Stop talking about coat hangers and start talking about misoprostol

Some thoughts on where we have been and where we go from here from an OB/GYN

Abortion was legalized in Canada under the Criminal Law Amendment Act of 1969, but could only be performed in a hospital after the approval of a three-doctor therapeutic abortion committee. They would decide if the pregnancy posed a health risk, and if so, they would agree to let a pregnancy termination proceed. As you can imagine, there were huge inequities in the system. Where you lived and which hospital received your application affected how these three people, who didn’t know you and almost never met you, controlled your destiny. Some committees never even bothered to meet. And there was no appeal. 

But shortly before the law was passed, Dr. Henry Morgentaler, decided to start performing abortions in his office in Montreal, even though it was illegal. Women were resorting to unsafe home procedures or “back alley” abortions, and they were getting injured and some were dying and he felt morally obligated to help. When abortion became legal, albeit with restrictions, Morgentaler carried on doing abortions. No three member committee. No hospital. Just a doctor and patient.

Morgentaler was arrested, tried, and acquitted. Three times. This resulted in a media circus. Growing up in Canada in the 1970s Dr. Morgentaler and his crusade to give women abortions without restrictions was in the news a lot. And this affected me greatly. Looking back, I don’t remember the news coverage painting Morgentaler as a villain. I might not be remembering correctly, but it seemed more that the reporters were dumbfounded that he was still doing abortions despite getting arrested over and over again. How did someone have such personal conviction? And of course that the government couldn’t actually get him convicted. 

After his third acquittal, the Quebec Court of Appeals overturned his acquittal, which was absolutely unprecedented, and the Supreme Court of Canada upheld the reversal, sending Morgentaler to jail. But the government changed the law, so an appeals court couldn’t overturn an acquittal. He was released from jail, only to be arrested and tried again! A fourth arrest and trial was to start, but by then the provincial government had changed and in 1976 they decided they would no longer prosecute doctors performing abortions in their clinics, even though they were defying the criminal code. 

Because of Dr. Morgentaler, abortion was in the news a lot, and so people talked. I’d heard about a girl who’d “done something” to herself, one of those hushed conversations you hear as a kid with your ear pressed up against a door. I also heard of a girl who was “sent away” for months and came back quieter and sadder. And a girl who had traveled to the United States for an abortion. I was 12 or 13 and I’d heard of three unwanted pregnancies. I also had a friend who didn’t have a dad and I had heard what some of the parents had said. 

Looking back now it seems obvious why Morgentaler was acquitted. In the 1970s at least one person on every jury would have known girls like the ones I had heard about. Or maybe they had been one of those girls. Maybe someone was the parent of one of those girls. 

And when I trained as an OB/GYN I learned the tragic medicine behind those stories. A uterus pumped full of Lysol. Bowel perforations. Pus. Bellies full of blood. In fact, because I listened to those stories after I graduated and moved to the U.S., I knew what to do when I saw my first patient with a botched abortion. As I was the abortion provider at the hospital, I was the one called to the emergency department.

Even though abortion was legal, it was still too expensive for many. There was a doctor who performed them for much cheaper than I did or the few other qualified providers in the state. He was an internal medicine doctor I was later told. Her uterus had been perforated and her uterine artery lacerated. She was close to death. Those arteries pump out a lot of blood. But I remembered what I was told. And she lived. 

(For the OB/GYNs and other providers reading this, I did the fastest anterior and posterior colpotomy and clamped off both uterine arteries from below. This stopped the bleeding, as the perforation was lateral and low, and bought time to treat the coagulopathy and then decide on a more definitive course). 

This was not the only complication I saw from that provider. 

I tell you all this to show that I know how bad it was and I understand the drastic measures taken by many women. 

But medically we are in a different place now. 

Around the time I graduated residency, in 1995, medical abortion entered the North American medical lexicon. A study was published showing that an injection of methotrexate followed 5-7 days later with 800 micrograms of misoprostol vaginally could successfully abort a fetus. Eventually, mifepristone and misoprostol were approved for medical abortion in 2000 (in the United States) and since then we have seen many studies bringing us to the point where we know these medications are not only a very safe way to induce abortion, but they can be dispensed without an in person appointment. People can now take the medications in their own homes and manage their bodies how they see fit. Or they could if the government would get out of the uterus. We also now have data on just using misoprostol alone, which given the difficulties getting mifepristone, is also very important. 

Abortion has changed a lot over my lifetime. It has gone from being illegal to legal (although just barely in the United States). It’s moved from dirty rooms and back alleys, to hospitals, to clinics, to the home. It’s gone from a procedure to either a procedure or medication. In fact, the residents training today in the United States have not known a time when medical abortion didn’t exist. 

Times have changed with abortion, and as we rise up against those who would oppress us and take away the right to abortion, I ask you to not use the coat hanger as a rallying cry, because that is the symbol of my era, a time when a pregnancy could only be ended with a procedure. The symbol for this era is a pill. And while it may be hard to get, and we need to work on improving access, we don’t want to give people the idea that in desperation a coat hanger or injecting Lysol or throwing themselves down the stairs is the best option. Because they’re not. If people are going to access a self-managed abortion that may be clandestine as far as the State is considered, the best option for many may be misoprostol. 

Mifepristone and misoprostol together is ideal, and while I think everyone should have that option, it may not be possible for everyone to access. So it is important that people know how effective misoprostol alone is and where they can get it. And as I have written here, there is no way any doctor or nurse or police lab can determine if you have taken it as long as you take it under your tongue or place the tablets against your cheek. 

Everyone needs to know this. 

What can we do now? In addition to taking political action and demonstrating, I want to give people five concrete action items, because I don’t know about you, but when things are in the shitter I feel better having something productive that I can do, no matter how small it is. 

But before I get to the concrete plans, I’ve summarized the doses of misoprostol for medical abortions and a little other information from this excellent article in NEJM. This should not be construed as direct medical advice, I just thought people might be interested. 

• ≤10 weeks pregnant: misoprostol, 800 μg (four of the 200 μg or microgram) tablets against the cheek or under the tongue every 3 hours for 3 doses. The success rate is 84-87% and the risk of a complication leading to hospitalization is 0.3%. 

• >10 wk to 12 weeks pregnant: Misoprostol, 800 μg against the cheek or under the tongue every 3 hours until the pregnancy delivers. The success rate is 75–93% success rate, but there is limited data on the complication rate.  

• >12 wk to 24 weeks pregnant: misoprostol, 400 μg against the cheek or under the tongue every 3 hours until delivery. It is 77% effective. The complication rates are higher, up to 6% of people will need a blood transfusion and about 2% will get an infection. 

And here are the five concrete actions you can take on behalf of yourself or a friend or loved one who needs your support:

One

Know the names of places that can help get abortion pills (either mifepristone and misoprostol or misoprostol alone) to people in states with restrictions. 

• Women on Web  https://www.womenonweb.org/en/

• Women Help Women https://consult.womenhelp.org/get-abortion-pills?z_language=en

• Safe2Choose https://safe2choose.org/

• Plan C https://www.plancpills.org/guide-how-to-get-abortion-pills

Misoprostol is available as a prescription in the United States for prevention of stomach ulcers, especially for people who are taking NSAIDS, like ibuprofen. A lot of people take a lot of ibuprofen for menstrual cramps. Just saying.

Misoprostol is also sold from Vet supply stores online (prescription required, apparently it’s great for preventing stomach ulcers for horses) and it is over the counter in Mexico and several other countries. 

Two

Get a TENS Unit. They can be helpful in reducing the pain from a medical abortion. You can always loan or gift one to a friend, but they are handy to have on hand just in case. You can read more about them here. 

Three

Hound your local politicians. I am no legal scholar, but if Tennessee can make Ivermectin available over the counter without a prescription, then any state can make misoprostol available over the counter. It would be great if our Veterinarian colleagues could also support this.

Obviously, this won’t fly in red states, but imagine if misoprostol were over the counter in several states? If someone mails misoprostol from, say Colorado and there is no return address, who would know? Or, if you ever happen to travel, you can bring some back. Assuming, of course, these options are safe. 

Four

Watch your digital back.

What you have been researching online can be tracked and even your menstrual apps could be an issue. Facebook had received data from at least 2 period apps, Flo and Ovulation Tracker, read more about that here (the article is a couple of years old, but I am just going assume they are still doing this because Facebook, ugh). And, a data broker has been selling data about who visits Planned Parenthood. Read about that atrocity here.

To learn more about how to protect yourself online, check out this guide here from Women Helping Women and this one here from the Electronic Frontier Foundation. 

Louisiana just advanced a bill that would make abortion a homicide at ANY gestational age. And Missouri is just waiting for Roe to fall. Really, learn how to protect yourself online. 

Five

Stop talking about coat hangers and start talking about misoprostol. 

We shouldn’t be here in this situation, but we are.

References

Medication abortion up to 70 days of gestation. ACOG Practice Bulletin No. 225. American College of Obstetricians and Gynecologists. Obstet Gynecol 2020;136:e31–47.

Tang, O., Gemzell-Danielsson, K. and Ho, P. (2007), Misoprostol: Pharmacokinetic profiles, effects on the uterus and side-effects. International Journal of Gynecology & Obstetrics, 99: S160-S167.

Hausknecht, RU. Methotrexate and Misoprostol to Terminate Early Pregnancy. N Engl J Med 1995; 333:537-540.

Raymond EG et. al. Efficacy of Misoprostol Alone for First-Trimester Medical Abortion: A Systematic Review. Obstet Gynecol. Obstet Gynecol. 2019 Jan; 133(1): 137–147.

Harris LH, Grossman D. Complications of Unsafe and Self-Managed Abortion. N Engl J Med 2020; 382:1029-1040.

Goldman AR, Porsch L, Hintermeister A, Dragoman M. Transcutaneous Electrical Nerve Stimuation to Reduce Pain with Medical Abortion. Obstet Gynecol 2021;137:100-7.