This article was originally published April 10, 2023, and updated to reflect that, as of Friday, May 1, 2026, a federal appeals court panel has reinstated nationwide rules requiring mifepristone to be prescribed in person.
What changed
For more than 20 years the standard medication abortion in the U.S. has been mifepristone followed by misoprostol. Under guidance relaxed during the Biden administration, clinicians could prescribe mifepristone by telehealth and have the pills mailed or picked up at a pharmacy for home use up to 10 weeks’ gestation. The recent court order 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.
When mifepristone remains accessible in states that allow abortion, patients can still receive the two-drug regimen in person. Where telemedicine or pharmacies can’t supply mifepristone, some providers offer misoprostol on its own.
Why misoprostol is an option
Misoprostol was initially approved for stomach ulcers and is commonly used for IUD procedures and to treat postpartum bleeding. Because it has other routine uses, it is widely stocked in hospitals and pharmacies and has been used for abortion for decades.
How the single-drug protocol differs from the two-drug approach
The typical two-drug regimen starts with mifepristone to block progesterone, then misoprostol 24–48 hours later to cause uterine contractions and expel pregnancy tissue. That sequence usually causes fewer side effects and is the preferred option when available.
A misoprostol-only protocol uses the same per-dose amount of misoprostol as in combination protocols, then repeats doses: a second dose about three hours after the first, then additional doses every three hours until three to four total doses have been taken or the pregnancy has passed. Passage commonly happens within roughly 9–12 hours after dosing begins. The combined regimen is slower overall because of the 24-hour wait between medications, typically taking around 30 hours from the first pill to completion.
Safety and effectiveness
Research finds misoprostol-only abortion to be safe and effective, though it tends to cause more nausea, vomiting, diarrhea and longer cramping and bleeding than the two-drug method. Major professional organizations — including the American College of Obstetricians and Gynecologists, the World Health Organization and the Society of Family Planning — recognize misoprostol alone as an acceptable option, particularly when mifepristone is not available.
What to expect and when to seek care
With misoprostol, patients should expect fairly strong cramping and bleeding as the uterus expels pregnancy tissue. Seek medical attention if bleeding is very heavy or prolonged, for example soaking through more than two pads an hour for over two hours, or if spotting and bleeding persist beyond about two weeks and a follow-up procedure may be needed.
A fever above 100.4°F lasting more than 24 hours after taking misoprostol can indicate infection and requires evaluation. Low-grade fever and chills are common and usually not dangerous. If no cramping or bleeding occurs at all, the medication may not have worked and additional misoprostol or a procedural abortion might be necessary.
Gestational limits and later pregnancies
The FDA permits the mifepristone-plus-misoprostol regimen through 10 weeks’ gestation; the WHO endorses the combined approach to 12 weeks. Evidence on misoprostol alone is less definitive. Some studies — including those of self-managed abortion — show misoprostol can still be effective later in pregnancy, even into the second trimester, but effectiveness falls and risks of heavier bleeding increase. In settings where second-trimester care is available, clinicians typically recommend a procedural abortion after 12 weeks rather than medication alone.
How people obtain these medications
In places where first-trimester abortion is legal, patients can get prescriptions through telehealth abortion companies, in-person clinics such as Planned Parenthood, or some general OB/GYN and family medicine practices. Many providers have said they can quickly switch to offering misoprostol-only protocols if mifepristone is unavailable.
Access in states with bans or heavy restrictions
Where abortion is banned or heavily restricted, medication abortion is not legally available, though some organizations help people access pills and information. Resources include AbortionFinder.org for clinic listings and state-specific legal information, and the Miscarriage and Abortion Hotline, which offers free clinician consultations for follow-up questions even when the care occurred in a state where abortion is restricted.
Some services outside the U.S. supply pills domestically; for example, Aid Access, based in the Netherlands, has mailed mifepristone and misoprostol to people in U.S. states with bans. Pills sent from abroad are not reviewed by the FDA, and legal and regulatory issues vary.
Bottom line
When mifepristone is available, the two-drug regimen remains the preferred option because it is faster and usually causes fewer side effects. When in-person access to mifepristone is required or the drug is unavailable, misoprostol alone is a safe, effective alternative endorsed by major medical organizations, though it may cause more side effects and carry different considerations for later pregnancies.
Mara Gordon is a family physician in Camden, New Jersey, and NPR’s Real Talk With A Doc columnist. She is on Instagram at @MaraGordonMD.