By LINDSEY TANNER and MATTHEW PERRONE Associated Press
Medical abortions became the preferred method of terminating pregnancy in the US even before the Supreme Court overturned Roe v. Wade. These involve taking two prescription drugs days apart, at home or at a clinic.
Abortion procedures are an invasive medical technique that empties the uterus. They are sometimes called surgical abortions, even though they do not involve surgery.
Pill abortion involves the drugs mifepristone and misoprostol. As more states seek limits on abortion, demand for the pills is expected to grow.
Mifepristone is taken first, it is ingested orally. The medication dilates the cervix and blocks the effects of the hormone progesterone, which is necessary to maintain a pregnancy.
Misoprostol, a medication also used to treat stomach ulcers, is taken 24 to 48 hours later. The pill is designed to dissolve when placed between the gums and teeth or in the vagina. It causes the uterus to cramp and contract, causing bleeding and expelling the pregnancy tissue.
Abortion medications are approved for use up to the tenth week of pregnancy.
The pills can be taken in a doctor’s office or clinic, where patients sometimes undergo ultrasound or lab tests beforehand. Some providers also offer the pills through telehealth visits and then mail the medications to patients.
The use of pills has been on the rise in recent years. As of 2020, they accounted for 54% of all abortions in the US, according to preliminary data from the Guttmacher Institute. The group’s final estimate is due later this year.
Studies and evidence from actual use show that when taken together, the pills are safe and up to 99% effective. Side effects can include nausea, vomiting, and diarrhea.
The bleeding is normal. Very heavy bleeding (soaking more than two pads per hour for more than two hours) is rare but requires medical attention.
Dr. Stephanie Rand, a New York OB-GYN and abortion specialist with the advocacy group Physicians for Reproductive Health, says pregnancy tests shouldn’t be used right away to determine if a medical abortion was successful because the hormone from the pregnancy can remain in the body for several weeks. Bleeding, with blood clots that include lighter-colored tissue, are signs of success, she said.
Serious complications are very rare. The Food and Drug Administration says that more than 3.7 million American women have used mifepristone since it was approved more than 20 years ago. The agency has received 26 reports of deaths in women using the drug, including two related to ectopic pregnancies, which grow outside the womb.
The drugs are not recommended for certain patients, including those with suspected ectopic pregnancies or those with implanted IUD contraceptive devices.
Costs vary by location, but are similar to abortion procedures and can add up to more than $500. Health insurance coverage varies, with some plans making the pills free or low-cost and others not covering them at all.
Mifepristone is sold under the brand name Mifeprex and misoprostol under the brand name Cytotec, but both pills are available as generics.
The FDA approved mifepristone to terminate pregnancy in 2000, when used with misoprostol. At the time, it placed various limits on how the drug could be prescribed and dispensed.
In December, the agency removed the biggest restriction: the requirement that patients pick up the drug in person. The FDA said a scientific review of the drug’s use, including during the COVID-19 pandemic, showed women could safely receive the pills by mail after an online consultation, without any increase in side effects or complications. .
The decision allowed the pills to be delivered by mail across the country, a change long sought by groups of medical professionals and abortion-rights supporters.
Still, millions of women will struggle to access pills because of a patchwork of state laws addressing abortion in general and pills in particular. About half of US states are expected to ban or heavily restrict abortion.
Legal experts foresee years of court battles over access to the pills, as abortion-rights advocates present test cases to challenge state restrictions.
There are strong arguments and precedents on both sides, experts say, though there is little certainty about which side might prevail.
The Biden administration’s Justice Department has already signaled plans to challenge state restrictions on medical abortion. And the federal lawyers are likely to be joined by outside parties, including abortion-rights groups like Planned Parenthood and even the companies that make the pills.
The main argument against pill restrictions is likely to be the long-standing principle that federal laws, including FDA decisions, trump state laws. In fact, few states have ever attempted to completely ban an FDA-approved drug because of prior decisions in favor of the agency.
Still, states with blanket abortion bans are likely to interpret them as a ban on abortion pills. Many of the laws do not distinguish between abortion procedures and medical abortion.
“In the short term, states that ban abortion will assume that their bans also include medical abortion and that will be banned,” said Greer Donley, a professor specializing in reproductive health care at the University of Pittsburgh School of Law.
Even if blanket bans are successfully challenged, more than 30 states have laws that specifically restrict access to abortion pills. For example, 19 states require physicians to be physically present when medication is administered.
Those laws could withstand court challenges. For a long time, states have had authority over how doctors, pharmacists, and other providers practice medicine.
States also set the rules for telemedicine visits used to prescribe medications. In general, that means health providers in states with restrictions on abortion pills could face penalties, such as fines or license suspension, for trying to mail pills.
Women have already been traveling across state lines to places where access to abortion pills is easier. That trend is expected to increase.
In the meantime, some women will continue to receive the drug through online pharmacies in Canada and abroad, often with telehealth consultations from foreign doctors. The practice is technically illegal but essentially unenforced, and advocates believe women will increasingly choose this method as more states ban abortions.
“Anti-abortion states are going to do everything they can to restrict medical abortion, but in practical terms people have had and will continue to access it through the mail from international pharmacies,” Donley said.
Donley expects lawsuits based on various legal theories to play out for a few years before clear decisions emerge.
A key question is how the nation’s highest court might rule if and when to hear those court cases. While the Supreme Court has rejected the constitutional right to abortion, conservative justices have also generally deferred to the FDA’s primacy over drug decisions.
The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.
Copyright 2022 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.