Medical abortion — sometimes called medication abortion, pharmacologic abortion, pharmaceutical abortion, RU-486 or the abortion pill — is a safe, effective means of terminating a pregnancy. This method is widely acceptable to women in developed and developing countries in all regions of the world.

Medical abortion involves use of pharmacologic agents, such as mifepristone and misoprostol, to expel the contents of the uterus. Used in combination, these medications stimulate uterine contractions and cause expulsion of the pregnancy. Other medications have also been used. The World Health Organization recommends the combined use of misoprostol and mifepristone as the safest, most effective method for termination in the first nine weeks of pregnancy.

Misoprostol alone may also be useful where mifepristone is unavailable; studies to identify ideal regimens are ongoing. Pending definitive recommendations, guidance on the use of misoprostol alone may be useful to providers, given the widespread use of the drug in many global settings.

Use of medication to terminate pregnancy is most often an option relatively early in pregnancy, up to nine weeks (or 63 days) since the woman’s last menstrual period; the safety and effectiveness of the regimen for use between nine and 12 completed weeks of pregnancy is under investigation. Other regimens are used for procedures performed after 12 weeks.

How the Drugs Work
Mifepristone blocks progesterone activity in the uterus, leading to detachment of the pregnancy. Mifepristone also causes the cervix to soften and the uterus to contract, and increases uterine sensitivity to prostaglandins (fatty acids produced naturally by the body), such as misoprostol.

Misoprostol is a drug that mimics prostaglandin developed for gastrointestinal indications (for example, to treat ulcers). Misoprostol softens the cervix and stimulates uterine contractions. It is used for various obstetric indications, including, increasingly, for medication abortion, often in conjunction with mifepristone.

In addition to termination of pregnancy up to nine completed weeks, misoprostol appears to be promising for other abortion-related conditions, including for treatment of incomplete or missed abortion, cervical preparation before vacuum-aspiration procedures and later abortion procedures.

Safety and Effectiveness
Combined regimens using mifepristone and misoprostol through nine weeks since the woman’s last menstrual period have been widely studied and safely used by millions of women in many countries. Studies to date indicate that use of mifepristone plus misoprostol stimulates complete abortion more effectively than does the use of either drug alone. Research protocols for pregnancies up to and including nine weeks since the woman’s last menstrual period report success rates up to 98 percent. Studies investigating the use of misoprostol alone for abortion up to nine weeks since the last menstrual period indicate a potential for some regimens to result in complete abortion in 85 to 90 percent of cases.

Most women undergoing medical abortion experience some amount of abdominal cramping and bleeding. Other possible side effects, depending on the doses and route(s) of administration used, include vomiting, nausea, diarrhea, chills and fever. Some studies suggest that misoprostol may be teratogenic (cause birth defects); therefore, after misoprostol has been taken, the abortion process should be completed.

The Process
After giving her informed consent, the woman begins by taking the proper dose of the first drug, mifepristone. Most women will not notice any change in how they are feeling immediately after taking mifepristone. Some women will have bleeding that begins before the second medication, misoprostol, is taken. Various dosages and ways of administering the second medication (for example, orally or vaginally) for different lengths of pregnancy are being studied. In up to 90 percent of women, the pregnancy will be expelled within six hours of vaginal administration of misoprostol (after mifepristone has already been used).

Conditions for Use
Medical abortion offers women the opportunity to terminate pregnancy (up to nine weeks since the woman’s last menstrual period) in circumstances that may be more private (for some women, this can be at home) than in a health-care facility and through a process that resembles a miscarriage. The use of medications at the community and primary-care levels may significantly increase women’s access to safe abortion care. Backup services, preferably vacuum aspiration, are required in the event of a failed medication abortion.

Women who have reviewed their options through counseling, understand the process and choose abortion can terminate a pregnancy in the first nine weeks by using mifepristone and misoprostol, or misoprostol alone, if they have no allergy to the medication and no medical condition that contraindicates use of the medication.
The drugs used in medical abortion are registered in many, but not all, countries. The drug availability map shows the countries in which mifepristone and misprostol are registered.

Pain Management
Pain during a medical abortion usually begins after the administration of misoprostol, often within one to three hours, and diminishes after the abortion is complete. As the uterus contracts and its contents are expelled through the cervix, women generally feel some degree of cramping. The amount of cramping and pain experienced varies greatly: Some women note only mild cramping; others experience severe pain.

Counseling and review of complete information before the provision of medications help women prepare for any cramping and pain. Reassurance and support by clinic staff or someone at home during the abortion process can also be helpful.

Women should be provided pain medications or a prescription for pain medication when the first drug is administered. Women should begin taking pain medication when cramping begins rather than waiting for it to become severe, when the pain cycle is more difficult to interrupt. The application of low heat to the abdomen or lower back (using a hot-water bottle or warm cloths, or taking a hot bath or shower) may also help relieve the pain of cramping.

Other Options 
When medical abortion is unavailable, women may have other method options, depending on the availability of a health-care provider who is trained and equipped with alternative methods and women’s individual clinical circumstances. Alternatives to having a medical abortion include undergoing manual vacuum aspiration, electric vacuum aspiration or sharp curettage, and carrying the pregnancy to term with prenatal care.

Ipas’s Work
Ipas’s work on medical abortion has increased in depth and breadth in recent years, especially in three key areas.

Resources

• Early Options: a Provider’s Guide to Medical Abortion
• Earlyoptionpill.com
• Frequently asked clinical questions about medical abortion
• Gynuity Health Projects
• The International Consortium for Medical Abortion
• Medication Abortion Website run by Ibis Reproductive Health
• Misoprostol.org
• The Population Council
• Reproductive Health Technologies Project
• The safety of mifepristone