A wave of court rulings in April 2023 has overturned the future of the abortion pill mifepristone in question. For now, a US Supreme Court decision on April 21 allows the drug to remain accessible without additional restrictions as is the bottom line weighed in lower court proceedings.
Depending on the outcome the pill may face a ban or increased restrictions about its use, a possibility that concerns many healthcare providers.
The Conversation asked Grace Shih, a family physician who practices in Washington State, to explain the science behind mifepristone, as well as its safety and effectiveness in medication abortions.
What is mifepristone and how does it work?
Mifepristone is a pill used in medication abortion in early pregnancy. It was initially approved by the Food and Drug Administration in 2000 and is FDA approved for drug-induced abortion up to 10 weeks after the first day of the last menstrual period.
It can be taken as part of a two-part medication abortion pill regimen. Mifepristone is prescribed as an oral dose of 200 milligrams, followed by an 800 microgram dose of misoprostol, which is placed in the vagina or between the teeth and cheek, where it dissolves and is absorbed, usually 24 to 48 hours later.
Mifepristone works by blocking the hormone progesterone, which is necessary for a pregnancy to develop. This stops pregnancy growth and softens and dilates the cervix. It also prepares the uterus for contractions, increasing its sensitivity to drugs such as misoprostol.
Misoprostol is a synthetic substance prostaglandin. Prostaglandin is a hormone-like substance that has multiple effects, including stimulating uterine contractions, which helps expel pregnancy tissue, such as the thickened uterine lining and the tissues that are precursors to the placenta.
misoprostol is currently FDA approved for reducing the risk of peptic ulcer disease in patients at high risk of peptic ulcer complications. But it’s often used off-label for things like cervical ripening or softening, to induce or aid labor. Mifepristone and misoprostol are also both used in the medical treatment of miscarriage.
Drug abortion can also be done with misoprostol alone, an approach known as the misoprostol-only regimen. This regimen is safe and has been widely used by people all over the world. In the misoprostol-only schedule, a dose of 800 micrograms is placed in the vagina or between the teeth and cheek every three hours for up to three doses.
Both protocols are highly effective, with the two-drug regimen up to 99.6% effective and the misoprostol-only regimen between 84% and 96% in medical abortions.
Why would a person choose one regimen over the other?
People usually don’t choose the type of abortion medication they get. Because the availability of mifepristone and misoprostol is highly variable, the method available to you is medically safe. Patients should be assured that medication abortion guidelines support the guidelines safety and efficacy of both drug regimens.
The American College of Obstetricians and Gynecologiststhe Family Planning Association and the World Health Organisation they all support both types of medication abortion.
How widely accessible is mifepristone?
In January 2023, the FDA has updated its guidelines to dispense mifepristone on prescription through pharmacies.
The change means that the drug will be available by mail as well as brick-and-mortar pharmacies, as long as that pharmacy is retail certified. In other words, people who live in states that don’t prohibit abortion can take their prescription for mifepristone and get it like they pick up other drugs.
For someone who can pick up mifepristone at a local pharmacy, the process is no different from picking up birth control pills or blood pressure medications. This allows mifepristone and its uses for abortion care and miscarriage management to be treated as typical health care.
While the January 2023 FDA ruling theoretically expands the ways a person can get mifepristone, it is not widely available from pharmacies until now.
Can I still get mifepristone?
The short answer is yes, mifepristone is still FDA approved. The Supreme Court ruling of April 21, 2023 means that there will be no changes to access to mifepristone for the time being. However, mifepristone still faces restrictions for use in abortion care, depending on your country’s legislation.
As of April 2023, 27 states have any restriction on medication abortion according to the Guttmacher Institute, a reproductive health policy organization. This includes 12 states that have nearly complete bans on abortion and one state that has stopped providing abortion care due to legal uncertainty.
Of the 15 states with restrictions specific to medication abortion, all require medication to be provided by a physician and not an advanced practitioner such as a nurse specialist. Six of the states require an in-person visit to a physician, one state requires mifepristone to be taken in the presence of a physician, and one state prohibits shipping abortion pill medications.
As a practicing family physician, I follow the science and make medical decisions with my patients based on the most up-to-date evidence. Medication abortion using mifepristone and misoprostol is extremely safe and highly effectivelike it is medication abortion with misoprostol alone. Side effects of the misoprostol alone regimen are similar to the combined regimen, although they may last longer due to the need for multiple doses of misoprostol.
Some coverage has focused on comparing the efficacy of the two regimens. But percentage points mean very little to an individual’s health – it’s about people getting the care they need.
I will continue to work, provide and promote science-based care. Leading healthcare professional associations, including the American College of Obstetricians and Gynecologiststhe American Medical Association and the American Academy of Family Physicians have any statements issued calling for the lifting of all restrictions around mifepristone and/or support the safety of misoprostol-only abortion.
This is an updated version of an article originally published on January 11, 2023.