Every Single Thing You Need to Know About Misoprostol-Only Abortions
Ever since The Supreme Court overruled Roe v. Wade in 2022, it's felt like abortion restrictions have been coming at us left and right. And by now, you’re probably familiar with alllll of the drama that’s gone down around the drug mifepristone—one of the two meds used in abortion pills—for over the past year.
After a very long process (more on that below!), the Supreme Court decided on June 13, 2024 that mifepristone will remain legal, widely accessible, and available. This is an enormous win for reproductive rights since just in March 2024, the Court heard arguments in a case that would have made it harder to get mifepristone…even in states where abortion is legal. Ultimately though, SCOTUS came to a unanimous decision that the opposers of mifepristone did not have grounds to sue.
The threat to mifepristone was certainly scary in its own right, but what made it a potentially bigger issue is that if it did get severely restricted or outright banned, people may have assumed that no mifepristone meant no more medication abortion at all. But that's not the case.
While mifepristone definitely cuts down on the time and symptoms involved in a medication-induced abortion (keep reading for the full deets on that later!), it’s not a necessary part of the equation—aka, you *can* safely and successfully end a pregnancy just with misoprostol, the other drug in the two-step abortion pill process.
In fact, in lots of other places—like Argentina and Nigeria—people have long used just misoprostol to end their pregnancies. "In countries where mifepristone is not available or abortion is severely restricted, it is not uncommon to use misoprostol on its own up until the 24th week of pregnancy," says Jamila Perritt, MD, an ob-gyn in Washington, D.C., and the president and CEO of Physicians for Reproductive Health.
Unlike all the turmoil mifepristone went through, misoprostol doesn't have really any risk of becoming restricted right now, says Dana Johnson, PhD, a senior research scientist at nonprofit organization Ibis Reproductive Health, where she studies abortion pills. That's because misoprostol has been used for decades for a bunch of different things, says Perritt, like managing pregnancy loss, inducing labor, and treating certain types of ulcers. So even if the Supreme Court did restrict or ban mifepristone, medication abortion wouldn't have become extinct, basically. Keep reading below on why that is.
Real quick, what is medication abortion, anyway?
Medication abortion is just the official name for abortion pills, which is actually a two-step process that includes taking two different medications: mifepristone and misoprostol. Mifepristone, the drug that was under scrutiny, blocks the hormone progesterone to stop a pregnancy from growing, while misoprostol empties the uterus to get rid of the pregnancy (by softening the cervix and making the uterus contract for all of you curious on the deets!).
Abortion pills are the most common method of abortion in the United States—in 2023, 63 percent of all abortions were done this way, up from 53 percent in 2020, according to the reproductive health research and policy group Guttmacher Institute.
Got it. So what was the Supreme Court deciding, exactly?
The federal rulings around mifepristone’s future have been very long and pretty confusing. Catch up on all that drama in full detail below:
But JIC you want the quick-ish version: In April 2023, a Texas judge suspended the FDA’s 23-year-old mifepristone approval, then hours later, a judge in Washington state countered with a ruling to maintain its status. Then in August 2023, a federal appeals court kicked the case up to the Supreme Court, which brings us to today. In March 2024, SCOTUS heard arguments from both sides on limiting access to mifepristone.
Ultimately, the Court was deciding if it would overturn the FDA’s recent updates (that happened in 2016 and again in 2021), which essentially expanded mifepristone access, like making the drug available through telehealth, explains Heidi Moseson, PhD, a senior research scientist at Ibis. By June 2024, SCOTUS announced its final decision to keep mifepristone legal.
Surprisingly, pro-choice advocates were anticipating this decision—they didn’t expect the Court to decide to completely ban mifepristone since it already vetoed a motion to kill the FDA’s overall approval of the drug, says Elizabeth Ling, ESQ, senior helpline counsel at If/When/How, a nonprofit reproductive justice group that helps with abortion-related legal issues.
Wait, why are people mad about mifepristone in the first place?
Anti-choice advocates are saying that the FDA's updates resulted in more "emergency complications," like excessive bleeding when the drug doesn't end the pregnancy. The two studies they quoted to back up this argument were recently retracted by the journal that published them for "fundamental problems" that "invalidated" the results, so there's that!
“This case has created confusion and fear," says Moseson. "It may lead some people to feel that these medications are no longer safe and effective, when in fact all of the scientific and medical evidence suggests otherwise."
Gotcha. So can I use abortion pills even without mifepristone?
Yes, because misoprostol can end an unwanted pregnancy on its own. If you take misoprostol by itself, a pregnancy will typically end within 24-hours of taking it (but usually within the first 12 hours), says Alisa Goldberg, MD, MPH, an associate professor of obstetrics, gynecology and reproductive biology at Harvard Medical School.
When you use mifepristone too (aka the usual/current way), you typically pass the pregnancy in just two to four hours. "When you're taking the drugs in combination, you can really predict when the pregnancy is going to pass," says Perritt, so you have a better idea when you need to be resting at home.
So in a misoprostol-only abortion, how do I take the pills?
In a misoprostol-only abortion, you'd take four pills every three hours, according to the World Health Organization (WHO) and the Society of Family Planning. You would do this three times. You can take the pills three different ways:
Under your tongue
With this method, you'd put four pills under your tongue for 30 minutes and let them dissolve. Once three hours passed, you'd do it again. After another three hours, you'd take the final dose. If any pills aren't fully dissolved after each 30-minute round, just drink the remnants down with water.
Inside your cheek
Take two pills and push them in the space where your cheek and gums meet on one side of your mouth. Do the same thing on the other side. Let them dissolve for 30 minutes, then do the whole process again after waiting three hours. Similar to above, you'd do this a total of three times.
In your vagina
If you go the vagina route, there is no applicator (like how there is when taking a suppository for a yeast infection), so you’ll hold each pill between your fingers and push them inside one by one. Make sure your hands are clean! Wait three hours, then run it back. You'll also go through this process a total of three times. After each dose, you’ll want to lay down for about half an hour so the meds don’t fall out before they actually absorb, according to Planned Parenthood.
Regardless of the way you took the pills, you’ll need to sport a super-sized maxipad for a couple of days, then a normal pad basically until you’re done bleeding. “I recommend patients don’t put anything in their vagina for a week, then it’s fine to switch to whatever menstrual product they prefer,” says Goldberg. So skip the tampons and menstrual cups at first. That way, you can keep an eye on bleeding.
As always, be sure to consult your medical provider on dosing and how to take the medication.
What does misoprostol do to the uterus?
Your uterus is shedding a thick lining, so you should expect heavy bleeding with some clots for about 24 hours, says Goldberg. But the blood doesn’t end there, unfortunately: You’ll likely have period-like bleeding for a week or two afterwards, with some lighter spotting potentially for up to a month. If you have heavy bleeding that doesn’t let up after 24 hours, or if you’re soaking more than two pads an hour for two hours straight, see a doctor, urge both Perritt and Goldberg.
If you haven’t already had an ultrasound to confirm the pregnancy and have abdominal pain that feels “different from cramping,” Dr. Goldberg also suggests checking in with a medical professional to be sure it’s not an ectopic pregnancy (when implantation happens outside of the uterus, usually in one of the fallopian tubes). "Trust yourself. You know your body and what’s normal for you," says Perritt. If you’re even a little concerned, check in with a medical professional.
Oh, and don’t expect to see the embryo itself pass, especially if the abortion happens early in the pregnancy, since it is “mixed in with blood and clots,” explains Goldberg. If the abortion happens around 11 or 12 weeks, aka towards the end of the first trimester, there’s a chance you may see a small embryo.
What are the side effects of misoprostol?
Strong cramping (almost like a mild contraction) is expected—that’s misoprostol doing its job. That said, you may notice more side effects with misoprostol-only abortions—like diarrhea, fever, and chills—than you would when taking mifepristone too because you’re ingesting more doses. "It tends to be the symptomatic medication," adds Moseson. Ibuprofen, acetaminophen, and anti-diarrheal medication can help, if necessary, says Goldberg.
Okay, but is a misoprostol abortion safe?
Many studies have shown that misoprostol-only abortions are very safe, even when they’re self-managed (aka without the help of a medical professional). "Sometimes people think that just because you're taking more medication, that means it's less safe or less effective, and that's not true—it just works differently," says Perritt. The risks are extremely small, she adds, even tinier than “the risk of hemorrhage, infection, and pain when compared to giving birth."
It’s also worth mentioning that misoprostol is a lab-made version of a hormone your body already makes, and that hormone helps with your uterus contracting, says Perritt (which, of course, happens during labor and when you have your period).
Have questions about taking medication in a state with abortion restrictions? Call the Miscarriage & Abortion (M&A) hotline (833-246-2632) for anonymous and free advice from healthcare providers. If you have to go to the ER or need legal counsel, call If/When/How lawyers (844-868-2812) for free and confidential help. "We will respond to every call that we get, and we'll make sure that we do what we can to connect people with the resources that they need," says Ling.
Do misoprostol abortions actually work though?
In short, yes. Misoprostol-only abortions are similar to the 95 to 99 percent efficacy rate that comes with using mifepristone. "The failure rates are comparable" between abortions with and without mifepristone, Perritt says, as long as you follow the WHO’s dosing recommendations (if not, there’s a chance the abortion won’t work).
Speaking of, is there any chance a misoprostol abortion might not work?
In the vast majority of cases, medication abortion is effective. But, like most meds, it’s not 100 percent foolproof. So how can you be sure that it worked? Bleeding and other symptoms are your main guide.
If you don’t bleed (or bleed very lightly) within 24 hours of taking the last recommended dose of misoprostol, and/or you continue to experience pregnancy symptoms—like nausea, breast tenderness, and fatigue—by one week after you take the meds, “that's a sign that it didn't work" and you still might be pregnant, says Goldberg. If that's the case, you should a call to a trusted healthcare professional, she says. Also get a medical opinion if you bleed beyond what’s expected, since this could be a sign that the uterus hasn’t fully emptied. In either case, you *might* need to take more medication or have an in-office abortion.
Goldberg recommends doing "some type of a test to confirm that the abortion was successful." So, if you got your pills through a medical provider, they may perform an ultrasound or a blood test.
If that isn’t possible because you’re handling your abortion without dealing directly with a medical professional (like if you had your pills mailed from a telehealth company, for instance) you can take an at-home pregnancy test (the kind where you pee on the stick). Just be sure to wait one month after your abortion to check. Yeah, I know...this sucks and is wildly anxiety-inducing, but the tests will continue to detect the pregnancy hormone and come back positive up until then, even if you aren't actually pregnant.
Where can I get misoprostol?
Misoprostol can be prescribed like any other medication by a healthcare provider, says Perritt. Although it may be limited in states with abortion restrictions, "it's not regulated in the same way that mifepristone is,” she adds.
Abortionfinder.org has a state-by-state guide to locate the nearest clinics that dispense medication abortion. Telehealth providers Hey Jane and Carafem also ship pills through the mail. Plan C offers an easy-to-use guide to find abortion pills at clinics, telehealth, and online pharmacy options that are accessible in all 50 states.
How much is it going to cost me?
Not too much. Misoprostol itself costs up to $32 for four doses. This is a lottt less than mifepristone, which runs about $90 Per! Pill! According to Planned Parenthood, getting a medication abortion—including both medications and a visit with a medical professional—costs about $580 at their clinics, and in general, up to $800. It may be covered by insurance, says Johnson, in which case you might just have a copay. Some clinics have sliding-scale pricing.
All of this, of course, varies depending on a lot of other factors, like where you live and if you need to travel. If you don’t have insurance or otherwise can’t afford a medication abortion, the National Network of Abortion Funds can link you with groups offering financial and logistical support.
There’s the law—and then there’s reality. "People have been choosing to self-manage their own abortion at home for generations. I think people will continue to do that regardless of the Supreme Court decision," says Ling.
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