diff --git a/docs/python-api.rst b/docs/python-api.rst
index 28adfba..c656045 100644
--- a/docs/python-api.rst
+++ b/docs/python-api.rst
@@ -716,6 +716,8 @@ If it cannot find such a table, it will create a new one using the names of the
 
 It it finds multiple candidate tables with foreign keys to both of the specified tables it will raise a ``sqlite_utils.db.NoObviousTable`` exception. You can avoid this error by specifying the correct table using ``m2m_table=``.
 
+The ``.m2m()`` method also takes an optional ``pk=`` argument to specify the primary key that should be used if the table is created, and an optional ``alter=True`` argument to specify that any missing columns of an existing table should be added if they are needed.
+
 .. _python_api_m2m_lookup:
 
 Using m2m and lookup tables together
diff --git a/sqlite_utils/db.py b/sqlite_utils/db.py
index c6bc606..14a9efc 100644
--- a/sqlite_utils/db.py
+++ b/sqlite_utils/db.py
@@ -2009,6 +2009,7 @@ class Table(Queryable):
         pk=DEFAULT,
         lookup=None,
         m2m_table=None,
+        alter=False,
     ):
         if isinstance(other_table, str):
             other_table = self.db.table(other_table, pk=pk)
@@ -2045,7 +2046,9 @@ class Table(Queryable):
             )
             # Ensure each record exists in other table
             for record in records:
-                id = other_table.insert(record, pk=pk, replace=True).last_pk
+                id = other_table.insert(
+                    record, pk=pk, replace=True, alter=alter
+                ).last_pk
                 m2m_table.insert(
                     {
                         "{}_id".format(other_table.name): id,
diff --git a/tests/test_m2m.py b/tests/test_m2m.py
index cbc9015..5423d2b 100644
--- a/tests/test_m2m.py
+++ b/tests/test_m2m.py
@@ -14,6 +14,24 @@ def test_insert_m2m_single(fresh_db):
     assert [{"humans_id": 1, "dogs_id": 1}] == list(dogs_humans.rows)
 
 
+def test_insert_m2m_alter(fresh_db):
+    dogs = fresh_db["dogs"]
+    dogs.insert({"id": 1, "name": "Cleo"}, pk="id").m2m(
+        "humans", {"id": 1, "name": "Natalie D"}, pk="id"
+    )
+    dogs.update(1).m2m(
+        "humans", {"id": 2, "name": "Simon W", "nerd": True}, pk="id", alter=True
+    )
+    assert list(fresh_db["humans"].rows) == [
+        {"id": 1, "name": "Natalie D", "nerd": None},
+        {"id": 2, "name": "Simon W", "nerd": 1},
+    ]
+    assert list(fresh_db["dogs_humans"].rows) == [
+        {"humans_id": 1, "dogs_id": 1},
+        {"humans_id": 2, "dogs_id": 1},
+    ]
+
+
 def test_insert_m2m_list(fresh_db):
     dogs = fresh_db["dogs"]
     dogs.insert({"id": 1, "name": "Cleo"}, pk="id").m2m(