A version of this story was originally published on April 10, 2023. It has been updated to reflect news that mifepristone must be prescribed in person as of Friday, May 1, 2026.
On Friday, a federal appeals court panel reinstated earlier in-person prescribing rules for mifepristone. For more than two decades, mifepristone plus misoprostol has been the standard medication abortion regimen in the U.S. Under guidance relaxed during the Biden administration, clinicians could prescribe mifepristone via telehealth and have pills mailed or picked up at pharmacies for use at home up to 10 weeks’ gestation. The court order immediately requires a return to in-person prescribing nationwide.
The makers of mifepristone have asked the Supreme Court to restore the relaxed rules while litigation continues; the high court has intervened in related cases before. Meanwhile, patients who can access in-person care in states that allow abortion can still receive the two-drug regimen. Telemedicine providers and clinics in some places may offer an alternative: misoprostol alone.
Misoprostol was originally approved to treat gastric ulcers and is also used for IUD insertion and to manage postpartum hemorrhage. It’s been used for abortion for decades and is widely available in pharmacies and hospitals because of these other indications.
How the single-drug protocol differs from the two-drug regimen
Most medication abortions in the U.S. use mifepristone first to block progesterone, then misoprostol 24–48 hours later to trigger uterine contractions and expel pregnancy tissue. That two-drug approach tends to cause fewer side effects and is the preferred option when available.
Misoprostol-only abortion starts with misoprostol at the same dose used in combination protocols. Patients take another dose three hours later and repeat doses every three hours for three to four total doses until the pregnancy passes. Passage usually occurs within about 9–12 hours. The two-drug method is slower overall because of the 24-hour wait between medications, typically taking around 30 hours from the first pill to completion.
Is misoprostol alone safe and effective?
Research shows misoprostol-only protocols are safe and effective, though they often produce more nausea, vomiting, diarrhea, and a longer duration of cramping and bleeding than the combined regimen. Organizations including the American College of Obstetricians and Gynecologists, the World Health Organization, and the Society of Family Planning consider the misoprostol-only approach an acceptable option, particularly when mifepristone is unavailable.
What to expect and when to seek care
With misoprostol, patients can expect cramping and bleeding as the uterus expels pregnancy tissue. If heavy or prolonged bleeding occurs—such as soaking through more than two pads an hour for over two hours—or spotting continues beyond about two weeks, a follow-up procedure may be necessary to complete the abortion.
A fever above 100.4°F that lasts more than 24 hours after taking misoprostol can signal an infection and warrants medical evaluation. Low-grade fever and chills are common side effects and not usually dangerous. If no bleeding or cramping occurs at all, the medication may not have worked and additional misoprostol or a procedural abortion might be needed.
Gestational limits
The FDA approves the two-drug regimen to end pregnancies up to 10 weeks’ gestation; the WHO endorses it up to 12 weeks. For misoprostol alone, data are less definitive. Some studies, including research on self-managed abortion settings, indicate misoprostol can be effective later in pregnancy—even into the second trimester—but efficacy decreases and risks of heavier bleeding increase. In U.S. settings where second-trimester care is available, clinicians generally recommend procedural abortion after 12 weeks rather than medication alone.
How patients obtain medication
In places where first-trimester abortion is legal, patients can get prescriptions through telehealth abortion companies, in-person at clinics such as Planned Parenthood, or at some general OB/GYN and family medicine practices. When mifepristone’s availability has been threatened in the past, many providers said they would shift to prescribing misoprostol alone; clinics can often make that switch quickly. Misoprostol’s broader clinical uses mean it’s more widely stocked than mifepristone.
Access in states with bans or heavy restrictions
In states that have banned or heavily restricted abortion, no medication abortions are legally available. Nonetheless, organizations and services help some people access pills. AbortionFinder.org maintains lists of services and state-specific legal information. The Miscarriage and Abortion Hotline offers free clinician consultations for follow-up questions even when the abortion occurred in a state where it’s illegal.
Some groups operate outside U.S. pharmaceutical distribution. Aid Access, based in the Netherlands, mails mifepristone and misoprostol to people in U.S. states where abortion is banned. Pills sent from abroad aren’t subject to FDA approval; Aid Access also employs U.S.-based providers who prescribe FDA-regulated abortion pills via telehealth where allowed.
Photo caption: Misoprostol is typically used as part of a two-drug protocol for a medication abortion. But it is also safe and effective when used alone, doctors say. — Robyn Beck/Getty Images
Mara Gordon is a family physician in Camden, New Jersey, and NPR’s Real Talk With A Doc columnist. She’s on Instagram at @MaraGordonMD.