We prescribe mifepristone and misoprostol to be used in combination. Mifepristone is taken first, 24 to 48 hours before misoprostol. Mifepristone is taken by mouth with water. 

After at least 24 hours have passed, misoprostol may be taken. Misoprostol is not swallowed like most pills. Instead it is placed in contact with a mucous membrane, where it can absorb directly into the bloodstream. We recommend either placing the tablets in your mouth, between your cheeks and gums like a chipmunk (buccal route), or using your fingers to push the pills into your vagina (vaginal route). Both sites have mucous membranes that absorb misoprostol effectively. 

For both buccal and vaginal routes, insert 4 tablets at one time and keep the tablets in contact with the mucous membrane for 30 minutes. If placing the misoprostol in your mouth, put 2 pills in each cheek and hold them there for 30 minutes. The pills may dissolve completely during this time, or they may dissolve partially. In either case, enough medication is absorbed within 30 minutes to function effectively. If pill residue remains after 30 minutes, you may swallow it with water. If inserting the tablets into your vagina, rest in a reclined position for 30 minutes to keep the pills in place and ensure adequate absorption. 

If you are less than 9 weeks pregnant and you experience the expected bleeding after taking 4 tablets of misoprostol, you are done. You should save the remaining misoprostol tablets for at least 2 months in a cool, dry place. If you are 9-12 weeks pregnant, you will need to take a second dose of misoprostol. Insert the second dose of 4 tablets buccally or vaginally, and keeping them in place for 30 minutes just as you did with the first dose.

There are three options for taking misoprostol - buccally, sublingually and vaginally. Each option has positives and negatives. Choose the route that is most comfortable for you and that best suits your context. 

Vaginal route
Positive: 
- Fewest side effects

Negative:
- Pill residue may remain in the vagina for a few days, and may be visible if a healthcare provider performs a vaginal exam during this time.
We recommend avoiding this route in settings where abortion is restricted and where there is concern about potential criminalization.
- Some individuals may not be comfortable using their fingers to insert pills into their vagina. 


Sublingual route: 
Positive: 
- Management of pill residue prevents criminalization
- Easily understandable placement under tongue 
- Relatively easy to hold pills under the tongue for 30 minutes

Negative:
- May cause the most unpleasant symptoms such as fever/chills and diarrhea.  


Buccal route:
Positive:
- Management of pill residue prevents criminalization. 
- Research and clinical evidence show fewer side effects than sublingual. 
- If planning to place pills in your mouth, we recommend the buccal route for its improved side effect profile 

Negative: 
- Placement between cheek and gums may be less comfortable than sublingual for some individuals. 

Most people have no symptoms after taking mifepristone. You can take this medication during a normal day of work, school or family obligations. Some people do experience mild cramping and light bleeding after taking mifepristone. When symptoms do occur, they are usually mild and do not interrupt normal daily activities.

Symptoms usually begin within 1 - 4 hours after taking misoprostol. Cramping can be much stronger than normal period cramps. You may have nausea, vomiting and diarrhea. A mild fever, chills, and headache are also common. Many people report these symptoms first and then bleeding starts a bit later. Bleeding with clots is expected. If possible, take misoprostol when you can be free of work, school and family obligations for at least 12 hours. You should be in a safe, private and comfortable place, where you have easy access to a bathroom. 

Vomiting during the two hours after taking mifepristone could reduce its effectiveness. To avoid this, consider taking an anti-nausea medication such as unisom, dramamine or metoclopramide before taking mifepristone if you have morning sickness. 

Misoprostol is absorbed directly into the bloodstream. That means vomiting shortly after taking misoprostol does not impact its effectiveness. If you use the buccal or sublingual route and feel the need to vomit while you are holding the pills in your mouth, try to remove the pills and place them on a clean dish before vomiting. After vomiting, place the pills back in your mouth and continue to let them dissolve for 30 minutes. 

Yes! There are no dietary restrictions during a medication abortion. It is important to drink a lot of water or other beverages to avoid dehydration. It is also important to eat nourishing foods to provide energy for the work your body is doing during the medication abortion process.

You can take pain medications to help with the cramping pain caused by misoprostol. Ibuprofen 800mg can be taken every 8 hours, or Naproxen 220mg can be taken every 12 hours. These medications are very effective at relieving uterine cramping pain. Ibuprofen and Naproxen are in the same class of medicines, so don’t combine them; choose only one. 

You can combine Tylenol with Ibuprofen or Naproxen, as it is in a different medicine class. Tylenol is less helpful with cramping pain, but it is good at reducing fever and general discomfort. You can take up to 1000mg of Tylenol every 6-8 hours. Do not take more than 4000mg in a 24 hour period. 

Other comfort measures include: 
- Applying a heating pad to the lower abdomen or lower back
- Spending time in a hot shower
- Movements such as hip circles, pelvic rock, squatting, walking
- Massage
- Staying distracted with a movie or show

Each person’s bleeding will be different. Bleeding may be similar to your normal period, or it may be heavier. Clots are expected. Clots the size of an egg are normal. It is normal for bleeding to get heavier in moments, especially when passing clots or tissue. Then it should decrease again. When the pregnancy tissue has passed, bleeding should decrease steadily over time. Bleeding may continue for a few days, or up to a month after a medication abortion. 

A sign of too much bleeding is the 2 X 2 Rule:
If you fully saturate 2 pads in an hour, for 2 hours in a row, your bleeding may be too heavy and you should seek immediate medical attention. 

Medication abortion is very safe and complications are rare. Communicate with your provider if you think you may be having a complication. Your provider can help you sort out what is normal and what is not. Many common concerns can be resolved at home with reassurance and recommendations from your provider. In the relatively uncommon case of a complication, your provider will help you identify when and how to take action. 

If you do not have a medical provider, or you cannot reach your provider, another resource for receiving information and support from trained medical professionals is the M&A Hotline: https://mahotline.org/, 1-833-246-2632

If you are seriously concerned that you are having a complication and are unable to reach a provider, you should go to the nearest emergency department.