Why Misoprostol Is So Much More Than A Pill Used For Medical Abortions

Misoprostol is one of two drugs taken to induce a medical abortion. But it’s used for a lot of other potentially life-saving purposes that make it essential for reproductive health.

Misoprostol is a prescription drug that's commonly prescribed by OB-GYNs.

Misoprostol is sold under the brand name Cytotec and was approved by the Food and Drug Administration (FDA) in 1988 to prevent stomach ulcers caused by NSAIDs, which are anti-inflammatory drugs like ibuprofen or aspirin.

In addition to preventing ulcers, misoprostol can also "ripen," or soften, the cervix, and cause uterine contractions, which is why OB-GYNs use it so often “off-label,” or for things a drug is not FDA-approved to treat — a legal and common practice with just about every drug.

"Off-label use of misoprostol for obstetric and gynecological purposes is a very widespread practice and it has been highly studied, but the labeling has never been changed by the FDA to include any of these indications," Dr. Sarah Prager, associate professor of obstetrics and gynecology at the University of Washington in Seattle, told BuzzFeed News.

Last week, a Walgreens pharmacist in Arizona refused to fill a woman's misoprostol prescription. The woman had miscarried at nine weeks and was prescribed misoprostol to help her body pass the nonviable pregnancy instead of having to have surgery. Arizona is one of six states in the US where it's legal for a pharmacist to refuse to fill prescriptions for moral or religious reasons.

Here’s what you need to know about how misoprostol is used and why it’s important.

Although misoprostol can be taken with another medication to terminate an early pregnancy, it also has a number of other important uses in reproductive health.

"Misoprostol is not 'the abortion pill.' Even though it's used for abortion, it is not the abortion pill ... that medicine is mifepristone [RU-486] and it is used with misoprostol to cause a medication abortion," Dr. Sanithia Williams, an OB-GYN at the Bixby Center for Global Reproductive Health at the University of California, San Francisco, told BuzzFeed News.

During a medical abortion, you take the two medications separately. First, mifepristone (200 milligrams) is given to stop the pregnancy from growing, then misoprostol is given 6–48 hours later to empty the uterus. Medical abortions are a safe, nonsurgical option for terminating a pregnancy in the first trimester.

Although misoprostol alone is only approved for ulcers, the combination of misoprostol and mifepristone is actually approved by the FDA. However, the term "abortion pill" is often conflated with misoprostol, which leads to a lot of confusion about why and how the drug is used.

"Misoprostol is really a one-stop shop, it does a lot of different things in obstetrics, but there's a lot of politicization around it because it's used as part of medication abortion ... there are many different reasons why women would need the medication outside of that," said Williams, who is also a fellow with Physicians for Reproductive Health.

Here are other, sometimes life-saving, uses of misoprostol.

It is used to treat miscarriages when the pregnancy fails to leave the body, which can lead to potentially life-threatening infections.

A miscarriage, or "spontaneous abortion," is usually defined as the loss of a pregnancy before the 20th week of gestation. As many as half of all pregnancies may end in miscarriage, but of women who know they are pregnant, about 10% to 20% will have a miscarriage.

After a miscarriage happens, the nonviable pregnancy is supposed to leave the body naturally, which may feel like a heavy period. Sometimes, the tissues have trouble leaving the uterus and passing out of the body. This is called a "missed abortion" or an "incomplete abortion" if only part of the tissue leaves the uterus. In these cases, women may not have any symptoms at all or notice they miscarried until they get an ultrasound, Williams said.

Women can manage the miscarriage by taking misoprostol to help expel the contents more quickly or they can have surgery to remove them, such as aspiration or dilation and curettage (D&C), according to the American College of Obstetricians and Gynecologists (ACOG).

Misoprostol can be given orally or vaginally to help open the cervix and expel pregnancy tissue. "It can help the uterus to contract more quickly and more effectively to empty the uterus and avoid surgical intervention," said Prager. Many women choose to take misoprostol because it is less invasive than the surgical options.

If the contents of the uterus do not leave the body, this could cause prolonged and heavy bleeding, which can lead to anemia or infection, Prager said. In some cases, the infected contents of the uterus can lead to sepsis in the mother's body, a potentially life-threatening complication.

Misoprostol can also be used to soften the cervix before certain gynecological and surgical procedures.

The drug is effective at ripening, or softening, the cervix before procedures that require something to pass through it. "In women who are not pregnant, some have cervical stenosis, or the narrowing of the cervical canal, and we use misoprostol to make it easier for us to enter the cervix safely," Williams said.

Providers might give a patient misoprostol before an IUD insertion or a hysteroscopy, where a telescopelike probe is inserted through the cervix to diagnose or treat problems of the uterus. Hysteroscopies might be performed to determine the cause of abnormal bleeding or repeated miscarriages, locate an IUD, look for fibroids, or aid in sterilization surgery.

Misoprostol is also used to help soften the cervix before a second-trimester surgical abortion or a dilation and evacuation (D&E), a surgical procedure used to manage miscarriages or pregnancy failure after the first trimester.

It can also help start contractions and induce labor for a viable pregnancy.

Misoprostol has been shown to be safe and effective as an agent for inducing labor. "For a person who needs to be in labor for whatever reason, if the cervix isn't quite ready then the misoprostol can help prepare the cervix and start labor altogether," Prager said. It can soften the cervix to help it dilate and also cause uterine contractions.

Finally, misoprostol can help prevent and treat postpartum hemorrhage, a potentially life-threatening complication.

"After delivery, if the uterus doesn’t contract well, called 'atony,' then misoprostol can be given to help the uterus contract and stay contracted so the bleeding decreases, or so it doesn’t become excessive in the first place," Prager said.

Women can lose a significant amount of blood after delivery if it is not controlled, which can result in death. Postpartum hemorrhage is the leading cause of maternal death around the globe, according to the World Health Organization (WHO).

Misoprostol is on the World Health Organization's list of essential medicines.

Due to its wide range of applications in maternal and reproductive health, misoprostol is on the WHO's list of essential medicines. These medicines are defined as "minimum medicine needs for a basic health-care system, listing the most efficacious, safe and cost-effective medicines for priority conditions," according to the WHO.

"It's very common for women to need misoprostol at some point in their reproductive lives," said Williams.

Misoprostol is often more accessible and safe in low-resource settings, where surgical procedures might pose a higher risk of infection. "In places where you don’t have access to blood banks or surgery, it becomes essential to have medications to help manage postpartum hemorrhage ... these meds can save women’s lives," said Williams.

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