Let me first say, I don’t hate Metformin for women with PCOS. For some women it really does help spur ovulation, control blood sugar and help with some weight management but….it’s not without its share of issues. And it’s definitely not the magic bullet for weight loss – although it’s usually presented that way.
How Metformin (or it’s generic form: Glucophage) Works
Metformin is typically given with meals throughout the day, or more commonly now the extended release version is given once with dinner or at bedtime. While only having to pop a pill one time per day is always appealing, this once a day dosing (especially at bedtime) is where I see the most problems with my patients.
How Metformin works is this:
It lowers both fasting and post meal glucose levels by decreasing the glucose absorption in your intestines after a meal; as well as decreasing the amount of glucose your liver makes for later use. It also does help improve insulin sensitivity by increasing glucose movement into a cell.
All sounds good so far right? Not so fast, here are the most common issues I see in women using Metformin:
Low Blood Sugar
Metformin is notorious for causing sometimes severe digestive issues including stomach pain or upset, nausea, vomiting, diarrhea and even a sense of body weakness or metallic taste in the mouth in some. And it is touted as not causing low blood sugar as many older blood sugar lowering drugs did, however I see it every day in my practice that Metformin can make the low carb life a living hell.
When a woman on Metformin follows a low carb diet and dials in her UCT, the standard dose (or the dose they were taking on their former diet) of Metformin can simply be too strong overall OR the bedtime dose can create low blood sugar symptoms come morning.
Women whose doses are too high or who don’t tolerate the bedtime dose will begin suffering with low energy, low morning appetite (especially for protein), increased appetite often the rest of the day and crazy carb cravings. It can make the high protein/low carb diet I recommend for PCOS almost impossible to adhere to. Most women say they wake up a little queasy and looking for a bagel – pretty much the last thing I want them to eat for breakfast!
Metformin is strong, it does its job but we need to remember it is designed for those that aren’t able to control their PCOS or insulin resistance with diet and exercise.
For those women, it can be a lifesaver. For those of you really working the nutrition and exercise angle (which have been shown to be more effective than Metformin for PCOS), it can still be a useful tool but you often only need a much lower dose.
If you have been taking Metformin and are noticing low blood sugar symptoms (more on that here), low morning appetite, more frequent waking in the night, increased cravings or appetite, or lower energy talk to your doc about lowering your dose or switching from the extended release back to meal dosing throughout the day.
As for the GI complaints, those typically don’t go away so if it bothers your tummy then this drug probably isn’t the best long term solution.
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Metformin has been shown in the research to create B12 deficiencies in up to 30% of those taking it.
Low B12 creates a type of anemia where your red blood cells are too big and thus can’t carry oxygen effectively and that ladies, is a metabolic deal breaker. I dive into this particular issue in this article for Girls Gone Strong.
You not only will be tired and foggy headed but losing fat with no B12 isn’t easy.
This low B12 issue is complicated for the fact that many women with PCOS also have autoimmunity (i.e. Hashimoto’s) which can bring with it an autoimmune based B12 deficiency AND/OR digestive issues leading to lower B12 absorption from their diet.
B12 deficiency is easily spotted on a blood test so if you take Metformin please ask for a CBC as well as a methylmalonic acid test (Note: a serum B12 level will be very elevated if you are taking any vitamin with B12 in it, so this is not a useful test for evaluating your B12 status but rather a reflection of if you took your vitamins in the last 24 or so hours.)
What makes this issue even more dicey for women with PCOS and insulin resistance is that B12 is a key nutrient in glucose metabolism as well as stress hormone balance. So the deficiency caused by the med makes the reason you needed the med in the first place worse – not good right??
It’s Not A Weight Loss Miracle And Luckily It’s Not Your Only Option
At least once a day I hear from a hopeful woman whose doc recommended Metformin with the promise that it will help them lose weight. Now if this woman is eating a garbage diet and/or totally overshooting her carb intake and getting little to no exercise, yes she will likely get some good initial weight loss from starting Metformin.
However, most women who come to me are eating a decent diet and making it to the gym – at least on occasion. For you all, I’ve never seen more than a 3-5 pound weight loss from starting Metformin and if dosing isn’t done right it can make it harder to stick with the diet you need to be following (as I mentioned above).
Research repeatedly shows when it comes to insulin resistance, neither supplements nor Metformin trump diet and exercise so the last thing we want to do is make doing those things harder with more sugar cravings and low energy!
And finally, Metformin is not the only game in town for insulin resistance.
Several natural compounds and nutrients have been shown to be as effective – and in some cases MORE effective – than Metformin for women with PCOS. This includes berberine, alpha lipoic acid, gymnema, vandadium and even our old friend chromium. All of these can be found in my balanced+beautiful multi with the exception of berberine. This one is so strong, I recommend starting with the balanced+beautiful at 2 caps three times per day and then layering in 400-500mg of berberine per meal until you’ve really found your optimal UCT + supplement combo.