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The Three M's of Medical Abortion — Mifepristone, Methotrexate and MisoprostolAmong the side effects of misoprostol are diarrhea, nausea and vomiting. Some women also get hot flashes or episodes of fever. Possibly because it enters the bloodstream more gradually, misoprostol seems to have fewer side effects when given as a suppository than by mouth.(5)
Medical Abortion Drugs and Birth DefectsAny medical abortion drug carries with it two main risks: one, that it will not work; and two, that if an unsuccessful medical abortion is not followed up by a traditional surgical abortion, the abortion drug or combination of drugs may harm the fetus.
Based on what we know today, of the three drugs we have mentioned, misoprostol is the most likely to cause birth defects. Limb and cranial abnormalities have been reported in babies born to women who remained pregnant after using misoprostol. Obviously, the newer the drug the less information is available. For instance, there is little or no evidence that mifepristone can cause any particular problem. Although in the high doses used in cancer treatment methotrexate poses a clear risk to a developing fetus, we do not know if the low dose of methotrexate used for medical abortion has a similar effect.(4)
It should be remembered, however, that most of the scientific data on these drugs come from studies in which women have agreed in advance to undergo a surgical abortion if medical abortion drugs fail. For this reason, it is difficult to collect enough data to determine whether these drugs will cause birth defects.
Medical Reasons Not to Have a Medical AbortionThere are a number of medical reasons why a woman might not be able to take the medical abortion drugs. The contraindications to these drugs should be discussed one-on-one between a woman and her own doctor. The most common medical conditions are long-term corticosteroid therapy, chronic adrenal failure, a disease called porphyria, conditions that cause internal bleeding or anticoagulant medication, as well as any indication of an allergy to one of the medications. If a woman has an IUD, it must be removed before taking the medications.(7)
For many women, medical abortion is desirable because it enables them to avoid a surgical procedure. However, because of the possible birth defect risk discussed above, all patients are required to agree that they will have a surgical abortion if the medical abortion fails.
The Steps of a Medical Abortion Procedure
Mifepristone/MisoprostolOn her first visit, following examination, counseling and signed permission, a woman undergoing a medical abortion takes mifepristone (600 mg). This generally causes few noticeable symptoms. (A small percentage of women, however, usually less than 5%, will have an abortion at this point.) Two days later, she takes misoprostol in pill form (400 mcg). Note that this is the PC regimen.
In the ARM version, the woman takes mifepristone by mouth (200 mg) and two days later takes misoprostol (800 mcg) as a suppository. In both of these regimens, two-thirds of women develop cramps and bleeding and complete the abortion in the next four hours. After 24 hours, the success rate nears 90%.(8)
The heaviest bleeding occurs on the day misoprostol is taken. For most women, bleeding and spotting continue for about two weeks. Uterine cramps also occur and vary from extremely severe to very mild. Women usually describe the bleeding and cramps as resembling a heavier than normal menstrual period.(5)(9)
Women having a medical abortion are normally given pain killers such as ibuprofen, acetaminophen or a stronger analgesic containing codeine.
Methotrexate/MisoprostolThe basics of a medical abortion with methotrexate are very similar to that using mifepristone, except that it takes longer. Methotrexate is given by injection (75-100 mg). At least two days later, a misoprostol suppository is given. At this point, about 60% of women abort within 24 hours. Twenty to 30% of patients do not complete their abortion for another three to three and half weeks, and the bleeding lasts longer than with mifepristone.(4)
Follow-up VisitIn all regimens, women are asked to return after 14-20 days for an examination to determine whether the abortion has occurred. While the overall success rate for medical abortion is around 90%, studies have shown that the greater the experience of the center providing the abortion, the lower the failure rate. (3)(10)(11)
Medical Abortion in the United States TodaySurveys show that medical abortion is well accepted — many phyisicans, for example, indicate they are willing to provide this option to their patients.(12) When women are asked why they chose medical over surgical abortion and whether they found the procedure acceptable, most say they wanted to avoid a surgical procedure, felt a medical procedure was more natural and more private, and allowed them to feel more in control. When the option of taking the misoprostol at home, rather in the clinic, was available, women who took their medication at home liked the increased sense of privacy and convenience, as well as having friends and family members nearby.
The political picture is less clear. In the United States, pro-life forces have focused on trying to restrict the use of mifepristone (RU-486). This is largely because the two other medical abortion drugs have been approved for other uses and are, therefore, already available. The PC and the ARM studies demonstrated the safety and efficacy of mifepristone and, despite the opposition, the drug was approved by the FDA in September of 2000.
The FDA has, however, put limits on the use of RU-486 — the medication is not sold in pharmacies but is provided directly to physicians' offices. Opponents of medical abortion continue to pursue the battle on two fronts. Upon his appointment as Health and Human Services Secretary, Tommy Thompson suggested that he might direct the FDA to reopen the approval process for RU-486.
Although Secretary Thompson has since backed away from his comment in his public statements, the possibility remains that the Bush Administration may further restrict the availability of medical abortion. Meanwhile, the U.S. Congress is debating a bill that would allow RU-486 to be prescribed only by the small minority of doctors who currently perform surgical abortions and only at clinics within an hour's drive of an hospital emergency room.
For More InformationTo learn more about the practical considerations of medical abortion, click on our interview with Planned Parenthood's Jini Tanenhaus.
May 1, 2001
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