By Melinda Young
Patients who had painful childbirth experiences or a prior cesarean delivery reported more severe pain after receiving medication abortion, a new study shows.1 Patients’ anticipated pain also may play a role, although the study found borderline significance for those findings, after adjusting for other factors, says Kelsey Loeliger, MD, PhD, who is graduating as a complex family planning fellow at the University of California San Diego. She is a former OB/GYN resident at the University of California San Francisco, where she conducted the study.
People who had a cesarean delivery appeared to be three times more likely to report severely painful medication abortion experiences, she says.1 “Our study can’t tell us why there is an association with the c-section being associated with pain, but we have some theories,” Loeliger adds.
“For patients who had a prior c-section, we can’t tease out whether they [had a cesarean delivery] because their cervix had a more difficult time dilating, which caused more pain, or because they had a scar on the uterus that causes a more painful medication abortion,” she explains. “Those are theoretical and are something to consider in light of those findings.”1
Researchers found that depression and anxiety did not have a detectably significant association with perceived pain, which suggests that patients with mental health conditions still can be good candidates for medication abortion.1 “It’s important to find out whether patients are experiencing anxiety directly related to their upcoming medication abortion,” Loeliger says.1
“Abortion-related anxiety, perhaps due to prior negative experiences such as painful childbirth, may play a role in one’s experience of pain with medication abortion,” Loeliger says. “Pre-abortion counseling should aim to reduce fear that might worsen the patient experience and instead empower and prepare patients with realistic expectations and an adequate regimen to manage their symptoms.”
Another finding was that people who had a prior vaginal delivery generally reported less pain with a medication abortion. But those who had a high pain score during childbirth — an 8, 9, or 10 — were 2.3 times more likely to have severe pain with a medication abortion, Loeliger explains.
“We cannot differentiate whether a prior painful childbirth experience was associated with a painful medication abortion experience primarily due to those individuals having particularly painful uterine contractions, or if there was also a component of fear of having a painful medication abortion experience due to their having a prior experience of painful contractions in labor,” she says.
Patients’ experiences of pain in childbirth often are associated with anxiety and a sense that they lack control. Women who labored painfully and then underwent unplanned cesarean delivery may be at higher risk for pain with medication abortion because of birth trauma or perceived lack of control, she adds.
These findings suggest that OB/GYNs can help make medication abortion more predictable for patients. This could reduce abortion-related anxiety. They also can improve pain management for patients, particularly if they have had painful birth experiences or a cesarean delivery, previously.1
“I would say that what we see in these findings reflects the importance of understanding the kind of experience the patient is looking for and what factors into their decision,” Loeliger says. “It’s common to counsel them about pain and other symptoms of medication abortion, but also important to understand what expectations they have and what are the things most important to them in terms of what they’re looking for and what their preferences might be,” she adds. “You might guide discussions with them about risk factors.”
For example, if patients focus on feeling in control of their abortions, then they may want to hear about what the process is like, what to expect, and how a medication abortion differs from a procedure abortion. “My job is to understand what control means to that patient,” Loeliger says. “Does it mean they want to manage the abortion at home with medication for pain? Or does it mean they want the most predictable experience possible?”
If patients want a predictable experience, then for some of them a procedural abortion may suit their needs better than a medication abortion. Medication abortion is less predictable because everybody’s body is different and everyone experiences things differently. While it is true that it is difficult to predict pain levels during procedural abortion, the experience generally is shorter and can sometimes be better tolerated with in-clinic medications, she notes.
“It’s important to me as a provider to understand what the patient is looking for. Does this idea sound OK to them, and is it aligned with their goals?” she adds.Providers can review the patient’s pain medication regimen, which may help relieve some of their anxiety about whether they will be uncomfortable with the experience.
“If patients come in with strong preferences, I would like to understand where those preferences come from,” she says. For instance, a patient who had a negative experience previously from an intervention during childbirth may want to avoid a procedural abortion. “When I’m able to delve into their reasoning, their priorities, and fears, I can help guide them in the direction they want to go,” Loeliger explains. “My philosophy is knowledge is power for my patients.”
For the vast majority of patients, medication abortion is extremely safe and has high satisfaction rates among patients. But patients may not like parts of the process, such as nausea and greater-than-anticipated cramping pain, she adds. “When I talk to patients about the full spectrum of things they may experience and how to treat each of those things and what is normal and not normal and who to reach out to if they have any questions, the vast majority of patients do extremely well and can have medication abortion in the privacy of their own homes, which is really important to patients,” she says.
“I routinely give them nausea medication and advise that patients are at a low threshold for using it,” she explains. “If they have even a twinge of nausea, take the nausea medication.” Not every patient will want or need pain medication or anti-nausea medication. But each person will want to know what their options are and what they can expect.
Strategies for helping patients manage pain with medication abortions include asking them at the initial visit if they have painful periods because that is a known risk factor, Loeliger says. “I take into consideration how far along they are in pregnancy, as well, and if they had prior medication abortion experience,” she adds.
The goal is to start conversations about what their prior experiences were, what they are looking for, what is most important to them, and what their fears are. “Discussing their experiences with painful previous childbirth and c-sections is a way to start a conversation with patients,” Loeliger says. “Some patients are less worried about pain but may hate being nauseated, and that’s not a small consideration.”
So, understanding patients’ goals and expectations and giving them information they need to take control over their experiences are a priority, she explains. Loeliger counsels patients on what she provides for them, their treatment, and how they may need to take a day off work and have someone with them if they need support.
Like other abortion providers in the United States, Loeliger occasionally sees patients from states that ban abortion. Her counseling for them is the same as it is for local patients. “Approximately 0.3% or so may present to the ER. But studies show that in most of those cases, no significant intervention is needed,” she explains.2,3 “It’s just that patients weren’t sure if the amount of bleeding was OK or if they should seek help because of their pain or nausea.”
In states where reproductive health is fully supported, patients can go to their emergency department and get treatment if they need it or at least be reassured that they are doing fine. “It’s my obligation as a physician to recommend that people seek care if they need care, and if the legal system targets them as a result, then I would hope first and foremost we would prioritize people’s health and safety,” she explains.
But patients have to make the decision about how to manage their medication abortion and what to do if there are problems. Providers can give them adequate information about what to expect so patients are less likely to go to an emergency department when it is not medically warranted.
“For patients that are seeking care from out of state, it’s really important to talk with them about how much bleeding is too much bleeding and what are the signs of infection they can look out for,” Loeliger says. Problems related to medication abortion are extremely rare, but they can occur, so patients need to know when to seek additional care, she adds. If at all possible, it would be best for out-of-state patients to take their abortion medication while they are still in a state that supports women’s reproductive autonomy.
For all patients, it is important they have a follow-up appointment — either in person or through telehealth — to confirm the medication was successful. “I typically recommend patients take a pregnancy test at home in four to six weeks to confirm it was resolved,” Loeliger says.
“For patients with a history of prior c-sections or prior painful childbirth experiences, most will still be good candidates for medication abortion if that’s their desired method of abortion,” she says. “But additional counseling and shared decision-making with patients regarding expectations and pain management strategies may be helpful.”
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
References
1. Loeliger KB, Dragoman MV, Kapp N, et al. Factors associated with severe pain during medication abortion at ≤ 9 weeks’ gestation: A secondary analysis of a multicenter, randomized, placebo-controlled trial. Contraception. 2025;Feb 27:110859. doi: 10.1016/j.contraception.2025.110859. [Online ahead of print].
2. Cleland K, Creinin MD, Nucatola D, et al. Significant adverse events and outcomes after medical abortion. Obstet Gynecol. 2013;121(1):166-171.
3. Upadhyay UD, Johns NE, Barron R, et al. Abortion-related emergency department visits in the United States: An analysis of a national emergency department sample. BMC Med. 2018;16(1):88.
Patients who had painful childbirth experiences or a prior cesarean delivery reported more severe pain after receiving medication abortion, a new study shows.
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