3 Things You Need To Know About Metformin

September 30, 2015

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:

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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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B12 Deficiency

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 is a metabolic deal breaker.

You not only will be tired and foggy headed but losing weight 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.)

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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, vanadium 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.

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Beyond Metformin & Diet: Other Ways To Improve Your Insulin Sensitivity

Not much beats exercise when it comes to lowering blood sugar and improving insulin sensitivity. Exercising muscles can take up glucose without the aid of insulin, very cool. They have special glucose transporters called GLUT4 proteins that will take up glucose from the blood into the muscles without the need for insulin (like other body cells require). So a brisk walk after a meal along with regular exercise (especially strength training) is key for supporting your blood sugar and improving your insulin sensitivity.

Also, fasting has been shown to be effective at lowering blood sugar and improving insulin sensitivity. Even a 12-14 hour overnight fast is helpful so it doesn’t need to be days on end of no food to improve your blood sugar.

And don’t forget that the other side of the blood sugar equation is cortisol, your stress hormone which will raise your blood sugar as a response to stresses vs. as a response to eating food.  These elevations in blood sugar will also need insulin to move that glucose out of the bloodstream and into a cell for use, this is why I often call stress “the other macro” (macros typically include proteins, fats and carbs). We need to remember that it may not be the need to lower carbs or get in another session at the gym, it may in fact be that our blood sugar and insulin resistance would be better helped with getting better sleep and managing our stress.

Now stress gets dicey as there’s often a lot of it for most of us. Some of it we can outsource, pass off, hire out or just stop doing. Some stresses like your job, your kiddos, aging parents or other family/friends may be stressful but you don’t want to get rid of them – at least most days. For the stresses that can go, do it. Get as much as you can off your plate. But for the stresses that you choose to keep because maybe work lights you up, your dreams are worth a little stress and your family is so important to you, for those stresses we need to learn to handle them differently.

Most women don’t know that we have a choice beyond fight or flight when it comes to stress. Just to name one, women are fantastic at the tend and befriend stress response thanks to my favorite hormone: oxytocin.

I talk all about how to rethink our response to stress in episodes #254, #255 and #259 of the Dr Brooke Show (listen here on my site or anywhere you get your podcasts).

Unsure what stresses are worth it? Grab my FREE Guide to finding your core values and creating your own inner compass.

To sum it up: Metformin is a powerful tool that can be helpful, but it’s not the best for some women and it’s certainly not the only option!


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