The legal battle over mifepristone, one of the two pills used in medication abortions, has created a lot of confusion around the availability of abortion pills. An appeals court has ruled that the pill will remain available, albeit heavily restricted, until a case challenging its FDA approval is heard. But even if the Justice Department’s appeal were unsuccessful and mifepristone were eventually to be pulled from shelves, medication abortion remains an option for patients thanks to the second drug in the regimen: misoprostol.
While the two-pill regimen accounts for most abortions in the United States, misoprostol-only abortions are currently the most common medication-abortion method used worldwide. The World Health Organization and other leading health agencies recommend terminating a pregnancy with misoprostol in contexts where mifepristone is not available or accessible, says Dr. Daniel Grossman, a professor of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco, and director of Advancing New Standards in Reproductive Health. Research has shown terminating a pregnancy with this method is safe, albeit less effective than medication abortion with mifepristone. As Jezebel has reported, several telehealth and traditional abortion providers — including Aid Access, Carafem, Just the Pill, and Planned Parenthood — are prepared to switch to misoprostol-only abortions if mifepristone gets taken off the market.
Judge Matthew Kacsmaryk’s order suspending mifepristone’s approval was riddled with anti-choice terms like “chemical abortion” and “unborn human,” as well as debunked science about the safety of mifepristone and its effect on patients, demonstrating how easy it is for anti-abortion misinformation to take root. (Studies have shown that medication abortion is safer than taking Tylenol or Viagra, with less than 0.4 percent of patients experiencing serious complications that require hospitalization.) “I know this is a frightening time for patients who need this care,” Grossman says. “They don’t know what services are going to be available. It’s important to reiterate that nothing has changed about what we know about these pills. It’s still very clear that they are safe and effective.”
Here’s what to know about using misoprostol off-label for a medication abortion; it’s not medical advice, but rather information gathered from Grossman, a practicing clinician and abortion researcher, as well as other expert sources.
What is misoprostol?
Misoprostol, which was developed in the 1970s, is a synthetic prostaglandin — a type of lipid that has hormonelike functions. In the U.S., the FDA has approved it to treat and prevent stomach ulcers. However, health providers prescribe the drug off-label for a wide range of gynecological purposes, including abortion, inducing labor, and miscarriage management.
How is misoprostol-only abortion different?
The combination regimen, in which a patient takes two different drugs, is the standard of abortion care in the U.S. and is recommended by the FDA up to ten weeks into pregnancy. The first pill, mifepristone, helps end pregnancy by blocking the effect of the hormone progesterone. “The effect of mifepristone is to cause the lining of the uterus to become thin, which causes the pregnancy to start to separate from the lining,” Grossman says. “It also seems to make the uterine muscle wall more sensitive to the effect of the misoprostol.”
Misoprostol causes both the cervix to open and the uterus to contract. “In doing that, it essentially expels the early pregnancy,” Grossman says. Misoprostol may be the second step in the regimen, but it does the bulk of the work in a medication abortion, which is why it can be used in higher doses to terminate a pregnancy without mifepristone.
The combination method is about 95 percent to 99 percent effective, while misoprostol-only abortions are around 90 to 93 percent effective. The World Health Organization recommends the misoprostol-only regimen for up to 12 weeks of pregnancy. According to a 2019 review of 38 studies, it’s also very safe — only about 0.7 percent of patients who took misoprostol alone in the first trimester experienced complications that required hospitalization.
What prep is needed?
Folks who’ve had medication abortions recommend stocking up on supplies as if to weather a bad period and the stomach flu in the same week. They recommend grabbing pads, since tampons or a menstrual cup are out of the question; dry foods that won’t trigger nausea, such as crackers and pretzels; clear liquids to help rehydrate, like Pedialyte or sports drinks; a heating pad, which can even be DIY-ed at home; and anything else needed to feel comfortable.
Before taking misoprostol, Grossman recommends taking ibuprofen, which health providers consider better for treating the pain associated with medication abortion than Tylenol. A transcutaneous electrical nerve stimulator, commonly known as a TENS unit, also can alleviate discomfort. “Putting those on the abdomen actually seems to help with the pain,” Grossman says. “And those are things you can get relatively inexpensively at a pharmacy or ordering online.”
Grossman also cautions that misoprostol pills are generally sensitive to moisture, so make sure the packaging is not punctured and store them in a cool, dry place. “We worry if the pills have been exposed to air, and especially humidity, over a period of time, they could lose their potency,” he says.
How is misoprostol administered alone for an abortion?
Clinicians prescribe between three and four doses of 800 mg (or about eight to 12 pills of 200 mg) of misoprostol, according to Grossman. He says providers consider how easily patients can obtain extra pills either at a clinic or at the pharmacy when deciding how many doses to prescribe.
Grossman says patients either take each dose of four pills sublingually (under the tongue) or place them vaginally. If taken under the tongue, he adds that patients should wait 30 minutes for the pills to dissolve before drinking water to swallow whatever remains. The doses are repeated every three hours. “If within three hours, they’ve only had just light bleeding or no bleeding, then it would be recommended that they take the extra dose as well,” Grossman says. “So it’s possible someone takes up to five doses of the medication.”
Whether to use the pills sublingually or vaginally is up to the patient and their provider. Grossman notes that taking the medication under the tongue can make nausea worse, while remnants of misoprostol pills placed vaginally may persist for longer.
Are there side effects?
Patients generally experience symptoms within 24 hours of taking the first dose of misoprostol. Symptoms will vary from person to person, Grossman says, but bleeding and cramping is normal. The bleeding will likely be heavier than a regular period. Some people may expel blood clots. Others may experience cramping for a longer time, so he says it’s important to have ibuprofen on hand.
Side effects including nausea, vomiting, chills, fever, and diarrhea can be pretty common with the misoprostol-only regimen, Grossman says. The bleeding may last several days on and off, or in some cases, several weeks. Medical experts warn against introducing objects into the vagina, and recommend skipping any type of intense physical activity until bleeding lightens. According to Grossman, all symptoms, including pregnancy symptoms such as nausea and breast soreness, should improve after a few weeks.
Does it work?
Yes, but for about 7 to 10 percent of patients, research shows that misoprostol-only abortions are not effective. Grossman says a common treatment failure is that the pregnancy will continue to grow, so it’s important to make sure the medications worked and the pregnancy has been terminated. “That can involve having a follow-up ultrasound to check,” Grossman says. “It could involve blood tests to see if the hormone of pregnancy, also known as HCG — if that’s falling appropriately. People can also do at-home urine pregnancy tests about four weeks after taking the medication.”
What about follow-up care?
Complications with misoprostol-only abortions are very rare. That said, anyone contemplating a medication abortion, or who has questions about aftercare, should consult with their health provider. While bleeding is normal during an abortion, Grossman says anyone who’s soaking through two pads or more in an hour, for two consecutive hours or more, should contact their doctor. And, though uncommon, he says there is a risk of infection with medication abortion. Grossman recommends that anyone who experiences a fever of 104 degrees Fahrenheit or higher that doesn’t go down 24 hours after taking the last dose of misoprostol consult their doctor.
Keep an eye out for bleeding that is different in color or smell from a regular period, Grossman says, as well as any signs of an allergic reaction, such as redness, itching, difficulty breathing, or swelling. Cramping is normal during an abortion, but severe pain that isn’t relieved with pain medicine could be a sign of an ectopic pregnancy. Grossman recommends anyone who experiences this, particularly feeling more pain on one side of the body, consult with a doctor.
Can people tell when someone’s had an abortion using misoprostol?
According to a recent report from the legal-aid network If/When/How that studied 61 cases of people who were criminalized for their self-managed abortions, the majority of those self-managed abortions were reported to the police by health-care providers. Grossman says that providers can only tell someone has taken misoprostol if they can identify physical remnants of the pills, which is more likely to happen when they are placed vaginally. Other than that, he says, “there is no commercially available test that can be done if someone goes to an emergency department — no test that a lab can do to easily check if someone has taken misoprostol. The most common way that people end up getting found out for taking misoprostol is because they end up telling someone.”
There are confidential resources available to discuss medical or legal concerns. People who are going through a miscarriage or having an abortion can call the Miscarriage + Abortion Hotline at 833-246-2632 for confidential medical advice, or the Repro Legal Helpline at 844-868-2812 for confidential legal support.