Friday Q&A: starting a statin; improving balance; cardiac calcium scan necessity; & side effects of osteoporosis drugs
Keep your questions coming!
ICYMI 👉
🙋🏻♀️ Programming note: My live show is moving to TUESDAYS at 5 pm ET. I hope to see you there!
💊 Join me Tuesday 6/10 at 5 pm ET for a live conversation about GUT HEALTH—right here. Bring your questions about IBS (irritable bowel syndrome), GERD (reflux), and any gastrointestinal woes you might have.
In this week’s reader-submitted Q&A, we’re tackling these questions:
Should I start a statin if I feel healthy but have mild plaque buildup?
Can I see a physical therapist for balance issues before I actually fall?
Do I need a cardiac calcium scan if my cholesterol is normal?
Are osteoporosis drug side effects more common than reported?
📣 Send me your questions for future Q&As! Click here to write me. ✍️
The following subscriber questions have been lightly edited for length and clarity.
QUESTION #1: STARTING A STATIN
I’m 62 and had a CAC scan that showed mild plaque buildup. My doctor says it’s “not urgent” but recommended a statin. I eat well, exercise, and feel great otherwise. How do you help patients weigh the risks and benefits of starting medication when they feel perfectly healthy?
-Tom
Hi Tom,
You're asking exactly the right question, and it's one I navigate with patients regularly. Your hesitation makes sense when there’s a gap between feeling great and being told you need medication.
Here's what I tell patients in your situation: feeling healthy and being at cardiovascular risk aren't mutually exclusive. Heart disease is often called the "silent killer" precisely because plaque builds up for decades without symptoms. Your CAC scan has given us a window into what's happening beneath the surface—and mild plaque at 62 is your body's way of saying “pay attention now."
The statin conversation isn't just about lowering cholesterol numbers. These medications have two important functions: they reduce future plaque formation and help stabilize existing plaque, making it less likely to rupture and cause a heart attack. Think of it as both prevention and damage control.
When I help patients make this decision, we look at the complete picture. What's your 10-year cardiovascular risk percentage? Do you have other risk factors like diabetes, high blood pressure, or strong family history? How do you feel about taking daily medication for prevention versus close monitoring with lifestyle optimization?
Some patients in your position choose to double down on lifestyle measures first—a thoughtful diet, regular exercise, stress management, good sleep—and recheck their risk factors in six months. Others feel more comfortable with the added protection a statin may provide.
The key is that this decision should align with your values and risk tolerance. Some people sleep better knowing they're on proven preventive medication. Others prefer avoiding pharmaceuticals unless absolutely necessary. Neither approach is wrong—but both require honest assessment of your actual risk, not just how you feel today.
Does that help?
QUESTION #2: IMPROVING BALANCE
I’ve always been active, but my balance feels off lately. I haven’t fallen, but I’m worried about the future. Should I see a physical therapist even if I haven’t had an injury?
-June
Dear June,
First, I love your name. Second, you don't need to wait for a fall to address balance concerns—in fact, you shouldn't. What you're describing is exactly the kind of proactive health approach I encourage patients to take with their physical infrastructure.
Balance issues rarely announce themselves with a dramatic event. They're usually subtle shifts that we notice in moments like yours—reaching for something and feeling unsteady, or that slight hesitation when walking on uneven ground. Your body is sending you valuable information, and listening to it now could prevent a serious injury later.
Falls are one of the leading causes of injury in adults over 50, but here's what many people don't realize: most falls aren't random accidents. They're often the result of gradual changes in strength, flexibility, coordination, and proprioception—your body's awareness of where it is in space. The good news? These changes are largely preventable and often reversible with the right interventions.
A physical therapist can assess your balance, identify specific areas of weakness or restriction, and design a targeted program to address them. They might find that your core stability needs work, your ankle mobility is limited, or your hip strength has declined. Sometimes it's as simple as retraining your nervous system to react more quickly to perturbations.
Balance training isn't just about preventing falls—it can improve your confidence in movement, enhance your athletic performance, and help you maintain independence as you age. Think of it as preventive maintenance for your body, like getting your car serviced before it breaks down.
Don't wait for your next physical or annual check-up to address this. Call your doctor and ask for a physical therapy referral for balance assessment and fall prevention. Many insurance plans cover preventive PT visits, especially with a physician's referral citing balance concerns.
Your instinct is spot-on. Taking action now, while you feel strong and capable, is exactly the kind of health agency that serves you well over the long term.
QUESTION #3: CAC NECESSITY
My doctor recommended a cardiac calcium scan because I have a family history of heart disease, but my cholesterol is pretty normal. What exactly does this test show—and do I really need it if I feel fine?
-Andrew
Thanks for this, Andrew,
This test could be a game-changer for your heart health strategy. A cardiac calcium scan—also known as a coronary artery calcium (CAC) scan—can reveal information that cholesterol numbers alone simply can't provide. It's like getting a peek under the hood when your dashboard lights all look normal.
Here's what the scan actually shows: calcium deposits in your coronary arteries, which indicate atherosclerotic plaque buildup. Think of it as measuring the actual "rust" in your pipes rather than just checking the quality of what's flowing through them. You can have normal cholesterol levels and still have significant plaque accumulation, especially with a strong family history like yours.
The scan gives you a calcium score. A score of zero means no detectable plaque (great news). Higher scores indicate increasing amounts of plaque, which correlates with higher cardiovascular risk. This information can completely change your treatment approach—and it's information you can't get from blood tests alone.
I've had patients with "perfect" cholesterol who had significant calcium scores, prompting us to start medications they otherwise wouldn't have needed. I've also had patients with borderline cholesterol numbers who had zero calcium, allowing us to focus on lifestyle measures rather than jumping to medication.
The "I feel fine" part is exactly why this test matters. Heart disease is often silent until it's not. By the time you have symptoms, significant damage may have already occurred. This scan helps us catch problems in the preventable stage.
That said, the test isn't right for everyone. If you're already on maximum heart-protective therapy or if the results wouldn't change your treatment plan, it might not be worth it. But given your family history and presumably good overall health, this could provide valuable information to guide your preventive care strategy.
The scan takes about 10 minutes, involves minimal radiation, and costs around $100-300. For many patients with your profile, it can be money well spent for peace of mind—and/or actionable information.
QUESTION #4: SIDE EFFECTS OF OSTEOPOROSIS DRUGS
I wonder if the side effects of the osteoporosis drugs are under-reported. I personally know and know of several women who suffered from severe side effects; one mentioned a full waiting room of women seeing a physician for treatment due to severe side effects. Have you seen this in your office?
-Marianne
Marianne,
I hear this concern regularly, and your observations are worth taking seriously. The disconnect between what we see in clinical trials and what patients experience in real life is a legitimate issue across many medications—osteoporosis drugs included.
These medications can cause a range of side effects, from relatively common gastrointestinal issues like heartburn, esophageal irritation, and nausea, to more serious but rare complications that can be genuinely life-altering when they occur. The challenge is that clinical trials don't always capture the full picture of how medications affect people in real-world settings over longer periods.
My concern is that osteoporosis medications are often prescribed reflexively, without adequate discussion of individual risk factors. Too often, women get a DEXA scan showing osteopenia or osteoporosis and are quickly told they need medication—without adequate discussion of their individual fracture risk, lifestyle factors, or alternative approaches.
The truth is, not everyone with low bone density needs medication. A 55-year-old woman with mild osteopenia and no other risk factors has very different needs than a 75-year-old with severe osteoporosis and a history of falls.
Before starting any osteoporosis medication, I encourage patients to ask: What's my actual 10-year fracture risk? Have we optimized calcium, vitamin D, weight-bearing exercise, and fall prevention? Are there other underlying causes of bone loss we should address first?
This comes down to risk tolerance and individual circumstances. Some women prefer the bone protection these medications can provide, even with potential side effects. Others feel more comfortable trying lifestyle approaches first, especially if their fracture risk isn't extremely high.
Your instinct to question and investigate is exactly right. Side effects that seem rare in studies can feel very common when you're hearing about them from friends and seeing full waiting rooms of affected patients. That anecdotal evidence deserves to be part of the conversation.
Disclaimer: The views expressed here are entirely my own. They are not a substitute for advice from your personal physician.
ICYMI, check out my recent Q&As on:
Excellent post!
An especially helpful column as I prepare for my annual wellness exam, and three of the four issues discussed today relate to me and my questions.