Clinical Updates in Reproductive Health

Pain management for medical abortion before 13 weeks gestation

Last reviewed: January 13, 2020

Recommendation:

  • Offer pain medication to all women undergoing medical abortion.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended either prophylactically or at the time cramping begins.
  • Non-pharmacologic pain management measures may be helpful.
  • Narcotic analgesics have not been demonstrated to be effective in relieving pain during the medical abortion process and are not recommended for routine use.
  • Paracetamol should not be used unless an allergy or contraindication to NSAIDs exists.

Strength of recommendation: Strong

Quality of evidence: Low

Pain during medical abortion before 13 weeks gestation

Pain is the most commonly reported side effect of medical abortion (Fiala et al., 2014). In one study of 6,755 women using medical abortion up to 63 days gestation, 78.4% reported moderate or severe pain and cramping (Goldstone, Michelson, & Williamson, 2012). Similarly, a 2006 systematic review of five large British and American case series of analgesia use during medical abortion concluded that 75% of women experience pain severe enough to require narcotic analgesia (Penney, 2006). A qualitative study of women’s experience with medical abortion pain in Nepal, South Africa and Vietnam found that women described pain as stronger than what they experienced during menstruation and manifested in four distinct patterns: minimal or no pain; brief intense pain, typically right before expulsion; intermittent pain, similar to contractions; and constant pain for one or several hours (Grossman et al., 2019). Pain typically peaks 2.5 to 4 hours after misoprostol use and lasts around one hour (Colwill et al., 2019). Patient characteristics associated with more pain include increasing gestational age, younger patient age, nulliparity, no previous vaginal deliveries, and history of dysmenorrhea (Suhonen, Tikka, Kivinen, & Kauppila, 2011; Teal, Dempsey-Fanning, & Westhoff, 2007; Westhoff, Dasmahapatra, Winikoff, & Clarke, 2000).

There are few trials assessing effectiveness of pain management strategies during medical abortion before 13 weeks gestation. Neither pain nor its treatment are systematically reported in clinical trials of medical abortion; where these data are reported, multiple regimens and treatment protocols have been used, rendering them difficult to compare (Fiala et al., 2014; Fiala et al, 2019; Jackson & Kapp, 2011).

Medications for pain management

Two small randomized controlled trials indicate that ibuprofen is more effective than placebo (Avraham, Gat, Duvdevani, Haas, & Frenkel, 2012) or acetaminophen (Livshits et al., 2009) in relieving medical abortion pain in women with pregnancies of less than seven weeks gestation. Pre-treatment with ibuprofen is no better for pain management than treatment once cramping starts (Raymond et al., 2013). In women with pregnancies up to 10 weeks gestation, one randomized controlled trial found that pregabalin (a gamma-aminobutyric acid analog) did not decrease maximum pain scores when taken at the time of misoprostol administration; however, women who received pregabalin were less likely to require ibuprofen or narcotic pain medication and more likely to report satisfaction with analgesia than women who received the placebo (Friedlander et al., 2018).  One randomized trial found no difference in the amount or duration of pain experienced by women receiving an oral opioid medication (oxycodone) to manage medical abortion pain, compared to placebo (Colwill et al., 2019). Study authors concluded that while providing routine opioid medications is unnecessary, it is reasonable to provide four or fewer oxycodone tablets to women who request them.

Non-pharmacologic pain management

There are no comparative trials evaluating the benefit of non-pharmacologic pain management strategies for medical abortion before 13 weeks gestation. However, experts recommend adjunctive non-pharmacologic measures to improve women’s comfort during a medical abortion, including thorough education about expected pain and bleeding (Teal, Dempsey-Fanning, & Westhoff, 2007), a supportive environment and application of a heating pad or hot water bottle to the lower abdomen (Akin, et al., 2001). These modalities are to be employed in addition to—not as substitutes for—pain medications.

Resources

Pain Medication Table

References

Akin, M. D., Weingard, K. W., Hengehold, D. A., Goodale, M. B., Hinkle, R. T., & Smith, R. P. (2001). Continuous low-level topical heat in the treatment of dysmenorrhea. Obstetrics & Gynecology, 97, 343-349.

Avraham, S., Gat, I., Duvdevani, N., Haas, J., & Frenkel, Y. (2012). Pre-emptive effect of ibuprofen versus placebo on pain relief and success rates of medical abortion: A double-blind, randomized, controlled study. Fertility and Sterility, 97, 612-615.

Colwill, A. C., Bayer, L. L., Bednarek, P., Garg, B., Jensen, J., & Edelman, A. (2019). Opioid analgesia for medical abortion: A randomized trial. Obstetrics & Gynecology, 134(6), 1163-1170.

Fiala, C., Agostini, T., Bombas, S., Cameron, R., Lertxundi, M., Lubusky, M., … & Gemzell-Danielsson, K. (2019). Management of pain associated with up-to-9-weeks medical termination of pregnancy (MToP) using mifepristone-misorpsotol regimens: Expert consensus based on a systematic literature review. Journal of Obstetrics and Gynecology, 1-11.

Fiala, C., Cameron, S., Bombas, T., Parachini, M., Saya, L., & Gemzell-Danielsson, K. (2014). Pain during medical abortion, the impact of the regimen: A neglected issue? A review. European Journal of Contraception and Reproductive Health Care, 19(6), 404-419.

Friedlander, E. B., Soon, R., Salcedo, J., Davis, J., Tschann, M., & Kaneshiro, B. (2018). Prophylactic pregabalin to decrease pain during medication abortion: A randomized controlled trial. Obstetrics & Gynecology, 132(3), 612-618.

Goldstone, P., Michelson, J., & Williamson, E. (2012). Early medical abortion using low-dose mifepristone followed by buccal misoprostol: A large Australian observational study. Medical Journal of Australia, 197(5), 282-286.

Grossman, D., Raifman, S., Bessenaar, T., Dung, D. L., Tamang, A., & Dragoman, M. (2019). Experiences with pain of early medical abortion: Qualitative results from Nepal, South Africa, and Vietnam. BMC Women’s Health, 19(1), 118.

Jackson, E., & Kapp, N. (2011). Pain control in first-trimester and second-trimester medical termination of pregnancy: A systematic review. Contraception83(2), 116-126.

Livshits, A., Machtinger, R., David, L. B., Spira, M., Moshe-Zahav, A., & Seidman, D. S. (2009). Ibuprofen and paracetamol for pain relief during medical abortion: A double-blind randomized controlled study. Fertility and Sterility91(5), 1877-1880.

Penney, G. (2006). Treatment of pain during medical abortion. Contraception, 74, 45-47.

Raymond, E.G., Weaver, M.A., Louie, K.S., Dean, G., Porsch, L., Lichtenberg, E.S., … Arnesen, M. (2013). Prophylactic compared with therapeutic ibuprofen analgesia in first-trimester medical abortion. Obstetrics & Gynecology122(3), 558-564.

Suhonen, S., Tikka, M., Kivinen, S., & Kauppila, T. (2011). Pain during medical abortion: Predicting factors from gynecologic history and medical staff evaluation of severity. Contraception, 83, 357-361.

Teal, S. B., Dempsey-Fanning, A., & Westhoff, C. (2007). Predictors of acceptability of medication abortion. Contraception, 75, 224-229.

Westhoff, C., Dasmahapatra, R., Winikoff, B., & Clarke, S. (2000). Predictors of analgesia use during supervised medical abortion. The Mifepristone Clinical Trials Group. Contraception61(3), 225-229.

Westhoff, C., Dasmahapatra, R., & Schaff, E. (2000). Analgesia during at-home use of misoprostol as part of a medical abortion regimen. Contraception, 62(6), 311-314.

World Health Organization. (2014). Clinical practice handbook for safe abortion. Geneva: World Health Organization Press.