Internal medicine's role in abortion care
Primary care internal medicine physicians explained to Internal Medicine Meeting 2024 attendees how they can help patients understand their options with an unintended pregnancy.
Recent restrictions on abortion have not reduced its incidence, Adelaide McClintock, MD, told attendees at the Internal Medicine Meeting 2024 session "Medication Abortion in 2024: What Internal Medicine Physicians Need to Know."
"In states with a limit under six weeks or at six weeks, there's been a decrease in abortions. In states where abortion is banned, there's been decreases. In the states that border states with bans, there's been a huge increase in abortion," she said. "And in all other states, we have also seen an increase, so overall, nationally, it's about the same or slightly more" as before the Supreme Court's 2022 Dobbs v. Jackson decision.
What the new regulations have highlighted is internal medicine physicians' role in providing care and information to patients with unwanted pregnancies. "Even if you're from a place where you can't yourself prescribe medication abortion, there are lots of ways that we can support reproductive health for our patients," said Dr. McClintock, an internal medicine physician at the University of Washington in Seattle.
She and three copanelists, all primary care internal medicine physicians, explained the process of prescribing a medication abortion but also provided guidance on how their colleagues can help patients with other steps, from understanding their options after a positive pregnancy test to receiving follow-up care after a self-managed abortion.
Prevention and testing
One easy first step is to talk to patients about the possibility of pregnancy.
"Any time you are prescribing a medication or refilling a medication that might impact pregnancy, it's a useful time to check in with your patients about whether or not they might be planning a pregnancy," said Dr. McClintock. "Any time you or a colleague of yours diagnoses a new chronic condition for your patient is another time to check in."
In that conversation, talk to patients about whether they could become pregnant and/or are planning to become pregnant soon and then "make sure that the care you're providing is matching those goals," she said.
That entails prescribing contraception as needed, Dr. McClintock added. "Then you can say something like, 'And if there's some mishap and your contraception doesn't work and you're pregnant and don't want to be pregnant, you can call me.' Just make yourself a safe person to have that conversation."
It's a conversation that many women in the U.S. have at some point, she noted. "One in six pregnancies result in abortion, meaning it's extremely common. One in four women will have an abortion by the age of 45."
Panelist Alexandra Bachorik, MD, EdM, led attendees through a group discussion of how to conduct a patient-centered conversation during a visit for a pregnancy test. It starts with preparing the patient, she said: "'We're going to run this test. This test is going to tell us whether or not you are pregnant.' And then letting them know that you'll support them, whatever the result is, and whatever they choose to do with the pregnancy."
It's helpful to try to read the patient's attitude about the situation, added Dr. Bachorik, an assistant professor of medicine at Boston University. "Make sure that we're matching their emotional valence and then clearly disclosing that result with a neutral tone," she said. "Then one of the hardest things I find in my clinical practice is sitting on your hands and letting the silence hang there for a moment."
If it seems suitable, you can offer the patient time to be alone. Then inquire in an open-ended fashion. "It's OK not to be happy about a positive pregnancy test. It's normal to have multiple feelings about a positive pregnancy test," said Dr. Bachorik. "Say something like, 'Let me know how I can be most helpful to you in this moment. We can talk about any options you're interested in hearing about, including options for ending or continuing your pregnancy.'"
The phrasing of those options may need to vary by state. "For those of you who may be practicing in restrictive states, couching this as general advice as opposed to specific advice may be safer for you and the patient—i.e., 'Some people when they do not wish to continue a pregnancy may pursue ordering pills online and pursuing a medication abortion at home,'" said Dr. Bachorik.
You can also refer patients to other sources of pregnancy and abortion care and support. "It's important to note that there are resources beyond us. There's a pregnancy options hotline folks can call," she said. The hotline she recommends is the All-Options Talkline at 888-493-0092.
It is important to make patients aware of any time restrictions on their decision making, for example, a six-week limit. "That's going to be particularly important for folks living in restricted states, right?" said Dr. Bachorik. "That's a reality that they're facing."
The options
How long it's been since a patient got pregnant is a determining factor in their abortion options, noted Dr. McClintock, who reviewed the considerations during the session.
"Up to 10 weeks based on the FDA labeling and about 12 based on the data that we know to be good, medication abortion can be used," she said. Up to 16 weeks, vacuum aspiration is an option.
A review of the pros and cons of each method can be helpful to a patient trying to decide between them, Dr. McClintock noted. Pros of medication include that it allows the pregnancy to be expelled at home and in private and that no invasive procedure or anesthesia is required. On the con side, it can take days to weeks to complete and may result in heavy bleeding and cramping, which the patient will have to manage at home. It has about a 95% success rate and typically requires a follow-up visit.
Aspiration is a more invasive procedure, sometimes done with sedation. Bleeding is typically light and completion can be confirmed immediately. The success rate is 99%. "There's no follow-up required in most cases, so if someone is considering something like how many days off from work, it might be a better option for them," said Dr. McClintock.
Medication abortion has become an increasingly common choice, reported panelist Cynthia H. Chuang, MD, MSc, FACP, professor of medicine at Penn State College of Medicine in Hershey, Pa. "In 2023, medication abortion accounted for 63% of the abortions in the U.S.," she said.
Dr. Chuang led the audience through the evaluation of a patient wanting a medication abortion. "First thing you need to do is confirm gestational age, and most of the time that can be done with menstrual dating alone, if the patient has regular cycles and is able to tell you with certainty what was the first day of their last menstrual period," she said.
If the patient doesn't know the date or has irregular periods, an ultrasound will be necessary. "Other indications for ultrasound are if you suspect an ectopic pregnancy or if you're in a state where ultrasound is legally mandated," she said.
The next step is to check for any contraindications to medication abortion, including any bleeding or clotting disorder or presence of an intrauterine device. "Mifepristone is actually a glucocorticoid receptor agonist, so adrenal insufficiency or chronic steroid use is a contraindication," said Dr. Chuang.
Because heavy bleeding can occur with medication abortion, aspiration may be preferred for anyone with a hemoglobin level below 9 mg/dL. "Typically, no labs are required prior to the medication abortion, but if the person has a known history of anemia, you may choose to check the hemoglobin," she said.
Once contraindications have been ruled out and the gestational age has been confirmed as 70 days or less, the medication can be prescribed. The preferred dosing is mifepristone, 200 mg orally, and misoprostol, 800 mcg, either vaginally or buccally. Misoprostol typically comes in 200-mg pills, Dr. Chuang noted.
"This is obviously a little different than the way we normally take pills, so make sure that your patient understands that if they take the pills vaginally, they take all four pills and put them in the vagina all at once. We instruct them to lay down for 30 minutes just to make sure that the pills don't fall out. If they take them buccally, we tell them to take two pills on each side, put them between the gum and the cheeks, hold those pills there for 30 minutes. If there's any remnants left after the 30 minutes, they can swish and swallow the rest," she said.
If the gestational age is nine weeks or more, a second dose of misoprostol is recommended and can be taken three to six hours after the first, Dr. Chuang advised. If mifepristone is not available, there is a protocol using only misoprostol, in three doses, three hours apart, but the dual regimen is preferred, she said. "Two of the disadvantages of [misoprostol only] are that it is slightly less effective and it's also associated with greater side effects."
Typical side effects of misoprostol include nausea, vomiting, diarrhea, headache, and temperature dysregulation. "We will tell people, 'It might feel like you're coming down with something. You might get body aches. You might get chills,'" Dr. Chuang said. Patients can take NSAIDs to relieve these effects.
Heavy bleeding is to be expected, and patients should be educated about what level is normal, she said. "We tell people, if you're soaking through two maxi pads an hour for one hour, that's OK. If you're going on two hours or more soaking through two pads an hour, that's more bleeding than we would expect and we want you to give us a call."
Aftercare
Bleeding can persist for weeks, and heavy bleeding is the most common complication of medication abortion. "Complications can happen but they are rare, so less than 1% of the time," said Dr. Chuang. "I think it's important to remember that having an abortion at pretty much every gestational age up until about 24 weeks is safer than continuing the pregnancy until birth."
Persistent pain or cramping may indicate that the abortion was not complete, and any signs of a ruptured ectopic pregnancy, hemorrhage, or infection should be treated as emergencies, the experts said.
The follow-up for a medication abortion is to confirm that it was successful, and there are three methods. "They can return for a transvaginal ultrasound, but that's an invasive procedure, and it's costly and it may not be preferred by the patient," said Dr. Chuang. Another option is serial human chorionic gonadotropin (hCG) testing, which should find an 80% drop from the time of the abortion to a week after.
"Or they can do a home self-assessment, and I have found this is preferred by most of my patients," she said. "They can do a home pregnancy test. It does need to be done at least four weeks later, though, because the hCG takes that long to get to the level where it's not detectable."
Technically, patients can do all of this at home on their own, and that is a choice that physicians should be aware that they may make, particularly in states with limitations.
"Self-managed abortion is basically use of medication abortion pills outside of the formal medical system. I know it likely makes us feel uncomfortable thinking about our patients getting health care outside of the formal medical system, but interestingly there have been two systematic reviews that have shown that self-managed abortion is both safe and effective," said Dr. Chuang.
Patients can buy the pills online, but there are potential legal consequences for patients and clinicians in some states with restrictions. "If they are interested in pursuing that, it's important for them to know that they are at risk for being prosecuted for self-managed abortion, and we need to be careful what we tell patients about self-managed abortion, because we may be at risk as well," she said.
Prescribing rules
The final speaker, Mindy Sobota, MD, MS, FACP, provided additional information on the legal landscape of medication abortion.
Until 2021, the FDA required that a patient be given the medication during an inpatient visit. "We can now prescribe this medicine to a mail-order pharmacy," said Dr. Sobota, who is an associate professor of medicine at Brown University in Providence, R.I. "For me, that was a big facilitator in being able to prescribe."
Local pharmacies, both retail and hospital, may also carry the drugs. "Our pharmacist got on board with this and got it in our hospital pharmacy," she said. "Just in the last few months we're now able to prescribe to Walgreens and CVS."
All three types of pharmacies require a physician to complete an "easy, two-page" prescriber agreement from the manufacturer, which says that you're able to diagnose pregnancy and would order an ultrasound if the patient had bleeding or cramping, Dr. Sobota noted.
She also discussed costs of medication abortion. "In states where there's no abortion coverage, or people are choosing not to use their insurance coverage because of privacy concerns, abortion visits have been as high as $500 to $600 at clinics, where the price [of mifepristone] is usually set to be the same as a procedure to avoid coercion."
However, the generic pill actually only costs about $50, Dr. Sobota said, noting that telemedicine has brought the cost of visits plus medication down to about $250. The experts also encouraged clinicians to be aware of nonprofit organizations that can help patients if they need travel or financial support for abortion care.
Note that those supportive resources do not include crisis pregnancy centers, added Dr. Bachorik. "Those are folks with an agenda. They're often looking to close Planned Parenthoods or other abortion care services," she said. "I think it's really important to signal to patients that we can help them avoid falling into the hands of pseudomedical establishments that might not support all their options."
