Exploring women’s options: regimens of misoprostol with mifepristone for early medical abortion

Exploring women’s options: regimens of misoprostol with

mifepristone for early medical abortion

B. Winikoff (1), T. Aldrich (1), C. Shannon (1), E. Wiebe

(2), E. Schaff (3) Gynuity Health Projects, New York, USA (1);

University of British Columbia, British Columbia, Canada (2);

University of Rochester, New York, USA (3)

Background: Efficacy, side effects, and acceptability to

both the patient and provider have important impacts on how a medical abortion

regimen is used. Current clinical practice varies greatly with respect to dose

and route of administration of misoprostol following mifepristone for early

pregnancy termination, especially before 56 days LMP. There is no consensus on

an ‘optimal’ dose of misoprostol in this case, although research suggests

that women’s acceptability of the regimen may vary depending on the dose.

Similarly, systematic investigation into the merits of different routes of

administration of misoprostol in medical abortion is lacking. Emerging data on

the efficacy and safety of various medical abortion regimens, together with

insight into women’s own preferences, will have important implications for

service delivery.

Methods: We reviewed current evidence and research

regarding the efficacy, safety, and acceptability of different medical abortion


Results: Findings from an array of recent and ongoing

trials suggest similar efficacy for selected medical abortion protocols at least

below 56 days LMP A recent three-arm randomized trial with 971 women found

comparable success rates and side effects for regimens of 200 mg mifepristone

followed by either 1) 200 mg oral misoprostol, 2) 400 mg oral misoprostol, or 3)

800 mg vaginal misoprostol. Preliminary findings from a current study comparing

vaginal and buccal administration of misoprostol following a 200 mg dose of

mifepristone also indicate similar success rates, with a trend towards greater

efficacy in the buccal group. These findings suggest that it may be feasible to

offer greater options for women who dislike vaginal administration of

misoprostol. The known pharmacokinetics and clinical correlates of vaginal, oral,

rectal, buccal, and sublingual administration of misoprostol for medical

abortion point to significant variability; however, studies suggest little

variation with respect to clinical efficacy for these different routes, at least

in the first part of the first trimester.

Conclusions: There appear to be a range of safe and

effective mifepristone-misoprostol medical abortion options. Where there are

small differences in the acceptability of different routes of administration,

the choice of route should ultimately be left to the woman. Such an approach

offers increased flexibility and patient autonomy in medical abortion provision

by taking into account the different personal and social factors that influence

women’s preference for a particular regimen; this in turn may improve overall

quality of abortion care. Future studies should continue to gather data on

patient experience and preference in medical abortion regimens.

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