More than one choice

LOST in the debate over the recent U.S. Supreme Court decision banning a type of midterm abortion has been the fact that 85% to 90% of abortions occur in the first trimester. And unlike the latter stages of pregnancy, when options can be limited, many women have a clear choice about the type of abortion they will have: surgical or medical.

Surgical abortions, in which a suction device is used to remove the contents of the uterus, have been performed legally in the United States for more than 30 years. Medical abortions rely on a combination of medications -- typically mifepristone (Mifeprex) and misoprostol -- to terminate the pregnancy and evacuate the uterus. Mifepristone, which was approved in this country in 2000, causes the lining of the uterus to thin and prevents the embryo from growing; misoprostol triggers uterine contractions that clear it.

But even early in a pregnancy, choosing the right procedure isn’t always simple. “In having an abortion, women often are making a decision that they didn’t want to have to make in the first place,” says Dr. Mitchell Creinin, professor and director of gynecologic specialties at the University of Pittsburgh. “Making yet one more choice can often be difficult.”

Although both procedures are considered safe, neither is entirely risk-free. The instrument used to perform surgical abortions can damage the uterus or lead to infection. Medical abortions pose the risk of excessive bleeding.

One of the most important differences between the two methods is their effectiveness. Surgical abortions are close to 100% effective; medical abortions have a low but measurable failure rate. Up to 5% of women undergoing a medical abortion require a subsequent surgical procedure to terminate the pregnancy.

While surgical abortions can be done relatively quickly, medical abortions typically take longer to complete. The cramping and bleeding brought on by misoprostol doesn’t typically begin for several hours and, occasionally, can be delayed for days or even weeks. When it does occur, it can be uncomfortable. (In general, women who undergo medical abortions experience heavier and more prolonged bleeding, and more pain than those who choose surgery.)

Timing also plays a role. Many providers offer medical abortions only through the first eight to nine weeks of pregnancy. Studies have found that during this period of time, women can safely use the medications at home and return to the doctor only to ensure that the fetus has been expelled. Beyond nine weeks, the safety of medical abortions on an outpatient basis has been unproved.

However, a recent study published in Obstetrics and Gynecology confirms earlier reports from Europe that medical abortions may remain an effective option throughout the first trimester. In that study, researchers followed 321 women who underwent medical abortions late in the first trimester. Although failure rates were somewhat higher than for medical abortions performed before nine weeks, 93% of women reported being satisfied or very satisfied with their experience.

“There isn’t one procedure that comes out clearly better than the other for every woman,” says Creinin.

Ultimately, each woman must decide what is most important. “Women have many different reasons for making the decisions they do,” says Mary Jane Wagle, president of Planned Parenthood, Los Angeles. “It really depends on their individual circumstances.”

The decision can be pragmatic or emotional, based on considerations such as cost, availability or a preference to have the abortion at home or in the doctor’s office. Women who opt for a medical abortion often prefer simply to avoid surgery.

At Planned Parenthood, the number of women electing medical abortions has grown significantly in the short time they have been available. In 2001, only 9% of eligible women chose them over surgical abortions; currently, nearly one-quarter of women with an option elect medical termination.

Word of mouth may have something to do with this increase. “More and more women are hearing from others that they’ve had a satisfactory experience with medication abortions,” says Wagle.

Many women, however, remain unaware of an alternative to surgical abortions. “By and large, many women still don’t know much about the procedure,” says Wagle.

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Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in L.A. She can be reached at themd@att.net. The M.D. appears the first Monday of the month.