PCOS and pre-diabetes - do I really need to go on Metformin?

November 30, 2011 11:15 AM

PCOS and pre-diabetes - do I really need to go on Metformin?

I'm a 31 year old woman, and I have what I have is a fairly common medical issue: PCOS. I am currently taking Yasmin and spironolactone for it, which have been helpful in reducing some of the symptoms. I am overweight by maybe 50lbs. I do some moderate exercise every day. I've been working on improving my diet since the summer, lost five pounds, hey ya! I felt like I was getting better.

However, I went for my well woman exam last week, and my reproductive endocrinologist noticed that my insulin levels are elevated - I'm prediabetic, apparently. My mom has diabetes so I'm a bit freaked out at the prospect of developing it, and am not sure of what to do next. My doctor emailed me to say that they have faxed a prescription for Metformin to my pharmacy, and that I need to follow a low-GI diet and exercise more, and they will see me in eight weeks.

I am somewhat reluctant to go on another medication without trying to correct the problem on my own first, especially because Metformin has some nasty side effects such as stomach upset and diarrhea. Do I need to go on Metformin right away, or is it feasible to try a low-GI diet for a few months? I emailed my doc about this but haven't heard back yet. I work full-time and am also in graduate school, so this is a very hectic time of year for me and would be a bad time to acclimate to a new medicine (although possible, I'm sure).

From those of you familiar with PCOS and insulin resistance/pre-diabetes - should I hop on the Metformin posthaste? Also, should I try the South Beach diet or is there some other special magic diet that is better for pre-diabetics?

posted by zoetrope to Health & Fitness (24 answers total)

Best answer: This is so clearly in the realms of 'you need to ask your doctor instead of internet strangers' that it's not even ambiguous. None of us can comment on what prescription medications you should or should not take, and it would be very irresponsible to do so.

But I do think your doctor should have discussed this with you rather than just 'hey we faxed a prescription, see you in eight weeks'. You'd be very justified in either seeing them again in person (or maybe talking by phone) or getting a second opinion to go over this more thoroughly. They may be able to refer you to someone qualified to answer the diet questions too (and you should definitely ask). My Mum has type II diabetes and she found working with a dietician even for a short while really helped get on top of that.
posted by shelleycat at 11:22 AM on November 30, 2011 [2 favorites]

From those of you familiar with PCOS and insulin resistance/pre-diabetes - should I hop on the Metformin posthaste?

IANAD - I would say yes. I have seen it produce some great effects (in one person) like lowered appetite, and without upset stomach or diarrhea, but with some light-headedness. Just watch working out before your body has had time to adjust. Also, if you do a few searches, places in your area should have it covered (read: free) under free diabetes medication programs. Make sure the dosage you have prescribed is the same you're getting in the program. Good luck.
posted by cashman at 11:23 AM on November 30, 2011

IANAD - but do look into low fat vegan diets, such as Dr. Macdougall. I know someone who has Type-1 diabetes, and since moving to this form of eating (tons of vegetables, no animal products, little to no added fats), her insulin requirements have dropped by 40%.
posted by machinecraig at 11:27 AM on November 30, 2011

Don't hop on the Metformin yet. Equally, please don't try an ultra low-fat vegan diet -- that's exactly the opposite of what you need to be doing, which is cutting as many carbs as you can from your diet -- cut out sugar and grains for a month and then reevaluate. I was prediabetic four years ago -- cutting out sugar and grains brought everything under control and I've never felt better -- and I have diabetes on both sides of the family.
posted by peacheater at 11:35 AM on November 30, 2011 [2 favorites]

Best answer: I was diagnosed with PCOS twenty years ago. I've been taking the Yasmin/Spiro/Met combo for a long time now and it works well for me number-wise, my lab results definitely show the difference between me taking the meds and me not taking the meds.

For me, the GI upset aspect of metformin went away within a week or two of increasing my dose. I've been on 2,000 mg for so long that I can take it without food and I don't have any upset from it. If you do start it, make sure you step up gradually.

As for the diet aspect, I had good results from The Insulin Resistance Diet. I notice a big difference when I eat the way I want vs. the way described in the book.
posted by crankylex at 11:36 AM on November 30, 2011 [1 favorite]

I have lost 50 pounds and my insulin is far lower since adopting a low carb, vegetable heavy diet and starting mild exercise. You should certainly consult a doctor, but eating well can compensate for the medication sometimes.
posted by PrettyKnitty at 11:40 AM on November 30, 2011 [1 favorite]

Best answer: Many people have no GI upset at all, especially when taking the ER (extended release) version. There is also a drug called Glumetza which is metformin that is absorbed further down the digestion tract which causes far less stomach upset. If you do go on metformin, you might be surprised at the difference in how you feel. When I was first Dx, I lost 45lbs almost without trying and I didn't have the must. have. sugar. NOW! cravings I had been dealing with. Metformin has been around forever and has a very low incidence of serious side effects when taken correctly.
posted by PorcineWithMe at 11:42 AM on November 30, 2011 [1 favorite]

Talk to your doctor, for sure. But metformin does great things for a lot of people; you may very well feel *better* on the metformin than not, and if the side effects do turn out to be bad, tell your doctor you don't want to take it. There is no law that says once you start taking metformin you have to take it for the rest of your life.
posted by mskyle at 12:00 PM on November 30, 2011 [1 favorite]

Best answer: Digestive distress is not inevitable. I have no adverse effects at all from Metformin when I take it in the middle of my meal. I have heard of the time of day when it is taken making a difference for people as well.

Especially if your insurance will cover it, consider asking your doctor to refer you to a nutritionist. While I've paddled my own nutritional canoe for a decade since, I found that very helpful.

I really wish someone would come up with different names for type 1 and type 2 diabetes. It would eliminate a fair amount of misunderstanding.
posted by gnomeloaf at 12:02 PM on November 30, 2011

Strictly anecdotal, and nothing to do with PCOS as the patient in question is a male, but Mr. Adams has a history of Type II diabetes in his family and was dx'd as "pre-diabetic" many years ago. His blood sugar numbers (and cholesterol level) went 'way down when we both did the Atkins low-carb diet for about a year (and his doctor encouraged him, "Whatever you're doing, keep it up!"), but we're both weak and couldn't maintain a no-potato, no-pasta ever diet. Mr. Adams' doctor put him on Metformin about two years ago, and at that time mentioned to us that Metformin is not infrequently prescribed to non-diabetics as a weight loss drug. In any case, Mr. Adams' blood sugar has been maintaining a safe range with Metformin, slight dietary changes (he doesn't eschew all sweets) and exercise. However, it took him a good month before his digestive system adjusted to Metformin; Imodium was his best friend during that time.
posted by Oriole Adams at 12:02 PM on November 30, 2011

Best answer: This is technical but might be helpful background for further discussion with your doc. Should all women with PCOS receive metformin?
posted by Mr.Know-it-some at 12:30 PM on November 30, 2011

Talk to your doc before your fill your prescription. I have diabetes and am on metformin. The GI effects lasted only a couple of days for me when I started. A coworker had zero side effect though she had resisted going on it because her mother had really bad side effects. So it can really vary. For me I was told that I seemed much moee energetic and felt better. It made losing a bunch of weight much easier.
posted by oneear at 12:33 PM on November 30, 2011

Why don't you get more information before you decide (with your doctor)? What are your HBa1c levels? Do you know what those are? It's an indicator of your blood sugar levels for the past 3 months.

I had the pre-diabetes stuff going on too, and it was stressed to me that through nutrition and exercise, if I followed the program, it could go away. And also stressed that this process takes up to one year, so you don't have to think OMG, I need to lose it all now or go on icky drugs!

Do you test your blood sugars now? Have you taken a diabetes nutrition class? Would your doctor be open to you doing those things, in addition to exercise, to stay of the meds? If not, discuss a plan to get you to that point. And no one should be prescribing you diabetes meds without instructing you when to take them. With meals, after meals, etc. They are designed to lower your blood sugar, so obviously on an empty stomach might not be a good idea, did you know that?

That said, my dad takes it and he does fine.

I went to the class and followed their instructions, and I used the Walk Away the Pounds powerwalking DVD recommended by the nurse/nutritionist. I read the labels on all my foods. I cheat now and then but I know if my pants get too tight, it's go back to eating right and moar exercise. I also check my blood sugars to make sure I'm not messing them up too much (just before eating and 2 hours later).

It may be that you have to go on it temporarily, until you get the weight and nutrition under control. If not, you will be okay. The most important thing is to communicate with your doctor and get more information before you freak out.
posted by Marie Mon Dieu at 12:41 PM on November 30, 2011

Pre-diabetes is a warning sign that you need to make some changes. It sounds like you're already on this path as you've lost 5 lbs -- good for you! Changing your diet, losing more weight and exercising regularly can all help to normalize your blood sugar and slow the progress from pre-diabetes to diabetes. I don't think it matters how you lose the weight, ie the important point is to lose weight, period. I would caution you against fad diets that you can't maintain.

There's more information on pre-diabetes here, at the Mayo Clinic website.

As for the metformin, IANAD, but I do know that dysglycaemia ie irregular blood sugar levels can wreak havoc with your vascular system (arteries and veins that carry blood to/from various organs). This is why people with diabetes are at increased risk for kidney disease, eye disease, heart disease, amputations, etc. Definitely talk to your doctor about the risks of not treating this immediately.

And good luck!
posted by lulu68 at 12:50 PM on November 30, 2011

As an aside, an A1C is usually completely normal for those of us with insulin resistance. A 4 hour glucose tolerance along with insulin level testing gives a far more accurate assessment of the state of things. If you decide to go on metformin, there is nothing saying you can't come off of it whenever you wish (under a docs supervision, of course).
posted by PorcineWithMe at 12:54 PM on November 30, 2011

BTW, I lost at least 45 pounds doing all of the above, making small changes at first and keeping up with the exercise and increasing it to more strenuous workouts as time went on. I was really discouraged at first (ewww, icky plain yogurt and blueberries, no more big bowls of oatmeal or Raman noodles), but as they said, it takes a year to get yourself in gear, with or without the meds. If that med freaks you out, ask about another med and when and how to take it.
posted by Marie Mon Dieu at 12:57 PM on November 30, 2011

What? I was told the A1C was the preferred measure for diabetics. Because it averages your blood sugar for the past 3 months. I have had a glucose intolerance test before and it told me I had low blood sugar. So color me confused.
posted by Marie Mon Dieu at 1:16 PM on November 30, 2011

The short answer is: Rather than guessing or relying on internet strangers, please please please, talk to your doctors, call the prescriber of this drug and tell the person who answers the phone that you have questions about your diagnosis and medication, and use the phrase "Because I am confused." When the doctor calls you back, ask specific questions about your specific concerns. Ask if there are alternatives. Ask if you can have 4 weeks to exercise vigorously every day and change your eating slightly. (I'm now a big believer that dietary modification for diabetes should be fairly gradual and permanent.) In the future, never assume that the doctor will invite you to ask questions. Just ask them, because doctors are not trained in "bedside manner" or "social sensitivity" and they really are not trained in sociology.

All of the medical professionals I know get extremely frustrated and irritated when they talk about non-compliant patients (never a specific one, just the topic of non-compliance gets panties wadded up) and non-compliant diabetics seem to be the most frustrating. They are, however, thrilled at the patients who ask informed questions and show the determination to make changes before things become dire.

You say: I do some moderate exercise every day.

I'm working on a literature review of the social narratives of diabetes in relation to biomedical narratives of diabetes. Here's what I've found:

Nearly everybody needs to exercise more, and despite commonly held beliefs that

I don't think it matters how you lose the weight, ie the important point is to lose weight, period.

It appears that losing the weight through exercise in combination with improved diet, and maintaining that level of activity offers much greater protection. Much more. Like, an hour a day is enough if you're talking about "moderate," which would mean walking at a not rushed pace, but you have to get your heart rate up. Brisk walking, 30-45 minutes. Running, 20 minutes.

But seriously, every day. Every damn day. Everybody knows that diabetes is no joke, but there is a huge difference between how doctors and patients talk about the disease. I have at least 50 PDFs of journal articles on the topic. The single biggest suggestion is, "arrange your life in ways that allow or force you to move more. Take the stairs, park as far away from the door as you can, bike or walk everywhere you can, swim, garden, do jumping jacks while you watch tv, volunteer for habitat for humanity building houses, chase kids around the playground instead of watching them while you read a book.

As an anthropology student, I participate in a lot of talk about the "structural" and "political economy" problems inherent in the above advice. It's not always safe to walk the three blocks to the grocery store, because you have to jaywalk across 6 crazy lanes of traffic or add 1/2 mile to your walk in search of a crosswalk, and that store is actually just a QwikEMart. Lots of people have jobs that keep them in the car for 4 hours a day, breakfast in the car, eating lunch at their desk, typing and taking calls, with no ability to take the stairs anywhere. We talk about ways that "we" can fix these problems - but until that happens, the responsibility is with the individual. Is that fair? NO. Do physicians (and patients and people who don't even know what diabetes really is) ascribe having diabetes to moral and character failures, or to a lack of self control? Unfortunately, yes, many do. But just because people will treat you that way, does not mean that it is true. Also, being pre-diabetic is only a guarantee that you will become diabetic if you don't make some changes in your life. So. Call your doctor. And then go for a nice long walk.
posted by bilabial at 1:26 PM on November 30, 2011 [1 favorite]

Diabetics, yes. Pre-diabetes (insulin resistance) the blood sugar levels are under control because the pancreas is pumping out insulin like crazy because the body isn't using the insulin effectively. Google 'insulin dumping' for a better explanation. The A1C measures blood glucose over time, and does not check for elevated insulin levels.
posted by PorcineWithMe at 1:28 PM on November 30, 2011 [1 favorite]

Metformin has really helped me - I don't have PCOS but I do have hyperinsulinemia. Metformin is not a do or die drug and it's not expensive. You can get your prescription filled, take it on a day when you can stay close to home for several hours, and see how you respond to it. If it's absolutely dreadful, call your doc and ask if you can hold off on it.

Unless the side effects are just horrendous, I personally think taking the pill is easier to manage in a hectic life than a dramatic diet change. Taking the Metformin can help stabilize your insulin while you work on changing your diet and exercise habits.

My doc recommended a lower-carb, not strict low carb, diet. She was certain that losing weight would fix the problem. But even after a lot of weight loss my insulin is too high without metformin. So I'm still on it, and it's not a big deal.

I was warned about digestive issues but in fact Metformin seemed to relieve some GI problems I was having at the time. YMMV.
posted by bunderful at 1:43 PM on November 30, 2011

Response by poster: Everyone, thank you for your advice. Rest assured, I do talk with my doctor, we have a good relationship, and I am always full of questions for her and her staff. I have been getting antsy waiting for a call/email from her about this metformin thing over the past few days, and that is where my anxiety is coming from. I wanted to hear from people with PCOS who have gone on metformin to see what their experiences were like. Dr. Google had me worried that everybody who takes it has horrendous GI problems, but from experiences shared here I can see that that's not always the case.

I'm sorry if I was less than clear--I'm still a little upset, I guess.
posted by zoetrope at 1:48 PM on November 30, 2011

Oh dear god. I can't advise you about whether or not to start the Metformin - it's a good drug, does magic things for some people - but for the love of all that's holy, if you start it, start it on a weekend, or over holiday break, or something. I started Metformin during my first year of grad school. That day was the first and only time in my entire life when I've had to literally dash out of a classroom mid-conversation to avoid being sick on the floor. That embarrassment was compounded, mind you, by the fact that my (male) professor eventually had to send someone into the ladies room to see if I was still alive, because I'd spent more than an hour in there suffering, um, unpleasant stomach activities. He then insisted on driving me home because I was clearly extremely ill and couldn't be allowed to take the bus I usually took home from class. I must have looked like death.

That...was a bad day.

On the other hand, the digestive complications tapered off to controllable levels within a few days, and from then on I knew that if I was going to be off it for a while, I needed to schedule starting up again carefully.
posted by badgermushroomSNAKE at 8:04 PM on November 30, 2011

Best answer: hi zoetrope, if you are still reading this - here is a wordy answer.

I have PCOS and I started metformin a month ago, so I can give you my anecdotal experience with it. Since I really want to whip my PCOS into shape for fertility purposes, I also decided to start metformin. I made the mistake of taking the full dose on day 1 - please DO NOT do that. Take half dose for a week at least. I thought since I felt fine after taking one pill that 12 hours later I might as well just take the other one. I woke up in the morning with.... well, suffice it to say the outcome was horrific.

Since then I have worked my way up from 1000mg daily to 1500mg daily. It has been a month and I still feel the nausea every single day. I am going to keep slogging through this though because I really want it to be effective. The GI effects seem to be worse at times if I eat a big/heavy meal.

The difference is that I am not overweight or pre diabetic, I just have mild insulin resistance. If I was pre diabetic, I would get on the lifestyle-changing bandwagon even bigger time than I am now. I am also a doctor and I see people with complications of diabetes every day. Diabetes is a bad disease and I desperately do not want it, not to mention that it puts you at risk for a ton of other complications like heart disease in the future (and kidney disease, and infections, and foot problems). So whether I would get on metformin or not in that scenario... I think I would try the lifestyle thing first but definitely use metformin if I found I did not have enough willpower to control my diet and exercise. The problem with going to metformin right away is that I think it could give you a false sense of being able to do whatever you want still and not improve your diet, because you can lose weight or at least not gain weight on it. I was not overweight and I even lost 5 pounds with it, and I like that, plus I can eat whatever I want now - I ate half a pizza for dinner last night, and a brownie and a milkshake for dinner tonight. I gotta say though, eating whatever you want is not nearly as much fun when you feel nauseated all the time and have no appetite.
posted by treehorn+bunny at 12:15 AM on December 1, 2011

IANAD. Consider a ketogenic, high-fat (65% of calories), low-carb (5%, mostly from non-starchy vegetables) diet. They are useful for both PCOS and pre-diabetes.

Here's a video of a fertility doctor talking about PCOS and low-carb diets.

Here's the best simple introduction to keto diets I've seen.
posted by callmejay at 8:34 AM on December 1, 2011