“Feelings and emotions associated with an unwanted pregnancy are more universal than we might think.”
That’s what Wendy Sheldon, a senior consulting associate at Gynuity Health Projects, a New York City-based reproductive health institute, said about the results of a study she conducted into the idea of “missed period pills.”
The study, published in the journal Contraception, explored a concept unfamiliar to most people in the United States: using medication to treat delayed menstruation and induce bleeding, without first confirming pregnancy.
To examine the potential of missed period pills, Sheldon spoke to Cari Sietstra, a principal at Cambridge Reproductive Health Consultants, and Sewa Adekoya, the owner and CEO of Local Mystic, a Los Angeles-based digital consultancy. The discussion has been edited for length and clarity.
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Sewa Adekoya: Hi Cari and Wendy, I am guessing you are as excited as I am to take a breather from wondering what fresh new hell the previous right-wing, anti-person-of-color administration had in store for us, and instead to think about how we, as advocates, can create new, innovative strategies to improve reproductive health and justice in the new Biden administration.
Cari Sietstra: Yes, absolutely. Systemic inequality in health care continues, and we know that courts will keep restricting access to reproductive health care. And yet we have an opportunity to build and envision again, and to think through new, creative ways to expand access and meet people where they are in terms of their health.
Wendy R. Sheldon: One option that’s not yet available in this country but would be desirable to many people is what we’re calling “missed period pills.” A key benefit of missed period pills is they can enable people to bring on a period when they want to, on their own terms, and to take control over their reproduction without being constrained by other people’s definitions of pregnancy, abortion, or other terms that may not reflect their beliefs or lived experiences.
SA: I am really stoked to discuss this new idea that you and others are working on. So to begin, what exactly are missed period pills? Do they make a person miss or skip a period?
CS: I love this question! No, these pills won’t cause someone to miss a period; it’s quite the opposite. These pills “bring down” a period when it’s late and someone doesn’t want to be pregnant. This intervention can also be referred to as menstrual regulation, “pushing” a period, or inducing a chemical pregnancy. It’s important to note that a person doesn’t have to be pregnant to use missed period pills, but if they are pregnant, the pills will end an early pregnancy.
SA: What are the benefits to using missed period pills? What’s the difference between missed period pills and abortion pills?
CS: We use the same pills for missed period pills that we do for medication abortion. The medicines are misoprostol and mifepristone—and they can be used together or we can use misoprostol alone. Given how much we know about the safety and efficacy of these medicines for abortion and other medical conditions, we are confident that they can also safely be used for early missed periods.
When pregnant people use these pills for an abortion, they are intentionally ending a confirmed pregnancy at least six weeks after their last period. In contrast, when people use them as missed period pills, the medicines bring on a late period. Through this approach, folks are choosing not to confirm or rule out a pregnancy beforehand.
People can take missed period pills as early as three to five days after a period is expected to arrive. This is far earlier than the 14-day wait for an abortion. Missed period pills may also fit well for people who want to take care of their late period at home, rather than going to a clinic.
WS: Missed period pills can also provide the psychological space for people to define what’s happening to their bodies on their own terms, consistent with their beliefs. For me, this is one of the most liberating and appealing aspects of this idea, especially in the U.S., where views about reproductive processes and interventions are so rigid and polarized.
SA: That’s incredible! So why haven’t I heard about missed period pills before? Are they available in the U.S.?
CS: Missed period pills are currently available in other countries, such as Bangladesh and Cuba, but not in the U.S. Although the pills themselves are available in the U.S. for abortion and other medical conditions, these medications are not yet provided for missed periods.
SA: How did you both become interested (or even aware!) of missed period pills?
CS: I spent years working on safe abortion in Southeast Asia, and learned about menstrual regulation from Bangladeshi colleagues and traditional pharmacists in Myanmar.
Then when I would come home to my two young sons in Park Slope, Brooklyn, I would be fascinated that highly educated, late-30s moms would talk about their journeys with IVF in ways that also made me think of menstrual regulation. I would hear conversations like, “Well, before we had Zoe, I had one miscarriage and at least three chemical pregnancies.” And I remember thinking, “Wait, what is a chemical pregnancy?” Turns out, it’s a patient-driven term that describes receiving a positive urine pregnancy test, only to have your period start in the next 24 to 72 hours before confirming the pregnancy via ultrasound.
Women were talking about this experience of losing a potential, early pregnancy as being different from losing an established pregnancy. I thought it was so interesting that on opposite ends of the Earth, there are similar concepts that a person can be just a little bit pregnant, or possibly pregnant, and that when bleeding happens very early on, this is different than having an abortion or miscarriage.
WS: I also learned about menstrual regulation from colleagues in Bangladesh and other settings where medicines are used to “bring down a period.” I was intrigued that such an option was acceptable in Bangladesh where abortion isn’t legal, and wondered if it might be of interest in a place like the U.S., where abortion is legal but stigmatized and often difficult to access. I wondered if people in the U.S. might want the freedom to choose for themselves whether or not to confirm pregnancy before taking medicines that might disrupt or terminate a pregnancy.
So I did a study to explore potential interest in missed period pills in two U.S. states; the results of it were published online in the journal Contraception.
SA: Wendy, could you share a little about your study with us? What was your hypothesis? And what did you find?
WS: The study was carried out by Gynuity Health Projects and reproductive health centers in two states, one red and one blue. We enrolled nearly 700 people seeking pregnancy tests at the centers. We told participants about missed period pills, emphasizing that they weren’t yet available in the U.S., and then asked about their interest if missed period pills were available. We hypothesized that one-third of participants would be interested and that interest would be greatest in the red state, due to the more conservative context. We also thought that desire to avoid abortion stigma would be a key reason for interest.
It turned out that interest was greater than we expected. Overall, 42 percent of participants and 70 percent of those who would be unhappy if they were pregnant expressed interest. There were almost no differences in interest between the two states and very few differences by education, ethnicity, religious affiliation, or frequency of religious attendance. The most common reasons given for interest were to prevent, avoid, or terminate pregnancy, or ensure one is not pregnant; and anticipated psychological or emotional benefits, including management of abortion stigma. The main takeaway was that if missed period pills were available in the U.S., interest would probably be substantial and wide-ranging across demographic groups.
SA: It was refreshing to see the truly diverse survey of women in your study, as personally I’m always conscious that medical initiatives are accessible to, and representative of, marginalized people. In your findings, what were some of the commonalities among these women? What stood out, or surprised you?
WS: I was a little surprised that there were no significant differences in interest by participants’ background characteristics, with the exception of age—older participants had more interest. The factors that were most correlated with interest were reproductive practices (e.g. prior use of contraception), pregnancy feelings (e.g. unhappiness about being pregnant), and abortion attitudes (e.g. believing that many people in one’s community think abortion is wrong).
This tells me that feelings and emotions associated with an unwanted pregnancy are more universal than we might think, and that missed period pills could be of interest to people from a wide range of backgrounds.
SA: Missed period pills may be a new thing to me, but Cari, you’ve previously written about how these interventions are actually quite traditional. Can you explain what you mean by that?
CS: For hundreds of years in the American colonies and the early United States, it was both legal and culturally acceptable for people who might be pregnant to do things to bring down their cycles. “Regulating menses” by taking herbs or teas was legal up until “the quickening,” when a pregnant person could feel the fetus move inside them—about 14 to 16 weeks into a pregnancy. This notion of pregnancy as a binary event, as a yes/no, or a “+” or “- “ on a pee stick, is really quite new. Whereas ideas of uncertainty, possibility, and options at the beginning of a potential pregnancy are far more traditional in the U.S., and in many other cultures as well.
SA: I find it interesting that we use the language of the missed period pill as an “intervention”—it’s nice to consider this as an option. An option that’s more patient and understanding of one’s actual circumstance; an option that’s arguably more removed from the emotional guilt and societal pressure of the word abortion. Is that a fair statement to say? Or rather, how does this help define more “patient-centered care”?
CS: I think option is a great term. We sometimes also talk about a spectrum of choices—from precoital contraception like condoms and birth control pills, through post-coital contraception like emergency contraception, and then on through missed period pills and abortion. People may want to choose missed period pills for many, many reasons, and for some, abortion stigma may be a part of their choice. But it’s really important for those of us who work in reproductive health to never reinforce stigma around abortion, while we also make sure we meet folks where they are. So if this option is a comfortable, positive one for many people, it’s a choice we can embrace on a full spectrum of care, even as we work to diminish stigma around other choices.
SA: What is your hope for the future of missed period pills? What are steps we can take to bring awareness of and access to missed period pills for those who desire them?
CS: Right now, we are both working on studies to develop data on the medications’ efficacy and acceptability as missed period pills, as well as on research analyzing what folks would call these pills if they were more widely accessible. My hope is to make the pills more easily available through a pilot project within the next three to five years.
WS: My hope is that if people in the U.S. do want missed period pills, then clinicians, advocates, researchers, and others in our field will come together to make this option available and widely accessible. An important first step would be for those who support this idea to share information about missed period pills with their communities and social networks, and to begin demanding that missed period pills be made available to those who want them.