Radiolab - Abortion Pills, Take Two

Episode Date: April 14, 2023

Abortion pills — a combo of two drugs, mifepristone and misoprostol — are on notice: on April 7, 2023, a federal judge said the FDA’s approval of mifepristone was invalid. And then, not more than an hour later, another federal judge in a separate case said that mifepristone had to stay on the market in certain states. With these two contradictory rulings, mifepristone — and medical abortion, in general — is in the crosshairs. So, today, we want to rewind to an episode we made last year. It looks at these two drugs over the last 40 years, from their origin stories and development, to how their administration from doctors to patients keeps evolving. This story, for us, started… Special thanks to Mariana Prandini Assis and Pam Belluck. EPISODE CREDITS  Reported by - Molly Webster, Avir Mitra Produced by Sarah Qariwith mixing help from - Arianne WackFact-checking by - Diane Kellyand Edited by  - Becca BresslerCITATIONS: Articles: From one of our sources, Abigail Aiken: “Safety and effectiveness of self-managed medication abortion provided using online telemedicine in the United States: A population based study” (https://zpr.io/kG3hNFXM4kb9) Our newsletter comes out every Wednesday. It includes short essays, recommendations, and details about other ways to interact with the show. Sign up (https://radiolab.org/newsletter)! Radiolab is supported by listeners like you. Support Radiolab by becoming a member of The Lab (https://members.radiolab.org/) today. Follow our show on Instagram, Twitter and Facebook @radiolab, and share your thoughts with us by emailing [e-mail] Leadership support for Radiolab’s science programming is provided by the Gordon and Betty Moore Foundation, Science Sandbox, a Simons Foundation Initiative, and the John Templeton Foundation. Foundational support for Radiolab was provided by the Alfred P. Sloan Foundation.

Wait, you're listening to radio lab from W and Y. Hey, this is Radio Lab. I'm Laptop Nasser. I'm Lulimiller. And we find ourselves, as sometimes we do, in a moment where we're thinking back to an old episode we did, because the topic we covered is sparking all over the news right now.

Yeah, and that topic is the quote unquote abortion pills. Yeah. And on April 7th, 2023, which for us is also known as last Friday, a federal judge in Texas ruled that the FDA's approval of one of those drugs, Mifopristone, was invalid. According to him, it should have never been approved. And later that day, an hour or so later, in an entirely separate case in Washington state, a federal judge ruled seemingly the opposite that the FDA must continue

to make MIFA Pristone available in certain states that same drug. And then on top of that, there have been multiple motions to appeal that first Texas ruling we talked about. Very chaotic, a lot going on for the time being MIFA Pristone is still available, but this all means that these cases will likely work their way up the federal court system, and we will eventually see rulings that could have real staying power and real consequences. And so, given that there is suddenly so much attention on this pill, we wanted to share with you a story we did back in the fall of 2022, last fall, about these very

pills. And actually, in particular, because this Texas judge in his ruling made an explicit argument about the safety of this drug and the approval process, and actually, that's exactly what we cover in this episode. Yeah, you can think of it as a profile of these pills. These pills are sort of characters, and we really go into the science of them, their origin story, how they interact with the human body and what their real risks are or aren't it came to us

Originally from our senior correspondent Molly Webster and contributing editor an ER doctor of your METRA So we'll start it off with them. I don't know. I was just gonna say a beer you start Okay, a beer is gonna tell you a story. Yeah. A love and a beer story. All right. Cool. And we should say before we get rolling, this story talks about abortion and has some kind of graphic descriptions. So if you don't want to hear that today, this is a good one to skip. Right. So I guess this one started because for, okay, for me growing up, my mom, she's a obi guy. And I just remember her telling me about stories

of her performing abortions back in her day. This would have been like the late 70s. Wait, wait, wait, wait. I'm just picturing like, Muppet Baby of Year. Like, even before you were a doctor, your mom would tell you doctor stories. Yeah, I just grew up around so many medical stories,

both my parents or doctors, that we talk about things at the dinner table that a normal family would be horrified, they would be actively vomiting and I'm so like, oh yeah, past the salt, please. So basically, when she would talk to me about these procedures, they were pretty invasive. It was not a small deal, if that makes sense.

And even now, in a hospital or clinic, it's pretty safe, but it's still something we take seriously. I mean, it's safe because we take it seriously. So, for the last couple months, ever since the Supreme Court decision about abortion, I've been thinking about, like, what is this going to mean for us in the emergency department now that we're living in this post-Row world?

Because, you know, like, regardless of what you think about abortion, if people aren't able to get them, I'm anticipating a lot more patients showing up in the ER with like complications or people who've attempted to do their own abortions and hurt themselves in the process. Yeah. So basically, you know, now at my job, you know, I have to occasionally organize conferences to teach ER residents things. And so I ended up hosting this OB doctor named Laura McEizek, where I work, who for many years has been running the division in my hospital that deals with the abortions that we do.

Now, what I was anticipating was sort of like this high drama, ER type of lecture of like, all right, when a patient comes in with a coat hanger abortion, these are the things you gotta think about, it's gonna be sepsis, here's how you evacuate, or you know, uncontrolled bleeding, where you, you know, what type of blood are you gonna do, how are you gonna match the blood?

This is what I was in my mind picturing the lecture would be about. But it actually wasn't like that at all. What she sort of talked about ended up kind of blowing my mind in a completely different way. Huh? So I emailed Molly and I was like, Hi, how's it going? How's it going? How's it going? How's it going? How's it going? How's it going? How's it going? How's it going? How's it going? How's it going?

How's it going? How's it going? How's it going? How's it going? How's it going? How's it going? How's it going? How's it going?

How's it going? How's it going? How's it going? How's it going? How's it going? How's it going? How's it going? How's it going? How's it going? How's it going? How's it going? The actual practice of it has been really on its own trajectory. Since I've been doing this work, it's changed probably more than any other thing I can think of. For the majority of abortions happening today, we're not talking about surgeries.

No, it's with the medications to induce abortion, pills. And while I knew that you can take pills to induce an abortion, I hadn't really thought about like how much this really does change everything about what it means to get an abortion. And how much of that has really just happened in the past few years since COVID and in a weird way because of COVID. Okay, so the story starts back in the 80s. Groovy Wade just happened and you have greater access to abortions and the way that we did abortions was surgically, right?

So it was like the woman, you know, it's put on a table, she's given anesthesia, someone actually had to go into a woman into the cervix and pull out the growing embryo or the growing fetus. And that's just sort of the way it was. Until two things start happening on opposite sides of the world. The first one is in Brazil. So in Brazil, abortion was illegal. And Brazilian know, when they would have an unwanted pregnancy, right? They would go into a pharmacy and they saw on these ulcer drugs that there was like a little sign that says like don't take this in pregnancy. Oh, interesting. So they started taking it.

And surprisingly, it worked. It would cause an abortion. And how does that work? How does it do that? Well, so that drug it's called misoprostol. Misoprostol is a prostaglandin. And prostaglandin is something that we make in our body and it does a bunch of different things all over the body. One of them is healing ulcers, but another one in the uterus,

it causes it to basically contract. That's it. And so if you're pregnant, you know, that can just basically make the uterus flush the embryo out. So just, it just basically, physically ejects it. And so it induced abortions, but no one really knew like how much to take and stuff. And it was like, do I take it in my mouth? Should I shove it up my vagina

and like get it near my cervix or my uterus? No one knows. Sure. So really what they were seeing is that sometimes it didn't work. Right. So that's misoprostal, which works some of the time. Okay. Right.

So meanwhile, while all this is happening in France, you have a doctor, Etienne, a meal, bull, you. And his whole idea was like, well, in the early stages of pregnancy and throughout pregnancy, we really need progesterone. Right. Because progesterone helps the uterus build up a thick layer of like bloody tissue that can support a possible pregnancy. And the embryo, you know, needs to implant into that tissue.

And so he was like, well, if we know that the body has to amp up progesterone in order to facilitate a pregnancy, what if I did something that like interrupted that? And so he and his research team develop this drug called RU486, otherwise known as Mifopristone. So Mifopristone is basically a progesterone blocker. And so when you take Mifopristone, that layer can't grow, and essentially that signals the body to shed that layer. Then essentially you're just saying like, you just say, nope. No place for you to implant here.

Yeah. Move along. So that's Mifopristone. There's one problem though, which is that Mifapristone will cause the uterus to be an unfriendly place for the embryo, but it won't then actually expel that embryo. And so you need to combine something

with Mifapristone to make it flush out the uterus. So then the doctors in France are like, wait a second, we're hearing about this ulcer drug in Brazil that's kind of doing what we need. And so what if we take that and combine the two? Because then the mesoprostal would get your uterus to like force out the stuff that has dropped off the edges of your uterus. Yep. Oh, that's very vivid and clear. Okay. Yeah. Yeah.

And then when they combine these two, what they see is like a 95% success rate and it's very safe. Avala, they created the abortion pill. Okay. So in 2000, the Mithymiso pill combo comes to the market in the United States. Oh, wow. So that's like, that's years later. Yeah. So basically, like, there was, like, scientific testing we had to do in the United States. Oh wow, so that's like years later. Yeah, so basically there was scientific testing

we had to do in the States, but then there was also all this politics because it is like an abortion drug. But eventually they get approved, though even then there were still all these hoops that doctors were jumping through to get it to patients. Yeah, like what? Like for example, doctors would run all these tests. You through to get it to patients. Yeah. Like what? Like, for example, doctors would run all these tests.

You had to check blood count. This is Laura MacEyzek again. So you'd have to draw blood. To make sure, is this person Benimic? We used to do a blood type. Check their liver function. Do an ultrasound and make sure that it was not a nectopic pregnancy. Every once in a while, a pregnancy will implant somewhere outside of the uterus.

If it's in a fallopian tube, that as it grows, it will rupture the mom's fallopian tube. And these hills do work for that or don't work for that? No, it wouldn't work for that. It would not. No, because you know, you are flushing out the uterus, but if the embryo is not in the uterus, it's just gonna keep growing.

Right. And so that's like a super dangerous situation that this situation can happen in any pregnancy, but it can also happen in this type of scenario. And I should say that you didn't have to do all these tests. Doctors just did them out of precaution, but there were some things that doctors had to do. Like the FDA rule was that they actually had to give

the patient the pills in the office. Like sit there and watch the patients take the pills. Like literally watch them ingest the pills in their mouth. Yeah, exactly. Is this all in one visitor, we at multiple visits at this point, to get all of that done? Yeah, it initially could take two visits. We too, why all the regulations and the testing was it because of politics or because of science, safety, stuff? Well, there was a little bit. It was some of it was politics, but then you also have to remember like

the day before these pills came out, the abortion was a surgery. You know, we can't forget that reproductive events, abortion, miscarriage, childbirth can be fatal, right? I mean, Laura was like, don't get me wrong, most of the time these things go fine. Totally. But when it doesn't, it is scary, and you have to act fast, and the light bulbs have to go on, and say, something's not right here. Why does she have a fever? She might be septic. I'm not going to leave her side till I figure this out. So it's not like bad shit never happens. And honestly, even when everything's going right, there's like you, you're heavy bleeding,

there's uterine contractions, there could be vomiting or diarrhea. It's a full body experience that can feel and be scary, even if it ends up being okay. And for folks where it's not okay, they'd have to get themselves to a hospital or a doctor or even get a surgical abortion to complete the procedure. So I did find myself when I was talking to Laura, like saying, as the person who could bleed from these pills, like I appreciate the guard rails because I have just a lot, I'm a person, I have a lot of questions all the time.

It's why I'm in the job that I'm in. If I could just have a little doctor living in the corner of my house, I would be the happiest person ever. How good is it they have to be? Yeah, I would just be. Here's applying for the job, basically. I know.

There's an opening. So I would be the happiest person. You know, so I understand like knowledge, say, CH. Totally, totally. The one thing with all these guardrails, though, is that guardrails do make it hard to get these pills to patients, right? You're missing work for all of these visits.

All these tests are expensive. Yeah, yeah. So to sort of like advance the story, right? This is the state of play in 2000. And the Miffi Miso abortion is approved for up to seven weeks. Okay. Now, over time, like the next couple of decades,

doctors are starting to, and these are obese specifically, right? They're starting to experiment and test the boundaries of clinical practice. So- Someone tries an experiment, meaning a scientist? Yeah, like a researcher doing a clinical trial. So the initial dose of Mithoprystone was 600, I think, milligrams.

Yeah. They try, well, maybe we could, this is pretty high. Let's try 400, same efficacy. Then they cut it down to 200. Same efficacy. So the dose is going down. The weeks are going out because remember at first you could only give the pills up to seven weeks. And that's not that much time considering, you know, it's typically going to be four weeks by the time you realize you missed a period. And then you have to get all your shit together, get these labs done, come back, get the ultrasound, you know, it doesn't bias that much time. So it started at seven,

then they tried eight, still works, tried nine, still works, 10, still works. Meanwhile, the labs that are being drawn, doctors are starting to think, well, do we really need this lab, the type in screen where we check the mother's blood type, do we really need that? And experimenting with taking that out, nothing bad is happening. The CBC, you're looking for anemia. Well, turns out, you can just ask someone if they have anemia. They take the CBC out. And I just want to say, a lot of this experimentation started in other countries.

So it'd be like, oh, the UK is doing it this way now. That's interesting. And then, you know, Sweden would do something. And then France would try something. Right. So basically what you see with these pills is just this kind of steady, steady step of progress in the science around them and the ways

that we give them to people. And then COVID happens. And almost overnight, everything about the way we use these pills changes in a huge way. When we come back, the abortion pills and the pandemic face off, stick with us. Lulu. Lutth. Aveer. Molly. Radio lab. Okay. So now it's the beginning of 2020.

And these pills are around, they're becoming more and more common. Yeah. So nearly half of abortions in the United States are happening because of these pills. And then, COVID happens. Everything changes. Women still need to have abortions and the ACLU leads a lawsuit against the FDA, basically saying that forcing patients to come into the office

to get these pills poses a huge medical risk to both the doctor and the patient. Now because of COVID, right? Because of COVID. Right, and they win. So now patients don't have to come in to the office to get these pills. Yeah, and on top of that,

doctors did away with ultrasound and testing for all but the most high risk patients. So now all of a sudden, the majority of abortions are happening over a video chat. They're essentially becoming like, quote, no touch. No touch abortion. That's Laura MacEysec again. Was that like for people who are doing this?

Was that a huge moment? Huge. When telehealth abortions first started, I remember my first feeling was, oh, some bad things are going to happen. We're going to miss some of the topic pregnancies or patients are going to estimate their gestational age poorly. I'm just used to doing it with patient in front of me. And medicine, you know, it's like we're super conservative. We don't want to rock the boat. We, one mistake makes us all feel terrible. Even if 99 of the rest of the time it went

fine. But it turns out, telehealth abortion and in-person abortion have the same outcomes. There's absolutely no difference. Oh my gosh. Really? Nothing? Nothing? Nothing. So the efficacy rate is the same, right? The failure rate is the same. The adverse event rate is the same. That's why else.

So it's like the worries may have been legit, but the worries were in vain. Yes, yes. Wow. I'm kind of shocked. Like I feel like especially when COVID first hit, like there are were in vain. Yes, yes. Wow. I'm kind of shocked. I feel like especially when COVID first hit, like there are all these stories of like, like it's like people doing Zoom funerals and Zoom weddings and those are all, and then but like nobody was talking about Zoom abortions going on some time.

Yeah. Exactly. And I mean, Laura's take on it is that like all of this happened precisely because, you know, there was so much else going on. And neither the pro-borsion movement or the anti-borsion movement even got the chance. They were too distracted by COVID to be fighting these...

Fighting over how doctors should be doing these abortions. Huh, wow. Yeah. But there's actually one more thing that Laura told us. It's zoning in on the US. Something that almost feels like a signal of what abortions might look like in the future. So this nonprofit called AID Access

has been providing women with MIFA, Pristone, and Misa Prostol through the mail. And AID Access is the US branch of this abortion provider that is literally mailing abortion pills all around the world. And it's run by this European doctor who has developed a company to practice essentially in other countries where access to abortion is really limited. What you do is you go online, you fill out a questionnaire and then

a doctor on the other end would read it and If they felt like you qualified to you have a medical abortion They would mail you the pills directly to your house in the first two years of the service There were 57,506 requests from people in the United States and they came from all 50 states This is Abigail Aiken professor at the University of Texas Austin. Abigail and her team looked at data from almost 3,000 of those patients and we found that 96% of people were able to end their pregnancy

without any intervention from medical provider. How does that compare to the same statistics for if this is done in a clinic setting? Yeah, that's a clinic setting. Yeah, that's a great question. So these results in terms of effectiveness are really on par with what you would see in the clinic setting. Yeah, again, same results, no greater adverse events,

even when a doctor and a patient weren't speaking to each other at all. And can I just say also that there was this other result that was very interesting. There were actually several topics, not many, a handful, maybe five and one study three and the other that were diagnosed by the service at the time of consultation. So the person would share symptoms of some kind, and they would say, we think that's probably an end topic. You should go get that checked out before you proceed with this.

And they would actually get into care earlier than if they had waited until they had severe abdominal pain and vomiting. So you mean it's like the form that they did sort of flag them? Yeah, exactly. Wow. Yeah. So it's a crazy study.

This is the idea that had been percolating and aid access is definitely the vanguard, but it's this idea of the self-managed abortion. And I think of it like Molly's probably tired of me here saying the same metaphor. Never, never. But Jenga, I just played it the other day. I see this whole thing like a game of Jenga, right?

How? When the medicines come out, we have a perfect block of Jenga, you know, like the whole structure is there. And as physicians were very scared to take things out of this structure, but we start saying, well, you know, really, I don't know if we need this particular lab, hepatic function, whatever. Let's take that out. Structure still stands, you know?

Boom, boom, we keep taking out different parts of this jenga tower. With COVID, huge chunks of the jenga tower come out. Structure still standing. And so what's incredible is just the amount of pieces we've been able to take out of this jenga tower and have it still stand. And really what's the last piece that is always there is the doctor, you know. We put ourselves at the center of this whole process, partially out of care, but partially probably out of some hubris, I would say, you know. And so taken to its fullest, the self-managed abortion is really saying, what if there's no face-to-face contact with the doctor at all? What if you fill

out a form and if you check the right boxes on this form, then you're just good to go. You do this completely on your own. And so that idea, I think, is subtle, but from my perspective, it's profound. There is no doctor directly involved in your care. You know, it's like getting like a IKEA couch, you know, it's just like, here's the instructions. So what, so like, what does this mean?

You know, that's what that's what I keep asking myself is like, so what? And right now 90% of abortions are happening in the first trimester where you could potentially use these pills. And so the so what to me is that like, what these pills are telling us is that we now have the ability to take abortions, a good chunk of them, outside of clinics, outside of hospitals, outside of institutions,

and put them into the hands of people, which I think is just such a cool and interesting trajectory. That said, one thing I think important to note is that we're talking about abortions with pills, but there are a chunk of people for whom that doesn't apply at all. They need to get the old school, you know,

surgical abortion and that's fine. But the percentage of people getting an abortion using pills, it's literally just a line graph that just keeps going up every year. And it's really just happening because of the science of these pills. It's, can I just say it's like so funny to hear you both tell this story because it's like we're

so used to every story about abortion. It's all about the politics. It's like so politically drenched. It's like every single little detail about it is like a culture war. But what you're telling is like the story that seems like there's no politics in it really. Right. Or very little. Which is kind of surprising to me. It's like making me do a double take kind of. That's what I think is so incredible. Science moves based on science. More or less. I mean, obviously there's politics involved, but in this case,

I'm seeing that these pills keep moving and moving and moving in the same direction. It's bigger than politics. It's bigger than the Supreme Court. It's bigger than all of that. Contributing editor of Vier Métra and senior correspondent Molly Webster. So that was the piece we played just a few months ago. At the time, it seemed to us, at least, like it really, really was mostly a science and medicine story, but obviously, now, the law and the politicians have caught up,

and now this pill is sort of in the crosshairs. But we should say for the moment, this pill, Mifapersonerson is still available at pharmacies, and it doesn't seem to be affecting the work of aid access. Yeah. We mentioned that sends patients abortion pills through the mail. So thanks for listening.

Stay tuned. Gradio Lab was created by Jad Abumrath and is edited by Soren Neweller. Lulu Miller and Labdith Nir are our co-host. Susie Leckinburg is our executive producer. Dylan Keith is our director of sound design. Our staff include Simon Adler, Jeremy Bloom, Becca Brusler, Richard Cusick,

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