Today, the Supreme Court is set to rule in the medication abortion case. The legal, medical, and public health implications of this case are huge. But regardless of what they rule, a really important piece of the story has gotten little attention the past few weeks: even if mifepristone is severely restricted, we have another option.
As an abortion provider and as a nurse-midwife I am very familiar with both medications and their use and efficacy. However, you missed a critical point: use of Mife followed by Miso is more comfortable and a kinder means by which to terminate a pregnancy. Three plus doses of Miso causes intense cramping for longer periods to get the end result. Not allowing Mife is pouring salt into the wounds of women who struggle when making the choice they feel is best for them. Imagine your rectum being in severe spasm for several hours: that’s what multiple Miso doses would be comparable to.
So this is the awful part. Miso works. So does methotrexate. But both can make you really sick. Vomiting and diarrhea for hours. (Re: miso at the dose needed when mife is not included)
The thing about mife, if I were to take it, non pregnant, I would likely feel nothing. It’s safer than Tylenol. So the question is… why are we taking away a safe medication with few side effects, and replacing them with meds that make people feel really awful?
monotherapy with misoprostol can cause life threatening uterine bleeding, and the risk of this is greater when taken in isolation without mifepristone. this can result in the need for emergency hysterectomy, D&C, hospitalization, blood transfusions, etc., and death. while the incidence of this is relatively low, it is hardly appropriate to blanketly call this drug "safe" and is irresponsible to women who might consider off label use of this drug for abortion. "relatively safe" would be a more appropriate description.
I take, or have in the past taken, two drugs prescribed by physicians precisely for their off-label effects. They are startlingly effective in those roles. It's cruel to force women to endure the potential painful side effects of miso taken alone. It resembles prohibited "cruel and unusual" punishment in the Bill of Rights. I wonder if an Eighth Amendment argument could be used in the lower federal courts to send up to the Supreme Court? It might have some traction.
Perhaps another way to minimize the need for abortions would be to pass a piece of legislation that stated, “From the moment of conception, the sperm producer will be responsible for appropriate child care related financial support until the child is 18 years old, or 22 years old under special circumstances.”
Have read about this but articles usually claim that Miso alone has higher health risks to the mother. Is there evidence that is true and, if so, how serious is that problem. Also the lawsuit threatened the FDA authority to regulate drugs. That could play into SC notions that Congress has improperly delegated too much to agencies in terms of granting detailed rules that might overstep the actual authority the agencies have been granted in the enabling legislation. Worrisome, despite the unlikely outcome that the SC would reach a serious far-reaching claim in these circumstances. More likely to rule narrowly, either way.
Valuable and greatly appreciated as always! However, I couldn’t resist chiming in here to remind readers that, even though miso works just fine, it’s the mistrust and misrepresentation of safety data that sow doubt in our trusted system and fuel disinformation. For me (a clinical trial professional and scientist), this is so much scarier than potentially losing access to mife.
I am writing as a family doc. I think the general public little understands that the current trend to exert the legal force of government to curtail the autonomous choice of individual people who are pregnant conflicts with the very foundation of the ethical and professional practice of the healing arts. Modern medical ethics encompasses four basic principles: autonomy, justice, non-maleficence, and beneficence. “Autonomy” is pre-eminent signifying that each person seeking or needing help should be existentially respected and is the ultimate source of medical decision making. In practice, this means that I am ethically bound to provide all the care my skills allow to any person who needs it without regard to whether I agree or disagree with their values or lifestyle or circumstances. This ethical mandate extends to prisoners of war, incarcerated prisoners, the unhoused, heroin addicts, and mentally incapacitated patients. At the same time I respect the fact that in the United States some individuals, doctors and patients alike, may have a different and valid perspective based on their values or religion. They have the right to define “malfeasance” according to their value system. It is totally appropriate for them to function and make decisions within their value or religious frame as long as it does not harm others. This consideration becomes important when an ill person seeking care may be unaware and not informed that the provider’s range of treatments will be limited by the provider’s values rather than the patient’s needs. In this context problems arise which both threaten the general ethical practice of medicine, and the foundation of our democracy, when a specific set of values based on a religious doctrine are generally imposed on the whole of society - and the practice of medicine - by the passage of laws or the rulings of courts. This is especially problematic from the medical point of view when laws are passed saying it is universally “just” to value the life of any fetus over the life of the pregnant person. Many cases have been reported when these laws have repeatedly placed the lives of women with complicated pregnancies at risk and ethical medical intervention has been prevented. Respect for human integrity and autonomy is violated.
As a physician I find that a legal system which divides people into those with unfettered autonomy over their lives, choices and bodies from others whose are by force of law prevented from seeking scientifically proven medical care to relieve their illness or save their lives is unacceptable.
This information is a great example of why I find your posts so valuable.
If I think about why "miso" has received such scant attention, I conclude that neither side in the abortion debate has an incentive to highlight this statistic and certainly not the media. "Abortion efficacy may decline from 95% to 90%" is not clickbait.
Thank you for keeping your subscribers so well informed.
Thank you! As a recipient of the two drug treatment (in the early '70's) I had not known that just one drug could be effective. Again such a great source of information.
This is a concerning “slippery slope.” If one drug is removed from the market successfully, then why wouldn’t misoprostol be next? Misoprostol has other important and unique (meaning it’s the only option) clinical uses, including in veterinary medicine. But if mifepristone is banned, then one could argue for removing misoprostol from the market next, and justify it by saying there are other medications that could be used for the labeled indication of preventing stomach ulcers. Unfortunately this would result in consequences for veterinary uses as well: vets often use drugs off-label but can’t if they can’t buy the drugs.
Just yesterday I read an article about a doctor who does early abortions using a small device that seems to work on suction. It seems practically anyone could learn how to use it properly. It basically brings on the heavy period those of us who've miscarried quite early are familiar with. What do you think of this, in terms of making reproductive healthcare available to women once again (at least early-on)?
I can't remember where I was reading it, but didn't ACOG have a letter asking FDA to include miscarriage management as an on-label instead of off label use? I don't know if this is now way too late, but seems like it should be part of the puzzle.
How could a medication that ends a life ever be considered a superhero? The shift from the tone of safe/legal/rare to one where there are superheroes is shocking.
As an abortion provider and as a nurse-midwife I am very familiar with both medications and their use and efficacy. However, you missed a critical point: use of Mife followed by Miso is more comfortable and a kinder means by which to terminate a pregnancy. Three plus doses of Miso causes intense cramping for longer periods to get the end result. Not allowing Mife is pouring salt into the wounds of women who struggle when making the choice they feel is best for them. Imagine your rectum being in severe spasm for several hours: that’s what multiple Miso doses would be comparable to.
So this is the awful part. Miso works. So does methotrexate. But both can make you really sick. Vomiting and diarrhea for hours. (Re: miso at the dose needed when mife is not included)
The thing about mife, if I were to take it, non pregnant, I would likely feel nothing. It’s safer than Tylenol. So the question is… why are we taking away a safe medication with few side effects, and replacing them with meds that make people feel really awful?
monotherapy with misoprostol can cause life threatening uterine bleeding, and the risk of this is greater when taken in isolation without mifepristone. this can result in the need for emergency hysterectomy, D&C, hospitalization, blood transfusions, etc., and death. while the incidence of this is relatively low, it is hardly appropriate to blanketly call this drug "safe" and is irresponsible to women who might consider off label use of this drug for abortion. "relatively safe" would be a more appropriate description.
I take, or have in the past taken, two drugs prescribed by physicians precisely for their off-label effects. They are startlingly effective in those roles. It's cruel to force women to endure the potential painful side effects of miso taken alone. It resembles prohibited "cruel and unusual" punishment in the Bill of Rights. I wonder if an Eighth Amendment argument could be used in the lower federal courts to send up to the Supreme Court? It might have some traction.
Perhaps another way to minimize the need for abortions would be to pass a piece of legislation that stated, “From the moment of conception, the sperm producer will be responsible for appropriate child care related financial support until the child is 18 years old, or 22 years old under special circumstances.”
Have read about this but articles usually claim that Miso alone has higher health risks to the mother. Is there evidence that is true and, if so, how serious is that problem. Also the lawsuit threatened the FDA authority to regulate drugs. That could play into SC notions that Congress has improperly delegated too much to agencies in terms of granting detailed rules that might overstep the actual authority the agencies have been granted in the enabling legislation. Worrisome, despite the unlikely outcome that the SC would reach a serious far-reaching claim in these circumstances. More likely to rule narrowly, either way.
Valuable and greatly appreciated as always! However, I couldn’t resist chiming in here to remind readers that, even though miso works just fine, it’s the mistrust and misrepresentation of safety data that sow doubt in our trusted system and fuel disinformation. For me (a clinical trial professional and scientist), this is so much scarier than potentially losing access to mife.
I am writing as a family doc. I think the general public little understands that the current trend to exert the legal force of government to curtail the autonomous choice of individual people who are pregnant conflicts with the very foundation of the ethical and professional practice of the healing arts. Modern medical ethics encompasses four basic principles: autonomy, justice, non-maleficence, and beneficence. “Autonomy” is pre-eminent signifying that each person seeking or needing help should be existentially respected and is the ultimate source of medical decision making. In practice, this means that I am ethically bound to provide all the care my skills allow to any person who needs it without regard to whether I agree or disagree with their values or lifestyle or circumstances. This ethical mandate extends to prisoners of war, incarcerated prisoners, the unhoused, heroin addicts, and mentally incapacitated patients. At the same time I respect the fact that in the United States some individuals, doctors and patients alike, may have a different and valid perspective based on their values or religion. They have the right to define “malfeasance” according to their value system. It is totally appropriate for them to function and make decisions within their value or religious frame as long as it does not harm others. This consideration becomes important when an ill person seeking care may be unaware and not informed that the provider’s range of treatments will be limited by the provider’s values rather than the patient’s needs. In this context problems arise which both threaten the general ethical practice of medicine, and the foundation of our democracy, when a specific set of values based on a religious doctrine are generally imposed on the whole of society - and the practice of medicine - by the passage of laws or the rulings of courts. This is especially problematic from the medical point of view when laws are passed saying it is universally “just” to value the life of any fetus over the life of the pregnant person. Many cases have been reported when these laws have repeatedly placed the lives of women with complicated pregnancies at risk and ethical medical intervention has been prevented. Respect for human integrity and autonomy is violated.
As a physician I find that a legal system which divides people into those with unfettered autonomy over their lives, choices and bodies from others whose are by force of law prevented from seeking scientifically proven medical care to relieve their illness or save their lives is unacceptable.
This information is a great example of why I find your posts so valuable.
If I think about why "miso" has received such scant attention, I conclude that neither side in the abortion debate has an incentive to highlight this statistic and certainly not the media. "Abortion efficacy may decline from 95% to 90%" is not clickbait.
Thank you for keeping your subscribers so well informed.
Thank you! As a recipient of the two drug treatment (in the early '70's) I had not known that just one drug could be effective. Again such a great source of information.
Thank you so much for alerting us. Is this something the fascists could go after next, or is the fact that it is off label make that difficult?
This is a concerning “slippery slope.” If one drug is removed from the market successfully, then why wouldn’t misoprostol be next? Misoprostol has other important and unique (meaning it’s the only option) clinical uses, including in veterinary medicine. But if mifepristone is banned, then one could argue for removing misoprostol from the market next, and justify it by saying there are other medications that could be used for the labeled indication of preventing stomach ulcers. Unfortunately this would result in consequences for veterinary uses as well: vets often use drugs off-label but can’t if they can’t buy the drugs.
Just yesterday I read an article about a doctor who does early abortions using a small device that seems to work on suction. It seems practically anyone could learn how to use it properly. It basically brings on the heavy period those of us who've miscarried quite early are familiar with. What do you think of this, in terms of making reproductive healthcare available to women once again (at least early-on)?
I can't remember where I was reading it, but didn't ACOG have a letter asking FDA to include miscarriage management as an on-label instead of off label use? I don't know if this is now way too late, but seems like it should be part of the puzzle.
Edit: found it - it was actually ama h
https://searchlf.ama-assn.org/letter/documentDownload%3Furi%3D/unstructured/binary/letter/LETTERS/lfdr.zip/2022-6-21-Joint-ACOG-AMA-Letter-to-FDA-re-Mifepristone.pdf
How could a medication that ends a life ever be considered a superhero? The shift from the tone of safe/legal/rare to one where there are superheroes is shocking.
I wondered why we weren’t hearing about miso, and still wonder. Surely it hasn’t been flying under the radar of the anti-choicers?