What is a medical abortion?
A medical abortion is the termination of a pregnancy with abortion pills and without a surgical abortion procedure. Abortion pills are only available by prescription, but healthcare professionals can write a prescription for medical abortion pills after meeting with the patient in person or virtually. The FDA has made it legal to ship abortion pills through the mail to patients in all 50 states, but each patient has to follow the laws of their state. We review what you need to know about medical abortion with abortion pills.
What is Plan A, Plan B, and Plan C?
Plan A
Plan A is the use of birth control to prevent pregnancy. Plan A includes hormone contraceptives like the pill or implants and barrier protection (condoms) and other contraceptives (IUD).
Plan B
Plan B, also called the morning-after pill, is an oral medication that a patient takes within 72 hours of having unprotected sex. To be most effective, the Plan B should be taken within 12 hours of having unprotected sex, which is why the name “morning-after pill” is appropriate. There are several forms of morning-after pill, but they all include a relatively high dose of a hormone that does three things: blocks ovulation (an egg being released from the ovary), blocks fertilization (prevents a sperm from being combined with an egg), or keeps a fertilized egg from implanting in the uterus. Plan B is not considered a medical abortion.
Plan C
Plan C, also known as a medical abortion, is when a patient with an unwanted pregnancy takes one or two kinds of pills that end a pregnancy. Plan C is sometimes referred to as abortion pills.
What are abortion pills?
A medical abortion can be accomplished by the use of one or two kinds of abortion pills: misoprostol and/or mifepristone. A third type of abortion pill, methotrexate, is no longer commonly used to achieve a medical abortion. Abortion pills can end a pregnancy that is no longer than 10 weeks along.
Mifepristone (Mifeprex)
Mifepristone blocks the progesterone receptor. Mifepristone comes in 200 mg tablets, though only one pill needs to be taken by mouth to achieve a medical abortion. Misoprostol also works by making the muscles of the uterus contract. The abortion pill also causes the cervix (opening of the uterus) to soften and dilate (open slightly).
Misoprostol (Cytotec)
Misoprostol is a synthetic (man-made) hormone, specifically prostaglandin E1. Misoprostol is the only prostaglandin that is specifically approved by the US Food and Drug Administration (FDA) to use for medication abortion. The patient allows the misoprostol pill to dissolve in the mouth without swallowing it. It may also be placed directly into the vagina. Misoprostol works by causing the muscles in the uterus (womb) to contract. These are the same muscles that contract and expel the fetus during birth.
How do I take abortion pills?
For abortion pills to be safe and effective, you must take the abortion pills exactly as prescribed by your healthcare provider.
Mifepristone plus misoprostol
The most effective way to achieve a medical abortion is to take a combination of mifepristone and misoprostol.1,2 The typical sequence is for the patient to take mifepristone (Mifeprex) on the first day of the medical abortion, and then take misoprostol (Cytotec) 24 to 48 hours later.3
On day one, the patient swallows one, 200 mg tablet of mifepristone. Then, on day two, the patient takes a total dose of misoprostol of 800 mcg. Because misoprostol comes in 200 mcg doses, the process is a bit unique. The patient typically places two, 200 mcg tablets of misoprostol (Cytotec) on each side of her mouth (four tablets total) between the cheeks and gums. She then lets the tablets dissolve in her mouth for 30 minutes. Ideally, the pills will dissolve completely during that time, but any remnants of the tablets can be swallowed with water. Alternatively, the patient can place all four tablets into her vagina where they will dissolve and act locally. All patients should have a follow-up appointment within one to two weeks to make sure the medical abortion was successful.
Misoprostol only
Some states have passed laws that prevent patients from obtaining mifepristone. While the combination of mifepristone and misoprostol is the most effective medical abortion, misoprostol alone can also be successful. Fewer regulations block the use of misoprostol than mifepristone, so in some states, it is the only practical option for patients who want a medical abortion.
Misoprostol is taken just as above: The patient places two, 200 mcg tablets of misoprostol on each side of her mouth (200 mcg total) between the cheeks and gums and lets them dissolve for 30 minutes. The vaginal route is also an option and may be more successful in patients who are only able to use misoprostol alone.1,2 Again, patients are strongly encouraged to have a follow-up appointment within one to two weeks after taking misoprostol.
A note for patient who are 9 to 11 weeks pregnant
Some healthcare providers will recommend a second dose of misoprostol be taken about three to six hours after the first dose for patients who are at weeks 9, 10, or 11 of pregnancy. Talk to your healthcare provider about this treatment option because it may be more effective than the single dose for some patients.4
Do abortion pills work?
When both abortion pills are taken, they are very effective. The medical abortion success rate of mifepristone plus misoprostol is between 96% and 99%.1,2,5 The success rate of misoprostol alone is about 88% if placed vaginally2 and 76% if taken as described above (allowing the pills to dissolve in the mouth).1
What are the side effects of abortion pills?
Patient should understand the potential side effects of abortion pills. Most of the effects that a patient will experience after taking abortion pills are related to the process itself. About one-third of patients will experience nausea, vomiting, and diarrhea.6 Likewise, fever, chills, headache, and lightheadedness are also common.6 Virtually all patients will experience abdominal cramping and pain during a medical abortion. The pain can usually be reduced by over-the-counter drugs like ibuprofen, naproxen, or acetaminophen before taking the abortion pills.7 In fact, patients are encouraged to take one of the analgesics (pain medications) about an hour before the first abortion pill and then as directed for two days. Talk to your provider if these medications do not relieve the abdominal pain of a medical abortion.
It is also normal and expected that patients who have a medical abortion will experience vaginal bleeding during a medical abortion. The amount of vaginal bleeding is usually described like a typical period or, more often, like a very heavy period. Spotting or bleeding may last for more than two weeks after taking abortion pills.8 It is also likely that the patient’s next one or even two periods will be heavier than usual.9
Is medical abortion safe?
In general, medical abortion is safe. The most dangerous side effects of abortion pills are heavy bleeding, undetected ectopic pregnancy, infection, and death, but these are rare. To put these into perspective, less than 1% of patients experience bleeding that requires some sort of intervention, such as surgery or transfusion.10 Infection also occurs in less than 1% of patients who have a medical abortion.11 In a study of 233,805 medical abortions, there were only eight ectopic pregnancies and only one that resulted in death.10 In fact, this was the only death related to medical abortion reported in the entire study. The mortality rate of medical abortion is lower than surgical abortion and far lower than the rate of death of the mother during childbirth.12
Can I get pregnant after a medical abortion?
Yes, a successful medical abortion has no impact on future fertility.13 About four out of five patients will be able to get pregnant during their very next cycle; that is, before their next period.14 In fact, a patient’s next ovulation (egg releasing from the ovary) can happen as early as eight days after a medical abortion. Therefore, to prevent an unwanted pregnancy, patients should use contraception immediately after an abortion, i.e., Plan A.
Will medical abortion harm my future pregnancies?
No, medical abortion does not appear to have any negative effect on future pregnancies.13 In clinical studies, pregnancy outcomes were the same between patients who had and who never had a medical abortion. The weight of the babies at birth, for example, was the same in both groups of patients.15 In a study of over 10,000 pregnancies, patients in both groups had similar rates of miscarriage, ectopic pregnancy, preterm birth, and low birth weight in the first pregnancy after their abortion.16 In short, medical abortion does not seem to cause any long-term pregnancy complications.
References
1. Ngoc NT, Blum J, Raghavan S, et al. Comparing two early medical abortion regimens: mifepristone+misoprostol vs. misoprostol alone. Contraception. 2011;83(5):410-417. 10.1016/j.contraception.2010.09.002
2. Jain JK, Dutton C, Harwood B, Meckstroth KR, Mishell DR, Jr. A prospective randomized, double-blinded, placebo-controlled trial comparing mifepristone and vaginal misoprostol to vaginal misoprostol alone for elective termination of early pregnancy. Hum Reprod. 2002;17(6):1477-1482. 10.1093/humrep/17.6.1477
3. Greene MF, Drazen JM. A New Label for Mifepristone. N Engl J Med. 2016;374(23):2281-2282. 10.1056/NEJMe1604462
4. Coyaji K, Krishna U, Ambardekar S, et al. Are two doses of misoprostol after mifepristone for early abortion better than one? BJOG. 2007;114(3):271-278. 10.1111/j.1471-0528.2006.01208.x
5. Raymond EG, Shannon C, Weaver MA, Winikoff B. First-trimester medical abortion with mifepristone 200 mg and misoprostol: a systematic review. Contraception. 2013;87(1):26-37. 10.1016/j.contraception.2012.06.011
6. Schaff EA, Eisinger SH, Stadalius LS, Franks P, Gore BZ, Poppema S. Low-dose mifepristone 200 mg and vaginal misoprostol for abortion. Contraception. 1999;59(1):1-6. 10.1016/s0010-7824(98)00150-4
7. Livshits A, Machtinger R, David LB, Spira M, Moshe-Zahav A, Seidman DS. Ibuprofen and paracetamol for pain relief during medical abortion: a double-blind randomized controlled study. Fertil Steril. 2009;91(5):1877-1880. 10.1016/j.fertnstert.2008.01.084
8. Spitz IM, Bardin CW, Benton L, Robbins A. Early pregnancy termination with mifepristone and misoprostol in the United States. N Engl J Med. 1998;338(18):1241-1247. 10.1056/NEJM199804303381801
9. Davis A, Westhoff C, De Nonno L. Bleeding patterns after early abortion with mifepristone and misoprostol or manual vacuum aspiration. J Am Med Patientss Assoc (1972). 2000;55(3 Suppl):141-144.
10. Cleland K, Creinin MD, Nucatola D, Nshom M, Trussell J. Significant adverse events and outcomes after medical abortion. Obstet Gynecol. 2013;121(1):166-171. https://10.1097/AOG.0b013e3182755763
10.1097/aog.0b013e3182755763
11. Shannon C, Brothers LP, Philip NM, Winikoff B. Infection after medical abortion: a review of the literature. Contraception. 2004;70(3):183-190. 10.1016/j.contraception.2004.04.009
12. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol. 2015;125(1):5-12. 10.1097/AOG.0000000000000564
13. Gemzell-Danielsson K, Kopp HK. Post abortion contraception. Patientss Health (Lond). 2015;11(6):779-784. 10.2217/whe.15.72
14. Schreiber CA, Sober S, Ratcliffe S, Creinin MD. Ovulation resumption after medical abortion with mifepristone and misoprostol. Contraception. 2011;84(3):230-233. 10.1016/j.contraception.2011.01.013
15. Yimin C, Wei Y, Weidong C, Xianmi W, Junqing W, Lin L. Mifepristone-induced abortion and birth weight in the first subsequent pregnancy. Int J Gynaecol Obstet. 2004;84(3):229-235. 10.1016/S0020-7292(03)00338-2
16. Virk J, Zhang J, Olsen J. Medical abortion and the risk of subsequent adverse pregnancy outcomes. N Engl J Med. 2007;357(7):648-653. 10.1056/NEJMoa070445
About the author
Michael Todd Sapko, M.D., Ph.D. Founder and Principal Medical Writer. Michael Todd Sapko obtained a bachelor’s of science with honors in neuroscience from the University of Pittsburgh. He went on to complete a dual MD/PhD program at the University of Maryland. Michael then completed an internship in Internal Medicine at Mercy Medical Center in Baltimore, Maryland in 2006.