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Last reviewed: October 12, 2022
Recommendation:
- Offer pain medication to all people undergoing medical abortion.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended either prophylactically or at the time cramping begins.
- Non-pharmacologic pain management measures may be helpful.
- Narcotic analgesics have not been demonstrated to be effective in relieving pain during the medical abortion process and are not recommended for routine use.
- Paracetamol should not be used unless an allergy or contraindication to NSAIDs exists.
Strength of recommendation: Strong
Quality of evidence: Low
Pain during medical abortion before 13 weeks gestation
Pain is the most commonly reported side effect of medical abortion (Fiala et al., 2014). In one study of 6,755 women using medical abortion up to 63 days gestation, 78.4% reported moderate or severe pain and cramping (Goldstone, Michelson, & Williamson, 2012). Similarly, a 2006 systematic review of five large British and American case series of analgesia use during medical abortion concluded that 75% of women experience pain severe enough to require narcotic analgesia (Penney, 2006). A qualitative study of women’s experience with medical abortion pain in Nepal, South Africa and Vietnam found that women described pain as stronger than what they experienced during menstruation and manifested in four distinct patterns: minimal or no pain; brief intense pain, typically right before expulsion; intermittent pain, similar to contractions; and constant pain for one or several hours (Grossman et al., 2019). Pain typically peaks 2.5 to 4 hours after misoprostol use and lasts around one hour (Colwill et al., 2019). More than 75% of patients report resolution of pain by 12 hours after taking misoprostol, with reports increasing to 90% by 24 hours (Friedlander et al., 2022). Patient characteristics associated with more pain include increasing gestational age, younger patient age, nulliparity, no previous vaginal deliveries, and history of dysmenorrhea (Dragoman et al., 2021; Kemppainen et al., 2020; Suhonen et al., 2011; Teal, Dempsey-Fanning, & Westhoff, 2007; Westhoff et al., 2000).
There are few trials assessing effectiveness of pain management strategies during medical abortion before 13 weeks gestation. Neither pain nor its treatment are systematically reported in clinical trials of medical abortion; where these data are reported, multiple regimens and treatment protocols have been used, rendering them difficult to compare (Fiala et al., 2014; Fiala et al, 2019; Jackson & Kapp, 2011; Reynolds-Wright, 2022).
Medications for pain management
Two small randomized controlled trials indicate that ibuprofen is more effective than placebo (Avraham et al., 2012) or acetaminophen (Livshits et al., 2009) in relieving medical abortion pain in women with pregnancies of less than seven weeks gestation. Pre-treatment with ibuprofen is no better for pain management than treatment once cramping starts (Raymond et al., 2013). A three-armed randomized trial compared ibuprofen plus metoclopramide, tramadol, or placebo taken at the time of misoprostol administration and again 4 hours later; finding that ibuprofen plus metoclopramide and tramadol alleviated pain more effectively than the placebo, but did not result in clinically significant differences in participants’ reported pain (Dragoman et al., 2021). In women with pregnancies up to 10 weeks gestation, one randomized controlled trial found that pregabalin (a gamma-aminobutyric acid analog) did not decrease maximum pain scores when taken at the time of misoprostol administration; however, women who received pregabalin were less likely to require ibuprofen or narcotic pain medication and more likely to report satisfaction with analgesia than women who received the placebo (Friedlander et al., 2018). One randomized trial found no difference in the amount or duration of pain experienced by women receiving an oral opioid medication (oxycodone) to manage medical abortion pain, compared to placebo (Colwill et al., 2019). Study authors concluded that while providing routine opioid medications is unnecessary, it is reasonable to provide four or fewer oxycodone tablets to those who request them. One hospital-based study randomized women undergoing medical abortion into two groups: intravenous patient-controlled-analgesia for pain, or on-demand oral, intramuscular, or intravenous administration of oxycodone for pain (Kemppainen et al., 2022). Results show that most participants in both groups utilized opioid medication; those in the patient-controlled-analgesia group were more likely to characterize pain as mild or tolerable (21% compared to 6% in the on-demand group), although maximum reported pain was the same in both groups.
Non-pharmacologic pain management
In one randomized trial, high frequency transcutaneous electrical nerve stimulation (80Hz TENS) applied to the abdomen and back when cramping began reduced women’s abortion pain compared to placebo (Goldman et al., 2020). Another randomized trial found no benefit of auricular acupuncture or acupressure in improving medical abortion pain, when compared to placebo (Westhoff et al., 2021). Other non-pharmacologic pain management strategies for medical abortion before 13 weeks gestation have not been the subject of comparative trials. However, experts recommend adjunctive non-pharmacologic measures to improve individual’s comfort during a medical abortion, including thorough education about expected pain and bleeding (Teal, Dempsey-Fanning, & Westhoff, 2007), a supportive environment and application of a heating pad or hot water bottle to the lower abdomen (Akin, et al., 2001). These modalities are to be employed in addition to—not as substitutes for—pain medications.
Resources
Continuum of depth of sedation: Definition of general anesthesia and levels of sedation/analgesis
References
Akin, M. D., Weingard, K. W., Hengehold, D. A., Goodale, M. B., Hinkle, R. T., & Smith, R. P. (2001). Continuous low-level topical heat in the treatment of dysmenorrhea. Obstetrics & Gynecology, 97, 343-349.
Avraham, S., Gat, I., Duvdevani, N., Haas, J., & Frenkel, Y. (2012). Pre-emptive effect of ibuprofen versus placebo on pain relief and success rates of medical abortion: A double-blind, randomized, controlled study. Fertility and Sterility, 97, 612-615.
Colwill, A. C., Bayer, L. L., Bednarek, P., Garg, B., Jensen, J., & Edelman, A. (2019). Opioid analgesia for medical abortion: A randomized trial. Obstetrics & Gynecology, 134(6), 1163-1170.
Dragoman, M.V., Grossman, D., Nguyen, M.H., Habib, N., Kapp, N., Tamang, A., Bessenaar, T., Duong, L.D., Gautam, J., Yoko, J.L., Hong, M., & Gulmezoglu, M. (2021). Two prophylactic pain management regimens for medical abortion ≤ 63 days’ gestation with mifepristone and misoprostol: A multicenter, randomized, placebo-controlled trial. Contraception, 103(3), 163-170.
Fiala, C., Agostini, T., Bombas, S., Cameron, R., Lertxundi, M., Lubusky, M., … & Gemzell-Danielsson, K. (2019). Management of pain associated with up-to-9-weeks medical termination of pregnancy (MToP) using mifepristone-misorpsotol regimens: Expert consensus based on a systematic literature review. Journal of Obstetrics and Gynecology, 1-11.
Fiala, C., Cameron, S., Bombas, T., Parachini, M., Saya, L., & Gemzell-Danielsson, K. (2014). Pain during medical abortion, the impact of the regimen: A neglected issue? A review. European Journal of Contraception and Reproductive Health Care, 19(6), 404-419.
Friedlander, E.B., Raidoo, S., Soon, R., Salcedo, J., Davis, J., Tschann, M., Fontanilla, T., Horiuchi, W., & Kaneshiro, B. (2022). The experience of pain in real-time during medication abortion. Contraception, 110, 71-75.
Friedlander, E. B., Soon, R., Salcedo, J., Davis, J., Tschann, M., & Kaneshiro, B. (2018). Prophylactic pregabalin to decrease pain during medication abortion: A randomized controlled trial. Obstetrics & Gynecology, 132(3), 612-618.
Goldman, A.R., Porsch, L., Hintermeister, A., & Dragoman, M. (2020). Transcutaneous electrical nerve stimulation to reduce pain with medication abortion. Obstetrics & Gynecology, 137(1), 100-107.
Goldstone, P., Michelson, J., & Williamson, E. (2012). Early medical abortion using low-dose mifepristone followed by buccal misoprostol: A large Australian observational study. Medical Journal of Australia, 197(5), 282-286.
Grossman, D., Raifman, S., Bessenaar, T., Dung, D. L., Tamang, A., & Dragoman, M. (2019). Experiences with pain of early medical abortion: Qualitative results from Nepal, South Africa, and Vietnam. BMC Women’s Health, 19(1), 118.
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Kemppainen, V., Mentula, M., Paklama, V., & Heikinheimo, O. (2020). Pain during medical abortion in early pregnancy in teenage and adult women. Acta Obstetricia et Gynecologica Scandinavica; 99,1603-1610.
Kemppainen, V., Mentula, M., Palkama, V., & Heikinheimo, O. (2022). Patient-controlled intravenous versus on-demand oral, intramuscular or intravenous administration of oxycodone during medical induced abortion from 64-128 days gestation: A randomized controlled trial. Contraception, 115, 6-11.
Livshits, A., Machtinger, R., David, L. B., Spira, M., Moshe-Zahav, A., & Seidman, D. S. (2009). Ibuprofen and paracetamol for pain relief during medical abortion: A double-blind randomized controlled study. Fertility and Sterility, 91(5), 1877-1880.
Penney, G. (2006). Treatment of pain during medical abortion. Contraception, 74, 45-47.
Raymond, E.G., Weaver, M.A., Louie, K.S., Dean, G., Porsch, L., Lichtenberg, E.S., … Arnesen, M. (2013). Prophylactic compared with therapeutic ibuprofen analgesia in first-trimester medical abortion. Obstetrics & Gynecology, 122(3), 558-564.
Reynolds-Wright, J.J., Woldetsadik, M.A., Morroni, C., & Cameron, S. (2022). Pain management for medical abortion before 14 weeks’ gestation: A systematic review. Contraception, 116, 4-13.
Suhonen, S., Tikka, M., Kivinen, S., & Kauppila, T. (2011). Pain during medical abortion: Predicting factors from gynecologic history and medical staff evaluation of severity. Contraception, 83, 357-361.
Teal, S. B., Dempsey-Fanning, A., & Westhoff, C. (2007). Predictors of acceptability of medication abortion. Contraception, 75, 224-229.
Westhoff, C., Dasmahapatra, R., Winikoff, B., & Clarke, S. (2000). Predictors of analgesia use during supervised medical abortion. The Mifepristone Clinical Trials Group. Contraception, 61(3), 225-229.
Westhoff, C., Dasmahapatra, R., & Schaff, E. (2000). Analgesia during at-home use of misoprostol as part of a medical abortion regimen. Contraception, 62(6), 311-314.
Westhoff, C.L., Nelson, I.S., Suarez-Rodriguez, A., & Gold, M.A. (2021). Auricular acupressure and acupuncture as adjuncts for pain management during first trimester medication abortion: A randomized three-arm trial. Contraception, 103(5), 348-355.