Medication abortion isn’t going away, even if access to mifepristone is restricted

(CNN) — Access to medication abortion has changed and then changed again over the past week, leaving doctors and patients confused.

The nonsurgical option used to manage abortions at home is still available, at least for now. The US Supreme Court issued a stay Monday that protects access to mifepristone, one of the two drugs used in a medication abortion, via telemedicine appointments or the mail. The stay is in place until next week while the high court reviews emergency appeals.

But even if the courts eventually limit access to mifepristone, medication abortion will remain an option in the United States through other methods, even in states with highly restrictive abortion laws.

The latest case

Medication, rather than surgery, has become the most frequently used method of abortion in the United States. Typically, the process involves two medications: mifepristone and misoprostol.

In 2023, President Joe Biden eliminated an in-person prescription requirement for mifepristone, permitting distribution of the drug via telehealth and the mail.

In October, the state of Louisiana asked the 5th US Court of Appeals to reinstate the in-person dispensing requirement for mifepristone. Louisiana argued that people who got the medication through the mail or telehealth were violating the state’s strict law that prohibits abortion with few exceptions.

The state claims that with remote prescribing, there are “nearly 1,000 illegal abortions in Louisiana per month.”

The appeals court agreed with Louisiana and issued a ruling Friday that would have stopped the telehealth and mail option for mifepristone, even in states where abortion is completely legal. The stay from the Supreme Court suspends that decision, at least temporarily.

If telehealth and mail are no longer an option for mifepristone, it will still be available through in-person consultations. But that could be logistically difficult for people who live in states with restrictive abortion laws, who may have to go out of state to see a provider.

The other option is to use misoprostol alone, as was done before mifepristone was approved by the US Food and Drug Administration in 2000. This is often the approach used in other countries.

How abortion medication works

Mifepristone blocks a hormone called progesterone, which the body needs for the pregnancy to continue. The hormone helps maintain the inside of the uterus, and without it, the uterus will expel its contents.

Misoprostol is approved to prevent and treat gastric ulcers caused by nonsteroidal anti-inflammatory drugs (NSAIDs). It also is used off-label for other kinds of ulcers and has several gynecological uses, including to induce contractions, to decrease blood loss after delivery and to treat miscarriages.

When used for an abortion, misoprostol works to help empty the uterus through bleeding and muscle contractions.

For the standard two-drug medication abortion regimen, a person would typically take 200 milligrams of mifepristone and then 800 micrograms of misoprostol up to 48 hours later, depending on what the prescriber advises. Misoprostol can be used orally or vaginally.

When used together, mifepristone and misoprostol are 85% to 98% effective at ending a pregnancy, reducing the likelihood that a person would need any kind of followup procedure. This combination also reduces the risk of complications, with studies showing a less than 1% rate of hospitalization.

Some health organizations such as Carafem, a national provider of reproductive health services, offer misoprostol alone as an option.
It considered a medically acceptable approach by the World Health Organization, and the American College of Obstetricians and Gynecologists says a misoprostol-only regimen is an “acceptable alternative” if mifepristone is unavailable.

Misoprostol alone is safe and effective

Although the two-drug approach is what is used most frequently in the US, using misoprostol alone is also a safe and effective way to have an abortion, studies show.

The two-drug regimen “makes the medication abortion a little bit more effective and a little bit safer, with fewer complications and fewer side effects,” said Dr. Rachel Jensen, a Virginia-based complex family planning specialist and the American College of Obstetricians and Gynecologists’ Darney-Landy Fellow.

When misoprostol is used alone, bleeding will typically begin within one to four hours. Heavy bleeding usually lasts about three to five hours, but bleeding can last two weeks or longer, studies show.

Without mifepristone, a person most likely has to use more misoprostol than they would with the two-drug regimen. One study suggested that patients should be prescribed three or four doses, as well as an additional dose in case it’s needed.

Using misoprostol alone is usually effective about 90% of the time, Jensen said, but because patients would probably need to take more of the drug, there can be more side effects including nausea and vomiting, and uterine cramping can be more significant.

“It’s important to understand these are side effects that we’re talking about, right? We’re not talking about complications,” said Dr. Jamila Perritt, president & CEO of Physicians for Reproductive Health, an organization of medical providers who work to ensure access to comprehensive reproductive healthcare, including abortion care. “We have not seen a greater likelihood of infection or hemorrhage or any of those kinds of things.”

Misoprostol is considered extremely safe. One 2020 study of nearly 12,200 women who used the drug by itself found that 26 had to be hospitalized or were transfused for abortion-related reasons.

Perritt says research has shown that people who use the drug alone in the US and internationally have a high satisfaction rate.

Mifepristone and misoprostol “are more commonly used together because it allows us to shorten the duration of the bleeding and also to predict the timing of the passage of the pregnancy,” she said. “It’s better in the sense that folks can organize it around their lives a little bit more.”

Used alone, misoprostol is harder to predict. That doesn’t make the two-drug regimen better per se, Perritt says, but it should be understood in the context of people’s lives.

“As clinicians, our goal is to make sure that our patients have the best experience as possible, including with medication abortion, and so we certainly don’t want patients to have those side effects,” Jensen said.

In states with restrictive abortion laws, Jensen said, there is also a concern that some patients who have severe side effects from misoprostol alone “might be fearful of where they go for care” and might not seek help at all. Plus, if the medicine doesn’t work, they’d have the hurdle of needing to go to another state for a procedure.

Perritt is also concerned that if people have more symptoms like heavier or more prolonged bleeding that is harder to manage, they may “find themselves in emergency rooms that may open them up to the risk of criminalization in places where abortion is restricted.”

“We know for people who are prosecuted for their pregnancy outcomes, a significant proportion of them come to the attention of law enforcement because they sought health care, and a doctor or nurse or social worker called the police, and so that’s the part that keeps me up at night,” Perritt said. “As concerning as this mifepristone ruling is, I’m much more worried that more people will be seeking care in places that make it unsafe for them.”

Jensen said that both drugs are “incredibly safe” overall and that access to both is important.

The effort to restrict the use of mifepristone doesn’t reflect the extensive medical evidence, she said.

“Like with any medication that we would prescribe – for example, a blood pressure medication – if we have a medication that has fewer side effects, that is better tolerated, that has a higher success rate, we would generally prefer to prescribe that even if the other option is still safe and effective, just maybe not quite as good.”

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