in the disease process, when non-calcified plaque predominates.
This lag in calcium presentation in women creates the potential for missed prevention. Take a 52-year-old man with a CAC score of 72 and his 50-year-old wife with several high-risk non-calcified plaques. If we were to base intervention strategies only on CAC score, the man’s CAC score would provide a clear signal to start aggressive lipid-lowering therapy. His wife, on the other hand, would leave with a score of zero and the impression that everything is fine. By the time she’s 60, her scan finally lights up—but she’s had ten years of missed preventive opportunity.
So how can we close this gap?
Clinical implications
Realistically, the clinical implications of CAC are the same in men and women. A high score is bad news in both sexes, and a low or zero score can be reassuring only if the rest of the risk profile is clean. In either sex, if other major risk factors are present—high apoB, hypertension, diabetes, or smoking—they warrant intervention, regardless of what the calcium scan shows. Having a CAC test does not reduce the importance of monitoring other risk factors, and a CAC score of zero should never overrule obvious risk apparent in those other metrics.
When uncertainty remains, especially in women with intermediate risk and a low appetite for pharmacologic intervention, additional imaging can help contextualize risk. Coronary CT angiography (CCTA) is a more sensitive test that can reveal non-calcified plaque and provide a more complete picture of disease, though it comes with trade-offs: the use of contrast dyes, higher radiation exposure than CAC, and limited value in low-risk patients. But for carefully selected patients, those trade-offs may be justified and worth discussing.
The bottom line
CAC is a great tool for quantifying coronary plaque burden and refining cardiovascular risk. In both men and women, higher scores predict higher risk. The difference lies at the low end of the scale. In men, a CAC of zero combined with low risk factors usually signals a truly low short-term risk. But in women, especially before menopause, the same score could be misleading. Non-calcified plaque may still be present, carrying risk that the scan cannot show.
The clinical rules are the same: treat risk factors aggressively when they are present, regardless of what the scan says. A zero score should be taken as reassurance only if the rest of the profile is clean, not as a pass to ignore risk.
Podcast Recommendations & Noteworthy News Articles
How low is too low for cholesterol levels?
https://www.sciencedirect.com/science/article/pii/S1050173825000945
Ovarian aging
Ovarian aging
https://www.ucsf.edu/news/2025/10/430841/why-does-female-fertility-decline-so-fast-key-ovary
TRT podcast
https://podcasts.apple.com/us/podcast/the-dr-gabrielle-lyon-show/id1622316426
Dr. Johnson's Naples Dates
November 1st-November 3rd
January 6-January 20
February 2-February 10
*More dates to come for 2026*