Safety Considerations with Buying Abortion Pills Online

Aug 7

The pills taken during a medication abortion have undergone many regulatory changes since first being approved by the FDA in 2000. Most recently in 2021, the FDA removed the requirement for in-person distribution of the first pill, Mifepristone. This increased the accessibility of abortion pills by making them available online.

For women considering abortion, ordering pills by mail may seem a lot more convenient than going to a clinic. After all, you may not have to travel or wait for an appointment. It may also be a more private experience since you don’t have to disclose the decision to others or interact with medical professionals, and the whole procedure can take place in the comfort of your own home. Ordering abortion pills online may also be cheaper than going to an abortion clinic. However, an abortion, whether surgical or medication-based, is a medical procedure with various risks, and is not medically indicated for everyone, so important safety screenings should be done beforehand to see if you are within the safety guidelines. The decision to have an abortion is a complex and highly personal choice. But no matter what option you choose for your pregnancy, short and long-term health and safety should be a top priority for all women.

When seeking a medication abortion at an established medical clinic, many of the following tests and precautions are likely to be offered. But for those accessing abortion pills online, the following tests and precautions will not be offered to you unless you seek them out yourself. The safety and efficacy of your medication abortion will vary greatly depending on the factors covered in this blog.

How a Medication Abortion Works

A medication abortion (commonly referred to as the “abortion pill”) is performed using two distinct medications – Mifepristone and Misoprostol.

Mifepristone is taken on day 1. This medication blocks progesterone (the hormone that typically supports a growing pregnancy) so that the pregnancy is no longer viable.
Then 24-48 hours later, Misoprostol is taken. Misoprostol causes uterine contractions to expel the pregnancy. Abdominal pain/cramping and bleeding is expected in all medication abortion patients.

This medication regimen is approved for termination of pregnancies up to 70 days (or 10 weeks) gestation. Mifepristone is not approved for ending pregnancies that are farther along. The use of Mifepristone is guarded by a Risk Evaluation and Mitigation Strategy (REMS) program – a safety strategy used with medications that have risks of “serious complications” (FDA).

Safety Considerations

Ectopic Pregnancy →

Medication abortion pills are not an effective treatment for terminating a pregnancy that is ectopic (FDA). A normal pregnancy will implant and grow in the uterus, but an ectopic pregnancy occurs when the fertilized egg implants in a location other than the uterus – most commonly in one of the fallopian tubes. Ectopic pregnancies cannot grow or survive long-term, and may eventually cause the fallopian tube to rupture (burst) which may lead to life-threatening internal bleeding for a woman. It is crucial to detect the presence of an ectopic pregnancy early on and seek treatment before it has a chance to rupture. Ectopic pregnancies cannot move or be moved to the uterus, so they always require treatment – either surgery or medication (ACOG).

However, the medication most often used to treat an ectopic pregnancy early on (methotrexate) is not the same as what’s used for a medication abortion. Medication abortion pills are not an effective treatment for ectopic pregnancy and should never be taken when a pregnancy is ectopic (FDA).

If a woman is unaware that her pregnancy is ectopic, and consumes abortion pills, the symptoms of a ruptured ectopic pregnancy can be very similar to the expected symptoms of a medication abortion (abdominal pain and uterine bleeding) (FDA). She may then ignore the symptoms, assuming the abortion is working properly, and eventually experience life-threatening complications such as heavy internal bleeding. It’s crucial for every woman’s health and safety to confirm that her pregnancy is not ectopic before taking medication abortion pills – this can be done through early confirmation ultrasound.

How Far Along Am I? →

The safety and completion of a medication abortion will vary depending on how far along the pregnancy is. Many online distributors of medication abortion pills will sell them to women who are 12 or 13 weeks along (Aid Access). However, the FDA has only approved the abortion pill regimen up to 10 weeks gestation (FDA). Research shows that within the first trimester, the rate of failed abortion increases with each passing week (Chen), already being as high as 7% for those taking the pills at 10 weeks along.

The best way to estimate gestational age is through early confirmation ultrasound, rather than dating back to the last menstrual period (LMP) (Taipale), (Morgan). One study found that almost 15% of women were wrong by more than 2 weeks when estimating their gestational age from their last menstrual period (Ellertson). Underestimating the gestational age of a pregnancy puts a woman at higher risk for complications such as failed abortion, incomplete abortion, infection, and heavy bleeding (Nivedita), (Mentula). Women who are farther along may also have a greater chance of seeing an identifiable fetus during a medication abortion, leading to potential emotional distress.

Confidently knowing your gestational age will help guide you as you consider which abortion procedures you are eligible for, and help avoid complications associated with being beyond 10 weeks gestation. Thrive Medical Clinic offers early confirmation ultrasounds at no cost with no insurance needed.

Schedule an Ultrasound

Am I Actually Pregnant? →

A positive pregnancy test does not medically confirm that you are pregnant. Why not? A pregnancy test can show a positive result when in fact there is not a viable pregnancy in the uterus. Two important elements of a viable pregnancy are: a fetus is developing, and the fetus has a heartbeat (ACOG).

It’s possible for a woman to receive a positive pregnancy test when a fetus has not actually developed–a form of miscarriage known as a blighted ovum (APA). It’s also possible for a fetus to develop, but naturally miscarry on its own. The symptoms of miscarriage do not always show right away, so it may be easy to assume that the pregnancy is progressing normally and proceed making plans, such as ordering abortion pills. However, if a pregnancy has ended in miscarriage–estimated to occur in 1/10 pregnancies–then an abortion is an unnecessary procedure (ACOG).

Confirming the viability of a pregnancy is an important step before pursuing an abortion. This can be done through an early confirmation ultrasound.

Quality, Safety, and Effectiveness of Online Pills →

Abortion pills purchased online may or may not be the FDA-approved version of each drug. Many websites sell generic abortion pills that are not regulated or inspected by the US government (Plan C). “The FDA does not recommend purchasing mifepristone outside of the Mifepristone REMS Program – e.g. buying it online or personally transporting it from a foreign country.” - FDA website

Why does it matter whether a medication is FDA-approved? The FDA reviews its medications for safety, effectiveness, quality, and inspects the manufacturing facilities (FDA REMS). Their oversight is an important safeguard designed to protect women's health. If the medication is not FDA-approved, then there is no guarantee that the medications actually contain what they’re supposed to. One study examined abortion pills ordered online; after sending the pills to be tested, they found that some misoprostol pills only contained 16% of the advertised active ingredient (Murtagh). The safety and effectiveness of an abortion using non-FDA-approved pills may be compromised.

Complications with Fertility →

A woman’s fertility can be affected by an abortion if there are undiagnosed sexually transmitted infections (STIs) at the time of the abortion. STIs like Chlamydia and Gonorrhea often have no symptoms, and are able to migrate up into a woman’s upper genital tract (uterus, fallopian tubes, and ovaries) during an abortion (CDC), (Pike). Once in the upper genital tract, these infections can cause Pelvic Inflammatory Disease (PID). If PID goes untreated, there can be permanent damage to these organs and complications such as long-term pelvic / abdominal pain, and scar tissue that blocks the fallopian tubes, which may lead to future ectopic pregnancies and/or infertility (CDC). For anyone considering abortion, testing for STIs is an important step for protecting your health. Learn more about tests to consider before an abortion here.

Concerns for Future Pregnancies →

It’s very important to know your blood type if you are pregnant and planning to have an abortion. If you have a negative blood type, there’s a possibility that your body could form antibodies against the fetus during an abortion, due to your blood and the fetus’ blood mixing (ACOG). This immune response is known as Rh Sensitization. If this occurs, the same antibodies could later attack a future pregnancy, causing fetal anemia, liver failure, heart failure, and even stillbirth (Cleveland Clinic), (ACOG).

For women with negative blood types undergoing a medication abortion, the FDA recommends receiving the same preventative treatment as would be given with a surgical abortion to protect against Rh Sensitization (FDA). This treatment involves receiving an injection of Rh Immunoglobulin–also known as RhoGAM®–before or during the abortion procedure to prevent antibodies from ever being made (ACOG). This treatment is crucial for protecting future pregnancies, should that be a desire down the road. Your blood type can be determined with a simple blood test. Learn more about tests to consider before an abortion here.

Lack of Informed Consent →

Informed Consent means you are given the full picture of accurate information about a procedure before choosing to opt into it. This includes what to expect, as well as the risks, benefits, alternatives, and having all your questions answered. You are then able to consent to the procedure knowing all possible outcomes (Wikipedia).

As with any other medical procedure, a medication abortion comes with potential risks and complications. There are also certain contraindications that would make a woman ineligible for the procedure, such as having an IUD or an ectopic pregnancy (FDA). When purchasing abortion pills online, many women will never interact with a medical professional who can offer education about making sure she’s eligible, complications to watch for and what to do if those arise, or how to prepare for the abortion safely. Abortion pills sent through the mail may or may not come with a printed medication guide, but the FDA states that this does not take the place of talking with a healthcare provider (FDA), (Murtagh). Women should be given access to this information, as well as a qualified medical professional who can answer any questions, in order to process their abortion options and safely consent to a medication abortion.

Risks with Medication Abortion →

Two of the most serious risks with a medication abortion are infection and prolonged heavy bleeding (FDA). These two risks are labeled on the Mifepristone packing with a black box warning. This is the most serious warning the FDA can give regarding a medication, and is intended to alert people to adverse reactions that could lead to serious injury or death.

Infection – after a medication abortion, some patients have acquired a bacterial infection (Clostridium sordellii) that can present without concerning symptoms like fever or abdominal pain, but can quickly lead to sepsis and death (FDA). Signs of infection may be as simple as abdominal discomfort or general malaise (including weakness, nausea, vomiting, or diarrhea) more than 24 hours after taking the second pill, Misoprostol (FDA). Though this is rare, it is a serious risk that women and medical professionals should be aware of to prevent severe complications.
Heavy Bleeding – bleeding heavier than a normal period is expected for medication abortion patients. However, prolonged heavy bleeding may be a sign that the abortion is incomplete (some pregnancy tissue remains in the uterus) or other complications (FDA). When performing an abortion at home, it may be hard to know how much bleeding is too much. Women are advised to seek immediate medical care if they soak through two maxi pads per hour for two consecutive hours. However, when bleeding has reached this point, it’s also advised that “prompt medical or surgical intervention may be needed to prevent the development of hypovolemic shock” (FDA). Hypovolemic shock is a life-threatening emergency where your body has lost too much blood to effectively circulate blood and oxygen throughout the body, and organs may begin to shut down (WebMD). For women who are alone, it may be difficult to safely access medical care when on the verge of shock.

Considerations with heavy bleeding:

Consider having someone with you to watch over your symptoms, and help you access emergency medical care if needed. Your proximity to emergency care should also be taken into consideration, given that shock is a time-sensitive condition.
If you have any sort of bleeding disorder or severe anemia, you may be at an increased risk for complications with bleeding during a medication abortion (FDA). Anemia can be assessed with a simple blood test. Learn more about tests to consider before an abortion here.
The amount of blood lost is correlated to how far along the pregnancy is (FDA), because blood flow to the uterus increases as the pregnancy grows. Get a confirmation ultrasound to know for sure how far along you are to avoid taking abortion pills at a gestation beyond the FDA-approved window of 10 weeks.

Alternatives →

Part of informed consent includes receiving information about the alternatives to a given procedure. For a medication abortion, alternatives would include surgical abortion, as well as adoption and parenting options. ACOG recommends that women receive counseling about all pregnancy options to ensure that they are certain about their abortion decision, and that any abortion procedures be delayed if a woman expresses feeling uncertain (ACOG). Information about alternatives may never be offered for those purchasing abortion pills online. Thrive Medical Clinic is here to offer information about all your pregnancy options and available resources. We also provide a caring listening ear to help you process through any difficult pregnancy decisions and plan your next steps with confidence.

Importance of Follow-Up Care →

The FDA states that all medication abortion patients should receive follow-up care from their provider roughly 7-14 days after the abortion takes place. If you are self-managing an abortion at home, it can be difficult to know where to go to receive follow-up care.

“This assessment is very important to confirm that complete termination of pregnancy has occurred and to evaluate the degree of bleeding. Usually, bleeding and cramping symptoms mean that the treatment is working. But sometimes you can get cramping and bleeding and still be pregnant.” - FDA Mifeprex Label

As indicated above, it’s possible that the pregnancy may not be completely terminated after taking both abortion pills. For pregnancies that are still viable after an abortion–aka failed abortion–surgical evacuation is then recommended to fully terminate the pregnancy (FDA).

It’s also possible for an abortion to be incomplete – meaning the pregnancy is no longer viable, but there is tissue remaining in the uterus. Up to 7% of women who take the abortion pills within the approved 10 week gestational window will experience an incomplete abortion and require a surgical procedure to complete their abortion (FDA). Incomplete abortion may be as high as 38.5% for those taking abortion pills in the second trimester (Mentula). The primary complications of incomplete pregnancy loss in the first trimester include retained POC, hemorrhage potentially requiring a blood transfusion, disseminated intravascular coagulation, endometritis, and sepsis (NCBI)

For women looking to purchase abortion pills online, make sure to explore your options for follow-up care. It’s also possible that you may develop questions during an abortion about whether your symptoms are normal vs. concerning, but not know who to ask. These are important elements to consider as you explore your abortion options.

Safe Standard of Care

For those pursuing a medication abortion, buying the pills online may feel easier, but it may not offer the highest standard of care when it comes to your safety. Women’s health and safety should remain the highest priority during any medical procedure. Before an abortion, it’s important to receive a pregnancy-confirmation ultrasound to confirm viability, gestational age, and rule out ectopic pregnancy; women should also receive lab work (to evaluate Rh status, STIs, and anemia); counseling; and informed consent regarding the risks of a medication abortion. Women should also have access to a qualified medical professional who can offer follow-up care and answer questions throughout the process. Consider the source of the abortion pills, your proximity to emergency care, and confiding in a safe person who can offer support throughout your experience.

Thrive is Here for You

If you are considering abortion and want more information about this option, Thrive is here for you. We offer clinical pregnancy tests, early confirmation ultrasounds, and a safe place to gather accurate and unbiased information about your pregnancy options. We passionately believe that no one should navigate a difficult pregnancy decision alone, and desire to support you without pressure or judgment.

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