Pregnancyoptions.info: a workbook of options including abortion, adoption and birth.

• Requirements, Considerations, Previous Experiences • Sample "ritual" to get ready If you have decided on abortion as the answer to an unexpected pregnancy, you may have a choice as to which method will work best for you. This workbook has assembled information about different methods available, other women's experiences of each method, and some wisdom from actual providers who have seen many, many women in your situation.
By the end of this book you will learn the complicated names of lots of medications that all seem to start with the letter "M" There are important differences between Mifeprex™ and methotrexate, both of which are used with misoprostol. We start with some definitions of each The next section is really about you. We have collected some questions and considerations that will help you make the best choice for who you are and where you are in your life. Use the knowledge we have gained from the experiences of thousands of women to help you decide what is right for you. We have also included 4 pages of quotes from real women.
When you have decided on a method and you are ready to choose a place to get an abortion, there is a list of questions and considerations. As one of the real women says, "Choose wisely." The next sections are the actual details and what to expect with either Mifeprex™ or methotrexate. Use this as a guide along with the information your doctor or clinic gives you. There is also information on pain relief, a symptom calendar, and some important resources and You also have a choice about how you want to think about the abortion experience. You can decide who to involve, how to take care of your feelings, and what this experience means for your life. The sections on "Feelings Afterwards," "Abortion is an Emotional Process Too," and a sample ritual may help your thinking. Our other workbook, Pregnant? Need help? Pregnancy Options Workbook also contains helpful information on spirituality, healing afterwards, and several exercises that may give you some things to think about.
Finally, Tina pops up with some important messages through this workbook. This is the information that you might get if you had a girlfriend who worked at a clinic. She will get to the point and tell you things that really matter.
OK, so you're pregnant. (Remember when you first found out.). What usually comes next is a gut (or "heart") reaction-- "Oh, no!" or "Yes!" Or sometimes it's more about "how" -- "How am I going to deal with this?" "How will __________ react to this news?" Or, "What if." and you think about your goals, your situation, your relationship with partner or family.
This can be a long difficult decision or a quick, clear choice. If the authors of this workbook have learned anything it is to pay attention to what your gut is saying. You should figure out your feelings, fears, and hopes first, before you think about what method to use, where to get It may seem like a good idea to "just get it over with." You may think that if you have a "miscarriage" with the help of these medications you don't have to deal with really being pregnant. You may want to hide your pregnancy or abortion from someone else. If so, be Sometimes women want the medical abortion because they are not OK with their decision to have an abortion, and an abortion with a pill seems more "natural" or less like an abortion. Not so! Sometimes the reasons we give for choosing medical abortion--like it's more private and "no one has to know"-- are covering up a problem with the decision itself!!! If you are not clear, please take the time and get the help you need to make a good decision. Many women need another person--or more than one-- to talk over your options. This might be your partner, a parent, a good friend, or a professional. You also need accurate information about your options. With a little help, you can make a good decision that you can be comfortable with. The Pregnant? Need help? Workbook might also be of help. Focus on the following question and try to do the right thing for you and your life: Is this the right time for me to bring a new life into the world through my body? This workbook is designed to help you decide whether medical abortion or surgical abortion is the best choice for you. We are assuming that you have already decided that you do not want to continue this pregnancy. If you are not sure about your choice, please take more time to consider your decision, even if that means you cannot have a medical abortion (because you might be too far along for a medical abortion--though still early for a surgical). If you need more help, check out Pregnant? Need help? Pregnancy Options Workbook. Some of the same people that are involved in this workbook wrote that one.
We are people who care deeply that women make the best pregnancy decisions for their lives. We know these decisions are not always easy, which is why we have assembled in both workbooks all the information, resources, "tools", and collective wisdom we can find about all options. Some of the most important advice we have embodied in "Tina", a cartoon character In this workbook we are especially interested in helping women understand the differences between medical and surgical abortion. We feel that women deserve complete information and can benefit from hearing other women's experiences and opinions.
We want to hear from you too. We will include your comments in future editions of this workbook (see last page). Please contact us via our web page www.pregnancyoptions.info or Medical Abortion (sometimes called Mifeprex™, RU-486, non-surgical abortion, or abortion using a pill) is a way to end a pregnancy with medication. It is an abortion method that uses two medications to end a pregnancy over a span of time (usually a few days, to a few weeks in some cases). It is available in early pregnancy, usually up to 7, or sometimes 9 weeks from your Last Menstrual Period (LMP). Basically, it is medically inducing a miscarriage.
There are two different methods of medical abortion available: mifepristone followed by misoprostol, and methotrexate followed by misoprostol. The methods are similar, but have some important differences. One or both methods might be available in your area. Not every doctor that provides surgical abortion offers medical abortion. Methotrexate, which takes longer, and is usually less effective, is usually not used when mifepristone is available, unless there is a concern about a possible ectopic pregnancy.
Mifepristone and misoprostolThis method is also called RU-486, the name of the drug in France, where it was developed. In this country, it is called mifepristone or Mifeprex™. Even though it is often called by the single name, there are two medications that are used. Mifeprex™ is a pill. It is usually swallowed in a clinic or doctor's office. It interferes with your body's use of a hormone called progesterone. Progesterone is needed for the pregnancy to grow. Without the supply of this hormone, the uterine lining, including the pregnancy, begins to detach--or pull apart--from the walls of the uterus. This stops the pregnancy from growing. A second medication called misoprostol or Cytotec™ is used usually 1 to 2 days later. It is either swallowed or placed in the vagina. It may be used at home or in a doctor's office. Misoprostol causes the uterus to empty itself by cramping and bleeding. This usually happens within several hours but may take longer. Effectiveness ranges from 92-96% or higher with newer "evidence- based" guidelines improving the success rate.
Methotrexate and misoprostolMethotrexate was used before Mifeprex™ was introduced in this country and is still offered by some doctors or clinics. Methotrexate is an injection, or sometimes an oral medication, that is given to you by a doctor. It stops embryonic cell growth. Methotrexate is also used to stop a pregnancy that is growing outside the uterus -- an ectopic or tubal pregnancy. After the first medication, you will wait from 4 to 7 days before taking the misoprostol to empty your uterus. The misoprostol usually starts the cramps and bleeding within a day or so, but it may take longer. Sometimes a second or third dose of misoprostol is required.
A surgical abortion or vacuum aspiration, is when a doctor, or other clinician, removes a pregnancy from the uterus. The doctor numbs the cervix with a local anesthetic similar to Novocaine™, then dilates--or stretches-- the cervix (the opening to the uterus) a little bit to put in a small tube, and then removes the pregnancy with suction. It usually takes less than 5 minutes when you are early in the pregnancy. It can cause some cramps which usually go away quickly, (less than half an hour). Some bleeding and cramps are to be expected for one week or so. Most doctors/clinics can offer different types of pain relievers, sedation, or anesthesia. Surgical abortion has been legal in the U.S. since 1973 and is very effective (about 99% successful) and has a very low risk of injury or infection when done properly by qualified An ectopic pregnancy is an abnormal pregnancy that grows outside the uterus, often in the fallopian tubes. It occurs in 1% of pregnancies, and is very dangerous. If you have an ectopic pregnancy, it is important to find out in the early stages before it harms you or threatens your future fertility. If undetected, the pregnancy can continue to grow and burst the tube, which could cause internal bleeding and possibly death. Your doctor or clinic will try to "rule out" an ectopic pregnancy-- or in other words, to make sure your pregnancy is growing inside the uterus, not outside it. Sometimes this can be difficult to figure out. One way is to do an ultrasound and that will usually show the pregnancy in the uterus. Another way is to do a surgical abortion and look at the tissue that is taken out to be sure it is pregnancy tissue, but this is not always a sure thing. If your doctor is not certain, he or she may order some blood pregnancy tests that measure the amount of pregnancy hormone in your system, or suggest that you be seen in a hospital or It is important to pay close attention to your symptoms and to report problems to your doctor or clinic. Tubal pregnancies typically cause pain on one side, sometimes severe pain or a "stabbing" sensation. This pain may radiate or "travel" to the back or shoulder. If you are having pain like this, report it immediately to your doctor, or if you are fainting or feeling very weak, call 911 or go to a nearby emergency room and ask them to consider the possibility of a tubal pregnancy.
It is a rare condition, but some women have died of a ruptured ectopic pregnancy and we want you to be aware of this potential problem. If detected early enough it can sometimes be treated with medicine, or it may need to be surgically removed. Either way, you need to be under the care of a doctor who can monitor your condition. Please cooperate with your doctor or clinic, and get all the tests they recommend.
Comparison Between Surgical Abortion and Medical Abortion with Mifeprex™, or Methotrexate, with Misoprostol 1. How far along in the pregnancy can I be? Mifeprex™ with Misoprostol:• Up to 7 weeks LMP (49 days). Some doctors use this method until 9 weeks (63 days). Success rate of 92-97%, may decrease as length of pregnancy increases. (See references.) Methotrexate with Misoprostol:• Up to 7 weeks LMP (49 days) Vacuum aspiration:• Vacuum aspiration is used up to 14 weeks LMP. Some doctors start at 5 weeks LMP 2. How long does it take for the abortion to be complete? Mifeprex™ with Misoprostol:• Usually 1-2 visits + required follow-up visit• Day 1 for Mifeprex™, Day 2 or 3 for misoprostol.
• Unpredictable when pregnancy will pass• Bleeding after misoprostol lasts 4-8 hours for most; days for some to complete • Ultrasound at follow-up 7-14 days after Mifeprex™ will make sure abortion is complete. Methotrexate with Misoprostol:Usually 1-2 visits + 1 or more required follow-up visits.
• Day 1 for Methotrexate and usually Day 5, 6, or 7 for misoprostol. • Very unpredictable when pregnancy will pass.
• Bleeding after misoprostol starts 12-24 hours later, may last 4-6 hours to several days.
• Ultrasound at follow-up 7-14 days after methotrexate will make sure abortion is complete. May need another dose of misoprostol.
Vacuum Aspiration:• 1 visit + follow-up exam• Actual abortion less than 5 minutes• Follow-up in 2-3 weeks at abortion facility or other doctor or clinic of your choice.
3. How painful is it? The amount of bleeding varies from person to person and with length of pregnancy.
Mifeprex™ with misoprostol: • Heavy bleeding & clots are common during the abortion process for 4-8 hours.
• Afterwards, bleeding like a period is common for an average of 13 to 16 days.
Methotrexate with misoprostol: • Heavy bleeding & clots are common during the abortion process for 4-8 + hours.
• Afterwards, bleeding like a period is common for an average of 10 to 17 days.
Vacuum Aspiration: • Not much bleeding immediately after procedure.
• Like a period, up to 14 days, usually about 9 days. Mifeprex™ with misoprostol: • Success rate varies from 92-97% by Day 15. Surgical abortion is necessary if it fails.
• Vaginal misoprostol improves effectiveness.
Methotrexate with misoprostol: • Success rate 92-96% by Day 30. A second or third dose of misoprostol may be required. A surgical abortion is necessary if it fails.
• Vaginal misoprostol improves effectiveness.
Vacuum Aspiration: • Over 99% successful. If it fails suctioning will need to be repeated.
• Early surgical abortion may be slightly less effective (98%).
5. Can I still have children later in life? Regardless of method, abortion is 20 times safer than childbirth. Infections are the greatest threat to fertility, not abortion. Childbearing is not affected, barring rare, serious complications.
6. What are possible serious side effects (complications)? Mifeprex™ with misoprostol: • Both Mifeprex™ and misoprostol have been formally studied and used safely.
• Mifeprex™ will not end ectopic or tubal pregnancies which, if undetected, can be dangerous or fatal. (See p.3)• Need for transfusion (rare).
• Some women may be allergic to medications.
Methotrexate with misoprostol: • Methotrexate and misoprostol have been formally studied and used safely.
• Methotrexate can effectively treat some ectopic pregnancies with supervision of a doctor.
• Need for transfusion (rare).
• Some women may be allergic to medications.
Vacuum Aspiration: • Surgical abortion has been formally studied for over 25 years. • Injury to the uterus is rare in the first trimester. Excessive bleeding is rare. Infection and retained tissue, which would require antibiotics or a re-suctioning, are less than 1%.
• Vacuum aspiration will not end ectopic or tubal pregnancies which, if undetected, can be dangerous or fatal. (See p.3) Mifeprex™ with misoprostol: • Nausea, vomiting, diarrhea, cramping, bleeding, headache, dizziness, fever or chills, anemia (rare). Possible need for surgical abortion.
Methotrexate with misoprostol: •Nausea, vomiting, diarrhea, cramping, bleeding, headache, dizziness, fever or chills, mouth sores (rare), and anemia (rare). Possible need for surgical abortion.
Vacuum Aspiration: • Cramping, bleeding• For some, light-headedness, nausea.
Mifeprex™ with misoprostol:• Sometimes higher than surgical. Prices vary. Check what is included.
Methotrexate with misoprostol: • May be less than Mifeprex™, same or more than surgery. Prices vary. Check what is included.
Vacuum Aspiration: • May be less than medical abortion. Prices vary. Check what is included. 9. What are the advantages of each method? Mifeprex™ with misoprostol: • Mifeprex™ induces a miscarriage-like process.
• If available, highly effective and safe for very early pregnancy.
• Avoids shots, anesthesia, instruments, or vacuum aspiration, unless it fails. (Blood work required. Injection needed if your blood type is Rh-. Vaginal ultrasound usually required.)• Being at home instead of a clinic may seem more comforting and private.
• Any support person can be there with you during the abortion process.
• It is finished quicker than the Methotrexate method.
• The timing is more predictable than for Methotrexate.
Methotrexate with misoprostol: • Methotrexate induces a miscarriage-like process. • If available, effective and safe for very early pregnancy.
• Avoids anesthesia, instruments, or vacuum aspiration, unless it fails. (Blood work required. Injection needed if your blood type is Rh-. Vaginal ultrasound usually required.)• Methotrexate may end a tubal pregnancy as well as a normal pregnancy.
• Being at home instead of a clinic may seem more comforting and private.
• Any support person can be there with you during the abortion process.
Vacuum Aspiration:• It's quick, predictable, and over in a few minutes.
• It's highly successful.
• If available, highly effective and safe for very early pregnancy.
• There's less bleeding for less time than with either of the other two methods.
• Less time cramping than with other methods.
• Performed by a doctor with support of medical or counseling staff, which may seem more comfortable and private.
• Some involvement of support person may be possible.
• If you are trying to conceal abortion, it may be better. • Avoids medication, except for pain relievers and sedatives.
• It can be done later in the pregnancy than other methods.
10. Who should not use one of these methods? (What are the contraindications?) Mifeprex™ with misoprostol: • If you are more than 7-9 weeks LMP (depends on dr.)• Medical conditions: allergy to medications; blood clotting problems or on blood thinners; chronic adrenal failure; chronic systemic corticosteroid use• IUD in place• inherited porphyrias• severe anemia • possible ectopic pregnancy• uncontrolled seizures Methotrexate with misoprostol: • If you are more than 7 weeks LMP• Medical conditions: allergy to medications; blood clotting problems or on blood thinners;active liver or renal disease; severe anemia; IUD in place, uncontrolled seizures; inflammatory bowel disease Vacuum Aspiration:• Some medical conditions or allergies to anesthesia may require a surgical abortion in a hospital setting.
11. What are the disadvantages of each method? Mifeprex™ with misoprostol: • It takes several days to end a pregnancy.
• It is not completely predictable. There is some uncertainty about when you will bleed and pass the pregnancy.
• Bleeding can be very heavy and lasts longer than with surgical abortion.
• There may be restrictions if you live more than an hour away from the clinic or a hospital, in case of very heavy bleeding, depends on dr.
• Cramping can be severe and lasts longer than with surgical abortion.
• 2-3 visits are required.
• It fails more often than surgical abortion but is more successful than Methotrexate.
• It cannot end an ectopic (tubal) pregnancy.
• It may cost more than other two options.
• Not good method if you are trying to conceal abortion.
• Advisable to have support.
Methotrexate with misoprostol: • It takes days and sometimes weeks to end a pregnancy.
• It is not completely predictable. There is more uncertainty about when you will bleed and pass the pregnancy.
• Bleeding can be very heavy and lasts longer than with surgical abortion.
• There may be restrictions if you live more than an hour away from the clinic or a hospital, in case of very heavy bleeding, depends on dr.
• Cramping can be severe and lasts longer than with surgical abortion.
• At least 2-3 visits are required, sometimes even more.
• It fails more often than surgical abortion and has a lower success rate than Mifeprex™.
• It takes longer to complete than either Mifeprex™ or surgical abortion.
• Not good method if you are trying to conceal abortion.
• Advisable to have support.
Vacuum Aspiration: • A doctor must insert instruments inside the uterus.
• Anesthetics and drugs to manage pain during the procedure may cause side effects. (Serious problems are rare.)• There are possible complications, although they occur in less than 1% of cases.
• You may have less control over the abortion process and who is able to be with you during some parts of the process.
• The vacuum aspirator makes a noise. If available, a manual aspirator is silent. • It may not be done as early in the pregnancy as with the other methods depending on doctor.
• It cannot end a tubal (ectopic) pregnancy.
No matter which method you choose, it's important to be sure of your decision. No one should be forcing you or pressuring you into any decision about pregnancy. If you have strong doubts about what is right for you, take the time to consider your choices, even if that means you will not be eligible for a medical abortion. Counseling or further thinking may help. The great majority of women do not regret their decision or have serious depression after an abortion. Of course you may have a variety of feelings, as you would about any important life decision.
Mifeprex™ with misoprostol: • Some women are anxious waiting for the abortion process to complete.
• Viewing the pregnancy tissue may be difficult.
Methotrexate with misoprostol:• Some women are anxious waiting for the abortion process to complete.
• Viewing the pregnancy tissue may be difficult.
Vacuum Aspiration: • Some women are anxious in a medical setting or with the idea of surgery.
OK, now you understand the difference between surgical abortion and abortion using medicine. Is medical abortion right for you? Here are some things you might want to think about: Each provider has different requirements which may determine whether this method is available for you at all. Some of these include: • LMP: When was your Last Menstrual Period (LMP)? _______ Most providers offer medical up to 7 weeks LMP or 49 days from the 1st day of your last period. Some go to 56 days LMP or 63 days LMP. Some doctors will provide surgical abortions as early as 5 weeks and some prefer to wait until 6 or 7 weeks LMP. An ultrasound can confirm how far along you are and what methods are available to you.
• Distance from the clinic? Many clinics want you to be an hour's drive or less from their facility so that if you have a problem you can come back easily. Are you within easy driving distance from the clinic? Do you have access to a car? ___ Yes ___ No • Visits: How many visits do they require? _____ Is that more than you want to commit to? ___ Yes ___ No Time problems? ___ Yes ___ No Need a ride? ___ Yes ___ No Can you return in two weeks to the office? ___ Yes ___ No • Age: Are you under 18 years old? ____ Does the facility or your state have limitations for young women, such as parental involvement?___ Yes ___ No • Cost: What is the fee? ____ Are there any extra costs? _____________Does your insurance or Medicaid cover? Will it pay the doctor/clinic you have chosen? ___ Yes ___ No Is the follow-up exam included? ___ Yes ___ NoIf a surgical procedure is necessary, is that included in the fee? ___ Yes ___ No • Phone: Do you have access to a phone? _____ Do you have enough privacy to call the clinic with a problem if you needed to? ___ Yes ___ No • Support: Who will be with you? _____________ Do you have a support person to be with you at the clinic? __________ At home? __________ Does the clinic require it?___ Yes ___ No • Talking to Clinic: Do you speak English well enough to talk to the clinic staff if you have a problem or question? ____ Yes ___ No • Medical Problems: Do you have any medical problems? (For some women one method may be safer than another.) Condition: _____________ • Convenience: Which method fits better into your schedule? • Waiting/ Unpredictability: Medical abortion is a process in which time is an important factor. How hard do you think it will be for you to wait between the first and second medications? Or for the pregnancy tissue to pass? • Support: Who can be with you? ________ at doctor visits? ______ At home, when you are bleeding? ________ Are you the kind of person who needs a lot of support or encouragement?Is your support person reliable? Caring? Reassuring to you? Doesn't panic? If you are thinking of doing this alone, who could you call if you really needed to? Would you have more support at the clinic? • Privacy: Is it important that certain people not know about this? ___ Yes ___ NoWho are they?_______________________Is it important for you to avoid being seen at a clinic? ___ Yes ___ NoWill medical abortion do that for you?How will doing part of the abortion at home help you? Will you be alone? With your partner? A friend? Family member? Who? _______________________ • Responsibilities: What responsibilities do you have? Children ____ What times of the day are you responsible for childcare? Are you likely to be feeling OK at those times? Elderly ____ Are you taking care of another adult? Does that person know about this? Can you still take care of this person? Partner ____ Do you have to prepare meals? Other expectations? _____________ Work ____ Can you get time off from work? What if the bleeding lasts longer than you expect? Or, you don't feel well enough to go to work/school? Other responsibilities?What happens if you are bleeding or in a lot of pain? What if you needed to seek medical attention? Who could come and help you? _____________ • Are you comfortable with your body? Medical abortion may include inserting vaginal medication, a lot of clotting and bleeding, being aware of your pregnancy symptoms, etc.
____ I'm completely OK ____ a little worried about that ____ not OK at all • Pain: Which method do you think will be less painful? _____________ Consider how long you are likely to be in pain. What pain relief medications are available to you? (Review Medical vs. surgical section, What to expect section, More about pain section, and Pain relievers section ) • Previous Abortion Experience: If you had a previous abortion you may need to figure out what was OK and what was not OK about that experience. Many women report that their experience was "the most difficult thing I ever did", "the worst time of my life", "the most painful experience I ever had." Others felt that the experience was hard but positive: "The staff made an unpleasant situation almost pleasant", "I felt understood and supported", "It was hard, but it made me see my life more clearly." Many others find that, although they were unhappy about the situation, the actual abortion wasn't so bad.
The following are some questions to explore: Either write about your previous abortion experience--or, if you have someone who is a good listener tell that person your story: Did you feel pushed into the decision by anyone? If so, who pressured you? At the time, were you "at peace" with the decision to have an abortion? Did you feel supported by others? _____________ Who? Parents, partner, friends, family? Did you feel alone or misunderstood? Was anyone actively against your decision or criticizing you? Who? What was the actual abortion like? What was good, what was bad? Describe: How did the doctor treat you? How did other staff treat you? Could they have done anything differently to help you through it better? Did you have problems afterwards? __________ Physical/medical? Emotional?Describe: When you talk about your experience, what you need this time may become clearer. Think about how you want this experience to be. Also, notice how you were handling it then and how different you are now. For example, one person might say, "It was a nightmare and it hurt a lot." It may be useful to figure out exactly what made it an unpleasant experience. For instance, if you felt a little pushed into the decision, or people were blaming you, then it may have been more difficult to cope with pain. How can you increase your ability to cope with this experience? (See sections on decision-making, More about Pain, and Pain relievers) Here's some things I need to help me get through this experience: I can ask these people to help me: __________ __________ Talk over your concerns with the people at the clinic. Do they seem understanding? Do they have good pain medication? Is it the same doctor? Can you talk to him/her? __________ Some women say, "I just want to get this over with as soon as possible and move on." Others say, "I want time to think about this experience and take time to have my feelings." Which statements best describe how you feel? How will medical or surgical help you get what you want? The following are other statements that people say about medical abortion. Do you agree or disagree with the following: (Use this scale 1= Strongly agree 2= Agree 3= No Opinion 4= Disagree 5= Strongly Disagree) "It's More Natural." 1 2 3 4 5Some people feel it is more "natural" to bleed at home and pass the pregnancy themselves. Some feel it is less "invasive" to take a pill than to have a doctor perform a procedure. Natural is really what is more comfortable for you. Some things to consider: Are you comfortable touching yourself? ___ Yes ___ NoDo you think you can insert the vaginal medication? ___ Yes ___ NoWhat kind of pain medication do you usually take for heavy periods or severe pain? Over-the-counter medicines: __________ Prescription pain pills: __________ Are you willing to take pain medications? ___ Yes ___ No Do you think this will be much worse than your regular periods? ______Are you the kind of person that asks for help when you need it? ___ Yes ___ No If you feel you are bleeding too much or the medical abortion is not working, will you call the clinic? ___ Yes ___ No Will you have a surgical abortion if medical fails? ___ Yes ___ No Will you go to your follow-up exam? ___ Yes ___ No "I just want to take care of this myself." 1 2 3 4 5 Do you feel you are taking greater responsibility for this decision if you take the abortion pill than if a doctor performs the abortion for you? Why? "I Just Want to Have a Miscarriage." 1 2 3 4 5Some women want to make themselves or someone else (partner, parent, etc) think that they are having a miscarriage instead of an abortion. If so, here are some things to think about: Are you clear that you are ending a pregnancy? Are you at peace with that idea? Do you think a medical abortion is more "moral" than a surgical abortion? If so, why? If you are trying to convince someone else that you are having a miscarriage, are you in danger if this person discovers you are having an abortion ? ___ Yes ___ No If yes, can you get to a safe place if you need to? ___ Yes ___ No Is that person likely to take you to a hospital if they think you are having a miscarriage? ______ Is that OK? ___ Yes ___ NoConsider the cost, risk of unnecessary surgery or anesthesia. Could you tell the ER doctor the truth? ___ Yes ___ No "I'm Afraid of Doctors or Needles, or Pelvic Exams etc." 1 2 3 4 5 (Avoidance of Doctors, Pelvic Exams, Needles, Things Medical.)Some women are afraid of medical encounters. If you are someone who hates going to the doctor, do you know why? Did you have a bad experience when you were young? How about a situation where you were taken advantage of sexually, or molested or raped? How scared are you? ____ I avoid all medical things ____ I only go to the doctor if I really need to ____ I get very nervous but I go to the doctor if something's wrong Some considerations:With either the abortion pill or surgery, will you still need blood work? (Yes)Will you need a pelvic exam? (Probably)Can you tolerate one or more vaginal ultrasounds? ___ Yes ___ NoIf medical abortion does not work, will you be OK with a surgical procedure? ___ Yes ___ No Or, will you avoid surgery at all cost? ___ Yes ___ No Do you know why medical stuff is so hard for you? Do you remember having a traumatic experience earlier in your life?If so, describe it: Have you ever been raped, sexually abused, or taken advantage of sexually? If so, have you gotten help with your feelings about this experience? If not, can you talk to a victim center or someone at the clinic? Does having a pelvic exam remind you of that experience? Can you talk to your doctor about finding a way to make it easier? How could you think of this differently so that you're not so scared? (For example, does it help to remind yourself that the assault or abuse was not in your control, but that this is --in other words, you are asking the doctor to perform this procedure?) Which questions were hardest or brought up issues for you? You might want to talk to someone at the clinic or a counselor about them. Write down any questions you have about either surgical or medical abortion.
How much of you wants medical and how much wants surgical? Draw a circle and divide it into sections.
What do your support people think you should do? Make a list of reasons why you should do surgical vs. why you should do medical. Circle the reasons that are most important to you.
Many women want to choose one method over another because they think it is less painful than the other method. The truth is that there is probably some cramping either way. Nobody wants to feel pain, but pain is a part of life, and frequently part of ending a pregnancy. Our ideas about pain can be very complicated and it might be interesting to explore the issue of pain in your life before you make a decision based on how much pain you might feel. 1. Period Cramps: What are your period cramps like? Use a 1-5 pain scale where 1 = mild cramps (you're aware of them but you can still do normal activities) to 5 = severe cramps (cramps where you cannot do anything and the cramps are the worst you ever felt, and pain medication doesn't seem to help.) Describe your experience of period cramps: 2. Pain Relief: What helps you when you have cramps? a. pain reliever _____________b. going to bedc. a heating pad or hot water bottled. someone sitting with me or sympathizinge. a back rub or massagef. having something hot to drinkg. distracting myself with an activityh. other _____________ 3. Feelings About Pain: How do you feel emotionally when you are in pain? (Circle all that apply) alone frantic sad upset irritable scared I feel sorry for myself ashamed numb out of control distracted angry frustrated that I can't do things other: _____________ Do the people that are supporting you understand what you need when you are in pain? Do they understand these emotions? ____ Yes ___ No Have they been around you when you are in pain? ____ Yes ___ No If you could have anyone at all with you who would it be? _____________ 4. Past experience: What are your past experiences with pain? (Examples: "I never have cramps and nothing bad has ever happened to me, so I'm worried about how it will feel." Or, "I have had a lot of surgeries and although I do OK, I really dread it each time.") 5. Negative feelings about the situation: Difficult emotions can make pain feel worse. For example, getting a tattoo or your ear pierced is painful but it's more tolerated because it's something you want. Having an abortion can bring up a lot of feelings, some of them negative.
Do any of these match what you are feeling? Put an X next to the examples that are most like what you are feeling.
What follows each example is a possible way to change how you are thinking about this experience.
______ "I really feel stupid and irresponsible."Even if you could have done things differently, remember that pregnancy is always a risk when you have sex. Sometimes we take more risks than we mean to around sex. Resolve to make a plan to protect yourself better and move on with your life. Even if it's true that you could have been more responsible, it doesn't mean that you deserve pain.
______ "I shouldn't have been with him, and now I'm paying for it." Sometimes it helps to figure out the reasons for our behavior (Example: "I was lonely", "I misjudged the situation." etc). Whatever the reason, it seemed like a good idea at the time. If you are feeling guilty (like you did something wrong) find a way to make things better. Getting pregnant, however, is not a punishment, and no one deserves pain, even if you didn't live up to your own standards.
______ "No one can know about this. I am so ashamed."When we are trying to hide something, we carry an extra burden of feelings: dread, fear, shame. Instead of imagining the worst possible reaction from someone, imagine the best: "I'm sorry you're in this situation, but I know you will make the best decision for your life." Even if the worst is true, does it mean that you deserve to be in pain? ______"I've heard so many awful things about abortion. I'm really scared. What if."Our society is in great conflict about abortion so it's no wonder that there are a lot of scary stories out there. But statistics show that abortion is one of the safest medical procedures, no matter what the method. There is a risk to everything, including riding in a car. So, learn as much as you can and let "reality" help you. Fear and tension can make everything feel worse so try to keep your fears in perspective.
______"I feel terrible about doing this, but I really have no choice."No one ever wanted to be in this situation, even though 43% of all women will have an abortion someday. Once you are pregnant, and don't want to be, you are making what you believe is the best choice for your life under the circumstances. You are not a bad person and you don't deserve to be in pain.
Write what you are feeling about this situation: Now rewrite a more positive message to yourself: Real Women Talk About Medical vs. Surgical Abortion Here are some comments from real women who chose either medical or surgical abortion. You might want to circle comments that seem true for you. "I heard it was much less invasive and I freak out just going to the gynecologist." "I thought the medical would be less "emotional", less scary for me than surgical." "I liked that it is safe and less pressure on me than surgical." "I was early in my pregnancy and didn't want to wait." "I chose medical because I thought it might be safer, I worried about something inserted in my cervix. Less room for human error." "I'm afraid of needles, so I thought this would be better." "Medical was very 'un-nerve-wracking'." "I did not expect to be so sick and have such extreme cramping." "I didn't like the bleeding-for-days part." "Less stressful, less embarrassing." "We think it's less pain and safer and less possibility of infection." "It seems more natural, like having a miscarriage." "It is PRIVATE. The environment is controlled because it is in your home and you can create the support you need." "The time between the two medicines --the 48 hours-- seemed to take forever." "I did not feel like I was killing something alive. I just thought of it as a period and that helped me out a lot." "Don't be so afraid. The experience isn't terrible. The nurses make it better and help you through it." "The clinic I went to had really nice women staff. I really liked all that support from them. It's strange, but I really felt great ." "I was scared before and during the surgery. Afterwards, it didn't seem so bad." "Surgical is easier than it sounds; medical is not as easy as it sounds." "Surgical was less painful. Quick and simple. Medical was very painful and lasted for hours." "I wanted it OVER WITH. Surgical did that." "I considered both. But I am new in town and my friends are far away. I felt more supported at the clinic than I would have at home." "Surgical was less pain, quicker physical recovery than medical, but more psychologically traumatic than medical (but then I was 19 years old)." "I didn't have time to wait around and not know when things are going to happen." "I went back to work the same day. That was important to me--to get back to my life." "I think the clinic staff make the difference. Choose wisely." "My boyfriend and I were not getting along. The last thing I wanted was to be home with him and in pain!" "Don't be anxious or afraid. It is very emotionally draining but try to ease your mind about the actual procedure itself. It was not as bad as I imagined." "It's cool under IV sedation. It's OK. Ya feel kinda high but the people are nice." More Comments on Medical Abortion from Real Women "A less invasive experience means less emotional trauma. I had a terrible experience with the machine many years ago." "It was private, effective, and relatively painless. It is more “moral” (from my Christian perspective anyway)." "I wanted the comfort of being at home; I felt it kept the situation private." "I have had problems with depression and I thought medical would be less depressing." " I felt relief. It wouldn't be so good if you're pressed for time and don't want to wait for the pregnancy to pass." "I really felt the loss. I had a lot of time to think about the whole thought of loss." "There is no real way to tell how much you will bleed or how much cramping you will have. That uncertainty makes it hard." "It was emotionally easier but physically harder than surgical." "I thought it would be more gentle and "natural" than the surgical option." "I thought it would be psychologically less scarring than a surgery." "I thought medical abortion would be like magic--easy and fast. (My experience) was long and I needed patience." "The bleeding was heavy at times, very painful the first day." "I expected it would be fast and personal and painless. (My experience) was longer than I expected, I had very heavy bleeding five hours after insertion." "The days in between were not happy days. I felt sad, emotional, and anxiety about doing the final step." "I thought it would be easier, emotionally, to handle as it allowed for privacy and 'extra time' in 'dealing' with it. The actual day was surprisingly more emotional than I had originally thought, but it was more sadness and emptiness than anything, and the feelings have substantially subsided since." "I didn't expect to be "homebound" on day 3." "I was very up and down waiting for it to happen. I was anxious, couldn't wait to get it over with." Comments on pain and bleeding with medical abortion "The first day was really bad and nothing seemed to help." "There is no real way to tell how much you will bleed or how much cramping you will have." "Unless I was knocked out, I don't think anything would have helped. The pain was so severe I couldn't walk." "I don't think morphine would have controlled this pain!" "There was a moderate amount of pain, however, with the comfort of home and the pain medicine I felt I was able to handle it." "The pain medicine made very little difference while the sac moved down my cervix." "The heavy bleeding was a concern on the second day, soaking through several maxi-pads throughout the day--it made me nervous. I didn't expect the bleeding so heavy on day 2. Day 3 was fine even after the miso." "I expected great pain and discomfort but experienced mild cramping. Was extremely nauseous and didn't expect that." "I think this (medical abortion) is a good method but I'd prefer to just get it over with in one day." Now you may be ready to choose a doctor or clinic that will offer you a choice of methods. Remember, "medical abortion" or "abortion with a pill" may refer to either Mifeprex™ or You can find a provider in the abortion section of your phone book, on the internet (www.ru486.com, www.abortionclinicdirectory.com, www.gynpages.com), or from your local family planning or Planned Parenthood clinic. It's probably a good idea to call a couple of places • What is the fee and what does it include? • Does your insurance or Medicaid cover this fee? If not, does it include the cost of ultrasounds, lab work, exam? • What medicines do they use? Mifeprex™ (also known as mifepristone or RU486) with Misoprostol (also known as Cytotec™) Or Methotrexate with Misoprostol? (see comparison chart).
• An ultrasound is an important part of the early abortion, both before and after taking the medicine. Is that part of the service? ___ Yes ___ No Is it included in the fee? ___ Yes ___ No Is it done on site or by referral to a hospital? • Are there other blood tests you might need? Sometimes one or two "quantitative blood pregnancy tests" are required. Is this likely? How much is this test? Is the test for blood type included in the service? ___ Yes ___ No Is there an extra fee for the testing? ___ Yes ___ No $ ______ How much is the injection of Rhogam that you will need if your blood type is Rh negative? $ _______ • What happens if the medicine doesn't work? Do they offer another dose of Misoprostol? ___ Yes ___ No If they recommend that the abortion be completed surgically, do they offer that service as part of the fee? ___ Yes ___ No If they refer you to someone else, how much will that cost, and where is that office? What if I change my mind and have surgical? Is there an extra charge? • How many visits do you need to make to the clinic/office? Are the follow-up visits included in the fee? ___ Yes ___ No • Is a counseling and education session offered? ___ Yes ___ No Does someone sit down and talk to you about whether you are making a good decision? ___ Yes ___ No Or whether you completely understand how to use this method? ___ Yes ___ No Is there written information for you to take home? ___ Yes ___ No Is your partner, parent or friend able to be with you in the educational session? ___ Yes ___ No • Do they have a 24 hour phone number you can call if you need to talk to someone about bleeding or other symptoms? ___ Yes ___ No • What is your impression of each clinic you talked to? Each clinic may have slightly different guidelines for these medications. Here are the FDA- approved guidelines and the most common alternatives. These alternatives are based on scientific studies as well as the clinic or doctor's experience. In many cases, these "evidence- based" guidelines are easier and more effective.
1. You must be under 7 weeks (49 days) pregnant.
This is determined by knowing the first day of your last normal period, and/or by doing an ultrasound and measuring the pregnancy.
VARIATION: Some providers use this method up to 8 weeks (56 days) or 9 weeks (63 days). Vaginal use of misoprostol is required. The effectiveness is about 95-97% according to several studies. 2. On Day 1 you take Mifeprex™ 600 mg. (3 pills).
Mifepristone causes the lining of the uterus to separate from the wall of the uterus. It works by interfering with progesterone, a hormone necessary in early pregnancy.
VARIATIONS: Many providers use 200 mg of Mifeprex™ (1 pill). Several studies have shown that this dose is just as effective. Even lower doses are being tested. (See references) SIDE EFFECTS: a. Some bleeding and cramping is possible. In a few cases (5%) the pregnancy will pass with just this medicine. (Check with your doctor/clinic if you think this may have happened and they may do an ultrasound for you.) b. Other side effects may happen to some women (nausea, headache, "flu-like" symptoms etc.).
3. On Day 3 you take misoprostol (Cytotec™).
Misoprostol causes the uterus to push out the contents of the uterus by cramping within 1/2 hour, up to 4 - 8 hours.
VARIATIONS: Some clinics/doctors are instructing patients to take the misoprostol after 24 or 36 hours. (See references) SIDE EFFECTS: a. Cramping may be moderate to severe. Your doctor/clinic will advise you about pain medication.
b. Mild fever or chills: mild fevers (under 100.4° F) or "sweats" or chills can be a temporary reaction to misoprostol. Keep track of your fever. If it lasts longer than 2 days call your doctor. If you have a high fever, over 100.4° F, for 2 or more hours call your doctor.
c. Nausea or vomiting: Oral (swallowing the pills) doses of misoprostol can cause nausea or vomiting. If you think you have vomited the medication (after 20 minutes or less), repeat the dose and/or consult your instructions. Vaginal suppositories containing misoprostol may help you avoid some nausea, vomiting, and diarrhea.
d. Diarrhea: This is a temporary reaction to the medicine. If it continues take some over-the-counter anti-diarrhea medicine.
4. On Day 3 you take misoprostol (Cytotec™) 400 mg. orally.
VARIATIONS: Misoprostol 800 mg. (4 pills) are used vaginally. Studies show that vaginal use of misoprostol causes fewer side effects like nausea and diarrhea and also starts the bleeding sooner. Vaginal misoprostol has been shown to be more effective and is now preferred by most providers. (See references) 5. Misoprostol is taken at the clinic or doctor's office at a second visit on Day 3.
1. You take the misoprostol at home. Most providers have found that women are more comfortable administering misoprostol at home. Several studies have shown that this works as well or better. (See references) 2. Some doctors/clinics are trying the misoprostol 36 or even 24 hours after the Mifeprex™. Studies show this is effective. (See references) 6. Bleeding, cramping, and clots will most likely happen within 1-4 hours (sometimes up to 8 hours or more) of taking misoprostol.
A period of heavy bleeding, clotting, and cramping is normal. Bleeding may be heavy for several hours. Keep track of how many pads you fill. Full means the pad is "saturated"; in other words, you could wring it out and blood would drip. If there is bleeding as heavy as 2 pads per hour for more than 2 hours, consult your instructions. Clots may be as big as a golf ball, or lemon, or even larger. You may see the pregnancy or "conceptus". If you wash the blood off, it will look like a small translucent sac an inch or less in diameter (at 49 days). If you do not bleed much, it may mean the misoprostol is not working. Go for your check-up or call your doctor/clinic. 7. You must have a follow-up exam within 14 days.
5 - 8 women out of 100 will not pass the pregnancy after 1 dose of misoprostol. Bleeding alone does not mean the pregnancy has ended. The most reliable way of knowing if it has ended is to repeat the ultrasound and see if the gestational sac has passed. The follow-up exam is extremely important. If you miss your appointment, call the clinic and tell them what is going on.
VARIATIONS:Some doctors schedule a follow-up exam in 7 days.
ADDITIONAL WAYS TO KNOW IF THE PREGNANCY HAS ENDED:a. You see the gestational sac pass. b. Your pregnancy symptoms, especially nausea, get better in a day or two.
c. A quantitative pregnancy test shows that the pregnancy hormone is decreasing. You will need two tests to compare.
d. A pregnancy test turns negative in about 4 weeks after the pregnancy has passed.
THIS IS NOT A SUBSTITUTE FOR A FOLLOW-UP EXAM! 8. There is a 5- 8 % chance that this will not work. (Note: Vaginal misoprostol has been shown to increase success of Mifeprex™.) You will need to consult your doctor.
To be completely sure the pregnancy is passed and you are OK, go for your follow-up visit. If it didn't work, here are some possible options: a. A second dose of misoprostol is given. Some women have taken 2 or more doses of the misoprostol before passing the pregnancy.
b. A surgical intervention. Sometimes continued bleeding and cramping is too inconvenient and you may want to have a suctioning of the walls of the uterus. The misoprostol may make surgery easier by "softening" the cervix so that it opens more easily. Sometimes a "D&C" or abortion procedure is necessary, just as it would be after some miscarriages.
c. Taking St. John's Wort, rifampin, dexamethasone, or some anti-convulsants like phenobarbital, phenytoin, and carbamazepine, may lower blood levels of Mifeprex™. Some antibiotics (eg, erythromycin and ketoconazole) and grapefruit juice may change how the medication works.
9. Both medications, but especially the misoprostol, may cause serious birth defects. Continuing a pregnancy if the medical abortion did not work is not recommended. If you are one of the people this method did not work for, you may need a surgical abortion. Some women may not want to do this because they are afraid; ask your doctor/clinic to help you find a way to get through the surgery if you need it. A few women feel that if it didn't work it must mean that the "pregnancy was meant to happen." Does this mean that your baby is meant to have birth defects? Possible birth defects include limb abnormalities (the fingers or arms and legs do not grow correctly), facial distortions (Moebius syndrome where the face is oddly shaped), and mental retardation. 10. Some women should not take mifepristone and misoprostol.
There are certain medical conditions that mean you cannot take these medicines. Please be honest about your medical history; these conditions can put you in danger if you take these medications.
In addition, your doctor/clinic may have certain other requirements for medical abortion. Tell your doctor if you have any of the following: a. A bleeding problem: if your blood does not clot well or if you are on medications that thin the blood (ex: Coumadin, Heparin, daily aspirin). Or, if you are anemic.
b. Your adrenal gland is not functioning. (Cushing's disease).
c. You are on corticosteroids orally (not topical creams).
d. You have an inherited condition called porphyria. e. You have a known allergy or reaction to prostaglandin or to the medications.
f. You have a confirmed or suspected ectopic pregnancy. Mifepristone will not work on a pregnancy that is in the fallopian tubes, outside of the uterus (see methotrexate section).
g. You have an IUD in place. The IUD must be removed first, which may also disrupt the pregnancy.
h. You must be willing to have a surgical abortion if the medicine does not work. Since there is a chance of birth defects with these medicines, you need to be clear that you will have a surgical abortion if you need it.
i. You are breastfeeding.
j. You need to follow the guidelines of the doctor/clinic you choose. Each doctor/clinic may make their own rules to ensure that medical abortion works and women can get the help they need. For example, if you live in a remote area, not near medical care, or if you have no phone.
There may be other requirements from the state, like parental consent or notification or a waiting period with state informed consent.
What to Expect When Using Mifeprex™ & How will I feel after the first medication (mifepristone)?You may not feel any different at all. Most women swallow the first medication while in the clinic or doctor's office. It takes about an hour to be absorbed, so it is important that you not vomit up the medication. If you are worried about this ask your doctor for an anti-nausea medication. If you vomit the medication, contact your clinic or doctor.
Some women may already be feeling nauseated or having morning sickness because of the pregnancy. Taking mifepristone may cause a slight increase in nausea or vomiting, but many women feel no change in symptoms. Many women do not experience any nausea or vomiting at all.
Will I bleed? If I do, do I have to use the second medication?About 50% of women will have some bleeding (or spotting) after taking the mifepristone. Have pads available. They may--or may not--have cramps with the bleeding. Even if you begin to bleed, it is important to use the second medication. Very few women (5%) complete their abortion with the first medication alone. Of course, if you begin to bleed excessively, contact your clinic or doctor right away.
Will I have pain?Most women do not experience pain or cramps after using the first medication. Some cramping is normal and expected. Your doctor/clinic will advise you about pain relievers.
I am nervous about waiting between the two medications.
Waiting is a part of medical abortion and should be considered in deciding what method is good for you. Some women feel anxious as they wait to take the second medication. This is normal -- there is much to anticipate and the waiting can feel like forever! It may be helpful to speak to someone -- a close friend or a counselor. Remember that medical abortion is a process. Your body is working to terminate the pregnancy with the help of the medications and time is a necessary factor. If you feel up to it, carry on your regular activities. see a movie, read a book, visit with friends to make the time pass.
How will I feel after the second medication (misoprostol or Cytotec)?There are more side effects with oral use of misoprostol than with vaginal use. The misoprostol takes between 30 to 90 minutes to be absorbed and begin to affect your body. Nearly all women will experience cramping. Many women experience some nausea or vomiting which will go away in a few hours. It is important to drink a lot of fluids and eat lightly. It helps to eat a small meal before using the misoprostol. If you have continuous vomiting for 4-6 hours and are unable to keep anything down, contact your clinic or doctor.
Some women experience diarrhea, another expected side effect of misoprostol use. Remember to drink fluids, especially water or tea; fruit juice may make diarrhea worse. Continued diarrhea (longer than 4-6 hours) should be reported to your clinic or doctor.
Some women get light-headed, dizzy or feel faint after using the misoprostol. This is also normal, and a good reason to have someone around while you use the medication! A support person can help you move around, bring you cool cloths for your forehead (helpful when you feel faint), bring you fluids, and watch over you in general. It is important to take care to move around slowly, especially when getting upright after lying down. Few women actually black out.
Some women may feel feverish or chilled. These are also common side effects of misoprostol -- the effect is similar to what many women experience with a menstrual period or a miscarriage. Wrap up in a blanket and sip warm tea if you are chilled -- use a cool cloth on your forehead or upper chest if you feel feverish. Take your temperature-- 100.4° F or higher for more than 2 hours should be reported to your clinic or doctor.
What will the bleeding be like?Most women have bleeding that is heavier than a normal menstrual period. If you have very light periods, then it will look like far more blood than you are used to. If you have heavy periods, the flow may seem quite reasonable to you.
The best way to judge what is an acceptable amount of bleeding during the abortion is to wear a maxi pad and check it every 30 minutes. If you soak (completely fill from end to end, or soaked to wringing wet) a pad in 30 minutes, change it, then see what happens in the next 30 minutes. After 2 hours of checking every 30 minutes, count the pads. If you have soaked 4 pads in the 2 hours, and the flow seems the same or heavier, consult your instructions. Another way to time the bleeding is to check your pad every hour. Your doctor/clinic will advise you at what point to call if you are having heavy bleeding. Some say 3 pads in 3 hours; some a pad every 1/2 hour for 4 hours. Call if you are worried.
The actual blood may look very different than your normal period blood. It may look more like jelly than a flow, or it can be quite watery. You may pass blood clots, some of which can be quite large -- even clots the size of lemons are common. If you are passing mostly clots, and little fluid-like blood, it is difficult to judge how often you might be soaking a pad (clots tend not to be absorbed by the pad). If this happens to you, keep track of the size of clots, the number of them, and how often you pass them. This information will be useful to the clinic in assessing your situation.
Some women feel most comfortable on the toilet. While this makes sense, it is difficult to judge bleeding if the flow ends up in the toilet. Remember to use the pad method to assess heavy bleeding.
How long will the bleeding last?It is very difficult to predict exactly when the bleeding will start or the pregnancy will pass. After using the misoprostol, most women begin to bleed within 30 minutes to 2 hours. The bleeding is usually heaviest in the next 4 to 6 hours, and then begins to taper off. Almost all women continue to bleed (some clots may pass too) for several days after. Many women continue to have a light flow for several weeks. This is normal. A few women will have light bleeding or spotting until their next menstrual period. Occasional episodes of heavy bleeding may happen to some women in the next few weeks; call your doctor if it is more than 1 pad/1/2 hour.
Will it hurt?Almost all women have some cramping (uterine contractions) during the use of the misoprostol. The cramps may be similar to a menstrual period, or very different. Remember that your uterus is working to pass the pregnancy, and your cervix needs to stretch slightly to allow the passage of clots and pregnancy tissue. The cramping tends to come and go in waves, and most women report having relief of pain shortly after passing the pregnancy tissue.
Cramping usually begins within 30 minutes to 2 hours of using the misoprostol. The strongest cramping tends to be during the next 4-6 hours, although some women experience cramping for longer. Most women get relief using pain medicine like Ibuprofen or a narcotic like Tylenol with Codeine. Some women do not and benefit from other techniques, like a hot water bottle or a heating pad, massage, or breathing exercises like those used in laboring for childbirth. (See section on pain relief) Some women feel best lying down; others prefer to move around a bit. This type of abortion is a process--most pain gets much better with time. If your pain continues without relief even after use of pain medicine and heat to your abdomen, contact your clinic or doctor.
Will I know when I have passed the pregnancy?You may or may not. For some women, the passage of the tissue is quite obvious, for others it is not. The pregnancy tissue will vary in size, depending on your stage of pregnancy. The sac is pinkish-white in color, and may look somewhat feathery or filmy at the edges. An early pregnancy (5-6 weeks) might be the size of a grape, while a later pregnancy (8-9 weeks) might be the size of a small lime. A few women may be able to see the embryo inside the sac at 8-9 weeks, although it is often too small for the untrained eye to detect.
Some women choose to view the tissue, others are happy not to. It is truly a private moment and women experience a range of emotions and decide to mark the moment in a number of ways. Some choose a ritual or a celebration; others flush the toilet with a sigh of relief! The moment is yours.
Do I really have to go to the follow-up visit?Yes! It's a really good idea because then you will feel reassured that everything went well and is back to normal. The follow-up is a chance for the doctor to hear about your experience and confirm with a test or an ultrasound that the pregnancy is gone. The doctor or clinic can also help you with your birth control plan. Also, remember the doctor or clinic is a partner with you in this abortion and they will want to know what happened to you and that you are OK.
Methotrexate is a medicine in use in the U.S. for over 40 years as an anti-cancer agent. It has also been shown to be helpful in treating ectopic pregnancies (see p.3 ). It is used with misoprostol, just like Mifeprex™, to induce a miscarriage. Methotrexate causes the pregnancy to stop growing and detach from the wall of the uterus. It is most effective when used early in pregnancy-- 7 weeks LMP or less. Because it takes longer, is more unpredictable, and less effective than Mifeprex™ it is not used as much. However, it is cheaper and may be what is available in your area. It may be helpful if an ectopic is suspected (only under the supervision of a doctor). Although methotrexate has been approved by the FDA for other uses, it is considered an "off label use" for termination of pregnancy. Any doctor may use any drug in an "off label use;" in the case ofmethotrexate there are many reliable studies that show its effectiveness for the termination of early pregnancies. (See reference section) On Day 1 an injection of methotrexate or an oral dose of methotrexate is given to a patient who is less than 7 weeks from the first day of her last period.
Discussion: The dose is based on body surface area, so your height and weight will probably be taken. It is usually given as a shot or sometimes as a medicine you swallow. An ultrasound is the best way to be sure your pregnancy is 7 weeks or less. The failure rate is considerably higher if you are over 7 weeks. If you are not completely sure of your last period date, ask for an ultrasound. You should avoid vitamins with folic acid for a few days.
Side Effects: Most women do not have many side effects with methotrexate in these low doses. At higher doses there can be some serious side effects. Some mouth sores have been reported.
On Day 5, 6, or 7 you will place 4 tablets of misoprostol 200 mg (Cytotec™) in the vagina. Rest with your feet up for 1/2 hour to 3 hours.
Variation: Some doctors recommend a second dose of misoprostol 24 hours after the first one if the pregnancy has not passed.
Discussion: Exactly when the bleeding will start--and when the pregnancy will pass--is very unpredictable. Most women will begin to bleed in about 12-24 hours. Once you start bleeding it is likely to be heavy for 4-6 hours. About half of all women will require a second dose of the misoprostol 24 hours later for this method to be effective. On Day 8 an ultrasound can show whether the abortion was complete. If it is not complete, another dose of misoprostol is given. An ultrasound can determine if the pregnancy has stopped growing, if the sac is still there, or if the pregnancy has been expelled.
If needed, on Day 15 another ultrasound can determine if the pregnancy is continuing. If it is, then surgery is recommended. Surgery means that a doctor will suction the inside of the uterus; it takes less than 5 minutes. On Days 29-45, if the sac remains, even if the pregnancy has not continued to grow, a surgical procedure is recommended. Some women should not use methotrexate with misoprostol. Tell your doctor/clinic if you have if any of the following are true for you: a. A bleeding problem: if your blood does not clot well or if you are on medications that thin the blood (ex: Coumadin, Heparin, daily aspirin). Or, if you are anemic.
b. Your adrenal gland is not functioning. (Cushing´s disease).
c. You are on corticosteroids orally (not topical creams).
d. You have an inherited condition called porphyria. e. You have a known allergy or reaction to prostaglandin or to the medications.
f. You have acute inflammatory bowel disease.
g. You have a confirmed or suspected ectopic pregnancy. Methotrexate may be helpful in treating a tubal or ectopic pregnancy. Tell your doctor if you have had a previous ectopic. h. You have an IUD in place. The IUD must be removed first, which may also disrupt the pregnancy.
i. You must be willing to have a surgical abortion if the medicine does not work. Since there is a chance of birth defects with these medicines, you need to be clear that you will have a surgical abortion if you need it.
j. You are breastfeeding.
k. You need to follow the guidelines of the doctor/clinic you choose. Each doctor/clinic may make their own rules to ensure that medical abortion works and women can get the help they need. For example, if you live in a remote area, not near medical care, or if you have no phone, or have trouble communicating with the staff, the clinic may caution you against this method.
A follow-up exam is extremely important. Since methotrexate is less effective, one or two follow-up exams may be required to be sure the pregnancy is gone. With methotrexate it can be difficult to be sure the pregnancy has ended so a repeat ultrasound is very important.
ADDITIONAL WAYS TO KNOW IF THE PREGNANCY HAS ENDED:1. You see the gestational sac pass. 2. Your pregnancy symptoms, especially nausea, get better in a day or two.
3. A quantitative pregnancy test shows that the pregnancy hormone is decreasing. You will need two tests to compare.
4. A pregnancy test turns negative in about 4 weeks after the pregnancy has passed.
THIS IS NOT A SUBSTITUTE FOR A FOLLOW-UP EXAM! What to Expect when Using Methotrexate & Misoprostol How will I feel after the first medication (methotrexate)?You may not feel any different at all. Most women receive the first medication as an injection while in the clinic or doctor's office. Some will take it orally. It takes several days for the methotrexate to end the pregnancy, so you may continue to experience pregnancy symptoms for that time. Some women may already be feeling nauseated or having morning sickness because of the pregnancy. Using methotrexate may cause a slight increase in nausea or vomiting, but many A small rise in body temperature can be normal with methotrexate. However, if you experience a fever of over 100.4° F, call your doctor or clinic.
Will I bleed? If I do, do I have to use the second medication?A small number of women will have some bleeding (or spotting) after using methotrexate. They may or may not have cramps with the bleeding. Even if you begin to bleed, it is important to use the second medication. A few women do complete their abortion with the first medication alone, but the process tends to take much longer (six weeks or more).
If you are bleeding in a steady flow, and have been instructed to use the second medication vaginally, you should contact your clinic for more instructions. The second medication might not have a chance to dissolve and be absorbed by the vagina if your flow is heavy. Of course, if you begin to bleed to excessive levels, contact your clinic or doctor right away.
Will I have pain?Most women do not experience pain or cramps after using the first medication. Some cramping is normal and expected. You can use the pain reliever you were given or prescribed.
I am nervous about waiting between the two medications. Is it hard? Waiting for your body to miscarry is part of medical abortion, especially with methotrexate. The timing is unpredictable. Some women feel anxious as they wait to take the second medication. This is normal - there is much to anticipate and the waiting can feel like forever! It may be helpful to talk with someone - a close friend or a counselor. Remember that medical abortion is a process. Your body is working to terminate the pregnancy with the help of the medications and time is a necessary factor. If you feel up to it, carry on your regular activities, see a movie, read a book, take a hot bath (not if you are bleeding heavily), visit with friends to make the time pass. If this seems too difficult for you, consider Mifeprex™ which is faster or a surgical abortion.
How will I feel after the second medication (misoprostol or Cytotec)?The misoprostol can take between 12 and 24 hours or more to begin bleeding and cramping. Many women experience some nausea or vomiting. It is important to drink a lot of fluids and eat lightly. It helps to eat a small meal before using the misoprostol. Nausea and vomiting usually last several hours then go away. If you have continuous vomiting for 4-6 hours and are unable to keep anything down, contact your clinic or doctor.
Some women experience diarrhea, another expected side effect of misoprostol use. Remember to drink fluids, especially water or tea; fruit juice may make diarrhea worse. Continued diarrhea (longer than 4-6 hours) should be reported to your clinic or doctor.
Some women get lightheaded, dizzy or feel faint after using the misoprostol. This is also normal, and a good reason to have someone around while you use the medication! A support person can help you move around, bring you cool cloths for your forehead (helpful when you feel faint), bring you something to drink, and watch over you in general. It is important to take care to move around slowly, especially when getting upright after lying down. However, very few women Some women may feel feverish or chilled. These are also common side effects of misoprostol - the effect is similar to what many women experience with a menstrual period! Wrap up in a blanket and sip warm tea if you are chilled; use a cool cloth on your forehead or upper chest if you feel feverish. Take your temperature--anything over 100.4° F should be reported to your What will the bleeding be like?Most women have bleeding that is heavier than their normal menstrual period. If you have very light periods, then it will look like far more blood than you are accustomed to. If you have heavy periods, the flow may seem quite reasonable to you.
The best way to judge what is an acceptable amount of bleeding during the abortion is to wear a maxi pad and check it every 30 minutes. If you soak (completely fill from end to end, or soaked to wringing wet) a pad in 30 minutes, change it, then see what happens in the next 30 minutes. After 2 hours of checking every 30 minutes, count the pads. If you have soaked 4 pads in the 2 hours, and the flow seems the same or heavier, consult your instructions. Another way to time the bleeding is to check your pad every hour. If you soak a total of 3 pads in 3 hours, contact The actual blood may look very different than your normal period blood. It may look more like jelly than a flow, or it can be quite watery. You may pass blood clots, some which can be quite large - even clots the size of lemons are common. If you are passing mostly clots, and little fluid- like blood, it is difficult to judge how often you might be soaking a pad (clots tend not to be absorbed by the pad). If this happens to you, keep track of the size of clots, the number of them, and how often you pass them. This information will be useful to the clinic in assessing your Some women feel most comfortable on the toilet. While this makes sense, it is difficult to judge bleeding if the flow ends up in the toilet. Remember to use the pad method to assess heavy How long will the bleeding last?This is quite unpredictable. After using the misoprostol, most women begin to bleed within 12 to 24 hours. After it starts, the bleeding is usually heaviest in the next 4 to 6 hours, and then begins to taper off. Almost all women continue to bleed (some clots may pass too) about 2 weeks after; many women continue to have a light flow for several weeks. This is normal. A few women will have light bleeding or spotting until their next menstrual period.
What if I do not bleed? Is it working?About half of the women who have used methotrexate will need more than one dose of the misoprostol (the second medication). This is quite common and does not mean the abortion is not working. Methotrexate works on the pregnancy alone, it does not prepare the uterus in the way that Mifeprex™ does, so the action of misoprostol takes a little bit longer. Some women simply require more than one--or two-- doses to pass the pregnancy tissue.
Your doctor or clinic may send you home with an extra dose to use if you do not experience any cramps or moderate bleeding after the first dose. Or they may give you only one dose, but ask you to call them for a second dose if you do not bleed. Some women may need more than two Despite this longer time frame, methotrexate and misoprostol are still 92-96% effective in ending a pregnancy. (Success rates vary: After 1 week, about 65% of women are likely to complete termination of pregnancy; after 2 weeks, 68%- 80% , after 3 weeks, about 90%, and after 4 weeks Will it hurt?Almost all women have some cramping (uterine contractions) during the use of the misoprostol. The cramps may be similar to a menstrual period or very different. Remember that your uterus is working to pass the pregnancy, and your cervix needs to stretch slightly to allow the passage of clots and pregnancy tissue. The cramping tends to come and go in waves, and most women report having relief of pain shortly after passing the pregnancy tissue.
Cramping usually begins within 12 to 24 hours of using the misoprostol. The strongest cramping tends to be during the next 4-6 hours, although some women experience cramping for longer. Most women get relief using pain medicine like Ibuprofen or a narcotic like Tylenol with Codeine. Some women do not, but might benefit from other techniques, like a hot water bottle or a heating pad, massage, or breathing exercises like those used in laboring for childbirth. Some women feel best lying down; others prefer to move around a bit. Like childbirth, this type of abortion is a process; most pain gets much better with time. If your pain continues and is unrelieved after use of pain medicine and heat to your abdomen, contact your clinic or doctor Will I know when I have passed the pregnancy?You may or may not. For some women, the passage of the tissue is quite obvious-- for others it is not. The pregnancy tissue will vary in size, depending on your stage of pregnancy. The sac is pinkish-white in color, and may look somewhat feathery or filmy at the edges. An early pregnancy (5-7 weeks) might be the size of a grape.
Some women choose to view the tissue, others are happy not to. It is truly a private moment and women experience a range of emotions and decide to mark the moment in a number of ways. Some choose a ritual or a celebration; others flush the toilet with a sigh of relief! The moment is Ask your doctor or clinic what pain relievers would be best for you. Here are some medicines that are usually suggested to help with cramps and pain: 1. Ibuprofen is the generic name for Advil™, Motrin, and similar products. It is available in 200 mg. tablets in the pharmacy or grocery store. Generally, 600-800 mg. (3-4 tablets) are recommended every 4-6 hours for cramps. If you have a prescription for Ibuprofen check the number of milligrams and do not exceed 800 mg. It usually starts working in 20-30 minutes.
2. Naproxen Sodium, is also known as Anaprox or over the counter as Aleve™. Two tablets of Aleve™ (440mg) is frequently recommended for moderate to severe pain, every 6 to 8 hours. It usually takes about 45 minutes to start working.
3. Tylenol™, Extra Strength Tylenol™, or Acetaminophen is a general purpose pain reliever and is good for people who get stomach upset from Ibuprofen or Aleve™. It is very important not to take more than 2 tablets in a 4- 6 hour period, or 8 tablets in 24 hours. Tylenol™ usually starts working in 30 minutes or so.
4. Narcotic pain relievers such as Tylenol #3 (Codeine), Hydrocodone (Vicodin™, or Vicoprofen™), or Darvocet™. Sometimes your doctor will prescribe small amounts of one of these in case you have severe pain. It can have side effects including nausea, light-headed feelings, sleepiness, etc. You should not drive or do activities that require you to be alert if you are taking one of these medicines. The usual dose is 1-2 tablets every 4-6 hours. Do not exceed 8 tablets (500 mg) in 24 hours.
5. Other medications may include Ultram™, Vioxx™, Orudis™, etc. Follow the directions carefully; ask your doctor for advice or consult a pharmacist. Do not take medicines prescribed for other people without checking with your doctor first.
Sometimes you may not have enough pain medications--or they may not be working fast enough for you--or you may not want certain side effects. Try some of these: 1. Lie down with a heating pad or hot water bottle and place it on your lower abdomen. Occasionally, ice for 10 minutes at a time works better than heat, especially if you are nauseous 2. Sometimes it works better to move around and stretch out. 3. Have someone give you a back rub or massage. The lower back and thighs are important to 4. If you are bleeding and clotting a lot, sometimes a uterine massage is helpful. Massage or rub the lower abdomen, just above the pubic bone until it feels better. (Works best after pain 5. If you are feeling emotional, ask someone to sit with you and talk about how you feel. 6. Some people deal with pain by distracting themselves with an activity or by talking.
7. Deep breathing. Many people use some version of deep breathing to relax and work through Lie comfortably with head and back supported. Take a few deep breaths and let it out slowly.
Now start at your feet and curl your toes, counting 1-2-3-4-5-, then relax your toes to the count of 5 again. Breathe in as you are tensing your muscles and breathe out when you are relaxing your muscles.
Bend your ankles and tense your feet to the count of 5 and then relax those same muscles to the count of 5.
Do the same thing with your thighs and buttocks, a slow count of five and then relax for five counts. Remember, breathe in and then breathe out SLOWLY.
Feel your uterus and lower abdomen cramp or tense and try to feel it relax as you breathe out. Then tense and relax your chest muscles. Next do your arms and hands. Breathe in and tense them for 5 counts then breathe out slowly and relax for 5 slow counts. Now tense your shoulders up around your ears and relax for 5 counts and sigh as you let your breath out.
Squeeze your facial muscles next including squeezing your eyes shut and then relax them.
Go back to your uterus /lower stomach muscles and repeat the tensing and relaxing of those muscles, being sure to breathe deeply and let the breath out slowly as you relax. Are the cramps better? (Have someone read these instructions to you slowly in a quiet voice. As you do the exercise try to imagine your pain going away with every breath you exhale.) How you will feel after an abortion depends on how you feel before. Although no one can predict exactly how you will feel, the time and care that you spend in making the decision will help you afterwards. Mostly, women feel relief with a mixture of other feelings. How you feel depends on many factors--the amount of support you have, how you cope with difficult situations, how Occasionally, you may need to review your reasons, your situation, your goals, and how you were feeling when you made your decision. Remember though, we only make decisions based on what we know at a point in time. If your decision seems wrong now, it did seem right then. Why? What It is completely normal to have strong feelings about any decision you make about pregnancy. All pregnancy decisions can be profound. Any decision can feel scary, or you could have mixed feelings about the choice you made. Sadness and relief are just some of the possible feelings you The question is: how do you express these feelings? Talking with others who try to understand what you are feeling is a typical way. Your support people should listen to how you are feeling. Some women write down how they feel in a letter or a journal. Some women pray or meditate--even asking for forgiveness for any hurt they may have caused, if that feels appropriate. Many women are discovering for themselves the comfort a ritual or ceremony can bring. Burning a candle during the process of expelling the pregnancy.
Creating something, like writing a poem or making art, or planting a flower or plant.
In some Buddhist cultures and in at least one Native American tradition there are prescribed rituals for women who want to acknowledge a pregnancy loss. Or, you can make up your own way to acknowledge your feelings. (See also www.pregnancyoptions.info) Feelings that don't get dealt with will keep popping up and interrupting your life until you notice them. If you can't stop crying, if you have trouble eating, sleeping, or concentrating, you should find someone to talk to. Time may help but a competent listener (counselor) can help you figure Here are some of the warning signs of women who may need more help coping after an abortion experience: • Someone else made the decision or you didn't really "own" the decision yourself.
• Someone close to you is opposing you or your decision. • You just don't have enough support-- you feel like you can't tell anyone, or you're alone, or you just don't have anyone to really talk to.
•You are going against your own deeply held beliefs, or you cannot seem to forgive yourself or someone else.
• There is another loss in your life. Or a break in a relationship (partner, parent?) A recent death? A previous loss, miscarriage, or abortion that needs more attention? If any of these things are true for you, take the time you need to figure things out. If you are unable to function normally--for instance, if you can't stop crying, if your normal sleep is disrupted, you cannot eat normally, or you can't concentrate, you may need more help. Emotional upset and physical symptoms like these usually get better over time; if they do not, get help. If you don't have anyone who is helpful, call your doctor/clinic, a local family planning clinic or Planned Parenthood, a clergy person, or your county mental health clinic.
Many women are creating their own rituals to help them deal with their feelings around ending a pregnancy. This can involve others, or not, as you wish.
The Night Before.
The night before you go to the doctor's, or before you take the medicine, draw a bath and sprinkle the water with a few rose petals or herbs. As you soak, notice how much you want to do the right thing for your life. Let your heart fill with love and wish for a peaceful separation of the spirit within you from your own. Collect the petals and let them dry out. Write down any thoughts or feelings you have.
Day 2 or 3.
When you take the misoprostol (the second medication), light a 24-hour candle. (Also called Memorial Candles, they are in a glass jar, available at most supermarkets.) As the candle burns, the process of passing the pregnancy will continue. Sometimes it will be painful, sometimes you will relax or sleep. At other times you may feel sad or even cry. See the path you are on continuing, but the path of the pregnancy (spirit/baby) going in another direction.
Later.
When the candle has finished burning think about how you feel. Are you at peace? If not, what is still troubling you? Think about what that is and write it down on a piece of paper. When you feel ready, gather the rose petals together with any messages or writings you have and either burn them, or bury them or cast them on a body of water. Remember your good intentions at the beginning of this process.
Websites:available on this site as well as important links.
Mifeprex™. It includes the Medication Guide and a patient brochure.
: This website is a directory of abortion providers organized by state or by service.
: This website offers information about medical abortion and is sponsored by the National Abortion Federation. The site offers educational information, a Women's Information Guide, and information about NAF resources on medical abortion.
contraception, and abortion, and information about Planned Parenthood affiliates across the Administration website which includes the FDA labeling of Mifeprex™, patient forms, Medication Guide, and other documents about the approval of this drug.
Phone Numbers:NAF Hotline (800) 772-9100 Monday-Friday 8 am -10 pm, Saturday and Sunday, 9 am -5 pm. National Coalition of Abortion Providers (703) 684-0055 Monday-Friday 8 am- 6 pm. Referrals to Planned Parenthood Hotline (800) 230-PLAN Referrals to Planned Parenthood affiliates Selected References for the Abortion: Which Method is Right for Me? workbook:Aubény E, Peyron R, Turpin CL, et al. Termination of early pregnancy (up to 63 days of amenorrhea) with mifepristone and increasing doses of misoprostol. Int J Fertil Menopausal Stud. Borgatta L et al. Early Medical Abortion with Methotrexate and Misoprostol. Ob/Gyn v. 97 #1, Bydgeman M, Swahn ML. Progesterone receptor blockage. Effect on uterine contractility and early pregnancy. Contraception. 1985;32:45-51.
Creinin MD, et al. Mifepristone 100 mg in Abortion Regimen. Obstet Gynecol Vol 98 #3 Sept. 2001 Creinin MD. Medical Abortion Regimens: historical context and overview. Am J Obstet Gynecol. Creinin, MD, Spitz, IM, Use of Various Ultrasound Criteria to evaluate the efficacy of Mifepristone and Misoprostol for medical abortion. Am J Obstet Gynecol 1999; 181:1419-24.
DeLoia JA, Stewart-Akers AM, Creinin MD. Effects of methotrexate on trophoblast proliferation and local immune responses. Hum Reprod. 1998;13:1063-1069.
Elul B et al. Mifepristone and Misoprostol Abortion vs. Surgical Abortion Contraception 1999; 59: Hausknecht, RU. Methotrexate and misoprostol to terminate early pregnancy. N Engl J Med. Kahn JG, Becker BJ, MacIsaac L, et al. The efficacy of medical abortion: a meta-analysis. Contraception. 2000;61:29-40. Tests to 63 days.
Koopersmith TB, Mishell DR Jr. The use of misoprostol for termination of early pregnancy. Kruse B, Poppema S, Creinin MD, Paul M. Management of side effects and complications in medical abortion. Am J Obstet Gynecol. 2000; 183: S65-S75.
Lipscomb GH et al. Analysis of 315 ectopic pregnancies treated with single dose methotrexate. National Abortion Federation Early Medical Abortion with Mifepristone or Methotrexate. Overview Paul M, Creinin MD, Early Medical Abortion. Supplement Am J Obstet Gynecol. 2000.
Peyron R, Aubény E, Targosz V, et al. Early termination of pregnancy with mifepristone (RU 486) and the orally active prostaglandin misoprostol. N Engl J Med. 1993;328:1509-1513.
Pheterson G. Medical Versus Surgical Abortion: Bias in Presentation of Early Options, 2001. See Pymar HC, Creinin MD. Alternatives to mifepristone regimens for medical abortion. Am J Obstet Gynecol. Supplement August 2000; 183: #2, s54-s64.
Schaff EA et al. Low dose mifepristone 200 mg + vaginal misoprostol for abortion. Contraception Schaff EA et al. Low dose mifepristone followed by vaginal misoprostol at 48 hours for abortion up to 63 days. Contraception 2000: 61:41-6 Schaff EA et al. Randomized trial of vaginal misoprostol administered 1, 2, or 3 days after mifepristone for early medical abortion. JAMA 2000: 284:1948-53.
Spitz IM et al. Early pregnancy termination with mifepristone and misoprostol in the United States. N Eng J of Med. April 30, 1998 338:124-127 Stewart F et al. Early Medical Abortion: Issues for Practice. Center for Reproductive Research Wieg ER Oral methotrexate compared with injected methotrexate when used with misoprostol for abortion. AmJ Obstet Gynecol. 1999: 181:149-52.
Winikoff B et al. Acceptability and Feasibility of Early Pregnancy Termination by Mifepristone and Misoprostol. Archives of Family Medicine. July/August 1998.

Source: http://www.pregnancyoptions.info/pdfs/WhichMethodIsRightForMe.pdf