Metformin: basic information

Many PCOS patients are prescribed Metformin for the treatment of their condition. It can be a bit confusing, because it is only FDA approved for treatment of diabetes; however, there are a lot of good reasons for using this drug to treat PCOS. Here’s a general overview of some things you should know.

How It Works
Metformin improves your body’s sensitivity to insulin. If you read my post about insulin resistance, you’ll remember that an insulin resistant person produces a lot of insulin, and her body is not very good at recognizing and using it to control blood sugar. Metformin improves the body’s ability to do this; it resensitizes the cells to insulin, so that your body doesn’t have to produce as much.

What It Does
From your perspective, you might see the following results from Metformin:
* Lower risk of developing diabetes.
* Easier weight loss (this varies from woman to woman, but many feel that Metformin makes it easier to drop pounds).
* Drop in testosterone production–this is directly related to the drop in insulin production. This can also mean less hirsutism, acne, and hair loss.
* Improved menstrual cycle regularity. Many women on Metformin have more consistent or frequent cycles. That is why it is often prescribed for women who are trying to get pregnant. (I took Met when I was trying to conceive my second child, and it did regulate my cycle very well.)
* Reduced risk of miscarriage. This is why many reproductive endocrinologists recommend that PCOS patients continue to take Metformin through the 12th week of pregnancy or later.

Side Effects
Metformin can have some major side effects for some women. These include GI symptoms (nausea, diarrhea), which can be bothersome, but not usually dangerous, at least in the short term (see below for suggestions on minimizing these problems). However, Metformin is also associated with liver and kidney problems; usually, this won’t be an issue for you unless you have a liver or kidney function problem already.

Metformin can also cause (or contribute to) a problem called lactic acidosis. This is rare (3 in 100,000 Metformin users), but it is a serious problem, so you should be aware of the symptoms: weakness, slow pulse, muscle pain, deeper and more labored breathing, and sleepiness. This is more common if you have liver/kidney problems, dehydration, diabetes, or a great deal of chronic stress. It is very important that you NOT take Metformin while fasting (for example, before a medical procedure) or if you are dehydrated, for this reason.

How to Minimize Side Effects
If you do have unpleasant GI symptoms while taking this medicine, there are a few things you can do to try to make them less severe. Make sure that you eat when you take your medication; break up your dose over the course of the day; and, at least at first, avoid very fibrous foods such as salads. Some people also find that the name brand (Glucophage) causes them fewer side effects.

The Bottom Line
Should you take Metformin? That’s a question you’ll want to discuss with your doctor. It’s worth considering, though, if you have many symptoms of insulin resistance. The side effects (which, by the way, I never experienced) are manageable for most people who use it, and it may be protective against diabetes over the long term.

insulin resistance: how to be tested and what to do if you have it

If you suspect that you have insulin resistance (and if you have PCOS, carry extra weight around your midsection, acanthosis nigricans (darkening of some parts of the skin, such as the neck or underarms), and/or high blood pressure, it is likely that you do), you may want to ask your doctor about testing for the condition.

Personally, I think that it isn’t always necessary, because the best treatment is lifestyle change to more healthful eating and exercise, and those are good for you anyway–but especially if you’re considering medication, you may want to have the lab work done.

Here are the things that your doctor might do in order to make or rule out a diagnosis of IR. What these lab values really measure is whether you are pre-diabetic; there is no formal diagnosis of IR to be made by these tests, as far as I know.

The Lab Tests
Since the hyperinsulinemic euglycemic clamp, the most accurate test for IR, is not a test that’s readily available, most doctors order either a glucose tolerance test or a fasting glucose test. The GTT–which will be familiar to most women who have had a pregnancy–is a fairly unpleasant test, though it’s not painful. The patient fasts for at least 8 hours (usually this is scheduled for the morning, so that you would fast overnight).

When you arrive at the lab, you’re given a sugary drink and then you wait; blood draws are conducted over the next two hours to see how your blood sugar responds to the sweet drink. It’s unpleasant because a) the drink is vile and b) most people don’t feel spectacular when they get a shot of sugar and nothing else for breakfast. After two hours, a glycemia of greater than 7.8 mmol/dl (140 mg/dl) indicates impaired glucose tolerance (a.k.a. pre-diabetes) or diabetes.

If your doctor prefers to order the fasting glucose test, you just go in the morning or after at least 8 hours of fasting, and the lab draws blood to measure the glycemia. Fasting glucose levels above 100 mg/dL indicate a problem; over 125 indicates diabetes. Most doctors seem to prefer the GTT, though.

Other Methods of Diagnosis

A lot of patients prefer to take a single lab test–it seems so cut and dried–but for insulin resistance, as with PCOS, the history of the patient is the best diagnostic tool. As the National Diabetes Information Clearinghouse says, any three of these symptoms indicates insulin resistance (also called metabolic syndrome or Syndrome X):

* waist measurement of 40 inches or more for men and 35 inches or more for women
* triglyceride levels of 150 milligrams per deciliter (mg/dL) or above, or taking medication for elevated triglyceride levels
* HDL, or “good,” cholesterol level below 40 mg/dL for men and below 50 mg/dL for women, or taking medication for low HDL levels
* blood pressure levels of 130/85 or above, or taking medication for elevated blood pressure levels
* fasting blood glucose levels of 100 mg/dL or above, or taking medication for elevated blood glucose levels

As you can see, getting your blood lipid panel done can give you diagnostic info, as can knowing your blood pressure.

The Bottom Line: Healthy Habits Are the Best Treatment
The main thing is, if you are in doubt, do something about it. Improve your diet. Squeeze in some exercise. Insulin resistance can not only be treated–it can be reversed. Weight loss doesn’t have to be dramatic to show major improvements, either: the Diabetes Prevention Program, a major study of diabetes treatments and outcomes, showed that a loss of only 5-7% of your body weight can improve your chances of staying diabetes-free by a whopping 60%. (For perspective, if you weigh 200 pounds, that’s a loss of 10-14 pounds–no one is suggesting you have to be a size 2!)

Other Treatments
In addition to making changes to your lifestyle, you may want to consider medications that can help prevent diabetes. The most commonly prescribed one of these, for PCOS sufferers, is Metformin. You can talk to your doctor about the advantages and disadvantages of Met. I will also be posting a discussion of its merits and problems here on the blog soon!

insulin resistance: basic overview

If you have PCOS, you have probably read about insulin resistance (or IR). Maybe your doctor has talked to you about it. Or maybe you keep seeing books out there with titles like The Insulin Resistance Diet or Syndrome X: The Complete Nutritional Program to Prevent and Reverse Insulin Resistance.

Most women with PCOS have a basic idea of what IR is. It means that your body is not as good as it should be at using insulin to control glucose levels, so you have to make more insulin than you should really need; eventually, it’s too much for your pancreas to handle and your blood glucose levels begin to rise. This is why, even though you may hear IR described as “too much insulin” and think it is the opposite of diabetes, it is really related to diabetes, and can often lead to diabetes if left unchecked. Your pancreas can’t continue to make huge amounts of insulin forever.

There are some other reasons that producing lots of insulin is undesirable. It affects the balance of other hormones in the body: for example, it spurs your body to produce more testosterone, which contributes to the symptoms of PCOS (hirsutism, acne, thinning of hair on the head). Testosterone also disturbs the menstrual cycle. It can suppress ovulation and lead to infertility or other problems of the reproductive system, such as menstrual irregularity.

Too much testosterone and insulin also set up conditions that cause weight gain and make it very hard to lose weight. In particular, insulin resistant people often carry weight around the midsection, which is the most dangerous place to have it. This fat, which is called “visceral fat,” is more hazardous to your health than fat carried in other places. (It’s not clear to me why this is; however, scientists and researchers are finding that the old view of the fat cell as something that just sits there is quite wrong, and that fat cells produce hormones.)

I will post more on this topic, including details on how to test for insulin resistance and what kind of steps you can take to fight against it; however, the important thing to remember is that if you have PCOS, you are probably at least mildly insulin resistant, and the treatments for it are mostly things that will be good for you anyway (like a healthful diet and exercise).

Metformin for low milk supply in PCOS mothers

Lisa Marasco–the ICBLC who is possibly the first researcher to examine the role of PCOS in low milk supply–has found evidence that Metformin can help with low milk supply in mothers with PCOS. The La Leche League has an excellent article by Marasco available on their web site (Marasco is an LLLI leader, as well as a lactation consultant).

Marasco suggests that anecdotal evidence shows a boost in milk production for low-supply moms with PCOS. She acknowledges that large-scale studies and high-quality research on this do not yet exist; however, in the absence of other good options, it may be worth trying. Marasco advocates using Metformin throughout the pregnancy and during breastfeeding.

Thomas Hale, the leading authority on the safety of drugs in breastfeeding mothers, has studied Metformin and concluded that it is quite safe. His assessment can be found here (warning: it’s pretty technical). Essentially, Hale found that the levels of Metformin in breastmilk were low, and that no adverse effects on the infants were reported.

He does point out, however, that “since metformin is largely excreted via the kidneys, particular caution should be exercised where the infant renal function is low or compromised (e.g. in premature neonates, or in rare cases of renal failure).” This doesn’t mean that no breastfeeding mother of a preemie should take Metformin; rather, it means that your doctor should consult with your child’s pediatrician and make the decision carefully. Since breastfeeding is beneficial, especially for premature babies, being able to produce more milk may benefit the infant enough to be worth the risk. Kidney function should be carefully monitored, though.

You may also be interested in this study, which examined infants whose mothers took Metformin over the course of their first six months of life. No differences in development or illnesses were found.

Finally, this page from Kellymom has a good list of links about PCOS and breastfeeding, including links to info about Metformin. (How much do I love Kellymom? A whole lot, that’s how much.)

Ultimately, my feeling on this matter is that it’s worth a shot. Metformin, which is a first-line treatment for PCOS, has a lot of benefits for PCOS sufferers; it can improve regularity of cycles and reduce other symptoms. I find it plausible that Met might make some differences to the hormonal balance that promote milk supply. Of course, not all patients find Metformin easy to tolerate; it often has significant GI side effects. Talk to your doctor about prescribing you the name brand (Glucophage) if that is true for you and adjusting your diet doesn’t help. Some PCOS ladies have reported that the generic has more side effects for them than the name brand.

That said, I took Met before I got pregnant with my son (and for the first trimester), and I had almost zero side effects. It regulated my cycle almost immediately and I conceived my son in the second month of trying. As a result, I’m a believer in Met’s ability to affect hormones for the better, which means that if I were going to have more children, I’d be taking it throughout the pregnancy and while breastfeeding.

some notes about birth control pills as PCOS treatment

One of the first lines of treatment for PCOS for women who are NOT trying to get pregnant [and for a few who are] is usually hormonal contraceptives. This has the superficial result of regulating your period, though it doesn’t actually improve your cycle in a meaningful way; you have an artificially-induced period, called a “withdrawal bleed,” when you switch to the week of placebo or iron pills in your pack. [In this post, I am discussing “birth control pills”–but this info applies also to the NuvaRing and the birth control patch.]

There are benefits to this for some women:

1) Obviously, it is more convenient to have a regular period instead of the erratic cycles or spotting that some PCOS ladies get.

2) Birth control pills can also improve bone density if you are otherwise not having cycles [estrogen is important for bone density, and most birth control pills provide it].

3) They also reduce testosterone, which can, in some cases, reduce other symptoms of PCOS–hirsutism [that would be the unwanted hair] and acne. If this is important to you, you might ask your doctor about Yaz, which also contains drospirinone, a drug that can help with those problems.

4) Some women find that hormonal birth control reduces PMS.

5) Having a period can decrease your risk of endometrial problems, including endometriosis, which can be painful and may reduce fertility.

6) Birth control pills can also increase fertility–yes, INCREASE. They are sometimes used as part of a program for treating infertility, as especially the first month after you stop using them, you may experience increased fertility. If your doctor recommends this line of treatment, there is probably more benefit to using them than there is reason to avoid them.

That said, there are also some compelling reasons to avoid hormonal birth control as a first-line treatment for PCOS. They carry risks: not just the standard “increased risk of stroke and blood clots” and less-serious side effects such as nausea or headache, which you always hear about and will see on the monograph that accompanies your prescription, but also the possibility of weight gain, which can make PCOS worse.

In addition–and this is my completely non-medical opinion–using hormonal contraceptives falsely regulates your cycle, which means that it masks one of the most significant measures of your health. At least for me, my menstrual cycle is a sort of litmus test for how well my lifestyle is working to control PCOS. When I eat well and exercise, my cycle is quite regular. If I don’t–well, my body will remind me, through irregular cycles, that it needs better care. This is a valuable way that my body reflects the success or failure of management, and I don’t want to obscure it. It would be a bit like taking ibuprofen every day because you have been prone to headaches: you wouldn’t know whether the headache was still there if you took it every time your dose was up! I would rather commit to treatments that are really treating my insulin resistance problem.

Finally–and let me emphasize that this is only my experience and that many women have excellent experiences with birth control pills–I no longer use hormonal contraceptives because they contribute a great deal to the depression that I have always suffered. Depression and anxiety are common adjuncts to PCOS. If you suffer either of these disorders, it’s important that you track your response to ANY drug you take, including contraceptives, to see whether they contribute to your problem. For me, it’s not worth it.

One final note about hormonal contraceptives AS contraceptives: I had a great experience with NuvaRing and used it for years, and I felt good while I was using it; however, I also got pregnant while I was using it. My doctor at the time said that women with PCOS often seem to have failures of hormonal contraceptives; in retrospect, I believe this to be true because many women with PCOS are overweight, and women over about 150-175 pounds in weight have decreased rates of effectiveness with hormonal birth control. Food for thought, eh?