the right method for me?
The next section is really about you. We have collected some questions and considerations that will help you make the best choice for who you are and where you are in your life. Use the knowledge we have gained from the experiences of thousands of women to help you decide what is right for you. We have also included 4 pages of quotes from real women.
When you have decided on a method and you are ready to choose a place to get an abortion, there is a list of questions and considerations. As one of the real women says, "Choose wisely."
The next sections are the actual details and what to expect with either Mifeprex™ or methotrexate. Use this as a guide along with the information your doctor or clinic gives you. There is also information on pain relief, a symptom calendar, and some important resources and references.
You also have a choice about how you want to think about the abortion experience. You can decide who to involve, how to take care of your feelings, and what this experience means for your life. The sections on "Feelings Afterwards," "Abortion is an Emotional Process Too," and a sample ritual may help your thinking. Our other workbook, Pregnant? Need help? Pregnancy Options Workbook also contains helpful information on spirituality, healing afterwards, and several exercises that may give you some things to think about.
Finally, Tina pops up with some important messages through this workbook. This is the information that you might get if you had a girlfriend who worked at a clinic. She will get to the point and tell you things that really matter.
OK, so you're pregnant. (Remember when you first found out...). What usually comes next is a gut (or "heart") reaction-- "Oh, no!" or "Yes!" Or sometimes it's more about "how" -- "How am I going to deal with this?" "How will __________ react to this news?" Or, "What if....." and you think about your goals, your situation, your relationship with partner or family.
This can be a long difficult decision or a quick, clear choice. If the authors of this workbook have learned anything it is to pay attention to what your gut is saying. You should figure out your feelings, fears, and hopes first, before you think about what method to use, where to get services, or how much it will cost.
It may seem like a good idea to "just get it over with." You may think that if you have a "miscarriage" with the help of these medications you don't have to deal with really being pregnant. You may want to hide your pregnancy or abortion from someone else. If so, be careful!!
Sometimes women want the medical abortion because they are not OK with their decision to have an abortion, and an abortion with a pill seems more "natural" or less like an abortion. Not so! Sometimes the reasons we give for choosing medical abortion--like it's more private and "no one has to know"-- are covering up a problem with the decision itself!!!
If you are not clear, please take the time and get the help you need to make a good decision. Many women need another person--or more than one-- to talk over your options. This might be your partner, a parent, a good friend, or a professional. You also need accurate information about your options. With a little help, you can make a good decision that you can be comfortable with. The Pregnant? Need help? Workbook might also be of help. Focus on the following question and try to do the right thing for you and your life:
Is this the right time for me to bring a new life into the world through my body?
This workbook is designed to help you decide whether medical abortion or surgical abortion is the best choice for you. We are assuming that you have already decided that you do not want to continue this pregnancy. If you are not sure about your choice, please take more time to consider your decision, even if that means you cannot have a medical abortion (because you might be too far along for a medical abortion--though still early for a surgical). If you need more help, check out Pregnant? Need help? Pregnancy Options Workbook. Some of the same people that are involved in this workbook wrote that one.
We are people who care deeply that women make the best pregnancy decisions for their lives. We know these decisions are not always easy, which is why we have assembled in both workbooks all the information, resources, "tools", and collective wisdom we can find about all options. Some of the most important advice we have embodied in "Tina", a cartoon character that appears from time to time.
In this workbook we are especially interested in helping women understand the differences between medical and surgical abortion. We feel that women deserve complete information and can benefit from hearing other women's experiences and opinions.
We want to hear from you too. We will include your comments in future editions of this workbook (see last page). Please contact us via our web page www.pregnancyoptions.info or write to us:
Thank you and Good Luck!
Margaret R. Johnston
Medical Abortion (sometimes called Mifeprex™, RU-486, non-surgical abortion, or abortion using a pill) is a way to end a pregnancy with medication. It is an abortion method that uses two medications to end a pregnancy over a span of time (usually a few days, to a few weeks in some cases). It is available in early pregnancy, usually up to 7, or sometimes 9 weeks from your Last Menstrual Period (LMP). Basically, it is medically inducing a miscarriage.
There are two different methods of medical abortion available: mifepristone followed by misoprostol, and methotrexate followed by misoprostol. The methods are similar, but have some important differences. One or both methods might be available in your area. Not every doctor that provides surgical abortion offers medical abortion. Methotrexate, which takes longer, and is usually less effective, is usually not used when mifepristone is available, unless there is a concern about a possible ectopic pregnancy.
Mifepristone and misoprostol
A second medication called misoprostol or Cytotec™ is used usually 1 to 2 days later. It is either swallowed or placed in the vagina. It may be used at home or in a doctor's office. Misoprostol causes the uterus to empty itself by cramping and bleeding. This usually happens within several hours but may take longer. Effectiveness ranges from 92-96% or higher with newer "evidence-based" guidelines improving the success rate.
Methotrexate and misoprostol
A surgical abortion or vacuum aspiration, is when a doctor, or other clinician, removes a pregnancy from the uterus. The doctor numbs the cervix with a local anesthetic similar to Novocaine™, then dilates--or stretches-- the cervix (the opening to the uterus) a little bit to put in a small tube, and then removes the pregnancy with suction. It usually takes less than 5 minutes when you are early in the pregnancy. It can cause some cramps which usually go away quickly, (less than half an hour). Some bleeding and cramps are to be expected for one week or so. Most doctors/clinics can offer different types of pain relievers, sedation, or anesthesia. Surgical abortion has been legal in the U.S. since 1973 and is very effective (about 99% successful) and has a very low risk of injury or infection when done properly by qualified clinicians.
An ectopic pregnancy is an abnormal pregnancy that grows outside the uterus, often in the fallopian tubes. It occurs in 1% of pregnancies, and is very dangerous. If you have an ectopic pregnancy, it is important to find out in the early stages before it harms you or threatens your future fertility. If undetected, the pregnancy can continue to grow and burst the tube, which could cause internal bleeding and possibly death. Your doctor or clinic will try to "rule out" an ectopic pregnancy-- or in other words, to make sure your pregnancy is growing inside the uterus, not outside it. Sometimes this can be difficult to figure out. One way is to do an ultrasound and that will usually show the pregnancy in the uterus. Another way is to do a surgical abortion and look at the tissue that is taken out to be sure it is pregnancy tissue, but this is not always a sure thing. If your doctor is not certain, he or she may order some blood pregnancy tests that measure the amount of pregnancy hormone in your system, or suggest that you be seen in a hospital or emergency room.
It is important to pay close attention to your symptoms and to report problems to your doctor or clinic. Tubal pregnancies typically cause pain on one side, sometimes severe pain or a "stabbing" sensation. This pain may radiate or "travel" to the back or shoulder. If you are having pain like this, report it immediately to your doctor, or if you are fainting or feeling very weak, call 911 or go to a nearby emergency room and ask them to consider the possibility of a tubal pregnancy.
It is a rare condition, but some women have died of
a ruptured ectopic pregnancy and we want you to be aware of this potential
problem. If detected early enough it can sometimes be treated with medicine,
or it may need to be surgically removed. Either way, you need to be
under the care of a doctor who can monitor your condition. Please cooperate
with your doctor or clinic, and get all the tests they recommend.
1. How far along in the pregnancy can I be?
2. How long does it take for the
abortion to be complete?
3. How painful is it? The amount
of bleeding varies from person to person and with length of pregnancy.
4. Can the abortion fail?
5. Can I still have children later
6. What are possible serious side
7. What are the common side effects
8. How much does it cost?
9. What are the advantages of
10. Who should not use one of
these methods? (What are the contraindications?)
11. What are the disadvantages
of each method?
12. How will I be affected emotionally?
OK, now you understand the difference between surgical abortion and abortion using medicine. Is medical abortion right for you? Here are some things you might want to think about:
Clinic/ Doctor Requirements
The following are some questions
Some women say, "I just want to get this over with as soon as possible and move on." Others say, "I want time to think about this experience and take time to have my feelings." Which statements best describe how you feel? How will medical or surgical help you get what you want?
The following are other statements that people say about
medical abortion. Do you agree or disagree with the following: (Use
this scale 1= Strongly agree 2= Agree 3= No Opinion 4= Disagree 5= Strongly
Make a list of reasons why you should do surgical vs. why you should do medical. Circle the reasons that are most important to you.
Try to answer the following questions:
1. Period Cramps: What are your period cramps like?
2. Pain Relief: What helps you when you have cramps?
3. Feelings About Pain: How do you feel emotionally when
you are in pain? (Circle all that apply)
4. Past experience: What are your past experiences with
pain? (Examples: "I never have cramps and nothing bad has ever
happened to me, so I'm worried about how it will feel." Or, "I
have had a lot of surgeries and although I do OK, I really dread it
5. Negative feelings about the situation: Difficult emotions
can make pain feel worse. For example, getting a tattoo or your ear
pierced is painful but it's more tolerated because it's something you
want. Having an abortion can bring up a lot of feelings, some of them
"Expensive, but worth it."
Comments on pain and bleeding
with medical abortion
You can find a provider in the abortion section of your phone book, on the internet (www.ru486.com, www.abortionclinicdirectory.com, www.gynpages.com), or from your local family planning or Planned Parenthood clinic. It's probably a good idea to call a couple of places and get a feel for their services.
Here are some things to ask:
1. You must be under 7 weeks (49
2. On Day 1 you take Mifeprex™
600 mg. (3 pills).
3. On Day 3 you take misoprostol
4. On Day 3 you take misoprostol
(Cytotec™) 400 mg. orally.
5. Misoprostol is taken at the
clinic or doctor's office at a second visit on Day 3.
6. Bleeding, cramping, and clots
will most likely happen within 1-4 hours (sometimes up to 8 hours or
more) of taking misoprostol.
7. You must have a follow-up exam
within 14 days.
8. There is a 5- 8 % chance that
this will not work.
9. Both medications, but especially
the misoprostol, may cause serious birth defects.
10. Some women should not take
mifepristone and misoprostol.
How will I feel after the first
On Day 1 an injection of methotrexate or an oral dose
of methotrexate is given to a patient who is less than 7 weeks from
the first day of her last period.
On Day 5, 6, or 7 you will place 4 tablets of misoprostol
200 mg (Cytotec™) in the vagina. Rest with your feet up for 1/2
hour to 3 hours.
On Day 8 an ultrasound can show whether the abortion was complete. If it is not complete, another dose of misoprostol is given. An ultrasound can determine if the pregnancy has stopped growing, if the sac is still there, or if the pregnancy has been expelled.
If needed, on Day 15 another ultrasound can determine if the pregnancy is continuing. If it is, then surgery is recommended. Surgery means that a doctor will suction the inside of the uterus; it takes less than 5 minutes.
On Days 29-45, if the sac remains, even if the pregnancy has not continued to grow, a surgical procedure is recommended.
Some women should not use methotrexate with misoprostol.
Tell your doctor/clinic if you have if any of the following are true
A follow-up exam is extremely important. Since methotrexate
is less effective, one or two follow-up exams may be required to be
sure the pregnancy is gone. With methotrexate it can be difficult to
be sure the pregnancy has ended so a repeat ultrasound is very important.
1. Ibuprofen is the generic name for Advil™, Motrin,
and similar products. It is available in 200 mg. tablets in the pharmacy
or grocery store. Generally, 600-800 mg. (3-4 tablets) are recommended
every 4-6 hours for cramps. If you have a prescription for Ibuprofen
check the number of milligrams and do not exceed 800 mg. It usually
starts working in 20-30 minutes.
Other Pain Relief Things To Try
Sometimes you may not have enough pain medications--or they may not be working fast enough for you--or you may not want certain side effects. Try some of these:
1. Lie down with a heating pad or hot water bottle
and place it on your lower abdomen. Occasionally, ice for 10 minutes
at a time works better than heat, especially if you are nauseous or
Deep Breathing Exercises
Occasionally, you may need to review your reasons, your situation, your goals, and how you were feeling when you made your decision. Remember though, we only make decisions based on what we know at a point in time. If your decision seems wrong now, it did seem right then. Why? What happened?
It is completely normal to have strong feelings
about any decision you make about pregnancy. All pregnancy decisions
can be profound. Any decision can feel scary, or you could have mixed
feelings about the choice you made. Sadness and relief are just some
of the possible feelings you may have.
The question is: how do you express
Some examples are:Burning a candle during the process of expelling the pregnancy.
Writing a letter of good-bye.
Burying some symbolic object.
Creating something, like writing a poem or making art, or planting a flower or plant.
In some Buddhist cultures and in at least one Native American tradition there are prescribed rituals for women who want to acknowledge a pregnancy loss. Or, you can make up your own way to acknowledge your feelings. (See also www.pregnancyoptions.info)
Feelings that don't get dealt with will keep popping up and interrupting your life until you notice them. If you can't stop crying, if you have trouble eating, sleeping, or concentrating, you should find someone to talk to. Time may help but a competent listener (counselor) can help you figure things out and feel better.
Here are some of the warning signs
of women who may need more help coping after an abortion experience:
If any of these things are true for you, take the time you need to figure things out. If you are unable to function normally--for instance, if you can't stop crying, if your normal sleep is disrupted, you cannot eat normally, or you can't concentrate, you may need more help. Emotional upset and physical symptoms like these usually get better over time; if they do not, get help. If you don't have anyone who is helpful, call your doctor/clinic, a local family planning clinic or Planned Parenthood, a clergy person, or your county mental health clinic.
Sample of a Ritual
www.earlyoptionpill.com: This information is sponsored by Danco Laboratories, the makers of Mifeprex™. It includes the Medication Guide and a patient brochure.
www.gynpages.com: This is a directory of abortion providers organized by state or by service.
www.EarlyOptions.org: This website offers information about medical abortion and is sponsored by the National Abortion Federation. The site offers educational information, a Women's Information Guide, and information about NAF resources on medical abortion.
This site offers information about fact sheets on sexual health, contraception,
and abortion, and information about Planned Parenthood affiliates across
NAF Hotline (800) 772-9100 Monday-Friday 8 am -10 pm, Saturday and Sunday, 9 am -5 pm. Referral to abortion providers
National Coalition of Abortion Providers (703) 684-0055 Monday-Friday 8 am- 6 pm. Referrals to independent abortion providers.
Planned Parenthood Hotline (800) 230-PLAN Referrals to Planned Parenthood affiliates
Borgatta L et al. Early Medical Abortion with Methotrexate and Misoprostol. Ob/Gyn v. 97 #1, 2001
Bydgeman M, Swahn ML. Progesterone receptor blockage. Effect on uterine contractility and early pregnancy. Contraception. 1985;32:45-51.
Creinin MD, et al. Mifepristone 100 mg in Abortion Regimen. Obstet Gynecol Vol 98 #3 Sept. 2001
Creinin MD. Medical Abortion Regimens: historical context and overview. Am J Obstet Gynecol. 2000; 183: S3-S9.
Creinin, MD, Spitz, IM, Use of Various Ultrasound Criteria to evaluate the efficacy of Mifepristone and Misoprostol for medical abortion. Am J Obstet Gynecol 1999; 181:1419-24.
DeLoia JA, Stewart-Akers AM, Creinin MD. Effects of methotrexate on trophoblast proliferation and local immune responses. Hum Reprod. 1998;13:1063-1069.
Elul B et al. Mifepristone and Misoprostol Abortion vs. Surgical Abortion Contraception 1999; 59: 107-14.
Hausknecht, RU. Methotrexate and misoprostol to terminate early pregnancy. N Engl J Med. 1995; 333: 537-40.
Kahn JG, Becker BJ, MacIsaac L, et al. The efficacy of medical abortion: a meta-analysis. Contraception. 2000;61:29-40. Tests to 63 days.
Koopersmith TB, Mishell DR Jr. The use of misoprostol for termination of early pregnancy. Contraception. 1996;53:238-242.
Kruse B, Poppema S, Creinin MD, Paul M. Management of side effects and complications in medical abortion. Am J Obstet Gynecol. 2000; 183: S65-S75.
Lipscomb GH et al. Analysis of 315 ectopic pregnancies treated with single dose methotrexate. Am J Obstet Gynecol. 1998; 178:1354-8
National Abortion Federation Early Medical Abortion with Mifepristone or Methotrexate. Overview of Protocol Recommendations. 2001
Paul M, Creinin MD, Early Medical Abortion. Supplement Am J Obstet Gynecol. 2000.
Peyron R, Aubény E, Targosz V, et al. Early termination of pregnancy with mifepristone (RU 486) and the orally active prostaglandin misoprostol. N Engl J Med. 1993;328:1509-1513.
Pheterson G. Medical Versus Surgical Abortion: Bias in Presentation of Early Options, 2001. See also www.Saludpromujer.org.
Pymar HC, Creinin MD. Alternatives to mifepristone regimens for medical abortion. Am J Obstet Gynecol. Supplement August 2000; 183: #2, s54-s64.
Schaff EA et al. Low dose mifepristone 200 mg + vaginal misoprostol for abortion. Contraception 1999: 59:1-6.
Schaff EA et al. Low dose mifepristone followed by vaginal misoprostol at 48 hours for abortion up to 63 days. Contraception 2000: 61:41-6
Schaff EA et al. Randomized trial of vaginal misoprostol administered 1, 2, or 3 days after mifepristone for early medical abortion. JAMA 2000: 284:1948-53.
Spitz IM et al. Early pregnancy termination with mifepristone and misoprostol in the United States. N Eng J of Med. April 30, 1998 338:124-127
Stewart F et al. Early Medical Abortion: Issues for Practice. Center for Reproductive Research and Policy. UCA-SF 2001.
Wieg ER Oral methotrexate compared with injected methotrexate when used with misoprostol for abortion. AmJ Obstet Gynecol. 1999: 181:149-52.
Winikoff B et al. Acceptability and Feasibility of Early Pregnancy Termination by Mifepristone and Misoprostol. Archives of Family Medicine. July/August 1998.