The Science Behind the Abortion Pill – Smithsonian

Posted: June 23, 2017 at 8:47 pm

The "abortion pill" (actually two separate medications) can be taken up to 10 weeks after pregnancy, according to the FDA.

Roe v. Wade may have legalized abortion in America 45 years ago, but the fight it ignited is far from over. While abortion is still legal, many states have since passed laws that restrict access to abortion to varying degreesmaking it more expensive, difficult or even illegal in specific circumstancesto terminate a pregnancy. Todayabortion clinics are disappearing at a record pace,andMedicaid payouts to Planned Parenthood are in jeopardy.

As a result, many women do not have access to a safe clinical abortion.

The fact that a clinic exists in her state doesnt help a woman who lives far away from that clinic and has no way to get there, says Susan Yanow, a reproductive health consultant for the international nonprofit Women Help Women(WHW). Seven statesKentucky, North Dakota, South Dakota, Missouri, Mississippi, Wyoming and West Virginiacurrently haveonly one abortion provider, and Kentuckymay soon bethe only state with none.

Now some women are once again taking the procedure outside the doctor's office, outside the law, and into their own hands. While the days of the infamous wire coat hanger aren't quiteover, many women are turning to asafer method made possible by modern medicine: the abortion pill.

For those with access to a clinic, the abortion pill has become anincreasingly popular wayto legally terminate an early pregnancy. The Food and Drug Administration mandatesthat medication can only be prescribed by a healthcare provider "who meets certain qualifications";19 statesalso require that a physician be there physically to supervise the procedure.

Anti-abortion activists argue against the safety of using this method outsidea doctor's office, and have even argued that states should require stricter medical supervision for abortion medication. These drugs are dangerous. They are deadly. If they are mishandled, they result in serious injury, Kristi Hamrick, spokeswoman for the antiabortion groupAmericans United for Life, recently told The Washington Post.(Hamrick is not a physician.)

Butwomen who can't get the medication legally can and dobuy it illegally, either online or in Mexico. In fact, thisis fast becoming the primary option for womenwho lack others: In 2015, more than 700,000 Google users in the U.S. typed in queries about self-induced abortions, includingbuy abortion pills online and free abortion pills,according to theNew York Times. In May 2016,Glamourmagazine chronicled the stories of women seeking these pills inThe Rise of the DIY Abortion.

Thats why, in April, WHW launched its first website to assist American women undergoing medical abortions on their own. The new Trump administration and anti-abortion legislatures in many states are moving swiftly to push abortion out of reach, said Kinga Jelinska, the groups executive director, ina statementannouncing the move. The new website,, provides women with confidential, one-on-one counseling on how to safely use theirabortion medicationregardless of where they may have obtained it.

It isn'tclear just how many women are seeking abortion medication outside of a clinic. To protect its clients, WHW does not disclose how many inquiries its trained counselors receive. But in the past several years,manywomenhave been charged for buying or taking it illegally, with several facing felony charges andjail time. As use of the abortion pill spreads outside the doctors office and into murky legal waters, we asked: How does this procedure work? And how safe is it?


While it's used by many abortion clinics, the name abortion pill is a bit misleading. Medical clinics actually administer two different types of medication: one mifepristone pill(which goes by the brand name Mifeprex), and four misoprostol tablets.

How does it work? The first dosea 200 mg mifepristone pillbegins the process by blocking the bodys progesterone, a hormone that is needed to continue a pregnancy in its early stages. Whenever a woman has a period, part of what stimulates that period is the withdrawal of progesterone, saysDr. Lauren Thaxton, an obstetrician-gynecologist in Albuquerque, New Mexico who has been performing abortions for six years

By blocking this hormone, the first pill helps break down the uterine lining that a woman normally sheds during her period, so that the embryo can detach from the uterine wall. After that happens (generally one to two days after taking the first mifepristone pill),a woman dissolves four 200 mcg misoprostol tablets in her mouth. This second medication, which is also used to induce labor, helps expel the detached embryo.

Misoprostol is in a class of medications called prostaglandins, saysobstetrician-gynecologist Dr. Daniel Grossman, who isthe director of Advancing New Standards in Reproductive Health and co-author of a recent paper exploring the possibility of moving early abortion medication over the counter. One of the effects of prostaglandins [is] that they cause whats called cervical ripeningmeaning causing the cervix to soften, open up, and become thinner. And it also causes the uterus to contract.

Misoprostol was first developed in the U.S. in 1973 to treat peptic ulcers,which it did by preventing harsh gastric secretions. But it had known,major side-effectson a pregnant uterus. In the 1980s, French researchers developed mifepristone,also known as RU-486, a pill that could be taken in sequence with misoprostol to induce an abortion. France legalized this regimen in 1988, andChina,Great Britain and Swedensoon followed suit.

In the U.S., reproductive rights activists hoped the FDA would adopt the method in the '90s, but anti-abortion activists helped delay its approval until 2000. When the U.S. first legalized abortion medication, it was available up to seven weeks after pregnancy. Women receiving it had to visit a clinic three timesonce to take the mifepristone, a second time to take the misoprostol, and a third time for a follow-up.

In 2016, the FDAextended the pregnancy period to 10 weeks and reduced the number of required visits to two, meaning that women could now take the misoprostol at home (though some states have restricted that as well). Today there are even clinicsthat aim tode-stigmatize the processby offering a "spa-like experience,"like a Maryland Carafem health center that offers hot tea and robes to women seeking medical abortions.

One to two weeks after taking the medication, the woman returns to the clinic to make sure the pregnancy has passed. When taken between nine and 10 weeks into a pregnancy, mifepristone and misoprostol are 93 percent effective at inducing an abortion, according to Planned Parenthood. The earlier they are taken, the more effective they are.

In 2014, almost half of U.S. hospital and clinical abortions performed before nine weeks were medication abortions, according to estimates from the Guttmacher Institute, a research and policy organization for reproductive rights. But if WHWs new counseling services, Google queries and the increase in articles on DIY abortionsare any indication, many moremedical abortions may be happening outside the clinic.



Cara Harshman, a freelance writer and marketer in San Francisco, had her (legal) medication abortion in January. In an interview, she said that her symptoms of cramps, bleedingand nausea lasted for about five days after taking the misoprostol. By the time she had her follow-up appointment, she was stable and feeling healthy. She wrote about her experience on the Facebook group Pantsuit Nationin an essay she thenre-published on Medium and Shout Your Abortion.

The only health issue that came up during Harshmans abortion was a blood test showing she was Rh negative, a rare blood type, meaning she had to receive a shot of the medication RhoGAM after taking the misoprostol. According to Thaxton, most women are Rh positive. But if a woman is Rh neg, pregnant and having bleeding, she needs to receive RhoGAM to prevent alloimmunization in future pregnancies, which is a condition wherein the mother develops an immune response to fetal red blood cells, Thaxton wrote in an email.

Overall [a medicationabortion]is extremely safe, says Thaxton, who is also a member ofPhysicians for Reproductive Health.Common symptoms include nausea, cramping and heavy bleeding, similar to what women experience during a miscarriage. Thaxton generally tells her patients that if they soak through four maxi pads in two hours, that's too much bleeding, and they should consult their physician. Theres a rare risk of [too much] bleedingsometimes bleeding requiring a blood transfusionand that can be related to the risk that the pregnancy has incompletely passed, she says.

To prevent this, abortion providers will counsel women about whether they have a history of bleeding disorders before prescribing this method. Theres also a small risk of infections like endometritis(inflammation of the uterine lining)or the contraction of the bacterium Clostridium Sordellii, both of which can also occur after childbirth. However, Thaxton said that the instances of infections after medication abortions are extremely, extremely rare.

Women are always screened for health conditions that might make a surgical abortion a safer option than the abortion pill, Thaxton wrote in an email. But for the vast majority of women, the abortion pill is a safe, private, effective way to have an abortion."


Both mifepristone and misoprostol are available to purchaseonline without a prescription, even though doing so isillegal under federal law (laws regarding inducing an abortion vary by state). Many women who have to resort to this method use only misoprostol, because itis easier to get on its ownand is available over (or under) the counterin many Latin American countries.

Texas women have been getting misoprostol at Mexican pharmacies for years, The New York Timesreported in 2013; whileabortion in Mexico is legally restricted, the medication is sold over the counter for ulcers.

Research has found that a larger amount of misoprostol is needed to induce an abortion on its own, and its usually less effective than the combined method. During the first 12 weeks of pregnancy, a woman who takes three 800 mcg doses of misoprostol orally at least three hours apart has an 85 percent chance of having a complete abortion, according toa 2007 study in theInternational Journal of Gynecology and Obstetrics.

Yet somestudies suggest that inducing an abortion using misoprostol alone is no less safe than the combined method. The World Health Organizationrecommends misoprostolas a safe alternative when mifepristone isn't available, andGrossman says he would use the misoprostol-only method if he didn't have access to mifepristone as well.

Over-the-counter abortion medication may sound pretty far-fetched in a country like the U.S., where even standard birth control requires a prescription in almost every state. Yet the fact that women are already managing their medication abortions on their own has led some to wonder: Could the abortion pill(s) ever be sold over-the-counter, asGrossman's study explored?

In a recent Guardian op-ed, he writesthat limited research suggests women who take abortion medication on their own are doing so safely, adding that there is no question that use of these medications has contributed to a reduction in abortion-related mortality worldwide. Abortion medication, he argues, could one day meet the FDAs requirements for over-the-counter drugs. In fact, the research group Gynuity Health Projects is already conducting an FDA-approved research project calledTelAbortion to test the safety of women using mail-order medication and online consultation to perform their abortions at home.

Of course, future research willbe needed to test these hypotheses. But even if the pill's at-home safety is confirmed,if history tells us anything, it's that efforts to make abortion more accessible will be fought every step of the way.

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