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Grossman D, Raifman S, Morris N, Arena A, Bachrach L, Beaman J, Biggs MA, Collins A, Hannum C, Ho S, Seibold-Simpson SM, Sobota M, Tocce K, Schwarz EB, Gold M. Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion After In-Person Screening. JAMA Intern Med 2024; 184:873-881. [PMID: 38739404 PMCID: PMC11091818 DOI: 10.1001/jamainternmed.2024.1476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/07/2024] [Indexed: 05/14/2024]
Abstract
Importance Before 2021, the US Food and Drug Administration required mifepristone to be dispensed in person, limiting access to medication abortion. Objective To estimate the effectiveness, acceptability, and feasibility of dispensing mifepristone for medication abortion using a mail-order pharmacy. Design, Setting, and Participants This prospective cohort study was conducted from January 2020 to May 2022 and included 11 clinics in 7 states (5 abortion clinics and 6 primary care sites, 4 of which were new to abortion provision). Eligible participants were seeking medication abortion at 63 or fewer days' gestation, spoke English or Spanish, were age 15 years or older, and were willing to take misoprostol buccally. After assessing eligibility for medication abortion through an in-person screening, mifepristone and misoprostol were prescribed using a mail-order pharmacy. Patients had standard follow-up care with the clinic. Clinical information was collected from medical records. Consenting participants completed online surveys about their experiences 3 and 14 days after enrolling. A total of 540 participants were enrolled; 10 withdrew or did not take medication. Data were analyzed from August 2022 to December 2023. Intervention Mifepristone, 200 mg, and misoprostol, 800 µg, prescribed to a mail-order pharmacy and mailed to participants instead of dispensed in person. Main Outcomes and Measures Proportion of patients with a complete abortion with medications only, reporting satisfaction with the medication abortion, and reporting timely delivery of medications. Results Clinical outcome information was obtained and analyzed for 510 abortions (96.2%) among 506 participants (median [IQR] age, 27 [23-31] years; 506 [100%] female; 194 [38.3%] Black, 88 [17.4%] Hispanic, 141 [27.9%] White, and 45 [8.9%] multiracial/other individuals). Of these, 436 participants (85.5%; 95% CI, 82.2%-88.4%) received medications within 3 days. Complete abortion occurred after medication use in 499 cases (97.8%; 95% CI, 96.2%-98.9%). There were 24 adverse events (4.7%) for which care was sought for medication abortion symptoms; 3 patients (0.6%; 95% CI, 0.1%-1.7%) experienced serious adverse events requiring hospitalization (1 with blood transfusion); however, no adverse events were associated with mail-order dispensing. Of 477 participants, 431 (90.4%; 95% CI, 87.3%-92.9%) indicated that they would use mail-order dispensing again for abortion care, and 435 participants (91.2%; 95% CI, 88.3%-93.6%) reported satisfaction with the medication abortion. Findings were similar to those of other published studies of medication abortion with in-person dispensing. Conclusions and Relevance The findings of this cohort study indicate that mail-order pharmacy dispensing of mifepristone for medication abortion was effective, acceptable to patients, and feasible, with a low prevalence of serious adverse events. This care model should be expanded to improve access to medication abortion services.
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Affiliation(s)
- Daniel Grossman
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Sarah Raifman
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Natalie Morris
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Andrea Arena
- Department of Family Medicine, Brown University, Pawtucket, Rhode Island
| | - Lela Bachrach
- Department of Pediatrics, University of California, San Francisco
| | - Jessica Beaman
- Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - M. Antonia Biggs
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Amy Collins
- Allegheny Reproductive Health Center, Pittsburgh, Philadelphia
| | | | - Stephanie Ho
- Highland Hospital, Alameda Health System, Oakland, California
| | | | - Mindy Sobota
- Department of Medicine, Alpert Medical School at Brown University, Providence, Rhode Island
| | - Kristina Tocce
- Planned Parenthood of the Rocky Mountains, Denver, Colorado
| | - Eleanor B. Schwarz
- Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - Marji Gold
- Department of Family and Social Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Barrow A, Cohen C, Serpico J, Goodman M, Grossman D, Raifman S, Upadhyay U. Brief of over 300 reproductive health researchers as Amici Curiae in FDA v. Alliance for Hippocratic Medicine. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2024. [PMID: 39074980 DOI: 10.1111/psrh.12281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
On January 30, 2024, over 300 researchers filed an amicus brief in FDA v. Alliance for Hippocratic Medicine, a United States (US) Supreme Court case that could have severely impacted access to mifepristone, one of the two drugs commonly used in medication abortion. The researchers summarize the legal challenges to the US Food and Drug Administration's (FDA's) original approval of mifepristone in 2000 and its 2016 and 2021 decisions modifying mifepristone's Risk Evaluation and Mitigation Strategy (REMS) Program and label, the responses from the FDA and drug manufacturer to the challenges, and the potential implications of the Court's decision on access to mifepristone in the US. The researchers detail how the FDA relied on a robust scientific record analyzing tens of thousands of patient experiences that conclusively demonstrated the safety and effectiveness of the changes to the mifepristone REMS Program and label and urge the Supreme Court to rely on the clear scientific record and preserve access to mifepristone without reimposing restrictions. What follows is a reprint of this brief.
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Affiliation(s)
- Amanda Barrow
- University of California Los Angeles Center on Reproductive Health, Law, and Policy, Los Angeles, California, USA
| | - Cathren Cohen
- University of California Los Angeles Center on Reproductive Health, Law, and Policy, Los Angeles, California, USA
| | - Jaclyn Serpico
- University of California Los Angeles Center on Reproductive Health, Law, and Policy, Los Angeles, California, USA
| | - Melissa Goodman
- University of California Los Angeles Center on Reproductive Health, Law, and Policy, Los Angeles, California, USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California San Francisco, Oakland, California, USA
| | - Sarah Raifman
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California San Francisco, Oakland, California, USA
| | - Ushma Upadhyay
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California San Francisco, Oakland, California, USA
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Raifman S, Gurazada T, Beaman J, Biggs MA, Schwarz EB, Gold M, Grossman D. Primary care and abortion provider perspectives on mail-order medication abortion: a qualitative study. BMC Womens Health 2024; 24:382. [PMID: 38956609 PMCID: PMC11221167 DOI: 10.1186/s12905-024-03202-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 06/11/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND This qualitative study aims to assess perspectives of clinicians and clinic staff on mail-order pharmacy dispensing for medication abortion. METHODS Participants included clinicians and staff involved in implementing a mail-order dispensing model for medication abortion at eleven clinics in seven states as part of a prospective cohort study, which began in January 2020 (before the FDA removed the in-person dispensing requirement for mifepristone). From June 2021 to July 2022, we invited participants at the participating clinics, including six primary care and five abortion clinics, to complete a semi-structured video interview about their experiences. We then conducted qualitative thematic analysis of interview data, summarizing themes related to perceived benefits and concerns about the mail-order model, perceived patient interest, and potential barriers to larger-scale implementation. RESULTS We conducted 24 interviews in total with clinicians (13 physicians and one nurse practitioner) and clinic staff (n = 10). Participants highlighted perceived benefits of the mail-order model, including its potential to expand abortion services into primary care, increase patient autonomy and privacy, and to normalize abortion services. They also highlighted key logistical, clinical, and feasibility concerns about the mail-order model, and specific challenges related to integrating abortion into primary care. CONCLUSION Clinicians and clinic staff working in primary care and abortion clinics were optimistic that mail-order dispensing of medication abortion can improve the ability of some providers to provide abortion and enable more patients to access services. The feasibility of mail-order pharmacy dispensing of medication abortion following the Supreme Court Dobbs decision is to be determined. TRIAL REGISTRATION Registry: Clinicaltrials.gov. TRIAL REGISTRATION NUMBER NCT03913104. Date of registration: first submitted on April 3, 2019 and first posted on April 12, 2019.
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Affiliation(s)
- Sarah Raifman
- Advancing New Standards in Reproductive Health, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA.
| | - Tanvi Gurazada
- Nell Hodgson Woodruff School of Nursing at Emory University, 1520 Clifton Rd, Atlanta, GA, 30322, USA
| | - Jessica Beaman
- San Francisco Division of General Internal Medicine, University of California, 1001 Potrero Ave, San Francisco, CA, USA
| | - M Antonia Biggs
- Advancing New Standards in Reproductive Health, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
| | - Eleanor Bimla Schwarz
- San Francisco Division of General Internal Medicine, University of California, 1001 Potrero Ave, San Francisco, CA, USA
| | - Marji Gold
- Montefiore Medical Center, Albert Einstein College of Medicine, 3544 Jerome Ave, Bronx, NY, 10467, USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
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Ralph LJ, Baba CF, Biggs MA, McNicholas C, Hagstrom Miller A, Grossman D. Comparison of No-Test Telehealth and In-Person Medication Abortion. JAMA 2024:2820321. [PMID: 38913394 PMCID: PMC11197442 DOI: 10.1001/jama.2024.10680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/17/2024] [Indexed: 06/25/2024]
Abstract
Importance In the US, access to medication abortion using history-based (no-test) eligibility assessment, including through telehealth and mailing of mifepristone, has grown rapidly. Additional evidence on the effectiveness and safety of these models is needed. Objective To evaluate whether medication abortion with no-test eligibility assessment and mailing of medications is as effective as in-person care with ultrasonography and safe overall. Design, Setting, and Participants Prospective, observational study with noninferiority analysis. Sites included 4 abortion-providing organizations in Colorado, Illinois, Maryland, Minnesota, Virginia, and Washington from May 2021 to March 2023. Eligible patients were seeking medication abortion up to and including 70 days' gestation, spoke English or Spanish, and were aged 15 years or older. Exposure Study groups reflected the model of care selected by the patient and clinicians and included: (1) no-test (telehealth) eligibility assessment and mailing of medications (no-test + mail) (n = 228); (2) no-test eligibility assessment and pickup of medications (no-test + pickup) (n = 119); or (3) in-person with ultrasonography (n = 238). Main Outcomes and Measures Effectiveness, defined as a complete abortion without the need for repeating the mifepristone and misoprostol regimen or a follow-up procedure, and safety, defined as an abortion-related serious adverse event, including overnight hospital admission, surgery, or blood transfusion. Outcomes were derived from patient surveys and medical records. Primary analysis focused on the comparison of the no-test + mail group with the in-person with ultrasonography group. Results The mean age of the participants (N = 585) was 27.3 years; most identified as non-Hispanic White (48.6%) or non-Hispanic Black (28.1%). Median (IQR) gestational duration was 45 days (39-53) and comparable between study groups (P = .30). Outcome data were available for 91.8% of participants. Overall effectiveness was 94.4% (95% CI, 90.7%-99.2%) in the no-test + mail group and 93.3% (95% CI, 88.3%-98.2%) in the in-person with ultrasonography group in adjusted models (adjusted risk difference, 1.2 [95% CI, -4.1 to 6.4]), meeting the prespecified 5% noninferiority margin. Serious adverse events included overnight hospitalization (n = 4), blood transfusion (n = 2), and emergency surgery (n = 1) and were reported by 1.1% (95% CI, 0.4%-2.4%) of participants, with 3 in the no-test + mail group, 3 in the in-person with ultrasonography group, and none in the no-test + pickup group. Conclusions and Relevance This prospective, observational study found that medication abortion obtained following no-test telehealth screening and mailing of medications was associated with similar rates of complete abortion compared with in-person care with ultrasonography and met prespecified criteria for noninferiority, with a low prevalence of adverse events.
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Affiliation(s)
- Lauren J. Ralph
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco
| | - C. Finley Baba
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco
| | - M. Antonia Biggs
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco
| | - Colleen McNicholas
- Planned Parenthood of the St. Louis Region and Southwest Missouri, St Louis
| | - Amy Hagstrom Miller
- Whole Woman’s Health & Whole Woman’s Health Alliance, Charlottesville, Virginia
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco
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Upadhyay UD, Koenig LR, Meckstroth K, Ko J, Valladares ES, Biggs MA. Effectiveness and safety of telehealth medication abortion in the USA. Nat Med 2024; 30:1191-1198. [PMID: 38361123 PMCID: PMC11031403 DOI: 10.1038/s41591-024-02834-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/24/2024] [Indexed: 02/17/2024]
Abstract
Telehealth abortion has become critical to addressing surges in demand in states where abortion remains legal but evidence on its effectiveness and safety is limited. California Home Abortion by Telehealth (CHAT) is a prospective study that follows pregnant people who obtained medication abortion via telehealth from three virtual clinics operating in 20 states and Washington, DC between April 2021 and January 2022. Individuals were screened using a standardized no-test protocol, primarily relying on their medical history to assess medical eligibility. We assessed effectiveness, defined as complete abortion after 200 mg mifepristone and 1,600 μg misoprostol (or lower) without additional intervention; safety was measured by the absence of serious adverse events. We estimated rates using multivariable logistic regression and multiple imputation to account for missing data. Among 6,034 abortions, 97.7% (95% confidence interval (CI) = 97.2-98.1%) were complete without subsequent known intervention or ongoing pregnancy after the initial treatment. Overall, 99.8% (99.6-99.9%) of abortions were not followed by serious adverse events. In total, 0.25% of patients experienced a serious abortion-related adverse event, 0.16% were treated for an ectopic pregnancy and 1.3% abortions were followed by emergency department visits. There were no differences in effectiveness or safety between synchronous and asynchronous models of care. Telehealth medication abortion is effective, safe and comparable to published rates of in-person medication abortion care.
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Affiliation(s)
- Ushma D Upadhyay
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
| | - Leah R Koenig
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Karen Meckstroth
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer Ko
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | | | - M Antonia Biggs
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
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Ferketa M, Moore A, Klein-Barton J, Stulberg D, Hasselbacher L. Pharmacists' experiences dispensing misoprostol and readiness to dispense mifepristone. J Am Pharm Assoc (2003) 2024; 64:245-252.e1. [PMID: 37913990 DOI: 10.1016/j.japh.2023.10.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/21/2023] [Accepted: 10/25/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Mifepristone, followed by misoprostol, is commonly used for medication abortion and early miscarriage care. Since mifepristone's approval in 2000, the Food and Drug Administration (FDA) has placed restrictions on where and how it could be dispensed, including applying a Risk Evaluation and Mitigation Strategy in 2011. In December 2021, the FDA removed the in-person dispensing requirement and, in January 2023, began allowing certified pharmacies to dispense the drug directly to patients. OBJECTIVES To explore pharmacist knowledge about misoprostol and mifepristone, experience dispensing misoprostol, as well as comfort and readiness to dispense mifepristone should federal regulations allow. METHODS We conducted in-depth interviews with 21 U.S.-based pharmacists and pharmacy trainees between June and December of 2021, a time when few pharmacists were allowed to dispense mifepristone. RESULTS Participants reported varied knowledge about medications for miscarriage and abortion but described themselves as generally knowledgeable about medications and reported strategies for learning about new medications. Most said they would feel ready to dispense mifepristone, and many described dispensing misoprostol without difficulty. Potential challenges specific to mifepristone dispensing included employer hesitation and colleague refusals. To assure successful dispensing, participants recommended basic training and fact sheets; relationships with prescribers for follow-up; and policies for prescription transfers in the event of refusal. CONCLUSIONS We found that nearly all participants would feel ready to dispense mifepristone with some basic training. Pharmacists self-report having the skills and resources to learn about new medications quickly. Our findings support the FDA's rule change allowing pharmacist dispensing of mifepristone and suggest that most challenges would stem from individual or institutional refusals.
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Zusman EZ, Munro S, Norman WV, Soon JA. Dispensing mifepristone for medical abortion in Canada: Pharmacists' experiences of the first year. Can Pharm J (Ott) 2023; 156:204-214. [PMID: 37435503 PMCID: PMC10331362 DOI: 10.1177/17151635231176270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 07/13/2023]
Abstract
Background Mifepristone for medical abortion was first dispensed by community pharmacists in Canada directly to patients in January 2017. We asked about pharmacists' experiences over their first year dispensing mifepristone in order to evaluate the frequency of the new practice and assess availability in urban/rural pharmacies. Methods From August to December 2019, we invited 433 community pharmacists who had completed a baseline survey at least 1 year prior to participate in a follow-up online survey. We summarized categorical data using counts and proportions and conducted a qualitative thematic analysis of open-ended responses. Results Among 122 participants, 67.2% had dispensed the product, and 48.4% routinely stocked mifepristone. Pharmacists reported a mean of 26 and median of 3 (interquartile range, 1, 8) mifepristone prescriptions filled in their pharmacies in the previous year. Participants perceived that the benefits of making mifepristone available in pharmacies included increased abortion access for patients (n = 115; 94.3%), reduced pressure on the health care system (n = 104; 85.3%), increased rural and remote abortion access (n = 103; 84.4%) and increased interprofessional collaborations (n = 48; 39.3%). Few participants reported challenges to maintaining adequate stock of mifepristone, but these challenges included low demand (n = 24; 19.7%), short expiry dating (n = 12; 9.8%) and drug shortages (n = 8; 6.6%). The overwhelming majority, 96.7%, reported that their communities did not resist the provision of mifepristone by their pharmacy. Interpretation Participating pharmacists reported many benefits and very few barriers to stocking and dispensing mifepristone. Both urban and rural communities responded positively to enhanced access to mifepristone in their community. Conclusions Mifepristone is well accepted by pharmacists within the primary care system in Canada.
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Affiliation(s)
- Enav Z. Zusman
- Contraception and Abortion Research Team of the Women’s Health Research Institute, UBC, and of the Collaboration for Outcomes Research and Evaluation
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver
| | - Sarah Munro
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research, Vancouver, British Columbia
| | - Wendy V. Norman
- Department of Family Practice, University of British Columbia, Vancouver
| | - Judith A. Soon
- Contraception and Abortion Research Team of the Women’s Health Research Institute, UBC, and of the Collaboration for Outcomes Research and Evaluation
- Department of Family Practice, University of British Columbia, Vancouver
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Koenig LR, Raymond EG, Gold M, Boraas CM, Kaneshiro B, Winikoff B, Coplon L, Upadhyay UD. Mailing abortion pills does not delay care: A cohort study comparing mailed to in-person dispensing of abortion medications in the United States. Contraception 2023; 121:109962. [PMID: 36736715 PMCID: PMC10759792 DOI: 10.1016/j.contraception.2023.109962] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 01/13/2023] [Accepted: 01/20/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Given the substantial barriers to abortion access in the United States, many clinics now mail patients abortion medications. We examined whether dispensing the medications by mail prolonged time to medication use. STUDY DESIGN We analyzed data from no-test medication abortions with medication provided either by mail or in a clinic from 11 United States clinics from February 2020 to January 2021. We examined mean number of days from patients' first contact with the clinic to mifepristone ingestion, its two-component intervals (first contact to medication dispensing and dispensing to mifepristone ingestion), and pregnancy duration at mifepristone ingestion. We used Poisson regression to compare mean outcomes across three dispensing methods: in-person, mailed from the clinic, and mailed from a mail-order pharmacy. RESULTS Among the 2600 records, patients took mifepristone on average at 49 days of gestation (95% CI, 47-51) and 7 days (95% CI, 4-10) after first contact. Mean time from first contact to mifepristone ingestion was 6 days when medications were dispensed in-person and 9 days when mailed (p = 0.38). While time from first contact to dispensing was similar across methods (6 days in-person, 5 days mailed, p = 0.77), more time elapsed from dispensing to mifepristone ingestion when medications were mailed (4 days from clinic, 5 days from mail-order pharmacy) versus dispensed in-person (0.3 days, p < 0.001). Time to mifepristone ingestion was shorter with higher pregnancy duration. Pregnancy duration at ingestion was similar across methods (48 days in-person, 50 days mailed). CONCLUSIONS Mailing medications did not significantly prolong time from patients' first contact with the clinic to mifepristone ingestion or increase pregnancy duration at mifepristone ingestion. IMPLICATIONS Abortion providers should offer a range of medication abortion dispensing options, prioritizing patient preference.
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Affiliation(s)
- Leah R Koenig
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, Oakland, CA, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA; Center for Gender and Health Justice, University of California Global Health Institute
| | | | - Marji Gold
- Department of Family and Social Medicine, Montefiore Medical Center, The Bronx, NY, USA
| | | | - Bliss Kaneshiro
- Deparment of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | | | | | - Ushma D Upadhyay
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, Oakland, CA, USA; Center for Gender and Health Justice, University of California Global Health Institute.
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Abstract
PURPOSE OF REVIEW This review is intended to provide perspective on the history of selective progesterone receptor modulators (SPRMs) and progesterone antagonists, their current availability, therapeutic promise and safety concerns. RECENT FINDINGS Despite keen interest in synthesis of these compounds, only a handful have had clinical test results allowing for commercialization. Mifepristone is well tolerated and effective for single dose first trimester at-home pregnancy termination and is available in much of the world. Ulipristal acetate, at single doses, is well tolerated and effective for emergency contraception, with less availability. Chronic use of these agents has been associated with abnormal liver enzymes, and rarely, with hepatic failure; causality is not understood. SUMMARY SPRMs and progesterone antagonists have great therapeutic promise for use in other reproductive disorders, including breast cancer, endometriosis, adenomyosis, estrogen-free contraception and cervical ripening but require additional study. Alternative formulations, whether local (topical breast or intrauterine) or extended-release may reduce the incidence of liver function abnormalities and should be explored.
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