Medora,

I have tracked several anecdotal cases of PCOS low supply mothers (internet,
other LC clients) who have tried metformin, and it seems to have varying
levels of effect, from zero to significant. Tom Hale has also received some
anecdotal reports. Of my clients who try metformin, for some it makes a
difference, and for others it doesn't. I think that available lactation
tissue makes a difference, for starters. In women who have poorly developed
mammary gland tissue, there is little to act on and therefore limited or no
change. 

Mona Gabbay MD and Heather Kelly IBCLC presented a case series study of 9
women to the Academy of Breastfeeding Medicine in 2003; here is their
results and conclusion:

Results:  Nine women between 2 and 9 weeks postpartum began treatment with
metformin from December 2002 to June 2003.  Duration of therapy ranged from
3 to 10 weeks and four women remain on the medication at the time of this
analysis.  Other interventions used by this cohort to augment milk
production include one or more of the following: pumping >5 times/day (n=9),
domperidone (n=8), fenugreek (n=3), supplemental nursing system (n=2), and
acupuncture (n=1).  Two women discontinued metformin due to side effects of
the medication: diarrhea in one, parasthesias in the other.  Of the
remaining 7 women, all had increases in milk supply of variable amounts.
One patient, exclusively pumping 6 ounces per day at 2 weeks
postpartum, started metformin alone (without domperidone) and was
exclusively breastfeeding after 6 weeks.  Another patient, supplementing 25
ounces of formula per day at 4 weeks postpartum, took metformin for 10
weeks, and was breastfeeding with a decrease in formula supplementation to
5-10 ounces per day.  This patient experienced engorgement for the first
time on the night she increased the dose from 1gm to 1.5 gm per day.  Three
other patients also developed notable  engorgement at dose escalations of
metformin: one had to stop due to intolerable diarrhea at the higher dose,
one mother of twins pumped 10 ounces during that engorged  state compared
with a previous maximum of 5 ounces but  had minimal improvement thereafter,
and a third is on her fourth week of therapy, with minimal increases in
production thus far.  The remaining three patients have had variable
increases to date and all three remain on therapy.

Conclusion:   It remains unclear whether metformin improves milk production
in this population of breastfeeding women.  The episodes of engorgement
experienced by 4 of the 9 patients at the time of dosage increases suggest
that improving insulin resistance with metformin may be helpful in
increasing milk production.  Treating these women during the last stage of
lactogenesis may be too late; we speculate whether earlier therapy, perhaps
during pregnancy, may improve outcomes.

***The assumption has been that metformin may help milk production via
insulin resistance, but I am not convinced that its potential beneficial
effects are limited to insulin-related issues. For one thing, metformin has
been found helpful in improving PCOS related pathology among PCOS women who
DON'T have insulin resistance. This seems to imply other modes of action
that simply haven't been identified yet. We have much more to learn.

As a side note: goat's rue and its constituent galegin is the herb that
metformin was original derived from. Phenformin was the first drug, but had
some toxicity concerns so metformin was then developed from that. Kathryn at
MotherLove Herbal tells me that she has been receiving positive feedback
from PCOS low supply mothers who try More Milk Special Blend, which includes
goat's rue. We don't know how many *don't* respond, but I find it notable
that some of the mothers feel that it makes a difference.

One of the difficult aspects of low supply among PCOS moms is that there are
multiple possible interferences. I would not expect one drug or herb to
address all of them.

Lisa Marasco MA IBCLC

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