Opinion: Telehealth abortion with mifepristone continues, with backup plans still in place

OpinionFirst Opinion Telehealth abortion with mifepristone continues, with backup plans still in place Mifepristone regulations, if they come to fruition, won’t mean the end of telehealth abortions Manage alerts for this article Email this article Share this article By Christine HennebergMay 15, 2026 Henneberg is a women’s health physician and a writer. On Thursday, the Supreme Court ruled that one of the drugs in a highly effective two-drug regime for medication abortion can remain accessible via telehealth and mail — for now. The decision comes after a chaotic weekend in April in which the 5th Circuit Court of Appeals prohibited providers from remotely prescribing or mailing mifepristone. The plaintiff in the case is the state of Louisiana, which claims that telehealth prescribing of a mifepristone undermines that state’s strict abortion ban. The 5th Circuit ruled that former Risk Evaluation and Mitigation Strategies (REMS) prohibiting remote prescribing of mifepristone, which the Food and Drug Administration lifted in 2021, should be reinstated while Louisiana’s case proceeds. The Supreme Court has now reversed that order — although the case will continue to make its way through the courts.Advertisement Since REMS restrictions on telehealth prescribing of mifepristone were lifted during the Covid-19 pandemic, and following the overturn of Roe v. Wade in 2022, the demand for telehealth abortion has surged. At the same time, multiple studies have shown telehealth medication abortion to be as effective and safe as in-person abortion care. Current estimates are that about one-quarter of all abortions in the United States are prescribed via telehealth — a doubling since the overturn of Roe. For abortion-rights advocates and providers like myself, and contrary to the claims of the anti-abortion plaintiffs, restricting telehealth prescribing of mifepristone won’t spell the end of telehealth medication abortion. Providers have other highly effective pharmacological methods with which to terminate a pregnancy — although pivoting to any of these methods will have significant implications for patients. In the simplest terms: Doctors have a duty to offer the highest standard of care to our patients. If Louisiana and anti-abortion advocates succeed in further limiting the use of mifepristone for medication abortion, they will be directly interfering with that duty. Instead of saving “unborn children,” they will be causing unnecessary suffering and harm to pregnant women.Advertisement Mifepristone works by blocking progesterone, a key hormone for sustaining a developing embryo. Although it was approved for use in medication abortion in Europe in the 1980s with an outstanding safety and efficacy profile, the FDA approval process in the United States dragged on until 2000. During that time (and well before), U.S. doctors and researchers were using and exploring other methods to help women safely terminate their pregnancies. Beginning in the 1970s, misoprostol, which is now used alongside mifepristone as part of a two-drug regimen, was used alone for medication abortion and miscarriage management. Misoprostol is a prostaglandin. It causes uterine contractions and often all sorts of unpleasant side effects, including nausea, vomiting, diarrhea, and flu-like chills. Mifepristone works to enhance misoprostol’s effects. Without mifepristone, misoprostol is just as safe but slightly less effective at terminating a pregnancy. Women typically need to take repeated doses, sometimes over several days. The process can be long, cumbersome, and unpleasant, and more women ultimately need follow up care for an incomplete abortion, compared with women who use the two-medication regimen. In the 1990s, awaiting FDA approval of mifepristone, researchers began studying methotrexate as a possible agent to combine with misoprostol. Every ER physician knows methotrexate as the folic acid blocker and chemotherapy agent used to terminate ectopic or “tubal” pregnancies. (Misoprostol, which induces contractions, doesn’t work for pregnancies located outside the uterus.) The thought by researchers was that, like mifepristone, methotrexate might enhance misoprostol’s effects, effectively speeding up the medication abortion process — but this isn’t exactly what happened. The protocol required that methotrexate be administered three or in some cases seven days prior to the misoprostol, rather than the typical 24-48 hours between mifepristone and misoprostol. In some cases it took weeks for women to completely expel their pregnancy.Advertisement And methotrexate was cumbersome in other ways: It’s often given as an intramuscular injection (although an oral formulation is also available), making it harder to stock and administer. Patients must also undergo laboratory monitoring of their liver and kidney function. In the current climate of abortion access in the United States, methotrexate simply doesn’t offer a fast, effective, easy-to-administer alternative to mifepristone — particularly not for telehealth medication abortion. Some promising new options are on the horizon. Over the past decade, multiple trials have investigated letrozole, an oral aromatase inhibitor used for ovulation induction and breast cancer treatment, as an alternative to mifepristone. To date, however, the only regimen with comparable efficacy requires dosing the letrozole in three separate doses over three days, followed by misoprostol. Absent further study of a more efficient letrozole-misoprostol protocol, misoprostol alone remains the preferred alternative regimen. Most recently, a study of ulipristal acetate, an FDA-approved drug for emergency contraception, found that a combination of a single oral dose of ulipristal (double the dose used for emergency contraception) followed 24 hours later by misoprostol had the same efficacy as the mifepristone-misoprostol regimen. When these “proof of concept” results were published in 2025, they were greeted with “both optimism and concern,” as Daniel Grossman, a professor of obstetrics and gynecology and director of Advancing New Standards in Reproductive Health at UCSF, noted in an accompanying opinion piece. The worry, as Grossman put it, is that “in the current political environment in the United States, if efforts to restrict mifepristone were successful, there may be little that could be done to stop similar efforts aimed at a pharmaceutical alternative.” For now, ulipristal is far from being ready for use outside of a research setting. Meanwhile, misoprostol alone continues to be a well-studied, safe, effective alternative to mifepristone and misoprostol. Unfortunately — and tragically for women already struggling to access care — expelling a pregnancy with misoprostol alone can be a prolonged and difficult process. That’s precisely why mifepristone was hailed as such a game-changer when it arrived on the scene: It made medication abortion — already safe — faster and easier for women.Advertisement Yet in many countries in the world, misoprostol alone remains the best or only available regimen for medication abortion and miscarriage management. Depending on how the mifepristone lawsuit plays out, this may soon be the case in the U.S. One doctor told me before the Supreme Court’s ruling Thursday that large-volume U.S. telehealth providers are already poised to pivot to prescribing misoprostol alone. Other alternative regimens (such as methotrexate, letrozole, and ulipristal) simply aren’t practical — at least not yet. Regardless of the case’s ultimate outcome, safe and effective medication abortion, including via telehealth, isn’t going away — but our most effective regimen still could. As a physician bound to do no harm, I see an act of cruelty in forcing a woman to endure an unnecessarily prolonged and painful abortion, when I know I could offer her better care. In no other area of medicine would such a reversal of standards be acceptable — let alone one imposed by the courts. Christine Henneberg is a women’s health physician and a writer. 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