To learn more about practical issues involving medical abortion, TheDoctor's Tom Gilbert, interviewed Jini Tanenhaus, Associate Vice President for the Clinician Training Initiatve, Planned Parenthood of New York City.
Tom Gilbert (TG)Does medical abortion (MA) always cause an abortion or can it also act as a contraceptive?
Jini Tanenhaus (JT)Mifepristone blocks progesterone, which is needed for development of the uterine lining in preparation for pregnancy. By doing this, it can prevent implantation.
Mifepristone cannot prevent fertilization.
TGHow is MA different from the "Morning After Pill"?
JTThe "morning after pill," or emergency hormonal contraception (EHC), works by preventing the implantation of the fertilized egg. EHC cannot terminate an already existing pregnancy. Mifepristone can both prevent implantation and terminate a pregnancy after implantation.
TGI have read that MA is more than 90% effective. What happens if it does not work?
JTA surgical abortion procedure would have to be performed if the pregnancy was not terminated through the use of medications alone.
TGDoes a woman have to see a doctor to receive this drug?
JTMedical abortion must be done under the supervision of a physician. An advanced practice clinician (physician assistant, nurse practioner or certified nurse midwife) may perform a medical abortion under the supervision of a physician, depending on state law.
TGWhat other bureaucratic steps are involved?
JTThe FDA has approved the use of mifepristone according to a specific protocol. Patients must sign a patient agreement and agree to return for subsequent visits. If an alternative protocol is being followed, the patient must sign an agreement for the alternative regimen as well.
TGWhat legal or other restrictions are there on a person's access to medical abortion?
JTMifepristone is not available by prescription. It is available only directly to physicians who meet certain criteria set forth by the FDA. Legal restrictions in regard to abortion vary from state to state but may involve who can perform an abortion, whether there is a waiting period after the patient gives consent and whether or not minors are required to have parental consent or notificiation.
TGWhat about medical abortion as a political issue — how do pro-life groups feel about medical abortion?
JTThere is similar opposition to medical abortion as there is to surgical abortion. Efforts are under way to try to impose further restrictions on the availability of mifepristone.
TGCan you describe how medical abortion works from the consumer's point of view?
JTThe steps of the procedure will vary according to whether the FDA protocol (a.k.a. French Protocol) is being followed or if an alternative protocol is being used. The FDA protocol requires three visits. The first visit is for medical evaluation and to take mifepristone (Day 1). Three tablets (600 mg)are taken orally. The second visit is two days later to get the misoprostol tablets (Day 3). Two tablets (400 mcg.) of misoprostol are taken orally. Patients are followed up on Day 14 to determine the completeness of the procedure.
Patients will experience bleeding that is usually heavier than a menstrual period and lasts on average 9-16 days. Cramps range from light to very severe and usually start several hours after taking misoprostol. Other side effects include nausea, vomiting and diarrhea.
There are many alternative protocols being used. The most common of these calls for using one tablet (200 mg) of mifepristone (rather than 600 mg) and using four tablets (800mcg.) of misoprostol, inserted vaginally at home on Day 3. Other alternatives include using misoprostol on Day 1 or 2 (instead of Day 3), offering mifepristone up to 63 days after the first day of the woman's last menstrual period (instead of 49 days) and scheduling the follow-up visit as early as Day 4.
TGIs it done the same way in all parts of the country and the world?
JTThe U.S. FDA-approved protocol is based on evidence from clinical trials completed in 1996 in France and the United States. The French still follow this protocol. Women return to the clinic on Day 3 for misoprostol and remain there for at least four hours while they expel the pregnancy tissue. I do not know what procedure is followed elsewhere. Most major providers in the U.S. are now following one of the alternative protocols described above.
TGHow much time off work do women usually take after having a medical abortion?
JTPerhaps a day, but women can usually schedule a medical abortion so that they do not have to take time off from work.
TGWhat does medical abortion cost? Does health insurance usually cover it?
JTThere is a wide range of cost from $350 to $650 or possibly more. Medicaid coverage varies by state, but states that cover surgical abortion will cover medical abortion as well. Health insurance coverage varies from state to state and facility to facility, but it is usually covered wholly or in part.
TGAre there any health risks or risks to future fertility from having a medical abortion?
JTThere is always some health risk involved with any type of abortion. The major risk is hemorrhage, or excessive bleeding, which can lead to further complications. There have been no deaths associated with medical abortion and there are no known effects on future fertility from the procedure or the medications alone.
TGDo we know how many women have had medical abortions to date in the US?
JTIf you include all the clinical trials with mifepristone, the use of methotrexate, and procedures done since mifepristone was approved, approximately 15,000.
TGAre these women being followed or studied?
JTMany studies have already been published and research continues (see resources below). As with any FDA-approved drug, mifepristone's safety is being monitored by the manufacturer.
TGCan you recommend any websites or other sources of information on medical abortion?
JTJournals: Early Medical Abortion Supplement, American Journal of Obstetrics and Gynecology (copies can be purchased from the National Abortion Federation by contacting (202)667-5881.
Websites:National Abortion Federation's dedicated early abortion site
National Abortion Federation
Planned Parenthood Federation of America
Planned Parenthood of New York City
Planned Parenthood of New York City's Clinician Training Initiative