Abortion Reproductive Health Women's Issues

Revisit Menstrual Extraction

Image courtesy of IPAS

            Before Roe v. Wade, and before pregnancy tests were easily available, there were ways a woman could get her period started if it was late. This is called “Menstrual Extraction” (ME) or “menstrual regulation”. Without knowledge if she were pregnant or her period was just late, ME was not considered an abortion.

            ME can be done with herbs, medicines or instruments. In Indonesia a doctor told me about “EM Kapsuls”, which are advertised on TV. Kapsuls are used to ease menstrual cramps, plus they are advertised to start a late period.

  “Emmenagog” is the word for herbs or medicines that are used to start a woman’s period. Herbal emmenagogs are used in many cultures and have a long history. One of the most used emmenagogic plants, pennyroyal, is mentioned in Aristophanes’ play, Peace, written in 421 BCE! Although pennyroyal is apparently effective both in starting menses or causing an abortion, it is also toxic; it can cause severe liver damage and death. Tansy and rue are two other plants with similar effects—and toxicity.

            Dr. Karmen, a psychologist, developed a MR technique using instruments: a flexible cannula and a syringe for suction. It is fast, simple and safe in the hands of an experienced person. That technology is still used for early abortions and incomplete miscarriages. I used Karmen cannulas until the office nurse pointed out that patients seemed to have more problems with that type of cannula than with the conventional, rigid cannula.

            In general, Islam is against abortion—although there are exceptions. For instance, abortion is illegal in Bangladesh, a Muslim country, but ME is acceptable. It was introduced to decrease maternal mortality associated with unsafe abortion. A doctor can legally perform MR up to 12 weeks from the onset of a woman’s last menstrual period. 

In addition to using herbs or suction to remove the tissue in the uterus, ME can be done with the same tablets, mifepristone and/or misoprostol, that a woman can take for a medication abortion. These medicines are even available in some countries without a prescription. They are also available in some states of the USA for ME through the Period Pills Project.

What are the dangers of ME? There is a risk that pregnancy, if indeed the woman is pregnant, may continue. Rarely the pregnancy isn’t in the uterus, but in a tube. A tubal pregnancy may have the same symptoms as a normal pregnancy, but it can tear the tube as it grows and cause internal hemorrhaging.

Performing an ultrasound before an abortion is wise for 2 reasons—to determine the pregnancy’s location and its gestational age. However, MR may skip the ultrasound if it’s done outside of the medical system. This means an ectopic pregnancy could escape detection, or that a pregnancy might be too far advanced for safe MR. Fortunately, the possibility of a continuing pregnancy can be excluded if the woman has a negative pregnancy test a week or two after she has had the ME.

Is MR going to make a comeback in US states where abortion is severely limited or entirely illegal? That is difficult to predict. However, there are studies suggest that women are interested in the idea. 

An old video, No Going Back, shows how ME is done with the Karmen cannula. Unfortuately, it neglects to mention sterile technique and other precautions, so I don’t recommend it. Nevertheless, do-it-yourself ME might be safer than a back-alley abortion.

I searched and could only find information about the efficiency of ME using a combination of mifepristone and misoprostol, which are very effective. There doesn’t seem to be any study of the success rate of either a single medication or of herbal products. A study is being done in California to test misoprostol; it will be interesting to find its results.

            The recent Dobbs decision by the Supreme Court has limited access to safe abortion care. However, ingenious women can find ways to get around the law. I just hope they can do so without compromising their safety.

© Richard Grossman MD, 2022

Abortion Public Health Women's Issues

Work Around New Antiabortion Laws

Number of Maternal Deaths from Abortion, data from the Guttmacher Institute

            Abortion has been practiced by all societies that anthropologists have studied. Most past ways of causing an abortion are either ineffective or dangerous—or both. Midwives prescribed herbs for centuries to cause abortion, but they can be fatal if the dose that is too large. Physical methods, like beating the woman’s swollen abdomen, were also frequent. Purposely falling down a flight of stairs was not uncommon. Perhaps the most frequent way of aborting a pregnancy in the 20th century, before Roe v. Wade, was to insert something into the uterus. Coat hanger wire or knitting needles were repurposed for this.

            Fifty years ago, when I was in general practice, I reviewed the chart of a woman in her 40s before meeting her. I learned that she had had a hysterectomy, then read the pathology report stating that there was a 6-inch splinter of wood found in the uterus.

            “How did it get there?” I asked innocently when I met her.

            “I don’t know” was her reply. Then it dawned on me.

            Other dreadful ways of attempting to terminate a pregnancy include douching with harsh chemicals, shooting the fetus while in the uterus, and suicide. The maternal mortality rate in the USA dropped precipitously in 1973 when the Supreme Court legalized abortion in all states. I fear that the Dobbs decision will cause an increase in our country’s already high maternal mortality rate.

            Death is not the only problem caused by making abortion illegal or unobtainable in many states. A good friend of ours had an illegal abortion in the 1960s, but was unable to conceive later when she was married. It is likely her unsafe abortion caused an infection that prevented the desired pregnancy.

            In the past, women in Chicago took abortion care into their own hands—literally. The Jane Collective learned how to perform abortions safely and did so in the apartments of willing tenants, thereby escaping police detection. A California psychologist, Dr. Karmen, helped women by developing aspiration instruments for “Menstrual Extraction”. To avoid the abortion laws, ME was done before pregnancy was diagnosed. And the Clergy Consultation Service, established in New York, referred women nationally to willing physicians for safe abortions.

            Since the Supreme Court’s Dobbs decision made it possible for states to outlaw abortion again, other ploys are being used to help women access safe abortions. Most take advantage of medication abortion, using 2 FDA-approved pills. Mifepristone and misoprostol are available by Internet; however, they are expensive and can take weeks to arrive. The advent of telemedicine has improved access in the USA.

            One plan is to have access to the medication available just over the border in a state that allows abortion. There is a new clinic in New Mexico, a few miles from Texas, so women can get the abortion pills if they cross the border. Planned Parenthood in Illinois will be providing the same service from a van for residents of Missouri and other neighboring states. Perhaps the most innovative work-around is in Arizona. Camelback Family Planning will perform the ultrasound and counseling, then the information is sent to a California doctor who then prescribes the medication. The woman picks up her pills at a post office in a California border town—all free, thanks to the Abortion Fund of Arizona.

            There are several funds that help women get to abortion clinics and also aid with the cost of abortion care, some local and some national. I donate to both Colorado’s Cobalt Abortion Fund and to the National Network of Abortion Funds—both are tax deductible.            

Almost 60 years ago the Clergy Consultation Service found ways around the laws that prohibited abortions. Now we have their experience, plus Internet and medication abortion. Although Dobbs is a setback, today women are better off than before Roe.

© Richard Grossman MD, 2022