![]() ![]() 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). 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 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). 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). 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). Pre-treatment with ibuprofen is no better for pain management than treatment once cramping starts (Raymond et al., 2013). 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. 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). There are few trials assessing effectiveness of pain management strategies during medical abortion before 13 weeks gestation. 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). ![]() 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). Pain typically peaks 2.5 to 4 hours after misoprostol use and lasts around one hour (Colwill et al., 2019). ![]() 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). 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). 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). Pain is the most commonly reported side effect of medical abortion (Fiala et al., 2014). Quality of evidence: Low Pain during medical abortion before 13 weeks gestation
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