CNN
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Mifepristone, one of two drugs used in medical abortions, can continue to be mailed to patients without an in-person consultation with a doctor after the U.S. Supreme Court rejected a lawsuit challenging regulation of the abortion pill.
“While many women obtain a medical abortion at a clinic or from their obstetrician-gynecologist, others obtain the pills themselves to induce or self-manage their abortion,” said Dr. Daniel Grossman, professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco.
“A growing body of research indicates that self-managed abortion is safe and effective,” he said.
Mifepristone blocks the production of progesterone, a hormone needed to maintain a pregnancy. The drug is approved to terminate a pregnancy up to 10 weeks gestation, or “70 days or less since the first day of the last menstrual period,” according to the U.S. Food and Drug Administration (FDA).
In a medical abortion, a second medication, misoprostol, is taken within 24 to 48 hours. Misoprostol causes the uterus to contract, which leads to cramping and bleeding. Approved for use in other conditions, such as preventing stomach ulcers, the medication has been available in pharmacies for decades.
Together, the two drugs are commonly known as the “abortion pill,” which is now used in more than half of all abortions in the United States, according to the Guttmacher Institute, a research group that supports abortion rights.
“Some people do it because they can’t get to a clinic — especially in states where the law restricts abortion — or because they prefer to take care of themselves,” said Grossman, who is also director of Advancing New Standards in Reproductive Health, a research group that evaluates the pros and cons of reproductive health policies and publishes studies on how abortion affects a woman’s health.
What happens during a medical abortion? CNN spoke with Grossman to find out. This conversation has been condensed and edited for clarity.
CNN: What is the difference between a first trimester medical abortion and a vacuum suction in terms of what a woman experiences?
Dr. Daniel Grossman: Vacuum aspiration is most often performed under a combination of local anesthesia and oral pain medication or local anesthesia combined with intravenous sedation, or what is called conscious sedation.
An injection of local anesthesia is given into the area around the cervix, and the cervix is gently dilated or opened. Once the cervix is opened, a small straw-like tube is inserted into the uterus and a gentle vacuum is used to remove the pregnancy tissue. Contrary to what some say, if the procedure is performed before about nine weeks, there is nothing in the tissue that could be recognized as part of an embryo.
The aspiration only lasts a few minutes. The patient is then placed under observation for one to two hours until the sedative effect has worn off. We also monitor each patient for very rare complications, such as heavy bleeding.
Medical abortion is a longer process. After taking the pills, bleeding and cramping may occur for several days. Bleeding is usually heavier when the pregnancy is expelled, but it usually subsides within a few hours. On average, women continue to have light bleeding for about two weeks, which is a little longer than after vacuum aspiration.
Nausea, vomiting, fever, chills, diarrhea, and headache may occur after using the abortion pill, and all people who have had a successful medical abortion usually report some pain.
In fact, the pain of a medical abortion can be quite intense. In studies that have looked at it, the average maximum pain level reported by women is about seven to eight out of ten, with 10 being the highest level. However, women also say that the pain can be brief, peaking just as the pregnancy is being expelled.
The intensity of cramping and pain may depend on the length of the pregnancy and whether or not the person has given birth before. For example, a medical abortion performed at six weeks or less gestation usually causes less pain and cramping than an abortion performed at nine weeks. People who have given birth before usually have less pain.
CNN: What can be done to ease the pain of a medical abortion?
Grossman: There are certainly medications that can be used to relieve pain. Research has shown that ibuprofen is more effective than paracetamol in treating the pain of medical abortion. We generally advise people to take 600 milligrams every six hours or so, as needed.
Some people take tramadol, a narcotic pain reliever, or Vicodin, a combination of acetaminophen and hydrocodone. Recent research I’ve been involved in has shown that medications like tramadol can be helpful if taken prophylactically before pain occurs.
Another effective treatment we studied combined ibuprofen with an anti-nausea drug called metoclopramide, which also relieved pain. Besides ibuprofen, these drugs require a prescription.
Another study showed that a TENS (transcutaneous electrical nerve stimulator) device helped relieve the pain of medical abortion. It works by placing pads on the abdomen that stimulate nerves with mild electrical shocks, interfering with pain signals. It is a device that women can get without a prescription.
Pain can be an overlooked issue in medical abortion because, quite frankly, as clinicians, we’re not there to support patients when they’re at home and they’re going through this ordeal. But as we’ve done research on the experiences of people who have medical abortion, it’s become clear that pain management is really important. I think we need to do a better job of addressing pain and making these options available to patients.
CNN: Are there any health concerns that make medical abortion unwise?
Grossman: Medical abortion can be dangerous if the pregnancy is ectopic, that is, if the embryo develops outside the uterus. This is rare, occurring in about 2 out of 10 cases. every 100 pregnancies — and it appears to be even rarer among people seeking medical abortion.
People who have had surgery on the pelvis, fallopian tubes, or abdomen are at higher risk of ectopic pregnancy, as are those with a history of pelvic inflammatory disease. Certain sexually transmitted infections can increase the risk, as can smoking, a history of infertility, and the use of fertility treatments such as in vitro fertilization.
If a woman is taking blood thinners or anticoagulants or has a bleeding disorder, medical abortion is not recommended. Prolonged use of steroids is another contraindication to the use of the abortion pill.
Anyone using an intrauterine device, or IUD, should have it removed before taking mifepristone, as it may be partially expelled during the process, which can be painful.
People with chronic adrenal insufficiency or who have inherited a rare disease called porphyria are not good candidates.
CNN: Are there any signs of trouble a woman should watch for after having a medical abortion?
Grossman: It is common to have a mild fever in the first few hours after taking misoprostol, the second medication used in a medical abortion. If a person has a mild fever (102.2 to 102.2°F) that lasts more than four hours, or a high fever over 102.2°F after taking the medication, they should be evaluated by a healthcare professional.
Heavy bleeding, which would require the use of two or more regular-sized thick sanitary napkins per hour for two consecutive hours, or foul-smelling vaginal discharge should also be evaluated.
One of the warning signs of an ectopic pregnancy is severe pelvic pain, especially on one side of the abdomen. The pain may also radiate to the back. Another sign is dizziness or fainting, which can indicate internal bleeding. These are all very rare complications, but it is wise to be vigilant.
We generally recommend that the person having a medical abortion have someone with them for the first 24 hours after taking misoprostol or for the rest of the pregnancy. Many women specifically choose to have a medical abortion because they can have a partner, family, or friends with them.
Most women know that the abortion is complete because they no longer feel pregnant, and symptoms such as nausea and breast tenderness usually disappear within a week after the abortion. A home urine pregnancy test may remain positive even four to five weeks after a successful medical abortion, simply because it takes this long for the pregnancy hormone to disappear from the bloodstream.
If a person still feels pregnant, is not sure if the pregnancy is completely complete, or has a positive pregnancy test five weeks after taking mifepristone, they should be evaluated by a clinician.
It is important to know that it is possible to ovulate two weeks after a medical abortion. Most methods of contraception can be used immediately after a medical abortion.
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