It was very pleasing to see a paper reporting a pilot study of Primary care endometrial sampling1as this was something I have been involved with over the last 25 years, although I was a little disappointed that there was no reference to some of the previous work on this subject in primary care2. I published two papers on the subject in 1998, The first considered the end of the operation Dilatation and Curettage (D & C) which until the 1990s had been the investigation of choice for abnormal uterine bleeding and the emergence of new techniques such as Pipelle sampling3. The second paper I published was entitled Endometrial sampling in general practice and was a case series of 38 women investigated for unexpected vaginal bleeding4. I had introduced the procedure to the Honiton Practice in 1993; having held the qualification for intrauterine techniques for many years and having acquired further training from the local gynaecology department and taken advice from the relevant defence unions. It was not part of General Medical Services then and under new general practice arrangements it was recognized as ‘provision of secondary care within primary care’ and remunerated. It is also important to realize that the current 2 week wait referral procedure did not exist and sometimes women with abnormal bleeding could wait quite a while for further investigation. One woman in this study was actually diagnosed with endometrial cancer from the primary care sample. The published study was awarded a local audit prize and I also received a research award from the BMA for it.

I tried to help other practices introduce the procedure with limited success. As further reorganizations of the NHS and primary care happened this important service was rarely recognized and eventually funding ceased although within the practice we continued to provide the service. I hope that this paper1 would encourage a renewed interest in undertaking this procedure in primary care.

1. Dickson JM, Delaney B, Connor ME. Primary care endometrial sampling for abnormal uterine bleeding: a pilot study. J Fam Pann Reprod Health Care 2017;43:296-301

2. Shapley M, Redman CWE. Endometrial sampling and general practice. Br J Gen Pract 1997;47:387-392

3. Seamark CJ. The demise of the D&C. J Roy Soc Med 1998;91:76-79

4. Seamark CJ. Endometrial sampling in general practice. Br J Gen Pract 1998;48:1597-1598

Regarding the Scottish decision on home abortion of 26th October 2017, Lord J, Regan L, Kasliwal A, et al. claim that "Home use of misoprostol in Scotland is relatively new. The larger abortion services in Scotland report widescale uptake of home use of misoprostol among women and that it is highly appreciated with no negative impact on services." The Scottish “abortion services” consulted are not named and the reference for the bold claim that home use of misoprostol is “highly appreciated” is “S Cameron [co-author], personal communication 2018”. Such statements do not inspire confidence.

In response to some other claims made in the article: women having better control over timing in practice will mean less precision in timing, since medical supervision is supposed to guarantee ‘correct’ time between drugs and a ‘correct’ route of administration, whether sublingual, buccal or vaginal. If these are departed from, the effectiveness goes down, and the complications go up. This is well-known.

As regards travel and onset of bleeding, the Creinin paper [1] referred to by the authors had a bleeding onset median time of 2 hours for the standard (misoprostol taken 24 hours after mifepristone), and 3.7 hours when mifepristone and misoprostol were taken together. Others state that the onset of bleeding with the standard regimen was after 2 hours and meant light to moderate spotting at 4 hours after misoprostol [2]. Depending on the travel time, there may be some women who would begin bleeding on the way home from a clinic. However, 30-40% of women will begin bleeding after mifepristone and before misoprostol in any case, and the chance that the abortion would occur on the way home would normally be slim.

If travel time is greater than a couple of hours, it is surely in any case risky to offer a woman misoprostol to take at home because by the same token she would presumably have difficulty accessing emergency care. Rural women without easy access to emergency care are not candidates for medical abortion. This is so whatever our views about whether abortion more generally is in fact ‘care’ or ‘treatment’ for the woman [3], given that her pregnancy is not a disease. We should also bear in mind that ambivalence in women about the abortion decision is common [4] and associated with regret [5]. Indeed, some women having medical abortions refuse to take misoprostol after mifepristone, whereupon the foetus may be found to be still alive, and born without adverse effects [6].

Nor is it clear as to why there should be better emotional support for a woman who takes misoprostol at home rather than at a clinic. Either way, the abortion will happen at home, and if, for example, a partner or family are going to provide emotional support at all to the woman as she loses the baby, there are multiple ways that they can do so. If misoprostol is taken at home, we must face the fact that not only will some women get no support at all but the ‘support’ they will get may be pressure to abort (bearing in mind the strong link between abortion and intimate partner violence ) [7].

A Scottish trial in 2010 surveyed women’s responses and experience of returning home immediately after the administration of misoprostol to abort. 100 out of 145 women answered the survey (making one wonder why 45 did not respond). 12 of the 100 responded that they were extremely upset by the experience. 8 out of 100 were home alone at the time of the abortion [8].

Removing a second visit to take misoprostol, with an increase in complications and side effects, could have a significant impact on resources because of the severity of some of the complications.
It is somewhat ironic that the authors refer to the paper by Lohr et al , which highlights the increased risk of complications when women take mifepristone and misoprostol simultaneously. Lord et al. [9]claim that because 85% of women choose to take misoprostol and mifepristone at the same time at the clinic, this demonstrates “how much of a barrier access is for many women.” Instead, we think it shows two different things. First, that BPAS is prepared to offer a less effective and more risky regimen that they know significantly increases harm to women (perhaps as a wedge to use in campaigning for home abortions?) And second, rather than choosing simultaneous drug taking because of access barriers, we think it just as likely that women choose simultaneous use because all they want is for the horrible process to be over sooner.

The experience is clearly unpleasant with high percentages of women experiencing a lot of pain, excess bleeding, cramps, chills, vomiting, diarrhoea, nausea, dizziness, weakness, fever, and headache. Some figures for these from the three key US trials are as follows: listed as very common (>10%) by the manufacturer of Mifegymiso (mifepristone plus misoprostol) include nausea (30.7 - 69.2%), vomiting (22.3 - 34.1%), diarrhea (31.8 - 58.6%), pain (91.6%), fever (21.3 – 44.3%), chills (36.5 – 44.3%), headache (12.3 – 42%), dizziness 13.1 – 45.5%), and weakness (19.2 – 56.6%). We wonder how many women undergoing this ordeal, many of whom would have been emotionally conflicted about the abortion, were offered help at any stage to have their baby.

I am grateful to Dr Greg Pike for the use of his research materials.

[1] Creinin M et al. (2007) Mifepristone and misoprostol administered simultaneously versus 24 hours apart for abortion. A randomized controlled trial. Obstet. Gynecol. 109(4):885-894.
[2] Sitruk-Ware R (2006) Mifepristone and misoprostol sequential regimen side effects, complications and safety. Contraception 74:48-55.
[3] McCarthy A (2018). Abortion Matters. Philos Educational Publications.
[4] Kero A, Högberg U, Jacobsson L & Lalos A (2001) Legal abortion: a painful necessity. Social Science and Medicine 53:1481-1490.
[5] Kero A, Högberg U & Lalos A (2004); Wellbeing and mental growth – long-term effects of legal abortion. Social Science and Medicine 58:2559- 2569.
[6] Delgado G et al. (2018) A case series detailing the successful reversal of the effects of mifepristone using progesterone. Issues in Law & Medicine.33(1): 1-12.
[7] Pallitto CC, García-Moreno C, Jansen HAFM, Heise L, Ellsberg M & Watts C (2013) Intimate partner violence, abortion, and unintended pregnancy: results from the WHO Multi-country Study on Women’s Health and Domestic Violence. Int J Gynecology Obstetrics 120:3-9.
[8] Cameron S et al. (2010) Women’s experiences of the final stage of early medical abortion at home: results of a pilot survey. J Fam Plann Reprod Health Care 36(4): 213–216.
[9] Lohr PA, Wade J, Riley, et al. Women’s opinions on the home management of early medical abortion in the UK. J Fam Plann Reprod Health Care 2010; 36:21-5.