>>I spoke with her today and her milk isn't in yet.  Do those of you
working with these women wait and see what happens with milk supply?
Would she respond to either Reglan or Domperidone (available locally)?
Or is Metformin the better choice and if so, what dose is recommended?
My collaborating physician says they usually start at 500 BID or 850 qd
and then increase up to 2000 a day to get them pregnant but I can't find
anything about treatment for low milk supply.  Resources for using
Metformin for treatment for low milk supply?<<

Patty, there isn't any info on treating with metformin for low milk
supply because it's just barely starting to be tried for that purpose.
In assessing the newly postpartum PCOS mom, take a look at her breasts
first and take a history. Did her breasts grow during pregnancy? Did the
areola darken and/or enlarge, and did her veining become more prominent?
Do her breasts *look* like they've gone through a pregnancy? If so, I'd
watch her another day or two before hitting the alarm button. Other
things to consider are if she experienced any pregnancy complications-
hypertension, pre-eclampsia, etc., things that may cause delayed
lactogenesis.

Metformin is definitely being used to get women pregnant-- sometimes
they are left on it during the pregnancy, sometimes they are taken off
as soon as pregnancy is achieved. Research by Charles Glueck MD and
colleagues suggests that metformin treatment during pregnancy helps to
significantly decrease pregnancy complications. I personally favor its
use during pregnancy with the further hope that the hormones necessary
for lactation will be normalized to allow for normal breast development
and lactogenesis.

If a mom has been taken off of Metformin, Tom Hale's research suggests
that it is safe to take while lactating. Given that a number of PCOS
women will experience rebound PCOS symptoms after childbirth, I think
that it is worth mom going back on met just for that reason. In
addition, as Kathy Leeper mentioned, we have had several reports now of
moms being put on or back on metformin and experiencing increase in milk
supply. I would like to emphasize here that these women generally had
decently developed breasts and partial milk supplies to begin with; I
have two other moms now who "did everything right," but their breasts
were severely underdeveloped and did not improve with pregnancy, and
they have made only drops of milk regardless of meds and optimum care.

If a PCOS mom's milk does not come in well, I would encourage the
metformin plus galactogogues. On the prescriptive side, domperidone
would be my first choice. On the herbal side, I am strongly favoring
goat's rue because of its reputation of increasing breast tissue (my
concern for these moms is underdeveloped glandular tissue) along with
milk supply; I may pair this with another galactogogue or combo
tincture. We have no real information on appropriate dosages for herbs,
but I am now leaning towards a more aggressive amount than is usually
recommended. Pumping as is possible is always helpful as well.

Hope this helps.

Lisa Marasco MA IBCLC

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