Abortion
Q. I heard there is a new pill that can induce abortion so that a surgical abortion is no longer necessary. Is this true? Is it safe to use? Can I take it at home?
A. There are two different types of drug therapies that can terminate pregnancy; one is available in the United States and one is not. In my opinion, at this time, neither therapy is better than conventional surgical abortion.
RU 486, the so-called abortion pill, is widely used in France. When combined with oral prostaglandins (substances that cause the uterus to contract), RU 486 can induce abortion up to the ninth week of pregnancy. As of this writing, however, RU 486 is not legal in the United States; therefore, it is not an option for American women. Anti-abortion forces have so far been effective in their efforts to block the use of RU 486 as an abortion drug, and it is only available in the United States to medical researchers for experimental purposes. Recent studies have suggested that RU 486 may be an effective treatment against breast cancer and other diseases, and a handful of American scientists are conducting further research.
There is another drug regimen for abortion that is both legal and available in the United States, but it is very new and somewhat controversial. According to a study published in the New England Journal of Medicine, two other drugs commonly prescribed for other purposes can, when combined, also safely and effectively terminate pregnancy up to nine weeks. The first drug, methotrexate, is approved by the Food and Drug Administration (FDA) to treat some cancers as well as rheumatoid arthritis and psoriasis. The second drug, misoprostol, is an approved anti-ulcer medication that can also cause uterine contractions. For the past decade, methotrexate has been prescribed "off label" (not for its approved use) to terminate ectopic pregnancies (a potentially life-threatening condition that occurs when the fertilized egg lodges within the fallopian tube). Misoprostol is also commonly prescribed "off label" to soften the cervix when inducing labor.
In order to induce abortion, the patient must be given a shot of methotrexate, which terminates a pregnancy in two ways: It interferes with the growth of the embryo and the placenta by killing rapidly dividing cells, and it also blocks the action of folic acid, an important B vitamin that is critical to the normal growth and development of the embryo. Five to seven days later, the patient must return to the doctor for a vaginal suppository containing misoprostol. Typically, within two days after getting the suppository, the woman will begin to bleed and cramp, as she would with a miscarriage. In rare cases, the pregnancy may not terminate and a surgical abortion is required.
There are some advantages to this new abortion procedure over surgical abortions. For one thing, it can be performed in any doctor's office and does not necessitate a hospital stay or a visit to an abortion clinic, which many women may find upsetting (particularly if anti-abortion people are picketing outside). For another, unlike a surgical abortion, which is best performed at around six weeks, the drug-induced abortion can be performed as soon as the woman knows she is pregnant, which eliminates the days or weeks of waiting.
There are some disadvantages, however, to this procedure that women should be aware of. First, the drug-induced abortion takes considerably longer than the usual surgical procedure. During the first twelve weeks of pregnancy, abortion is usually done by vacuum aspiration, which takes between ten and fifteen minutes. In this procedure, the cervix (at the entrance of the uterus) is dilated and a blunt-tipped tube is placed in the uterus. The tube is connected to a small suction machine which draws out the contents of the uterus. A vacuum aspiration can be performed with either local or general anesthetic. In most cases, after an hour or two of rest, the woman can go home. Although there may be some residual bleeding for up to two weeks, the abortion is over quickly and efficiently. On the other hand, the drug-induced abortion can take up to two weeks before the abortion is finalized, which can be emotionally wrenching for many women. In addition, if unprepared, many women may be very distressed by the amount of bleeding and cramping, although most of the women who have had this procedure find that the pain is easily controlled with medications. In addition, since neither methotrexate nor misoprostol have been approved by the FDA for use for abortion, some doctors may be reluctant to administer them for this purpose. As of now, I personally would not recommend this procedure until it has been tested further.
Q. I had an early abortion when I was a teenager and my doctor said that everything went well. Now that I want to get pregnant, I'm having difficulty. I sometimes think that I'm being punished for the abortion. Could the abortion have caused my fertility problems?
A. A legal abortion performed by a doctor under sterile, medical conditions rarely results in fertility problems. Keep in mind that about 15 percent of all couples have difficulty conceiving for any number of reasons. If you are concerned about infertility, you should not assume that the abortion was to blame, but you should consult a fertility specialist for a complete diagnostic workup.
It is true, however, that illegal abortions, typically performed under less than sanitary conditions, could cause problems that might make it difficult to conceive. For example, infection, a common complication of illegal abortions, could cause scarring in the Fallopian tubes, thus closing down the passages the sperm must pass through to reach and fertilize the egg. In rare cases, an illegal abortion could cause a more serious complication, like a perforated or torn uterus, which is a medical emergency that often requires a hysterectomy. Fortunately, since abortions are legal and done in medical settings, these complications rarely, if ever, occur.
Q. I had an abortion over twenty-five years ago. Since then, I have had one child and am happily married. Although I know that I made the right decision at the time, I still feel very bad about the abortion. In fact, lately I have been waking up at night crying. Is this normal? I'm becoming menopausal, and wonder if I'm just being "over-emotional."
A. I frequently see women who, having had an abortion many years earlier, apparently without any ill effect, suddenly and inexplicably begin to grieve about it years later. Often the grief surrounds the loss of reproductive ability, as in the case of menopause, or the death of a child, or some other severe blow that makes them believe they are being punished for their past "sin" of abortion. If the patient is really suffering, I usually refer her to a psychiatrist. Very often, simply talking about the issues that may have provoked the reawakening of regret and guilt may be enough to bring the patient relief. If the obsession over the abortion continues, the psychiatrist may prescribe an antiobsessive or antidepressant medication like Prozac.
I do not believe there is such a thing as being "overemotional." However, I tell patients who feel unable to deal with their emotions, whether they be of unbearable internal pressure, grief, sorrow, or simply anxiety, to get help early. Check with your family doctor first: She probably knows you the best and can refer you to the appropriate consultant if you need psychiatric care or medication.
Copyright © 1997 by Marianne Legato and Carol Colman
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