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Exploring Nonsurgical Options

Abortion * Other drug combinations provide effective alternatives.


Even as the abortion drug known as RU-486 traverses a bureaucratic obstacle course in the United States, women are finding ways to get abortions without surgery.

"There is definitely a feeling that we need to explore other agents" for nonsurgical abortions, says Dr. Bryna Harwood, a researcher at USC.

Doctors, usually those who also perform surgical abortions, will sometimes prescribe methotrexate, a low-cost cancer drug that has been in use since 1953, as an alternative to surgery. About a dozen studies have shown the drug to be safe and effective for inducing abortion early in pregnancy, according to a recent report in the Journal of the American Medical Women's Assn.

The Food and Drug Administration has not approved methotrexate for use in abortions, but doctors may prescribe it for an "off label," or unapproved, use. Physicians are allowed to use a drug for a medical purpose not approved by the FDA if there is information indicating that such use would be reasonable and appropriate.

As part of a two-drug regimen, methotrexate prevents the embryo from implanting itself in the uterus. About three days after a woman takes methotrexate, she is given misoprostol, a drug approved for the treatment of ulcers that causes uterine contractions and triggers an abortion.


Methotrexate is about as successful in producing abortion as mifepristone. In studies of the drug, about 95% of women who are seven weeks pregnant or less have a complete abortion.

USC researchers are studying whether misoprostol, taken by itself, can produce an abortion. Misoprostol is also part of the two-drug regimen used in mifepristone (or RU-486) abortions.

In prior studies, misoprostol used alone has been effective in 61% to 94% of cases in women who are no more than seven weeks pregnant, according to the Journal of the American Medical Women's Assn. In more recent studies, however, USC researcher Daniel Mishell reports success rates similar to those of mifepristone or methotrexate. Mishell gives women one 800-microgram dose of misoprostol (sold under the brand name Cytotec) in a vaginal suppository, along with medication to prevent pain, nausea and diarrhea.

A key advantage of his single-dose method, Mishell says, is that the woman needs to make only one visit to her doctor or health care professional.

Marie Harvey, an associate professor of public health at the University of Oregon in Eugene, says a one-dose method should have broad appeal to women seeking abortions.

"Rural women may have to drive two or three hours to get a dose of mifepristone on day one, then have to drive back two days later for the dose of misoprostol," she says. "But women with jobs or children at home can't easily do that."

There is research, still inconclusive, that suggests a woman might be able to self-administer misoprostol at home at the direction of her doctor, Harvey says.

Meantime, researchers report that a black market has developed for one of the abortion medications. Misoprostol, a drug sometimes called "the star pill" for its hexagonal shape, is widely used in Brazil, where abortion is banned, researchers report. And a recent survey of 610 women, primarily Latinas, in New York City found that 5% admitted having used "the star pill" for an abortion. More than a third of the women surveyed said they knew about the method.


Despite consumer demand and a growing body of research on alternative methods, none has generated the same interest as mifepristone among the medical community, however.

One problem with methotrexate is that about 20% to 30% of women wait three weeks or more after taking the drug for the abortion to be completed. Most women who take it, however, abort within 24 hours.

And, taking misoprostol alone is associated with a higher rate of side effects, such as nausea and diarrhea.

The nonsurgical methods of abortion are almost always offered only by doctors who also perform surgical abortions. There are an estimated 90 doctors offering abortion with methotrexate, according to the recent journal report; all of them also do surgical abortions. And, despite the street use of misoprostol alone in places such as New York City, it is typically available only in clinical trials, such as the one at USC.

Doctors who don't currently perform abortions may be hesitant to try abortion drugs because the Food and Drug Administration has not approved the therapies for that use. In some cases, the doctors have no experience in using the drug for abortions, says Tina Hoff, a researcher at the Kaiser Family Foundation, a health care philanthropy based in Menlo Park, Calif.

A 1997 Kaiser foundation survey of 772 health professionals found that few prescribe methotrexate.

"Physicians state a strong preference for offering mifepristone over other methods," says Hoff. "There are differences in how the drug works. Mifepristone is a more effective abortifacient, and getting a stamp of approval from the FDA is something that will strengthen the appeal of mifepristone."

Hoff and other researchers say they believe having an FDA-approved method of medical abortion will be crucial to eventually expanding the pool of abortion providers.

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