Brief Answer:
You have PCOS and metformin, clomid and weight loss will help

Detailed Answer:
Thank you for the question and I am happy to help. Her is a summary of your situation:

1. You are 42 years of age
2. You are trying to get pregnant for about four months
3. You had a prior miscarriage in April of 2017
4. You have an elevated BMI at 44
5. You were started on metformin 500mg twice daily
6. You have cycles that occur every 25-29 days
7. You have had some unexplained 'extra' bleeding

In women who are overweight, they commonly suffer from a condition that we refer to as polycystic ovarian syndrome (PCOS). In this syndrome, women are commonly overweight, pre-diabetic, and do not ovulate on a regular basis. Obviously you did ovulate before because you were able to get pregnant, but it is almost certainly not predicatable. Normally at the start of a cycle you recruit eggs, these eggs produce estrogen, the rise in estrogen triggers ovulation (release of one egg) and the remaining eggs are absorbed. If pregnancy does not occur, hormone levels drop and women get a period and the cycle restarts. In women who are not ovulating, they have abnormal bleeding. This may manifest as skipped periods, but it can also manifest as breakthrough bleeding that is confused as a period. The bleeding followed by spotting does not sound like a normal period and is likely the result of breakthrough bleeding after not ovulating. I sometimes describe this to patients as trying to get pregnant in slow motion. Finally, your age is a factor as fertility rates go down and cycles become more irregular as you age. In someone such as you the following should (or should have) occurred:

1. Continue the metformin as this will help to decrease insulin resistance and increase the chance of ovulation. It will also help with weight loss
2. In patients with PCOS, the addition of clomid or letrazole will increase the chance of pregnancy
3. You should have had an ultrasound to evaluate the uterus
4. Your partner should have had a semen analysis
5. You need to aggressively pursue weight loss. Not only will this increase your chance of achieving pregnancy, but it will also decrease the risks of pregnancy.
6. You need to be using ovulation detection kits as this is the best way to tell if you are ovulating

I hope that this helps. I understand that time is not on your side. The good news is that you WERE able to get pregnant. The problem is that it is an uphill battle to get back there!

I hope that this helps.
Dr. Raichle

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Brief Answer:
Please answer the following question

Detailed Answer:
Have you ever had an ultrasound of your uterus? If so, what were the results?
Kindly upload the reports so that I am better able to help.

Dr. Raichle

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Brief Answer:
Please do not assume cancer

Detailed Answer:
First of all, I am sorry about the delay.

Second, PCOS is not something that you can rule out - remember it is a 'syndrome' which is just a constellation of symptoms. The symptoms typically include:

1. Patients who are not ovulating regularly (and their ovaries appear polycystic on ultrasound)
2. They are often unable to get pregnant
3. They often have unpredictable bleeding (related to #1)

But it is a distraction to consider whether or not you have this 'syndrome'. The fact is that you are not ovulating predictably and this is leading to irregular bleeding and the inability to get pregnant. You are on the right path but you need:

1. An ultrasound to evaluate the anatomy of the uterus as there are anatomic changes that can occur that will interfere with pregnancy and lead to abnormal discharge (such as polyps)
2. After the ultrasound, assuming that it is normal, there needs to be consideration of ovulation induction medications (see my prior answer)
3. You need to pursue weight loss as this almost certainly is playing a role

Does this help? What other questions do you have?

Dr. Raichle

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Brief Answer:
No, I advice you continue metformin.

Detailed Answer:
Sorry for the delay. I suggest you continue metformin as your BMI is very high, it will help reduce your weight as it is also necessary for the continuation of pregnancy. Metformin will not come in the way for you to conceive naturally, so you can go ahead with it as planned. Please upload the ultrasound of uterus if done so that I can help you better.

I hope that this helps.
Dr. Raichle

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