Monday, September 29, 2008

Suicide by Pregnancy?

I recently received yet another story of tremendous size bigotry from an OB, who basically tried to scare this poor woman to death about being pregnant at her size, and who more or less told her she had committed suicide by daring to be pregnant at her size.

I can't tell you how much stories like these infuriate me; NO ONE should have to put up with this kind of bullsh*t treatment. People in the healthcare professions should be ASHAMED that this kind of medical bullying occurs. Yet sadly, it is all too common with women of size, especially in obstetrics.

I have permission to quote her email; I have edited it slightly.

I am 31 years old and I weigh 400 pounds. The last time I was pregnant, which sadly ended in miscarriage, I weighed 350 pounds...I've overcome as best as I can and I want to try for a baby again.

My current OBGYN says he can get me and my baby safely through pregnancy, and that he has lots of history with obese women and pregnancy. I want to believe him, but I worry because of what another doctor told me.... and because of what I've been brainwashed for years to believe.

Anyway, when I was pregnant, I went to a doctor who CONDEMNED me the moment I walked into the office. He told me that I wasn't going to make it alive through my pregnancy and that they would "have to take drastic measures to try save me before they would even attempt to save my baby" etc.

He kept saying I shouldn't have gotten pregnant, that I had in a sense, committed suicide! He told me that my heart was going to give out, or that I was going to stroke out while attempting to push my LARGE baby out, therefore I was going to have a c-section. He told me that I was going to have massive blood clots in my legs and severe pre-eclampsia.

I left his office completely panicked and in tears. I was shaking so bad I could hardly walk and all he did was look at me and said in a cold voice with no emotion at all, "It's really scary, isn't it."

I regretted all the years of trying and numerous fertility treatments (I have PCOS) to get pregnant. It was 4 days later that I lost my very much-loved baby. I believe it was a good part due to the stress and fear that he caused me.

I'm sorry; this kind of treatment is INEXCUSABLE.

Yes, statistically there are more risks in pregnancy with obesity, and yes, these risks probably do go up somewhat as BMI increases, but at NO point do they reach 100% or even remotely close. Being at increased risk for a problem does not mean you will inevitably experience it, and in the meantime there are proactive things you can do to lessen your risks for problems. Even if you do experience a problem, most of the time there are treatments that will help. Most of the time things are fine.

Let me say it once again. MOST women of size have healthy babies just fine.

"Even" in the 400 lb. size range, I know of a NUMBER of women who have had healthy pregnancies and babies. Most in that size range are not "allowed" to labor (or the doctors induce their labor early and then they end up with a cesarean) so the cesarean rate in this group is very high....but I DO know women of that size range who have had vaginal births too. None that I have known have died or even come close. None have stroked out during labor or birth; none have had heart attacks or any of the other dire things this doctor said would surely come to pass.

The largest-sized woman I have come upon so far in case reports in the medical literature was around 500 lbs. She did NOT experience gestational diabetes, she did NOT experience blood pressure issues, she did NOT have blood clots, or any of the other terrors this doctor would have said she obviously would get. The only complication she had was asthma, and she and baby were just fine. As is so common with obstetrics, they did pressure her to have a cesarean, and surgery on a person of that size is more difficult and challenging.....but it went just fine. There were no complications at all.

Although certainly there is more risk for complications, it is NOT a bygone conclusion that bad things will happen, even in women of very large sizes.

Medical bullying is a blight upon the profession. That's not to say that doctors and midwives cannot share that obese women are at increased risk for some complications; they would not be doing their jobs adequately if they didn't share these possible concerns. However, HOW you discuss these things makes all the difference in the world.

You can present possible risks without implying that they no doubt will happen; it's important to present the risks in proper perspective. The truth is that they do NOT happen to the majority of women of size, and the worst-case scenario very rarely happens. You can also present them in a neutral way, without the judgment and harshness and condemnation so often used on women of size.

Furthermore, you can present ways to be proactive that can help lessen the risks for complications. Excellent nutrition (not dieting) and regular exercise go a long way towards lessening the risks, and for women at particular risk, there are other options too, such as using metformin prophylactically or considering low-dose aspirin (with medical supervision). These are all things that can be discussed calmly and reasonably, without having to resort to hyperbole and scare tactics.

The kind of over-the-top BULLYING shown above is a total exaggeration of the risks, and basically amounts to trying to scare women of size out of having babies rather than giving her reasonable counseling about possible risks. It is a unique and insidious form of bullying and eugenics and IT MUST STOP.

Sunday, September 21, 2008

My Own Experience With Hypothyroidism

Previously, I wrote about hypothyroidism issues in pregnancy in general. Now I want to write a little bit about my own experiences with hypothyroidism. It's a widely varied journey, but one with lessons for others who think they might have thyroid issues, so I want to share it.

Hypothyroidism Begins with a Roar

When I was younger, everyone always considered me "overweight" and I had lots of pressure to diet, but I wasn't really "obese" at that point. Then the PCOS and hypothyroidism really hit.

Starting at about age 16, I began skipping periods. Scared me to death, but it didn't happen that often and I knew periods could be variable, so I figured I was just one of those people who was a bit irregular.

Then around age 17 I began gaining weight and lots of it. I had been on a diet recently so I just figured it was re-gain (and I'm sure some of it was). Looking back now, though, I think much of it was also the big gain that often accompanies the double-whammy of PCOS and hypothyroidism.

Between 17 and 21, I gained about 100 lbs. That's right, a hundred pounds. [Wow, it's upsetting even writing that; I can still hardly wrap my mind around it.] It happened without changing any of my food habits or anything else significantly. It was devastating. But I couldn't seem to stop it, no matter what I did........and I did a lot.

I fought it with everything I could think of. I cut back on food......but I kept gaining. I thought maybe it was dorm food, so I moved out of the dorm and started cooking for myself.....but still kept gaining. I went to Weight Watchers again......but kept battling crazy fluctuations of weight. I signed up for a college fitness class and spent an extreme semester exercising like crazy.....yet I gained 25 lbs. in that semester alone, WHILE doing all that exercise and being on Weight Watchers. (And no, that was definitely not muscle gain.) The coach thought I was lying and that I must be a binge eater....but I wasn't.

Dealing with Doctors: Round One

During this time period, I went to the doctor a couple of times and they tested my thyroid levels. I was told they were always "normal" or "a little on the low/borderline side, but nothing that needs treatment." So we concluded that thyroid wasn't an issue for me, despite the tremendous weight gain I was experiencing.

Now, of course, I wish I had the exact results from those tests to look at. Back then, the ranges considered "normal" were much wider, and I suspect strongly that I fell into a gray area, where TSH tests are within normal limits as they were defined then but would now be considered abnormal by many endocrinologists.
[So lesson #1: Always get your exact test results and know the range the lab used to define "normal," and then keep those results so you can track them over time.]

I finally got so desperate about the weight gain that I signed up with a radical commercial diet center. 500 calories a day, plus vitamin/mineral supplements. Seriously. I did that for 6 months. I lost 50 lbs. all right, but it was NOT a "good" or "healthy" loss. I'm lucky I didn't seriously damage my body. That was the turnaround that began my fat-acceptance journey.

I ended that diet for many reasons, but in particular because by the end of 6 months, I began gaining weight on 500 calories per day. Yes, GAINING weight on 500 calories a day.

That's when I realized that the whole "calories in/calories out" mantra was full of crap, and that there must be something more to all this. The math didn't add up; there must be more variables than doctors realized.

I also began realizing that the whole dieting thing was taking me places mentally and emotionally that I didn't want to go, and I felt for my own health and sanity I had to stop. So I did. (Smartest thing I ever did.)

For the time being, I gave up on seeing doctors and concluded I must not have any thyroid issues. I knew something was going on, but figured that yo-yo dieting had screwed everything up. I gave up on trying to find answers and tried to concentrate on stabilizing my weight.

Dealing with Doctors: Round Two

Fast forward a few years. I was married and working at a career, but seeing more and more signs of problems. I was skipping periods again, I had many other symptoms that were bothering me, and I was constantly fighting my weight. I finally decided I had to go consult an endocrinologist because I just knew something was wrong.

We had just moved to a new town so we picked an endocrinologist from the phone book. I went there and filled out all the paperwork, extensively describing my symptoms and history. The doctor didn't even really look at it. He was very disdainful, very dismissive. He didn't take my concerns seriously at all.

He told me I was just looking for an excuse for being fat.

I was devastated and didn't go back to a doctor for several years. I continued to skip periods and to experience other worsening symptoms, but I couldn't see going back to a doctor and being dismissed like that again. So I only kept getting worse.
[Lesson #2: Don't give up if you can't find a doctor who will take your concerns seriously; don't let a fat-phobic doctor keep you from getting the care that you need. Find a new doctor!]

Dealing with Doctors: Round Three

Finally a friend gave me a book about thyroid issues. I read it and went, wow, that's me. I got a basal body thermometer and starting taking my basal body temps (BBTs) and sure enough, they were in the basement, and I had so many of the other symptoms they listed too.

This friend recommended a doctor to me who was trained in complementary medicine as well as traditional medicine, and who might be more inclined to listen to what I said. I was dubious.....complementary medicine?......but decided to give it a shot.

This doctor was SUCH a breath of fresh air. He was so nice, and he really listened to me. He didn't discount what I said just because I was fat and therefore "must" be lying about food. He asked me lots of questions and took a lot of time with me. He wasn't a whacked-out hippie; he knew his science and used traditional treatments, but he also kept an open mind to the possibility that traditional views of medicine might be missing some things. He was a gem.

My blood tests were nominally in the "normal" range. However, he said that my symptoms certainly pointed to hypothyroidism and he took all the BBT data I brought seriously. He suggested a "trial of meds"----putting me on a low dose of thyroid meds (Armour thyroid) for a short period of time to see what happened, re-doing the blood tests, and then re-evaluating at that point.

WOW, what a difference. I felt SO much better, so quickly. I had energy again, my periods became regular again, my weight dropped without any change of habits, my skin was no longer like a lizard's.....I felt like a new person.

We tested my levels again after a few weeks on the thyroid meds, and my levels were much better within the normal range instead of at the edges of normal. He felt that if I truly didn't have hypothyroidism, the meds would have made my TSH levels go into the abnormal range, when what they actually did was get them into a better range. So he felt that this (plus the symptom improvement) merited a diagnosis of hypothyroidism. We continued my medication.

Dealing with Doctors: Round Four

A few years later, my insurance changed and this doctor was no longer "in-network." So I switched to an internist closer to home, thinking it wouldn't make that much difference.

Unfortunately, he insisted I switch to Synthryoid instead of Armour Thyroid for meds, and I never quite had the same level of benefit again. But I guess I should count my blessings that he kept me on some form of thyroid meds; some doctors might have taken me off them completely.
[Lesson #3: Not all doctors are equally knowledgeable and willing to work with you on your thyroid issues. It's worth it to hold out for a good one.]
My Experiences with Pregnancy and Thyroid Issues

After that, we moved and I began my family. I am so relieved that I didn't start a family before my hypothyroidism was discovered and treated....who knows how things would have gone without it!

I think having my thyroid levels normalized helped me conceive without any problems (despite my age and size) and it helped me keep my pregnancies normal. We tested my levels periodically in my pregnancies and they never went haywire at all, so I was lucky in that way.

However, after baby #4, I did experience postpartum thyroiditis. I never experienced the hyPERthyroidism that often accompanies this, but boy howdy, did I experience the hypo part! I gained a lot of weight postpartum (normally I lose weight postpartum while breastfeeding), I was exhausted, I was cold all the time, and my skin started looking lizardy again. Yet even with all my years of experience with hypothyroidism, I didn't recognize that my thyroid had gone whacko until many many months later, in retrospect. I just failed to see the patterns.
[Lesson #4: A history of thyroid issues means you may be particular vulnerable to thyroid wackiness during vulnerable times such as pregnancy, postpartum, menopause, and advanced age.]

I'd had my thyroid levels tested at about 4 months postpartum, as part of my yearly thyroid tests. My TSH came back higher than usual, but still well within normal so they didn't adjust my dosage. Now, we don't know how much it fluctuated before and after that; my personal opinion is that it was probably bouncing all over the place and we just didn't know it because we only tested once.
[Lesson #5: If you suspect your thyroid is out of whack, you may need to test multiple times over a short period of time to catch the variations.]

Fine-Tuning Thyroid Meds

Over the years, with much experimentation, I have found that I feel best when my TSH levels are between 1.0 and 1.5, and any even small deviation over that really affects how I feel, the stability of my weight, and skin etc. symptoms. So even though my TSH postpartum had come back "normal," it wasn't normal for me and where I feel best.
[Lesson #6: Some people are exquisitely sensitive to even small changes in TSH levels, and even when levels test "normal," they may not be optimal for that person.]

I also found that I feel better with a combo of both T4 and T3 meds; if I take only Armour, my TSH may be fine but my T3 numbers are too high. If I take only T4 meds (Synthroid and its equivalents), I don't feel as well. It's a combo of a little of both that seems to keep me closest to normal. Makes for twice the prescription co-pay, but it's worth it.

[Lesson #7: Many people feel better when using alternatives to Synthroid, or combos of T3 and T4 meds. However, it's important to track not only your TSH but also your T3 and T4 numbers, as these may be out of whack even when the TSH is fine.]

After going on thyroid meds, I never skipped a period again. EVER. Many of the skin problems I'd experienced (cystic acne, boils etc.) lessened significantly. I was no longer gaining weight uncontrollably. Keeping a stable weight was still a struggle, but not a losing struggle anymore. And I just felt so much better, in so many ways.

Now, I have to be honest.....I didn't experience a total resolution of all my symptoms. I still have some of them.....even after fiddling with my dosage, even after getting meds with both T3 and T4 in them, even after doing all the things I'm "supposed" to do.

There may still be something out there to try yet, or there may be some other problem complicating full resolution......but I also have to concede the possibility that hypothyroidism may be more complex than we think, and even with thyroid meds my symptoms may never be fully resolved. I hope doctors will keep researching hypothyroidism and its implications because there are a lot of people out there like me that experience help but not full resolution of symptoms with treatment.

But the improvement I have experienced has been remarkable in so many ways that I am grateful that I persevered in getting diagnosed and treated. It has absolutely been worth the time and trouble.

[Lesson #8: Not everyone gets full remission of symptoms even with best current treatment, but perhaps as they learn more about hypothyroidism and its co-morbidities, treatment will get even more effective. Partial remission of symptoms is far better than no remission at all.]

Hypothyroidism Needs to be Taken More Seriously

My experience (and the similar experience of many others) tells me that many symptomatic people with "borderline" TSH readings actually benefit significantly from treatment to optimize their thyroid levels, yet there is a great deal of resistance to this in the medical community.

Although more study is needed, some research does seem to indicate that people of size and those with PCOS do tend to have thyroid issues (especially the "borderline" kind) more frequently. People in these categories should have their thyroid levels tested regularly throughout their life, as a precaution, and especially before pregnancy.

Yet it's still so hard to get doctors to take "borderline" TSH readings and symptoms seriously, or to get newer diagnostic standards widely accepted by most doctors and labs. Far too many people are still being told they are "fine" when they are not, or are not being tested at all.

This is a story that is so common among people of size. We tell doctors over and over that something is wrong, that something is "off" and we just don't feel right. And over and over, we are not taken seriously, or it's all blamed on being fat.

The tremendous resistance to our experiences and concerns seems to come from the belief among some healthcare professionals that fat people are "just looking for an excuse for being fat" and you can't really trust what they say. And that if they'd just get off their butts and lose weight, all these issues would be resolved.

For a while, there was some headway on this problem, but now I see the pendulum swinging back again towards blaming and closed minds. If you protest that something else besides "calorie math" must be going on, they think you are making excuses for yourself, lying about what you actually eat, or are simply in denial.

Healthcare professionals simply MUST start stepping outside the paradigm that obesity itself is the main cause of all problems in fat people, and that weight loss is the only way to really deal with these issues.

They must consider the possibility that obesity may sometimes simply be a symptom of other issues, instead of the cause of them. They must recognize that permanent weight loss is difficult and not just a matter of willpower. They must start recognizing that this focus on weight loss at all costs often causes more problems than it fixes. And they must start looking for ways to improve symptoms and quality of life in people of size that don't necessarily involve weight loss as the "fix."

And they simply must lose the judgmental attitudes that fat people are always simply looking for an excuse for being fat.

Final Advice to Those with Hypothyroidism

If you suspect you may have hypothyroidism, or if you have already been diagnosed and are working with a healthcare professional, inform yourself as much as possible about thyroid issues. Find a healthcare professional who listens to your concerns, will work with you to find the best possible meds and dosage, and keep reading the research.

There are good, decent healthcare professionals out there that will take your concerns seriously; it's really worth finding them. But the first step is informing yourself and becoming an advocate for your own needs.

Sunday, September 14, 2008

Hypothyroidism and Pregnancy

Over at the blog, the-f-word, the author has had a series of recent posts discussing hypothyroidism. This is a topic of special importance when discussing pregnancy and postpartum issues so I thought I'd highlight it here too.

[There's no need to repeat all her information, so we'll just mention a few points particularly pertinent to pregnancy and postpartum, and then tell you to GO READ IT. ]

Many fat folk have undiscovered or undertreated hypothyroidism. Doctors often do not take hypothyroidism concerns seriously in fat people, thinking they are trying to excuse their supposed eating problems. So it can be difficult to find a care provider who is willing to take these concerns seriously or test them in any meaningful way.

Furthermore, exactly what TSH levels should be used to diagnose hypothyroidism is controversial. Newer diagnostic cutoffs favored by some medical groups tend to diagnose and treat more people; the older cutoffs miss a lot of borderline or "subclinical" cases. Yet these folks often experience typical hyothyroidism symptoms like:
  • obesity/unexplained weight gain/difficulty losing weight
  • tiredness/fatigue
  • very dry or cracked skin
  • menstrual problems/irregularity
  • dry/brittle hair and nail changes
  • muscle or joint aches and pains
  • feeling cold a lot/intolerance to temperature variations
  • depression issues
  • "brain fog"
  • constipation
  • fertility issues
If you have a combination of these symptoms you might want to consider thyroid testing. However, if you do have thyroid testing, BE SURE TO GET YOUR EXACT RESULTS AND THE DIAGNOSTIC CUTOFFS USED TO DEFINE "NORMAL." Compare your exact results to the levels considered "normal" and see where your levels fall.

Too often, people are told their results are "normal" when in fact, closer examination may show that their results are borderline (and should be watched and retested later) or are actually abnormal when using the newer, lower cutoffs.

[I really can't stress this enough. Do NOT just accept a "normal" or "abnormal" on lab tests; actually get the numerical results, the range the lab used to determine "normal" and compare them. Then request a copy of your lab results and keep a record of them so you can track them over time. Remember, lots of people who may have been diagnosed as "normal" in the past might now be considered to have "abnormal" results now under revised guidelines.]

Thyroid Tests and Pregnancy Concerns

If you are considering pregnancy at any time in the near future, you might want to have your thyroid levels checked as a precaution beforehand, even if you don't suspect a problem.

Some doctors these days recommend that ALL women have their thyroid levels checked before or during pregnancy, but it's not certain whether this broad a testing distribution is really justified by research. More study is needed before such widespread testing is implemented.

However, for women of size (and especially those with PCOS), it probably is sensible to have the thyroid levels checked before pregnancy. Although not all research agrees, some research suggests that obese people tend to have higher rates of both overt and subclinical (or "mild") hypothyroidism. Other research suggests that women with PCOS also have more subclinical hypothyroidism. Therefore, it probably makes sense for women in these two groups to have their thyroid levels checked carefully, preferably well before conception.

For some women, it also makes sense to check thyroid levels during pregnancy as well. If you have had thyroid issues in the past (or suspect them), are being treated currently for hypothyroidism, or if you have a strong family history of hypothyroidism, you should have your levels monitored regularly during pregnancy.
Even if your hypothyroidism was well-controlled beforehand, it may not stay that way during pregnancy, and can change fairly quickly. Therefore, periodic testing during pregnancy is a must for those with hypothyroidism.

Your levels should be measured about every trimester, on average. However, some women need to increase their thyroid medication dosage even early in the first trimester. If your thyroid levels historically have bounced around a lot, you may be particularly susceptible to early problems and should be closely monitored. If you haven't seen your midwife or OB yet, your family doctor/GP can help you get the tests you need until you have a care provider for your pregnancy.

Does Hypothyroidism Make a Pregnancy High-Risk?

Some women with hypothyroidism have been told that their hypothyroidism makes them "high risk" and so they are not good candidates for a birth center or home birth, or that they should only see an OB or even a perinatologist during pregnancy.

However, it's only UNTREATED or INADEQUATELY TREATED hypothyroidism that is really a risk. As long as thyroid levels are tested periodically and treated adequately, women with hypothyroidism don't need to be treated as "high-risk." Most women with adequately-treated hypothyroidism have normal, healthy pregnancies and babies. (I did, four times, and so have many other women with hypothyroidism that I know.)

Unless thyroid levels are particularly difficult to keep under control, women with hypothyroidism can see any type of provider they wish...nurse-midwife, homebirth midwife, family doctor, or OB.

Nurse-midwives and doctors all can order thyroid tests and adjust prescriptions as needed; homebirth midwives often can order lab tests and work with consulting doctors to make prescription adjustments if needed. Any of these types of care providers can provide care for a pregnant woman with hypothyroidism.
Some women prefer to be followed by both a pregnancy care provider and an endocrinologist, as they feel their endocrinologists may pay closer attention to smaller changes in their thyroid levels. Others do not feel the need for care beyond their normal provider.

Hypothyroidism does not preclude you from birthing at home or at a birth center, nor does it necessitate a high-risk provider. Choose whatever provider you feel most comfortable with. However it's a good idea to ask your care provider about his/her plan for monitoring your thyroid levels during pregnancy; some care providers are more knowledgeable about thyroid concerns than others. Be sure they also have a plan for checking your levels postpartum.

Postpartum Thyroid Issues

After the baby is born, many women experience thyroid difficulties. Even if you've never had thyroid issues in your life, were fine during pregnancy, or were totally fine in all previous pregnancies, you may still develop postpartum thyroiditis. It is important to watch ALL women carefully for thryoid symptoms after birth.

Postpartum thyroiditis classically involves a period of hyPERthyroidism (thyroid is overactive) followed by hyPOthyroidism (thyroid is underactive). However, be aware that some women skip straight to the hypothyroidism part and never experience any real signs of hyperthyroidism first.

About 5-10% of all women develop postpartum thyroiditis, but the incidence is higher in women with a history of thyroid or autoimmune issues. Doctors often miss postpartum thyroiditis since they usually only see you briefly several weeks after the baby is born. And with a new baby, many moms tend to dismiss symptoms or don't take time to have them investigated. So postpartum thyroiditis tends to be underdiagnosed and the incidence may be higher than generally acknowledged.

Women experiencing difficulty with breastmilk production should have their thyroid levels tested (as well as testing for anemia etc.), because this can affect milk production. There are many other possible causes of low milk production, of course, but this is one that is often missed. And because thyroid levels can fluctuate widely after childbirth, repeated testing may be needed. Although most women with a history of thyroid issues can breastfeed without problems, they should be particularly watchful for possible thyroid issues.
Women who gain a lot of weight in the months after giving birth (despite normal intake and despite breastfeeding) may also be experiencing postpartum thyroid issues and should be checked.

Women who experienced severe bleeding during and after birth should also be aware of a potential for thyroid problems. Sometimes severe hemorrhage can damage the pituitary gland, which in turn can lead to hypothyroidism. This is called Sheehan's Syndrome. As one website notes:

Rarely, hypothyroidism after childbirth is caused by Sheehan's syndrome, also called postpartum hypopituitarism. This condition may occur in women who have severe blood loss during childbirth resulting in damage to the anterior pituitary gland.

Finally, women who experience thyroid issues during and after pregnancy should also be warned to watch for possible recurrence of thyroid issues during perimenopause and menopause. Advanced age is another period of time when women are particularly vulnerable to hypothyroidism too. Thus, periodic thyroid tests should become part of women's life-long care.

Thyroid Medicine and Supplements

Hypothyroid medications are generally considered safe during pregnancy and breastfeeding. Remember, these medications are simply putting back into your body what should already be there. Babies are at far greater danger from untreated hypothyroidism than they are from typical hypothyroid medications. Just make sure to monitor your thyroid levels periodically.

I know of no "official" correlation between hypothyroidism and vitamin D levels, but it's my observation that many folks with hypothyroidism also have chronically low vitamin D levels as well. Whether there's a causal connection is debatable, but they often do seem to go hand in hand. So while you are at the doctor's having your TSH etc. checked, consider asking them to run Vitamin D levels as well.

Finally, remember that many things interfere with absorption of thyroid medicines. In particular, thyroid meds should NOT be taken at the same time as prenatal vitamins. (Many doctors don't know this; mine didn't.) Iron and calcium in particular interfere with absorption of thyroid medications, and prenatals are full of iron and calcium. Take your thyroid meds and your prenatals at least 2-3 hours apart instead.

Take your thyroid meds as consistently as possible. Thyroid meds are most effective taken in the morning, on an empty stomach, with plenty of water. Avoid eating for about an hour afterwards if possible. Do not take with any other meds or vitamins, and if possible, take them about the same time each day.


Although most women will not have problems with their thyroid during their pregnancies or postpartum, the frequency with which it occurs (even in women with no prior thyroid issues) merits close attention from birth attendants.
However, because not all birth attendants are fully aware of hypothyroidism issues in pregnancy, women need to be proactive about informing and advocating about this issue for themselves, particularly women of size.

Saturday, September 6, 2008

Metformin and B Vitamins?

Many people of size take metformin (a.k.a. Glucophage). They might take it for insulin resistance/PCOS issues, or they might take it for blood sugar issues....or both, since the two are often related.

This post is of particular concern to those women of childbearing age who take metformin, but anyone on metformin should know about it.

I recently ran across some research linking metformin with low levels of B vitamins, particularly vitamin B12 and Folic Acid.

Although the worst effects seem to happen with years of treatment and higher dosages, even short-term treatment (16 weeks) reduced the levels of folate and B12.

These lowered levels of folate and B12 also seem to be linked to an increase in homocysteine levels, which is commonly seen after metformin is started. Now, what significance this has, if any, is still being debated. In terms of general health, homocysteine levels may be tied to heart health; high levels are considered a risk factor for cardiovascular disease. There is some research indicating that administration of B-group vitamins reduces homocysteine levels in non-pregnant PCOS patients treated with metformin. But we don't really know yet if lowering homocysteine levels results in any meaningful reduction in long-term endpoints like decreased heart attacks or mortality.

However, we do know that some people on metformin do develop megoblastic anemia at some point during treatment. So certainly, it's seems like it's something that anyone on metformin should be aware of and monitored for periodically.

It might even be sensible to take extra B vitamins (B group complex, presumably) while on metformin, although formal studies on the value of that seem to be lacking so far. There is also one study that found that supplemental calcium may help blunt or reverse B12 malabsorption with metformin.

Implications for Pregnancy?

All this information about metformin impacting B12 and folic acid levels makes me wonder if there are special implications for women of childbearing age. We know that folic acid levels are important for preventing birth defects like neural tube defects (NTDs, like spina bifida or anencephaly). If a woman with PCOS has been on metformin for years and her folic acid levels are chronically low when she conceives, does this increase her risk for NTDs?

As far as I can tell, no one knows. There doesn't seem to be any increase in birth defects in women on metformin so far, but research is limited. Because preliminary research on metformin in pregnancy indicates that it cuts the risk for miscarriage and gestational diabetes in women with PCOS, it's likely to be used more and more often in the future, provided the research continues to be supportive.

So the question becomes, should women on metformin who are considering conceiving (or who are of childbearing age at all) be supplemented with extra folic acid and B12 (or B vitamins in general)? And if so, by how much? What about calcium, if it helps reverse the malabsorption of B12? Should levels of B12 be monitored during pregnancy?

At this point, I don't think anyone knows for sure. Anecdotally, many women on metformin do seem to be taking additional folic acid at least. Consult your care provider about this topic and what dosages might be appropriate beyond a normal prenatal vitamin. (And if you do decide to take supplemental vitamins in addition to metformin, you should probably take them at different times of day.)