Abortion Reproductive Health Women's Issues

Investigate Illegal Abortion

In the early 1990s I read about women who were using a medication to cause abortions without visiting a doctor. Brazilian women had found that misoprostol (CytotecÒ) was available without a prescription, and would cause strong uterine contractions that could expel an early pregnancy.

Since then, this knowledge has spread to all corners of the globe. Misoprostol is now approved by the US Food and Drug Administration for use in conjunction with mifepristone to be prescribed for legal abortions. This combination has been found to be both very effective and very safe. Recognizing the safety of this combination, the FDA has decreased restrictions on mifepristone. The combination can also now be prescribed by telemedicine. However, misoprostol is almost as effective when used alone.

The original indication for misoprostol had nothing to do with abortion. Instead, it was found to protect the stomach lining in people who had irritation from NSAIDs, such as ibuprofen. It has other uses, including induction of labor (in a teeny dose) and is a lifesaver for treating postpartum hemorrhage.

A Honduran friend sent me the transcript of a BBC News Program, “Inside Honduras’s abortion pill black market.” Abortion is illegal under all circumstances in this Central American country—the most restrictive law in the world. Having an abortion is punishable by 6 years in prison. Although “back ally” surgical abortions may still occur, this excellent piece of investigative journalism is about medication abortion. Only misoprostol is available in Honduras, not mifepristone. Unfortunately, this article doesn’t give any follow up on women who use the medicine. There are risks, and some women end up in the hospital.

One of the risks is that the pregnancy will continue; misoprostol alone is only about 90% effective. Follow up is needed to detect the one in 10 women who doesn’t abort. If the first dose doesn’t work, she should use a second dose or she may go to term. Sadly, a fetus exposed to miso early in pregnancy may be affected with serious congenital anomalies—one of the risks of unsafe abortion.

Back to Honduras. The reporter, Laura, first spoke with a young woman who didn’t use protection during a one-night-stand and was 2 months pregnant. She bought 4 tablets of misoprostol on the black market. José, the black-market supplier, charges on a sliding scale. He gets from $70 to $270—depending on what he thinks the woman can pay. In this country they might cost $10, with a prescription. José has to pay off his ex-girlfriend who works in a hospital and supplies the prescription. He may also keep the police happy with bribes.

Honduras’s largest public hospital is in the capital, Tegucigalpa. It treats around 60 women each week for bleeding during pregnancy, either from miscarriage or induced abortion. The UN estimates that there are about 70,000 unsafe abortions in Honduras each year. Making abortion illegal doesn’t prevent desperate women from having unsafe abortions. Without sexual education teens don’t know how to prevent pregnancies; Honduras has the highest rate of adolescent pregnancies in Central America. Could these facts reflect the unrealistic religious teachings in a country where 48% of people are evangelical Christian and 34% are Roman Catholic?

What lessons does Honduras have for the USA? Outlawing abortion doesn’t prevent women from obtaining abortions, but they may be unsafe, expensive and exploitive. Similarly, US states that have acted to restrict or outlaw abortion are among those with the highest teen pregnancy rates, the least sex ed and the poorest support for mothers and children. Many also have high maternal mortality rates, which will probably rise as desperate women take abortion into their own hands.

©Richard Grossman MD, 2023

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