| Up to | Effectiveness | Dosage |
|---|---|---|
| 63 days | 85-90%[84] | misoprostol 800 mcg (vaginally inserted then moistened with a few drops of water), repeated after 24 hours. |
| 49 days | 92%[85] | mifepristone 200 – 600 mg (sublingually on day 1), and misoprostol 400 mcg (sublingually on day 3). (Scientific studies have shown initial dose of mifepristone can be reduced to 200 mg and still be 92% effective.) |
| 63 days | 95%[86] | Same day administration: mifepristone 600 mg (sublingually), and misoprostol 800 mcg (vaginally). |
| 49 days | 95%[87] | methotrexate 25 mg (sublingually on day 1), and misoprostol 800 mcg (vaginally on day 7, day 8, and again on day 9 if abortion does not occur) |
| 56 days | 90%[88] | mifepristone 200 mg (orally) and misoprostol 800 mcg (vaginally) taken at the same time. |
| 63 days | 92%[89] | misoprostol 800 mcg (vaginally on day 1) and misoprostol 800 mcg (vaginally on day 2). |
| 84 days | 86%[90] | misoprostol 600 mcg (sublingually every three hours up to maximum of five doses) |
| 84 days | 91 - 94.5%[91] | For treatment of incomplete abortion: Single oral dose misoprostol 600 mcg. |
Menstrual Extraction
Menstrual extraction is a powerful example of medical research done by women on and for ourselves.
-Our Bodies, Ourselves for the New Century, 1998.
Menstrual extraction is a procedure where the contents of the uterus are removed in a few minutes with a suction device. A procedure similar to menstrual extraction was first developed in the mid-1800s by a physician named Simpson who called the method dry cupping. He states, “I have made frequent use of a tube resembling in length and size a male catheter and having an exhausting syringe adapted to its lower outer extremity been introduced into the cavity of the uterus.”[92] The method of ‘dry cupping’ was not widely taught and this early technique was lost to medicine.
Menstrual extraction was invented in the 1970s in the United States by feminist activists Lorraine Rothman and Carol Downer. A low cost and low-tech device, known as a Del-EM™ was assembled from a flexible plastic cannula (called a Karman cannula), a 50 c.c. syringe, a check valve, some tubing, a rubber stopper, and a mason jar. The procedure was simple, effective, and relatively safe. Rothman and Downer toured the United States educating women’s groups on the procedure, and the practice became well known. By 1993, over 20,000 menstrual extractions had been performed in the United States by women in self-help groups.[93]
Today, menstrual extraction, also known as menstrual regulation, is used around the world as a strategy to circumvent antiabortion laws. Because confirmation of pregnancy is optional, antiabortion governments (like Bangladesh, Korea, and Cuba) can support ‘menstrual regulation’ clinics where women are offered menstrual regulation if their period is late, with no pregnancy test required.
Menstrual extraction, when performed in a clinical setting, is called manual vacuum aspiration (MVA). MVA has been in use in the United States for thirty years. MVA has been found to be 98% effective, only 2% of procedures must be repeated, and those on the second attempt are usually successful. Before twelve weeks LMP, only 1% of MVAs have complications. In the early second trimester, the rate of complications and incomplete procedures for MVA increases.
Menstrual extraction is most effective when used around seven weeks LMP. According to the World Health Organization and the Allan Guttmacher Institute, menstrual extraction can be used up through 12 weeks, and possibly up to 15 weeks, if the necessary sized cannulas can be secured and adequate cervical dilation achieved, and one study indicated that manual vacuum aspiration (MVA) could be used effectively into the first half of the second trimester, for MVA was found to be as effective as electric vacuum aspiration in weeks 14 to 18.[94] Cervical dilation is important in second trimester abortions, and misoprostol has been found to be effective in dilating the cervix in early second trimester abortion.[95]
The procedure of menstrual extraction is valued in the third world especially, because it is inexpensive, portable, quiet, and does not require electricity. Menstrual extraction, with less vacuum pressure than clinical electrical vacuum aspiration units, is also believed by some to cause less disruption of evacuated tissue, making identification of products of conception easier for very early gestations.
Words to the Wise: If the procedure is done too slowly and without sufficient vacuum pressure, clots readily form in the cannula tip and discomfort is increased as the procedure takes longer and can end incomplete. The woman having a menstrual regulation procedure can often experience cramping and possibly nausea, sweating, and lightheadedness as well. To avoid unnecessary duration and discomfort it is essential to establish sufficient vacuum. Most MVA procedures, regardless of gestation are completed in 15 minutes.
Bleeding after menstrual extraction may vary from a few days of spotting to a few weeks of moderate flow, and some women do not bleed at all. It is not unusual to stop bleeding and begin again. Often 48 - 72 hours after the abortion, there is a hormonal shift that may suddenly cause cramping, bleeding, and clots. This is considered normal. (See Post Abortion Care).
Although complications are rare because the cannula is very thin and flexible, any use of instruments in the uterus can result in complications.
1. Incomplete evacuation. (1 out of 100 clinical MVAs) 3% of clinical manual vacuum aspirations (before 6 weeks LMP) are incomplete and require a second procedure. The most effective gestational age for menstrual extraction is seven weeks LMP. To ensure complete evacuation, one should watch carefully for the uterus gripping the cannula, the grating sensation, and meticulously examine the collected blood and tissue for signs of conception. A repeat procedure may be needed in an incomplete evacuation.
2. Uterine perforation. (2 out of 1000 clinical MVAs) Uterine perforation occasionally happens during dilation with metal tools in a clinical setting or an instrument goes through the wall of the uterus during the procedure. Uterine perforation is less likely to happen with the flexible plastic cannula used in menstrual extraction. Often, no dilation is necessary for the 6mm cannula used before seven weeks LMP. Surgery or rarely hysterectomy may be needed in the event of uterine perforation.
84
“Instructions for Use: Abortion Induction with Misoprostol in Pregnancies up to 9 weeks LMP,” Gynuity Health Projects (2003). K. Blanchard, B. Winikoff, and C. Ellertson, “Misoprostol used alone for the termination of early pregnancy: A review of the evidence,”
85
R. Peyron, E. Aubény, V. Targosz, et al., “Early Termination of Pregnancy with Mifepristone (RU 486), and the Orally Active Prostaglandin Misoprostol.”
86
H. el-Refaey, D. Rajasekar, M. Abdalla, L. Calder, and A. Templeton, “Induction of Abortion with Mifepristone (RU 486), and Oral or Vaginal Misoprostol,”
87
J. L. Carbonell Esteve, L. Varela, A. Velazco, R. Tanda, and C. Sánchez,“Oral Methotrexate Followed by Vaginal Misoprostol 7 Days after for Early Abortion A Randomized Trial,”
88
Mitchell D. Creinin, Courtney A. Schreiber, Paula Bednarek, Hanna Lintu, Marie-Soleil Wagner, and Leslie A. Meyn, “Mifepristone and Misoprostol Administered Simultaneously Versus 24 Hours Apart for Abortion: A Randomized Controlled Trial,”
89
J. L. Carbonell Esteve, L. Varela, A. Velazco, R. Tanda, E. Cabezas, and C. Sánchez, “Early Abortion with 800 µg of Misoprostol by the Vaginal Route.”
90
Oi Shan Tang, B.Y. Miao, Sharon W.H. Lee, and Pak Chung Ho, “Pilot Study on the Use of Repeated Doses of Sublingual Misoprostol in Termination of Pregnancy up to 12 weeks Gestation: Efficacy and Acceptability,”
91
C. Bique, M. Usta, B. Debora, E. Chong, E. Westheimer, and B. Winikoff, “Comparison of misoprostol and manual vacuum aspiration for the treatment of incomplete abortion,”
92
J.Y. Simpson
93
Rebecca Chalker, “The Whats, Whys, and Hows of Menstrual Extraction,”
94
Catherine S. Todd, “Manual Vacuum Aspiration for Second Trimester Pregnancy Termination,”
95
Catherine S. Todd, “Buccal Misoprostol as Cervical Preparation for Second Trimester Pregnancy Termination,”