Medication abortions may be more painful than women expect, study finds

Many women are surprised by how much pain they experience during a medication abortion, a study published Tuesday in the journal BMJ Sexual & Reproductive Health found.

More than 60% of abortions in the U.S. are medication abortions, meaning a person takes two drugs, often at home, to end a pregnancy. The study, which surveyed women in the U.K., found that many don’t feel prepared for the amount of pain they may feel during the procedure. 

Pain does not mean the procedure is unsafe, but some women may feel caught off guard based on the information health providers gave them. 

“There is a bit of a reckoning in the world of gynecology right now and the pain patients are experiencing during procedures,” said Dr. Alyssa Colwill, an associate professor of obstetrics and gynecology at the Oregon Health and Science University School of Medicine who wasn’t involved with the new research.

In the study, researchers looked at survey responses from about 1,600 women in the U.K. who had undergone a medication abortion and then answered questions about the experience. Most were between the ages of 20 and 39 and half had never given birth. 

More than 90% of respondents ranked their pain at least a 4 out of a maximum of 10, and about half said the pain was more than they had expected. About 40% said their pain was severe, between an 8 and a 10 on the pain scale. 

Women are often told to expect cramping akin to strong menstrual cramps during a medication abortion, both in the U.K. and in the U.S. While some respondents felt that was an accurate description, others said they felt unprepared and that the pain aspect of medication abortion was “sugar-coated” or downplayed. 

One woman who responded to the survey said: “Pain was so much stronger than period pain, it was like having contractions in labour. I’ve given birth three times and the pain really wasn’t too much different from that pain, the cramping contraction pain.” 

Another said: “I think it’s worth reassuring people that just because it [pain] is stated severe it doesn’t necessarily mean that it will be. I spent more time worrying about the possibilities of the side effects than needed!”

The researchers concluded that women wanted detailed, realistic pain counseling and general preparatory advice, including details from firsthand experiences that illustrate the range of pain women may experience during medication abortion. 

“What’s important here is the acknowledgement that everyone’s experience of pain during a medical abortion will be different,” the study’s lead author, Hannah McCulloch, an evaluation researcher at the British Pregnancy Advisory Service, wrote in an email. “It’s important to be realistic about what women experience during medical abortion in order to provide meaningful patient-centred care.”

Medication abortions involve taking two pills. The first, mifepristone, blocks the hormone progesterone, which is critical for a pregnancy to continue. One or two days after taking mifepristone, the person takes a second drug — usually misoprostol — which causes the uterus to cramp and soften and the cervix to dilate so the pregnancy can pass, usually within 24 hours of taking misoprostol, according to Colwill. 

“That process, the uterus having to cramp and expel the pregnancy, inherently is going to cause pain,” she said, adding that many factors play into how much pain each person feels. 

Women who may report less pain with a medication abortion include those who have experienced labor or given birth vaginally and women who have painful menstrual cramps every month, such as those who have endometriosis, Colwill said. 

“Understanding these past experiences, and things like how they experience Pap smears and vaginal exams, can help us better support patients to be prepared for how pain may be for them,” she added, noting that she was not surprised to see many women did not feel they were adequately prepared to manage pain during a medication abortion. 

Medication abortion is an extremely safe procedure. Serious side effects occur in less than 0.5% of people who take Mifeprex, the brand-name version of mifepristone, according to the drug’s label, and the number of women managing their own abortions has increased since the Supreme Court overturned Roe v. Wade in 2022. 

“Patients need to be adequately informed about what to expect and be told what we know about how to manage the pain. Pain is downplayed in medicine in general and particularly in women’s health and obstetrics and gynecology,” said Dr. Daniel Grossman, a professor of obstetrics and gynecology and director of advancing new standards in reproductive health at the University of California San Francisco.

Even if a person accesses abortion medication through telehealth, Grossman said people should still be counseled on what to expect and how to treat the intense pain and nausea that can happen during the procedure. His best advice, he said, for managing pain during a medication abortion is to take a nonsteroidal anti-inflammatory drug, or NSAID, such as ibuprofen, at the same time as misoprostol. If possible, he recommends also taking an anti-nausea medication such as metoclopramide, which requires a prescription. 

Colwill said that acetaminophen, or Tylenol, is also an option, but NSAIDs do a better job of blocking this specific pain. 

Putting a heating pad, a hot water bottle or over-the-counter trans-electrical nerve stimulation pads on the lower belly can also help “confuse” nerves in the area and help relieve pain, Grossman said.

He said it’s also important to understand what pain is “normal” and when it may be time to seek medical help, especially in situations where people are at home. 

Pain in the middle of the lower abdomen is normal, for example, but pain higher up or pain just on one side could be a sign that something is wrong, such as an ectopic pregnancy, a life-threatening condition in which a fertilized egg implants outside the uterus.  

If someone experiences severe pain on one side of the abdomen or pelvis, they should go to the emergency room, Grossman said. “If they have mild to moderate pain on one side, they might try to talk to a clinician first by phone. But if there’s any question, they should go to an emergency department,” he added. 

Ectopic pregnancies are detected on ultrasounds, however, “many people have a medication abortion without having an ultrasound and it can even be missed on an ultrasound,” Grossman said.

Medication abortion will not work for an ectopic pregnancy, according to the Food and Drug Administration. 

Pain beyond 24 hours after a pregnancy is passed, especially if the person also has a fever or is vomiting, could be a sign of infection, he said. 

Women should also not discount the importance of moral support, he added: “Feeling supported and having someone there makes a big difference, too.”