Misoprostol

Cytotec (misoprostol) by Pfizer

The New York Times
Op-Ed Columnist
July 31, 2010
By NICHOLAS D. KRISTOF

Another Pill That Could Cause a Revolution

“Could the decades-long global impasse over abortion worldwide be overcome — by little white pills costing less than $1 each?

That seems possible, for these pills are beginning to revolutionize abortion around the world, especially in poor countries. One result may be tens of thousands of women’s lives saved each year.

Five-sixths of abortions take place in developing countries, where poor sterilization and training often make the procedure dangerous. Up to 70,000 women die a year from complications of abortions, according to the World Health Organization.

But researchers are finding an alternative that is safe, cheap and very difficult for governments to restrict — misoprostol, a medication originally intended to prevent stomach ulcers.

“I feel like people must have felt when they discovered the nuclear bomb,” says Dr. Beverly Winikoff, president of Gynuity Health Projects, a nonprofit research institution on reproductive health. “This technology is world-shaking.”

This pharmaceutical approach is called “medical abortion.” In the United States and Europe it typically consists of two sets of “M” pills. The first is mifepristone, formerly known as RU-486, and then a day or two later the misoprostol.

Using the drugs in combination produces a miscarriage more than 95 percent of the time in early pregnancy. But mifepristone is difficult to obtain in much of the world, because it is used only to induce abortions. In contrast, misoprostol is very widely available and can’t easily be banned because it is also used for ulcers and can save lives of women with postpartum hemorrhages. Whatever one thinks of misoprostol for abortions, it also is a potential lifesaver for women who hemorrhage after childbirth.

Researchers are finding that if women take misoprostol alone, effectiveness drops to 80 to 85 percent. That may sound low, but it’s typically far better and safer than alternatives that women turn to, Dr. Winikoff noted.

“Medical abortion represents a revolution in women’s reproductive health,” said Dana Hovig, the chief executive of Marie Stopes International, an aid group that provides women’s reproductive health services in 43 countries around the world. “It saves women’s lives and has enormous potential to increase access to safe abortion at minimal cost.”

Medical abortion causes a miscarriage that is indistinguishable from a natural one. That’s important for women in countries where they risk arrest if they seek help in a hospital after a botched abortion. The risks to a woman seem no greater than with a natural miscarriage, and there’s no known harm to a woman who turns out not to have been pregnant after all. One serious downside is that misoprostol is suspected of causing birth defects, perhaps 1 percent of the time, but only if it fails and the pregnancy continues to term.

In the United States, only about one abortion in eight is done with pills. Partly that’s because by law, mifepristone must be taken in a clinic. But worldwide, the number of medical abortions is surging, accounting for nearly 70 percent of all abortions in Scotland, according to Marie Stopes International.

It’s not clear how late in pregnancy medical abortion is feasible. “It sounds like a simple question, but it’s not,” Dr. Winikoff said. In some form and strength, medical abortion seems to work “from Day 1 to the end of pregnancy,” she said — but the effectiveness and safety of later-stage abortions still need to be worked out.

In the United States, the pills can be taken up to nine weeks’ gestation. In Britain, inpatient use of the pills is permitted up to 24 weeks.

What do these pills mean for the political battles over abortion? To firm opponents of abortion, the means of ending a pregnancy doesn’t matter. But my hunch is that, for those in the middle, taking pills at home may seem a more natural process than a surgical abortion, and the result may be a tad more acceptance.

In any case, it would be tough to carry out a ban on medical abortion. Indian companies are producing mifepristone and misoprostol in a big way, and blister packs with the combination of drugs can be purchased for less than $5 — and then shipped anywhere.

In addition, misoprostol on its own can be found all over the world, from Internet sites to over-the-counter pharmacies in Delhi. In India, misoprostol costs just pennies per pill.

Misoprostol is likely to become even more widely available, because last year the World Health Organization expanded its uses as an “essential medicine” to include treatment of miscarriages and incomplete abortions.

Brazil and some other countries have tried to tighten access to misoprostol because of its use for abortion. But curbing access to misoprostol would mean that more women would die of hemorrhages.

As word spreads among women worldwide about what a few pills can do, it’s hard to see how politicians can stop this gynecological revolution.”

Personal comment: Using Misoprostol by itself may be an option in countries where abortion is banned, but our clinic recommends against trying to induce a medical abortion using Misoprostol alone. For medical terminations the clinic uses Mifeprex and has had a very high success rate with it. Misoprostol alone used for a termination (rather than Mifeprex which uses both Mifepristone and Misoprostol) results in lower effectiveness of the procedure and more severe side effects such as pain and heavy bleeding. But if Mifeprex is not available then using Misoprostol alone will usually work.

The website Women on Waves: http://www.womenonwaves.org/set-274-en.html posted the following World Health Organization instructions for performing a medical abortion using Misoprostol alone.

“Misoprostol alone can be used to cause an abortion. However, incorrect use of Misoprostol can be harmful for the health of a woman!!

To cause an abortion, a woman must put 4 pills of 200 micrograms (in total 800 mcg) Misoprostol under the tongue. Do not swallow the pills (at least until 30 minutes after putting the tablets under the tongue!!)

After 3 hours she should put another 4 pills of Misoprostol under the tongue.

After 3 hours she should put another 4 pills of Misoprostol under the tongue again for a third time. Do not swallow.

The success rate is 80%- 90%.

After the first dose of Misoprostol a woman should expect bleeding and cramps. Bleeding mostly starts within four hours after using the pills, but sometimes later. Bleeding is often the first sign that the abortion starts. If the abortion continues, bleeding and cramps become more severe. Bleeding is often more and heavier than a normal menstruation, and there can be clots. The longer the pregnancy, the more heavy the cramps and the bleeding will be. If the abortion is complete, the bleeding and the cramps diminish. The moment of abortion can be noticed with a peak of heavier blood loss and more pain and cramps. Depending on the length of the pregnancy, a small pregnancy sac with some tissue around can or cannot be seen. For instance, if the woman is only five to six weeks pregnant, there will be no visible sac. At nine weeks, a woman could probably find a sac in between the blood.

If no bleeding occurs after the third dose, the abortion did not take place and the woman has to try it again after a couple of days or travel abroad to a country where it is legal or try again to find a doctor.

If a woman would want to relieve the pain, she can use painkillers such as Paracetamol.

(Von Hertzen H, ea WHO Research Group; Efficacy of two intervals and two routes of administration of misoprostol for termination of early pregnancy: a randomized controlled equivalence trial, Lancet. 2007 Jun 9;369(9577):1938-46. )”