'Medical Abortion' Regimen Is Not a Simple One

From the WebMD Archives

Sept. 28, 2000 -- It's private and noninvasive, but by no means a single-step way to end a pregnancy. Those are the facts behind the newly approved mifepristone, better known by its experimental designation RU-486.

Women who choose this new form of "medical abortion" will likely find the find the regimen easy to follow and, researchers say, the physical side effects tolerable. But it may not be so easy to find a doctor who prescribes it, a pharmacy that will dispense it, a hospital where a follow-up procedure can be done, and the money to afford it.

The process begins, as with all abortion procedures, with counseling. It's an especially important component in medical abortions, because they take place in two parts, using two different drugs.

"Once you commit to this decision you do need to follow through, because you're taking a drug that is going to harm the fetus," says Kirsten Moore, MS, project director for the Reproductive Health Technology Project in Washington.

The drug she's referring to is mifepristone. It doesn't directly kill the embryo, but instead changes conditions inside the uterus to make further growth of a fertilized egg nearly impossible. "Mifepristone begins to break down the lining of the uterus so the embryo begins to detach from the uterine walls," Moore says.

That causes up to half of women who take the drug to experience vaginal bleeding, says Mitchell Creinin, MD, an associate professor of obstetrics and gynecology at the University of Pittsburgh.

Taken alone, mifepristone induces abortion about 80% of the time, research has found. But its effectiveness jumps to an estimated 95% (some experts believe the rate is even higher) when a second drug, misoprostol, is added two days later.

Medical-abortion regimens require the use of this drug, which ulcer patients have long known as Cytotec. While misoprostol protects the lining of the stomach, it wreaks a small measure of havoc on the uterus. "It causes uterine contractions," Moore says. "And that's when she'll experience bleeding and pain. ... For some it's like a normal period, for some it's closer to a miscarriage."

The Population Council, the New York-based organization that holds the patent on mifepristone, says the bleeding can sometimes linger in a spotty fashion for up to three weeks, and patients may experience nausea, vomiting, and diarrhea, as well. But for most, those side effects will be short-lived.

"Within 24 hours after misoprostol, almost 90% of women have their abortions," says Vicki Saporta, executive director of the National Abortion Federation.

While many abortion providers will probably opt to administer both drugs under office supervision, Moore says some will allow patients to take the misoprostol at home. Suzanne Trupin, MD, medical director of Women's Health Practice in Champaign, Ill., says many patients will abort within four hours of using misoprostol and may be kept in the office for that period of time. If sent home, she says, the patient must be accompanied by someone and should have access to emergency transportation.

In any case, all patients are expected back for a follow-up appointment two weeks later to make sure the pregnancy is actually over -- something that is verified with an ultrasound.

As for what the misoprostol expels, at seven weeks into a pregnancy -- which is the latest time at which a medical abortion is now recommended -- the embryo is about the size of a marble.

Mifepristone's effectiveness wanes beyond that seven-week period because the placenta -- not the uterus -- begins secreting progesterone, and at levels that are potentially too high for mifepristone to block. But Creinin says there are plenty of data to justify the use of mifepristone nine and even 10 weeks into a pregnancy -- if the follow-up dose of misoprostol is inserted into the vagina rather than taken by mouth.

Other possible alterations to the regimen include reducing the number of mifepristone tablets and shortening the interval between the two drugs. "There are tons of studies showing one tablet is effective" instead of the recommended three, Creinin says, adding that "if you could shorten the regimen, the woman has less time for the whole process to conclude, and less time to have side effects."

Moore says there is little doubt of the regimen's safety. "The level of confidence comes from the French experience. It's now been used for more than 10 years [in France]. ... There have been no serious adverse events reported."

Still, there is one adverse event women need to consider with a medical abortion: the possibility that it won't work. This happens in about 5% of cases, according to Saporta, leaving abortion providers with two options: "If it's incomplete you could give a follow-up dose of misoprostol or complete with a surgical [abortion] procedure."

And then there is the possibility some women might take the first drug, but not the second. Creinin says it could happen, but will likely prove a rare occurrence. "We're talking about human beings," he says. "They have the right to start down a path and change their minds. It happens very, very infrequently. Part of it is that women who go through medical abortions are very well counseled."

Medical abortion is not for everyone, Trupin tells WebMD. Women who live in remote or rural locations, more than 50-75 miles from the provider, are not candidates. Neither are those with certain medical conditions, including severe anemia; adrenal disease; severe pulmonary, liver, or kidney disease; clotting disorder, heart disease; ectopic pregnancy; or glaucoma, Trupin says.

At some point in the counseling process, patients will also be apprised of the cost for a medical abortion. And they may be surprised. "In an ideal world, there would be no difference in cost compared with surgical abortion," Creinin says.

In other words, a medical abortion could end up costing even more.