At the end of September, the FDA approved Mifeprex (also known as mifepristone, and before that as RU486) for termination of early pregnancy. It is the only FDA approved non-surgical option for ending early pregnancy. The arrival of Mifeprex has heightened the furor between the Right to Life movement, and the Right to Choose movement. I would like to provide the medical viewpoint.
Mifeprex works by blocking progesterone, a hormone necessary for the uterus to support a developing pregnancy. The lining of the uterus softens without adequate progesterone, and begins to break down. This process takes several days. A second medication, misoprostol, causes the uterus to contract, expelling the lining and terminating the pregnancy. Mifeprex can be used only in the very early stages of pregnancy, up to 49 days after the beginning of a woman's last period, or no later than 3 weeks after missing her period. Mifeprex is 92 percent to 95 percent effective in terminating the pregnancy.
Mifeprex is licensed for use only by physicians with expertise in evaluating the age of a pregnancy, who have ready access to ultrasound testing, and who are experienced in treating pregnancy complications such as miscarriages. It will primarily be used by gynecologists, and not by primary care physicians. It is not available by prescription from a pharmacy. It must be ordered from the drug company, and used in the specialist's office, clinic or hospital. Women receiving Mifeprex make three visits to the specialist over a two-week period. During the first visit, a woman receives detailed counseling about the use and side effects of the process, the age of the pregnancy is confirmed, and the dose of Mifeprex is given. Two days later she returns, and takes misoprostol. The final visit, approximately 12 days later, is vital to ensure that the pregnancy has ended, since that can only be determined with testing and examination.
Bleeding and cramping are a normal part of the process, and should be expected. The bleeding and cramping are typically worse than that experienced with a normal menstrual period, and are most intense in the first three days after receiving Mifeprex. Bleeding typically lasts nine to 16 days. On rare occasions, bleeding can be so severe that treatment in an emergency room is needed. Nausea, headache and vomiting are fairly common side effects. A few women who take Mifeprex will need a surgical procedure, known as a D&C, to end the pregnancy or to stop heavy bleeding.
Choosing to terminate a pregnancy is a very personal and difficult choice for any woman. No woman takes this choice lightly. At Tufts Health Service, our mission is to meet the medical needs of a very diverse community. Our students come from many different cultures and religions, from many walks of life, and with a wide range of family and personal beliefs. Our goal is to provide them with information about their medical condition, and the range of treatment options available. They need to know about risks, benefits, side effects, and long-term consequences of all the possibilities.
Our responsibility is to help them understand their choices, and to work with them as they evaluate their choices within the parameters of their own belief system. We then direct our patients to the best source of care, to carry out the treatments they chose. Those sources might include abortion providers, counselors, or agencies that provide support to pregnant young women to help them continue a pregnancy. We are not seeking approval to use Mifeprex at Health Service since we do not provide the range of gynecologic services on site that are needed for that level of medical care. We will certainly be providing information about Mifeprex for women who chose early pregnancy termination. Mifeprex is a non-invasive option for ending early pregnancy. It is taken orally, avoiding surgery or anesthesia in most cases.
In the discussion of pregnancy termination, it is vitally important to focus on pregnancy prevention. We would all like to see the number of abortions decrease. A very important way to achieve this goal is to improve our services to women wanting to prevent pregnancy. There are many options available to young women to prevent pregnancy. Birth control pills, birth control shots, and condoms and spermicide are the most popular methods for university-age women. Even with the best plans and intentions, these methods can fail. A back up option in this situation deserves much greater publicity: emergency contraception, or the "morning after pill."
Emergency Contraceptive Pills (ECP for short) are ordinary birth control pills taken in special doses within 72 hours after unprotected intercourse to prevent pregnancy. They reduce the chance of getting pregnant by 75% to 85%. ECPs have been available and approved by the FDA for a number of years, although many women do not have adequate information about them. The sooner ECPs are taken after intercourse, the more effective they are. ECPs prevent pregnancy by one of three mechanisms: 1) temporarily stopping eggs from being released from the ovary, or 2) by stopping fertilization, or 3) by stopping a fertilized egg from attaching to the womb.
ECPs can make some women feel nauseous or even vomit. Taking anti-nausea medication before ECPs usually prevents this, and some of the newer ECPs are much less likely to cause stomach upset. Widespread use of ECP has the potential to reduce the number of unwanted pregnancies and abortions in this country. Every woman of childbearing age should know about Emergency Contraception pills.
At Health Service, we are committed to providing sensitive and respectful care for the whole range of women's reproductive and sexual health needs. Depending on a woman's situation and desires, this may involve gynecologic examinations, information about sexually transmitted diseases, treatment for infections, pregnancy prevention options including ECPs, and sometimes counseling about pregnancy termination. As health providers, we always welcome a variety of options to help patients deal with their medical needs.
Dr. Margaret Higham is the Medical Director of Tufts University Student Health Service.
