Over-the-Counter Misoprostol (Cytotec)

Photo by SliceofNYC

The New York Times has an interesting article about the overt-the-counter availability of misoprostol (Cytotec) in small, family-run pharmacies in the city:

Amalia Dominguez was 18 and desperate and knew exactly what to ask for at the small, family-run pharmacy in the heart of Washington Heights, the thriving Dominican enclave in northern Manhattan. “I need to bring down my period,” she recalled saying in Spanish, using a euphemism that the pharmacist understood instantly.

It was 12 years ago, but the memory remains vivid: She was handed a packet of pills. They were small and white, $30 for 12. Ms. Dominguez, two or three months pregnant, went to a friend’s apartment and swallowed the pills one by one, washing them down with malta, a molasseslike extract sold in nearly every bodega in the neighborhood.

The cramps began several hours later, doubling Ms. Dominguez over, building and building until, eight and a half hours later, she locked herself in the bathroom and passed a lifeless fetus, which she flushed.

I suspect the number of repro aged women "suffering" from gastric ulcers will skyrocket once abortion is banned.

On a slightly more serious note, one thing that stood out for me in the article is the mention of two women, Amber Abreu, an 18-year-old Dominican immigrant from Massachusetts, and Gabriela Flores, a 22-year-old Mexican migrant farm worker from South Carolina. Both women have been arrested and charged with illegally performing an abortion and sentenced to probation and therapy (?), and 90 days in jail, respectively.

I wasn't familiar with their cases, nor with the fact that "performing an abortion" on yourself and "procuring an improper miscarriage" for yourself are criminal offenses. [In Massachusetts the charge could carry up to seven years in state prison.]

I guess when various zealots propose legislation banning abortion they really are most magnanimous when they include a clause to exempt women who obtain abortions from prosecution.

Vaginal vs. Oral Misoprostol

Interesting report on misoprostol regimens. I don't have access to the study on the computer I'm on, but according to the article:

In this study, Dr. Helena von Hertzen, of the Department of Reproductive Health and Research at the World Health Organization, and her colleagues studied 2,046 women who were divided into four groups that received misoprostol either vaginally at three- and 12-hour intervals, or under the tongue at three or 12-hour intervals.

Among women who took misoprostol at 12-hour intervals, pregnancy continued in 9 percent of those who took the drug orally and in 4 percent of those who took it vaginally. Among those who took the drug at three-hour intervals, pregnancy continued in 6 percent of those who took it orally and in 4 percent of those who took it vaginally.

Side effects such as nausea and vomiting were more common among women who took misoprostol under the tongue and vaginally at three-hour intervals than among those who took the drug at 12-hour intervals. Side effects such as pain, diarrhea, chills and shivering were slightly higher among women who took the drug orally.

"Administration interval can be chosen between three hours and 12 hours when misoprostol is given vaginally. If administration is [oral], the intervals between misoprostol doses need to be short, but side effects are then increased. With 12-hour intervals, vaginal route should be used, whereas with three-hour intervals either route could be chosen," the study authors concluded.

A couple of points.

1. You could use misoprostol (Cytotec) alone, but you shouldn't (for now, anyway. Once abortion is outlawed, we'll revisit the recommendation.). Adding mifepristone (RU-486, Mifeprex) to the regimen improves efficacy and reduces side effects.

Note: I'll have more on the misoprostol/mifepristone (RU-486) drug regimen in Part II of my post exposing Senator Jim DeMint (R-SC) lies in support of his amendment to regulate mifepristone (RU-486). [Part I, here.]

In the interim, and without looking it up, try to answer this question: Why do the two drugs work better together? What's more likely: A) the drugs have different actions, or B) the drugs have similar actions, and one potentiates the other?

2. Vaginal misoprostol is not part of the FDA-approved regimen. FDA approved 600 mg mifepristone (RU-486) and 400 mcg misoprostol, both administered orally.

Medical Abortion, Misoprostol, and Latin American Pharmacies

Well, isn't this a grand combination: Abortifacient provision is common at pharmacies [in Latin America] but knowledge about medications is low among pharmacy staff.

A number of studies have documented that women seek and that pharmacy staff distribute drugs intended to induce abortion at pharmacies in Latin America. Abortion is legally restricted in almost all of Latin America. Nonetheless, the region has one of the highest abortion rates in the world. In the 1990s, reports that women were using the prostaglandin analog misoprostol to self-induce abortion in Brazil emerged. Interviews with Brazilian women revealed that they tended to use misoprostol because of its lower price as compared with other medical alternatives, its immediate availability, the fact that the process seems more like a natural miscarriage and its apparent safety. In Brazil, prior to the drug's removal from the market, pharmacies were the main source of misoprostol.

Some evidence suggest that the availability and use of medical methods to terminate a pregnancy may contribute to declining complication rates from clandestine procedures, yet little is known about the role of pharmacist provision of medical abortifacients. We performed this study to learn more about pharmacists' knowledge and provision of medical abortifacients, particularly misoprostol, in a large Latin American city. Although the legislation of the country where the study was performed requires a prescription to purchase misoprostol, in practice, this law is not enforced and misoprostol is commonly sold without a prescription in pharmacies. Moreover, misoprostol is not approved for use as an abortifacient and legal abortions are very rare in the study country. We elected not to identify the study location because of the sensitive nature of the topic.

...

Similar to a study on pharmacies in Mexico City in 1993, our study found that the most frequently recommended abortifacients were hormonal injectables in both the survey (67%) and the mystery client encounters (71%). Although there is no scientific evidence to support their efficacy, it is widely believed both by pharmacy staff and the general population in Latin America that hormonal injectables are effective abortifacients. In our study, the second most common abortifacient was misoprostol: 33% of pharmacy staff mentioned it in the survey and 39% recommended it in the mystery client encounters. However, knowledge about adequate dosage, route of administration, side effects, complications and effectiveness was poor. In fact, no information was offered (even when requested) on any of these topics in at least half of the mystery client encounters in which misoprostol was recommended. Few pharmacy staff had received formal training regarding misoprostol use; most had consulted a drug reference guide or learned about the medication from colleagues, which could explain why so little information was known about dosage, side effects and complications.

Read the whole thing.

Accuracy in Media Health Reports

Errors in newspaper articles covering emergency contraception pills (ECPs) may have contributed to incorrect beliefs about this form of birth control, according to an abstract* presented at this year's Association of Reproductive Health Professionals (ARHP) conference.

The researchers found that, despite EC's potential to prevent unintended pregnancies and abortions--51,000 abortions deterred in 2000 alone--errors in newspaper articles about ECPs were prevalent, and persisted over time.

The study analyzed the content of 1077 articles in 113 newspapers, from 1992 to 2002, discussing both ECPs and medical abortions (MTP). Of all articles, 44.5% (n=479) included more than one instance of confusion between ECPs and one of the drugs used for MTP, mifepristone. Inaccurate portrayal of ECPs' mechanism of action as medical abortion was noted in 31.8% (n=343) of articles, and 13.1% (n=141) inappropriately applied terms such as "abortifacient post-coital contraceptives" for ECPs.

I haven't conducted a formal study, but while doing research for my book I most certainly noticed that the majority of articles about Seasonale and period control are inaccurate. They consistently get two basic facts wrong:

1. The real and the fake period are not one and the same.

Seasonale, or any comparable Pill regimen for that matter, doesn't reduce the number of yearly periods from 13 to four.

Women using the Pill don't have menstrual periods. Extended-, or continuous-use Pill regimens only shift the frequency of the fake period (withdrawal bleeding) from 13 to four.

2. There are over 30 years worth of studies on the safety of menstrual suppression.

Menstrual suppression isn't a new, experimental thing, and there is an abundance of long-term studies on the side effects of suppressing the period.

Tens of millions of women have been using the Pill, and thus suppressing their menstrual periods, since the 1960s. According to the FDA, over the years, more studies have been done on the pill to look for serious side effects than have been done on any other medicine in history.

Because skipping a real period has a different risk/benefit profile than skipping a fake period [I'll do a separate post on this topic], these entrenched errors negatively affect your ability to make an informed decision about menstrual management.

Between the errors found by the study on EC newspaper articles, the mountain of misinformation about menstrual menstrual management, and the factually challenged major media reports about the Ortho Evra skin patch, I think we have a candidate for Jeff Jarvis' new mediawatch segment about stories that receive too little [try none] coverage: Prevalent, and persistent errors in media health reports.


*Pruitt S, Dolan Mullen P. Contraception or Abortion? Inaccurate Descriptions of Emergency Contraception in Newspaper Articles, 1992-2002. Contraception. 2004;70(3):259-60.