Sarah Gutman is an OB-GYN and complex family planning specialist in Philadelphia. Every week, she prescribes misoprostol and mifepristone. Sometimes she gives them to patients to manage a miscarriage or postpartum hemorrhage. Sometimes, they are not for pregnancy care at all: Misoprostol can prepare patients for a hysteroscopy, IUD insertion, or endometrial biopsy.
Though misoprostol and mifepristone are best known as the two components of medication abortion (referred to by many as the “abortion pill”), what they actually do is help soften the cervix and cause contractions, making them vital for a variety of gynecological uses. Yet because they are involved in medication abortions, Gutman is worried about whether doctors like her will be able to continue offering them. While prescribing misoprostol and mifepristone for reasons other than abortion technically remains allowed everywhere, “abortion bans create confusion, fear, and distrust,” she said. There are already signs that providers, patients, and pharmacists might now avoid these medicines out of fear of being prosecuted. Doctors also worry that medical training in abortion-related procedures, namely dilation and curettage, could be restricted or lost in some states. Besides abortion, these procedures can be used to treat heavy bleeding or evaluate the uterus for cancer.
Despite the shroud of stigma that has been attached to abortion—both surgical and medication—the medical methods behind pregnancy terminations are ordinary, critical elements of routine gynecological care. By creating legal gray areas and exacerbating existing stigma, the reversal of Roe v. Wade may now leave many doctors profoundly limited in how they can treat common health conditions that have nothing to do with pregnancy or abortion. Across the country, there will be unexpected consequences for people seeking care associated with the uterus, ovaries, and cervix—including those already dealing with chronic reproductive illnesses that have long been underfunded, understudied, and undervalued.
This problem stems from a deeper issue with how medicine views “women’s bodies” and particularly the “female reproductive organs.” Like abortion—itself a treatment sought for a number of reasons—these organs have long been culturally deemed as solely reproductive, and their functions viewed as constrained within the limits of producing pregnancies. The language we use to describe them re-emphasizes this bias, implying that their only function is to create a baby, when in fact the uterus and ovaries help support bodywide health and immunity throughout a person’s life. This bias has shaped the direction of American gynecology, which began with efforts to increase the reproductive potential of enslaved Black women. Even today, the Gynecologic Health and Disease Branch of the National Institutes of Health is subsumed under NICHD, the National Institute of Child Health and Human Development.
Likewise, the tools of abortion have come to be considered inextricable from pregnancy termination—erasing the fact that at their core, these are medical technologies with expansive uses and benefits in addition to the lifesaving care that is abortion.
The reality is that medical tools serve a wide variety of purposes, even across medical disciplines. Take misoprostol, for instance: mifepristone’s counterpart in a duo that many know by the name “medication abortion.” Misoprostol initially began as a treatment for stomach ulcers. In the 1980s, activists in Brazil discovered its abortifacient properties and developed the world’s first grassroots abortion pill network. Decades later, this wonder drug is also used to soften or “ripen” the cervix to facilitate hysteroscopy, endometrial biopsy, and the insertion of an IUD. All of these can be performed in the diagnosis, treatment, and management of various chronic illnesses; hormonal IUDs, for instance, are one tool doctors use to manage endometriosis or chronic pelvic pain.
Its slightly less famous cousin, mifepristone—which increases the effectiveness of misoprostol for inducing abortion—can be used in the management and treatment of fibroids and Cushing’s syndrome by blocking progesterone.
These medications are already difficult to access in other parts of the world where abortion is highly stigmatized and restricted—particularly mifepristone, which has fewer gynecological uses. In a 2021 research paper on misoprostol use in Francophone Africa, for instance, medical sociologist Siri Suh described misoprostol as “widely recognized as an essential obstetric medication,” yet added that “the stigma of abortion stalls its integration into routine obstetric care and availability to the public.” Suh’s ethnographic and interview data revealed that misoprostol is highly inaccessible due to a combination of legal restrictions and widespread abortion stigma.
There are already worrying signs of this pattern repeating across the United States. Linda Bradley, an OB-GYN at the Cleveland Clinic in Ohio who specializes in treating fibroids and menstrual disorders, said that recently a post-menopausal patient reported that she had been “harassed” by her pharmacist when she was trying to fill her prescription for misoprostol. This was despite the fact that her prescription was not in a high enough dose to be used for abortion and that “there’s no way a 70 year old’s gonna be pregnant,” Bradley said.
Bradley had prescribed the medication to help soften the cervix so she could perform an operation to remove uterine fibroids, growths that can cause heavy menstrual bleeding and pelvic pain. Misoprostol can be particularly important when doing procedures on post-menopausal women, because the cervix tends to close up and toughen after menopause.
The tools of surgical abortion may also be in peril. This type of abortion can be performed through the dilation of the cervix, followed by a curettage, or scraping, of the uterus, commonly referred to as a D&C. This procedure, which can also involve manual or vacuum suction, removes the current lining of the uterus as well as any other contents, including pregnancy, tumors, infections, or other growths. (For later gestation, doctors typically use D&E, or dilation and evacuation by suction and instruments—which has long been highly restricted across the U.S.)
But D&C is more than an abortion tool. It’s long been used to both treat chronic menstrual disorders and sample the lining of the uterus to check for conditions like cancer. “It’s basically like a biopsy,” said Tami Rowen, an OB-GYN and sexual health expert at the University of California, San Francisco. Doctors use D&C to clear out the uterus after childbirth or miscarriage, and to fully evacuate the uterus following a hysteroscopic surgery for fibroids or uterine cancer. It’s also used to remove the uterine lining (which grows back) in order to treat heavy bleeding stemming from fibroids or polycystic ovarian syndrome. In some cases, a D&C for heavy bleeding can be a matter of life and death.
Yet again, simply because D&C is associated with abortion, increased stigma means that medical residents in states where abortion is banned will likely get inadequate training in this common technique. A study published in April in the journal Obstetricians and Gynecologists predicted that between 43.9 percent and 56 percent of OB-GYN residents would lack abortion training if Roe was overturned. Research on Catholic hospitals in the U.S., where abortion training is already restricted, bears this out: A 2020 survey found that nearly half of OB-GYN residency programs at faith-based hospitals reported their own abortion training as “poor,” with one-quarter of residents not performing enough D&C procedures to meet graduate training requirements.
This is concerning because training in D&C is often how gynecological health providers become comfortable working with the cervix and uterus, said Rowen, which in turn allows them to routinely perform uterine biopsies, insert IUDs, and evaluate uteruses. Even if they still learn the basic procedure, not getting enough practice would mean that they are less competent and capable of handling emergencies. “The lack of abortion access is going to harm our patients,” said Rowen. “But as physicians, we are going to lose the ability to perform a critical skill well. And that skill allows us to help treat patients who have a myriad of gynecologic problems that will help preserve their fertility, treat cancer, and also save their life.”
Being less comfortable with D&C could result in OB-GYNs escalating the procedure: sending patients to the operating room, where they face general anesthesia, higher risks of complications, and greater costs, says Meg Autry, a professor and interim chair of obstetrics and gynecology at UCSF Fresno. “The less experienced you are, the worse it is for the patient,” she said. If providers don’t have the option of misoprostol, there will also be a higher risk of laceration and injury to the cervix and uterus when doing any procedure inside the uterus. Limiting the availability of misoprostol and D&C training “certainly limits what you can offer to your patient and I would say limits the standard of your care,” Autry said. “That’s true for fibroids, it’s true for cervical dysplasia, it’s true for endometriosis, and it’s true for pregnancy.”
“These are incredibly essential tools in our arsenal to try to help women,” added Erin Bradley, an OB-GYN at Massachusetts General Hospital and a district chair-elect of the American College of Obstetricians and Gynecologists. “And who knows? We don’t know what may be next and what we might lose access to in terms of treatment.”
Make no mistake: Abortion itself is routine, lifesaving, essential medical care. Yet labeling the tools of abortion as purely reproductive, and attaching stigma and criminality to these medical practices, harms not only patients far beyond those who are pregnant, but the very field of gynecology. This limited framework mirrors a broader problem in science’s treatment of the “female body.” Rendering the bodies of half the population as purely reproductive has produced countless blind spots in science—overlooking the immensely regenerative properties of these organs, for instance, which could otherwise be used to improve upon various facets of medical research. After all, countless medical breakthroughs wouldn’t have been possible without the cells scraped off Henrietta Lacks’ cervix (and used without permission).
There are myriad examples of how this narrow lens harms medicine: For one, the labeling of endometriosis as purely a “reproductive disease”—rather than one that involves bodywide inflammation—has prevented researchers from exploring potential cures beyond hormones and surgery. The historical overfocus on ovaries as “egg baskets” delayed a broader appreciation that these glands are also responsible for producing powerful hormones that support the heart, brain, and bones throughout a person’s life. And an overemphasis on fertility in medicine often limits patients from being able to choose elective sterilization procedures such as hysterectomy, even when it is critical to their quality of life, because doctors fear they will regret losing the ability to have children.
The divide between “abortion care” and “reproductive health” is one that is made along moral fault lines, not scientific ones. It is impossible to separate out abortions from gynecological health care in general: Just as you can’t “target” your abs with diet and exercise, you can’t simply remove these tools from medicine without expecting dire and wide-ranging repercussions. Abortion bans continue medicine’s tendency to look at the female body as purely reproductive, while making the consequences of this myopic mislabeling more visible and extreme. Anyone with a cervix, uterus, and ovaries—and not just those who can or want to get pregnant—is likely to suffer the consequences.
