Gabriela is back after being on metformin for 3 1/2 weeks. We hadn’t gotten any phone calls from her since she started, which to me means two things. One is that she didn’t have terrible side effects, because she would have called us. The other is that she never got her period, because she was supposed to call us when her period came, so that we could add the Clomid. For women with no periods on their own, metformin can help them ovulate and get regular periods. So for those patients, we are happy when they get their period. For Gabriela, however, she DOES get periods on her own, so her not getting her period was even more suprising.
Everyone knows that the most suspenseful part of reproductive endocrinology is after each IUI or IVF cycle, when patients come in to have a pregnancy test done. However, not many realize that the next most suspenseful scenario is probably the follow-up visit after starting a patient on metformin. Sometimes patients come back and report that they had horrible side effects of diarrhea and stomach upset. They didn’t notice any change in their sweets cravings or carbs cravings. They didn’t notice any improvement in their sluggishness and sleepiness, especially after meals. They felt horrible for three weeks and were tempted to quit the medication and not only that, they gained 2 pounds. This type of disappointing outcome or something similar happens in about 1 out of 5 patients, and for them, we usually discontinue the metformin immediately. The other 4 out of 5 have more promising results.
Gabriela’s was definitely one of the better responses. First of all, she had a huge grin on her face and surprised me by joking that she totally loved me. Before I could respond, she said that my giving her metformin was the greatest thing anyone had ever done for her and she explained that she felt better these past 3 1/2 weeks than she ever did in her life. Her waistline had shrunken and she was in need of some new clothes. Our scale said that she was at 154 pounds, down 6 from before she started the metformin. She says her husband and co-workers all were amazed at how much weight she lost in such a short time. When I asked her what she thought was the reason for her weight loss, she said it was definitely her decrease in eating sweets. She went on to share that after her last visit when she was first started on the metformin, she went home and did a lot of research on the internet and became even more convinced that she did indeed have PCOS. She also came to the realization that she probably ate a whole lot more sweets than she realized. At work, there was always some candy available and she unavoidably kept consuming it all day without thinking. However, ever since starting the metformin, she no longer felt the same uncontrolled urges. She would still sneak a bite of chocolate every once in a while, but that bite was enough to make her happy so she stopped. Whereas she used to be ready to take a nap after lunch every day, she now reports greater energy and no desire to nap. She hadn’t really increased her exercise habits any more than before, but she reported that she is looking for a personal trainer now and is inspired to start working out to further help her weight loss. And with regards to side effects, she had mild diarrhea for the first two days and no more since then.
I was thrilled for her. This was pretty much a perfect textbook response. I told her that her weight change and her dramatic change of symptoms were pretty convicing, and the right thing to do would be to keep her on the metformin. I refilled her prescription and told her that the next decision was whether to start fertility treatment with Clomid and insemination as planned or try on her own for a while. Because the metformin was making such a dramatic difference in her life, it wouldn’t be unreasonable to see if it also made the difference in her ovulation status. I felt she could give it maybe 3 more months on her own now. She disagreed with the plan. She was so excited about the progress that she wanted to just keep the momentum going. We therefore agreed that with her next period, she would come in and get started on Clomid. She thanked us again and happily left the office.
Weeks went by and still no call regarding her period. When she finally did call 3 weeks later, it was to tell us that she had done a home pregnancy test and that it was positive!! She had gotten pregnant on her own.
To briefly summarize after that, her pregnancy was monitored for the first trimester, while she remained on the metformin. After 12 weeks gestation, she graduated from our care and went on to her OB, who kept her on the metformin as well. She was later diagnosed with gestational diabetes and given a combination of insuilin and metformin throughout the pregnancy. She delivered a happy 8-pound baby boy.
