Misoprostol is typically used as part of a two-drug protocol for a medication abortion. But it is also safe and effective when used alone, doctors say.

Getty Images

hide caption

toggle caption

Advertisement

Getty Images

Misoprostol is typically used as part of a two-drug protocol for a medication abortion. But it is also safe and effective when used alone, doctors say.

Getty Images

A version of this story was originally published on April 10, 2023. It has been updated to reflect news that mifepristone must be prescribed in person as of Friday, May 1, 2026.

On Friday, a panel of federal appeals court judges changed rules for a medicine called mifepristone. For more than two decades, mifepristone has been used with another drug, misoprostol, for most medication abortions in the U.S.

The Food and Drug Administration, under President Joe Biden, relaxed prescribing rules for mifepristone. That allowed doctors to prescribe the two-drug regimen over the phone or online. The medicines could be mailed or picked up at pharmacies and taken at home to end pregnancy up to 10 weeks of gestation.

Friday’s court order said that the FDA has to go back to its earlier in-person prescribing rules for mifepristone. The order immediately applies to the whole country.

The makers of mifepristone have appealed to the Supreme Court asking for a quick change back to the Biden-era rules, as the case continues. In an earlier case involving mifepristone, the high court did just that. Something similar may happen again — or not.

In the meantime, the standard two-drug medication regimen is still available for in-person patients in states that allow abortion. And telemedicine abortions may continue in those states using only the other drug, misoprostol.

Misoprostol has been on the market longer and was first approved to treat gastric ulcers. It is also used for IUD insertion and to treat hemorrhage.

Here’s what to know about how misoprostol-only abortions work, how safe they are and how patients may be able to access them.

How does the single-drug protocol differ from the standard of care which uses two drugs?

Most medication abortions in the U.S. have used both mifepristone and misoprostol because patients experience fewer side effects when the medications are combined. A regimen involving both medications is also used for miscarriages.

But misoprostol alone can be used effectively for abortions — and is commonly prescribed in some countries. A grassroots effort among women in Brazil, Argentina and other South American countries in the late 1980s and early 1990s spread word that the medicine originally on the market as an ulcer treatment could be used to end unwanted pregnancies.

“This regimen is still incredibly safe and effective,” says Dr. Kristyn Brandi, a New Jersey family planning specialist and spokesperson for the American College of Obstetricians and Gynecologists.

With the two-drug regimen, patients first take mifepristone — which blocks the hormone progesterone — to end the pregnancy. Patients then take misoprostol 24-48 hours later, which causes the uterus to expel the pregnancy tissue. Patients experience bleeding and cramping, and usually pass the pregnancy within 4-6 hours after taking the misoprostol.

In a misoprostol-alone abortion, patients start the process with misoprostol, using the same amount as is used in the two-drug regimen. Three hours later, they take misoprostol again, causing the uterus to contract. They repeat this for three to four doses until the pregnancy passes, which usually takes between 9-12 hours.

Is the misoprostol-alone regime safe? What can patients expect to experience?

There’s lots of research that shows the misoprostol-only protocol is as safe as the two-medication protocol – but it does tend to cause more side effects.

Even though the two-drug protocol is still preferred when possible, there’s ample evidence that misoprostol alone is a very effective alternative, according to the Society of Family Planning, an abortion research organization.

Multiple organizations, like the American College of Obstetricians and Gynecologists and the World Health Organization, say the one-medication protocol is an acceptable choice, particularly when mifepristone isn’t available.

Patients using misoprostol alone, however, tend to experience more nausea, vomiting, and diarrhea, and a longer duration of cramping and bleeding. That’s why it’s usually the second choice regimen.

The misoprostol-only protocol is actually faster than the two-medication protocol, which takes about 30 hours total since patients take the second drug at least 24-hours after the first. In the misoprostol-alone regimen, the process usually only takes 9-12 hours, but patients typically experience cramping and bleeding for longer.

When might a patient need to seek further medical help for a medication abortion?

With either regimen, the reasons to seek follow up care are the same.

If patients experience heavy or prolonged bleeding — spotting that persists for over 2 weeks, for example, or bleeding so heavy they soak through more than two pads an hour for over two hours — they might need a procedure to complete the abortion.

A prolonged fever above 100.4 degrees Fahrenheit is also a reason to seek medical care. While low-grade fevers and chills are an expected side effect of misoprostol and aren’t life threatening, if a fever persists for more than 24 hours after taking misoprostol, it could be a sign of infection.

Also, if a patient does not experience any bleeding or cramping, the medication may not have worked to end the pregnancy, and she might need more misoprostol or a procedure to have a complete abortion.

How far along into the pregnancy does medication abortion work?

The Food and Drug Administration has approved the two-drug regimen to end pregnancies up to 10 weeks gestational age; the World Health Organization endorses it up to 12 weeks. After that, they’re less likely to be effective and may cause more bleeding and cramping.

For misoprostol-only abortion, it’s less clear cut. There’s some data showing that the regimen can be effective in ending pregnancies up to 22 weeks. That’s according to one study that looked at patients having self-managed abortions, without the direct involvement of a doctor in countries that have had restrictive abortion laws.

But in U.S. states where second trimester abortion is allowed, Brandi says, doctors will typically recommend a procedural abortion in a hospital rather than a medication-based abortion to end pregnancies after 12 weeks. That’s because second trimester misoprostol-only abortions can involve more bleeding and prolonged cramping. Doctors would probably only recommend misoprostol-alone in the second trimester in states where patients don’t have other legal options.

How do patients get prescriptions for medication abortions? Would they be able to get them for the one-drug regimen?

In states where abortion is legal in the first trimester, patients can speak to a health care provider and get a prescription for medication abortion via telehealth abortion companies, in-person at clinics that provide abortion like Planned Parenthood, and at many general OB/GYN and family medicine clinics.

When mifepristone’s legality was in question before, many providers indicated they would start prescribing misoprostol alone.

Dr. Jamie Phifer, the medical director of Abortion on Demand, said at that time that her team would continue to provide mifepristone and misoprostol combination abortions to their patients unless it becomes illegal.

“But we’re ready,” she added. “We can make the switch [to misoprostol-only protocols] within hours.”

In fact, misoprostol is easier to access than mifepristone because of its additional uses, so it’s stocked in almost all pharmacies and hospitals.

Are patients able to get the medication in states where abortion is banned?

Patients in states that have banned or heavily restricted abortion have been able to access telehealth medication abortion, and this is at the heart of the case Louisiana brought against the FDA.

No medication abortions are available legally in states that have banned abortion. But some organizations have been helping women in those states access pills. Abortionfinder.org keeps an up-to-date list of services that help people access abortion, and includes state-by-state legal information.

The Miscarriage and Abortion Hotline offers free consultations with clinicians if a patient has follow-up questions about a medication abortion, even if she had the abortion in a state where it’s illegal.

Some organizations have flouted the law openly to provide abortion medications in all 50 states.

Aid Access, for example, is based in the Netherlands and will mail mifepristone and misoprostol to patients in states where abortion is banned. Pills sent from abroad are not subject to FDA approval and safety regulations.

Mara Gordon is a family physician in Camden, New Jersey, and NPR’s Real Talk With A Doc columnist. She’s on Instagram at @MaraGordonMD.