Metformin

There is lots of debate about Metformin at the moment - some women swear by it, others say that it either does no good at all, or worse, that it made them feel really poorly and they were unable to tolerate the side-effects. We are all individuals of course, and thus have diverse reactions to drugs, but surely the results can't be as widely spread as that?

Furthermore, fertility specialists are now questioning its ability to give positive results in terms of pregnancies and live babies.

So, why bother with Metformin? - what are the positives, the negatives, and what should you be aware of when considering whether it's a treatment for you.

What is it?

Metformin is a medication widely used to control blood sugar. It was discovered in 1922 and has been used extensively throughout the 20th and 21st Centuries in the treatment of diabetes.

Why take Metformin as a Treatment for PCOS?

Metformin has been thought to improve fertility in women with PCOS, and in 2004 NICE, Great Britain’s National Institute for Health and Clinical excellence recommended that women with PCOS that have a BMI above 25 be given metformin when other therapies fail to produce results (National Institute for Health and Clinical Excellence 2004). 

What's the Problem Then?

Despite the above, there is, however, confusion about the efficacy of Metformin as a treatment for fertility and specialists are now questioning whether it is therefore worth prescribing to our group. Recent studies have shown a relatively minor improvement in fertility leading to the birth of live babies, compared over a 6 month trial to other, more aggressive treatments such as Clomid.

The Bigger Picture

In order to evaluate this, it's worth looking at the bigger picture. To judge Metformin on fertility alone is simplistic and ignores the wider benefits it provides.

Today, fertility as a medical specialism is almost myopic in its focus, which is great in many ways - we all want an ultra-specialist to get down to the problem, but this overlooks the simple fact that the body functions as one organism and that if we wish to solve one problem, we'd find the best result by going back to the source of all the issues rather than trying to sweep up, symptom by symptom.

Metformin and Insulin

Metformin may have limited direct effect on fertility, but its effects to control insulin are incontrovertible.

Let's return to my hypothesis that PCOS is actually a symptom of endocrine (hormonal) distress, and look at the wider issue.

• - Many women with PCOS suffer with a wide range of hormone problems, high insulin levels being one of the most prevalent.
• - High insulin levels lead to uncontrollable weight gain, inability to lose weight and to disturbance of the other master hormones (oestrogen, testosterone, progesterone etc) and thus affect, amongst other things, fertility (imbalance of these hormones also affects the androgenic symptoms we see in PCOS sufferers such as hirsutism, alopecia, etc).

If you suffer with the symptoms I describe above, you really need to control your insulin by some means and Metformin is an excellent tool to control insulin. It's not the only one, and there are more natural means of controlling insulin which should be considered first, but if you're struggling with weight gain or are unable to lose weight, Metformin is something to consider.

Metformin and Fertility

Metformin has always been thought to improve fertility due to a number of diverse factors, the chief amongst them being the key attribute of controlling blood sugar. It is not directly (and never has been), a fertility treatment and therefore to judge it as such is a unfair and unhelpful to those of us doing our best to navigate our way through the options.

HOWEVER

Still, the biggest, most effective treatment you can get for fertility is to lose 10% body weight. This is more effective than any of the heavy hormone treatments (Clomid etc). 

Simple enough, but what if you've tried to lose weight and you just can't: your body doesn't respond to the diet, you exercise and are an active person and yet you gain weight if you so much as look at a chocolate hobnob?

Why Metformin can be Awesome

If you fall into the category I describe above, where weight gain is easy and weight loss is either extremely difficult (or in my case impossible), then in this case, insulin control can make a tremendous difference, and in that role, Metformin can be a terrific tool.

• - If taking Metformin means that you control your insulin, and thus are able to lose weight, it's likely that you'll (over time) acheive your 10% weight loss and your fertility will improve naturally. 
• - Similarly, by controlling insulin, you'll give your reproductive hormones a chance to return to proper levels, meaning that fertility may be restored. 

All this takes time, of course, and the findings in the recent study were performed over a relatively short period (6 months). This may not be enough, but far better to balance the body slowly than to "shock" it further by use of heavy fertility treatments.

Magic Bullet? Of Course Not...

Metformin is a brilliant tool, but it can't do it all. If you are unwittingly boosting your insulin production through your lifestyle (stress, either psychological or physical through over-exercising) or by eating foods which boost insulin production (e.g. cakes, sugary snacks and grains such as bread, pasta), then you may be cancelling out the benefits. 

I genuinely believe that, as the medical profession have been giving out Metformin without proper dietary advice, the amount of successful results have been mitigated, and of course, the conclusion has been drawn that Metformin isn't that effective, which is really unfair. 

It's a bit like tying someone's shoelaces together and then claiming that they're rubbish at running!

Supporting Metformin for Best Results

For some users, Metformin can be extremely effective and make a big enough difference to insulin levels to begin controlling weight and restoring other hormone levels. If you fall into this group, that's brilliant, I'm really pleased. I know it works for a good proportion.

For me, it's not enough. I take 2000mg per day and it barely controls my levels. I tried to downgrade the dose on my Metformin a few months ago (to 1000mg per day) and was genuinely surprised how quickly my insulin levels got out of control – within four days I had to abandon the experiment as I felt terrible, was gaining weight, had insomnia, anxiety and a whole host of other symptoms. 

In my case, it takes a suitable diet, plenty of sleep, stress control and other measures to produce a positive result.

Here's my top tips for getting the best out of the treatment:

If you're already taking Metformin: support it by modifying your diet (see my article on the Paleo diet for the optimum insulin control), get plenty of good quality sleep and control your stress

If you're not taking Metformin: consider taking it, but before you do, see if you can otherwise control your insulin naturally first. No-one should see pills as a quick fix and if adopting the following methods can make a difference, that's always going to be better. Support your own body by modifying your diet, get plenty of good quality sleep and control your stress.

In my case, after 10 years undiagnosed, it was too late and I needed the extra support that Metformin can provide,  so I wholeheartedly support it as a treatment, but try the other options first. 

Similarly, consider Metformin as a control mechanism, but work towards not needing it anymore: in my case, I hope to reduce my dose and eventually cease my dependency on it as my natural mechanisms improve. It does not follow that once you start taking this medicine that you will have to take it forever (it might be the case for some diabetics, but we don't fall into that group).

Controlling the Side Effects

Some women experience side-effects when taking Metformin, most commonly gastro-disturbances such as diarrhea. 

For this reason, as with any medicine or supplement, start on the lowest dose and build up gradually over a number of weeks (not days). There are also slow-release versions which can be easier to tolerate. 

Remember that altering the way that a master hormone works will inevitably cause some turbulence, and this may be a difficult adjustment in the short term. 

Should We Keep Metformin as a Treatment Option?

Definitely. Whilst it won't work for all, and there are probably a number of other treatments which we ought to try in preference, it has its place and is beneficial for many. We'd be silly to overlook it as a sensible option for some women. 

How did you get on with Metformin? Let me know how you got on and what worked for you. I love comments and look forward to hearing them.