The Case Against Menstrual Extraction
by Louise Tyrer

With abortion debates escalating, "self-help" menstrual extraction (M.E.) has been promoted as a way for women to exercise full control over their reproductive options. While all women should be actively involved in all matters related to their healthcare, the health dangers and political risks associated with this unsupervised medical procedure far outweigh any possible conveniences or advantages in a society in which legal abortion is still an option.

Every woman should be free to choose whether or not to undergo "self-help" M.E., be it to minimize monthly cramps or to terminate a suspected pregnancy. However, women deserve the opportunity to make a fully informed decision which must include the case against menstrual extraction.

Health Risks

Menstrual extraction refers to removing, by suction, the contents of a woman's uterus, which may be the lining that builds up prior to menstruation as well as the products of conception. This entails the insertion of a small, flexible, blunt-tipped cannula into the uterus and attaching it to a vacuum source, generally a hand-held syringe. Most lay women who perform this procedure for other women will only do so within 50 days of the onset of the last menstrual period, in an attempt to avoid initiating an abortion in a woman whose pregnancy is so fir advanced it cannot be completed with the equipment utilized. Some lay providers will perform it for women with late periods without establishing that the woman is in fact pregnant. In all cases, M.E. can pose serious health risks.

Infection. Every time a woman's uterus is invaded, as it is when a cannula is inserted into the uterus during monthly menstrual extractions, the chance of pelvic infection becomes greater. Any degree of pelvic infection can increase a woman's chance of subsequent ectopic (tubal) pregnancy, or lead to infertility.

Hidden symptoms. Heavy menstrual flow, which sometimes leads to a desire for repeated menstrual extractions, may be an indication of cancer of the lining of the uterus, as may intermenstrual bleeding. Women with such symptoms need to be examined by specially trained physicians to evaluate, diagnose, and manage their condition.

Pregnancy. For a woman who is pregnant, the risks associated with M.E. as a "self-help" abortion technique are particularly great. First of all, pregnancy tests alone are not always accurate. If a woman thinks she may be pregnant, a pelvic examination and sometimes ultrasonography are necessary to establish the certainty of a suspected pregnancy, and to identify whether the pregnancy is a normal uterine implantation, or is an ectopic pregnancy. Furthermore, some women continue to have periodic bleeding with pregnancy and a woman may be unknowingly 12 or more weeks pregnant before she suspects that she is so. Since "self-help" M.E. is performed by a nonmedical person unqualified to determine the site and duration of the pregnancy or perform a complete medical examination, the risk of complications - such as the inability to complete the abortion, uterine perforation, hemorrhage and/ or infection - would be significantly increased.

Pre-existing pelvic conditions. Sometimes women unknowingly have a pelvic pathology such as uterine fibroid tumors, a double uterus, ovarian cysts, or cervical scarring. When a woman is pregnant, each of these conditions can increase the likelihood of an incomplete abortion, or complicate the performance of the procedure. A pelvic evaluation by a specially trained health professional is essential to determining the appropriate procedures and techniques to terminate pregnancy safely in these situations.

Puncturing the uterus. Improper use of surgical equipment can occur in "self-help" M.E. and may result in uterine perforation. This risk is lessened when the procedure is performed by an experienced clinician.

Incomplete abortion. The more complex the abortion procedure, the less chance of hemorrhage, infection, or both. Health professionals experienced in performing abortions are more capable of determining whether the products of conception have been fully removed. They can send the specimen to a pathology laboratory when indicated in order to establish whether a woman's pregnancy is ectopic, which is a life-threatening condition.

Post-abortion infection. Health professionals are trained and better equipped to minimize the risk of infection, as well as diagnose and treat possible infections that may occur after abortion. Carefully sterilized instruments, "no-touch" techniques, and minimal insertions of instruments into the uterus are necessary to reduce risk. A "self-help" procedure, however, may require multiple insertions of the suction cannula to finish the abortion procedure. Furthermore, trained health professionals are better able to identify abnormal cervical and vaginal discharge, which may require antibiotic treatments, as well as administer antibiotics at the time of abortion to minimize the risk of post-abortion infection. "Self-help" M.E. groups are not able to do so.

AIDS. The emergence of AIDS and Hepatitis B pose an ever greater need to minimize possibilities of infection during the abortion procedure. This requires the wearing of clothes, gloves, and plastic eye and face masks to protect the operator and patient from any potential contamination with blood and other bodily fluids, such as vaginal secretions. Abortion tissue requires the utmost care in analysis. Furthermore, all instruments must be decontaminated and sterilized, and all disposables must be properly bagged and handled by designated collection centers. Even the slightest break in skin, e.g., a torn hangnail,can be an entry point for the fatal HIV virus. It is reasonable to assume that women seeking abortion care and providers alike will want to be in a medical-care environment that can assure the minimum risk.

Consistency and continuity of care. The woman who obtains an abortion from a licensed and specially trained health professional is assured of more consistent quality of care, as well as 24-hour access to experienced physicians who have surgical capabilities for the rare - but sometimes serious - complications that may occur with any abortion.

Political Risks

It is unfortunate that current laws and harassment by antichoice bigots have created a climate in which physicians are discouraged from providing abortion services. However, "self-help" menstrual extraction is not the answer.

As a resident physician in ob/gyn prior to the legalization of abortion, I saw too many women die from every manner of complication or become reproductive cripples for the rest of their lives as a result of illegal abortion. We cannot, we must not, go back to those dark days, nor should women ever need to rely on less than the most informed, technically advanced and individually sensitive reproductive healthcare services - including elective abortion.

For the benefit of the health of women in the U.S., we need to expand our energies to ensure that abortion remains a legal, available and accessible option for all women. In this light, "self-help" menstrual extraction must be seen not only as a potential health risk, but also as a counterproductive political tactic. Women must not be lulled into thinking that menstrual extraction will provide a safety net should abortion again be made illegal. I say we can Never go back.

I envision that a more useful way to ensure women full control over their reproductive health is to take two courses of action. First, we need to change the dynamics of the politics in this country so that medical providers and women seeking abortion can feel comfortable in providing and receiving high quality abortion care. Bill Clinton's promise to overturn the "gag rule" is an important step in this direction.

Second, we need to expand the pool of adequately trained abortion providers to include licensed, non-physician reproductive healthcare specialists as well as certified nurse midwives, nurse practitioners, and physician's assistants. These health professionals, many of whom are women, are already grounded in the anatomy and physiology of women's reproductive systems. Unlike "self-help" menstrual extraction providers, this cadre of specially trained health professionals can recognize in advance when a patient has a pelvic pathology and make sure that she receives specialized physician care. Furthermore, they are experienced in working as members of teams, including physicians, who are experienced in handling the sometimes life threatening emergencies that can occur with abortion.

Not only has this innovative approach to women's reproductive healthcare been endorsed by organizations such as the American College of Obstetricians and Gynecologists, the National Abortion Federation, the Association of Reproductive Health Professionals and Planned Parenthood Federation of America, it has been proven successful: A report by NAF found that women undergoing early abortion by trained nonphysician health professionals experienced no increased risk than had the procedure been performed by a medical doctor.

"Self-help" menstrual extraction - no matter how many anecdotal reports of individual experience are put forward - cannot be considered either safe or empowering. Women deserve, and must demand, the best healthcare available, including abortion training for non-physician health professionals. Furthermore, women must unite to ensure that safe and legal abortion is always an option. We can never forget how many women lost their lives before the right to choose became the law of the land.

Louise B. Tyrer, M.D., F.A.C.O.G., was motivated to commit her life to women's healthcare after growing up in old China, where she witnessed the suffering associated with unwanted childbearing. As an obstetrician and gynecologist, she has devoted the last 22 years to family planning. Tyrer directed the family planning division of the American College of Ob/Gyn for five years, and went on to serve 16 years as Vice President for Medical Affairs at Planned Parenthood Federation of America. Tyrer is currently the Medical Director of the Association of Reproductive Health Professionals. She has published over 100 articles.

WHY MENSTRUAL EXTRACTION IS A GOOD IDEA By Rebecca Chalker

THE CASE AGAINST MENSTRUAL EXTRACTION By Louise Tyrer