Important conversations about women’s reproductive health continue to accelerate across the country, focused on topics like the benefits and risks of hormonal birth control, the complex definition of the term “abortion,” and the need for more research on common conditions like PCOS. One of the latest developments in women’s health is the “missed period pill” (MPP). But, what exactly are MPPs and how do they work? What are their benefits and risks? And most importantly, how could MPPs affect the women who consider taking them?
What are MPPs?
Simply put, MPPs are a rebranding of the drugs used to perform a chemical abortion.
According to the Period Pills Project, a website run by the National Missed Period Pill Working Group, MPPs consist of either mifepristone in combination with misoprostol (the drugs making up the abortion pill) or misoprostol alone. When a woman’s period is late, taking these pills will induce cramping and shedding of the endometrial lining. This is commonly referred to as “bringing down” a period. If pregnancy is the cause of the missed period, that pregnancy will also be aborted. Even if pregnancy has not occurred, though, a period will be induced.
Why Rebrand the Abortion Pill?
Proposed Social and Emotional Benefits
The primary distinction between taking MPPs and getting a chemical abortion is the absence of a pregnancy test. Without confirmation of pregnancy, it is uncertain whether an abortion actually occurred. In an interview with NPR, Dr. Suzanne Bell likened this situation to that of Schrodinger’s cat, a classic quantum physics problem in which a cat is stuck in a box with a vial of poison. She said, “The cat in the box could be dead or alive at the same point, but until you open up the box and confirm, both realities could be true. In the same way, you know, you could be, perhaps, pregnant and not pregnant at the same time. But if you don't test, you don't know.”
Dr. Bell calls this situation “productive ambiguity.” In a 2021 research article, she expounded upon this concept, arguing that because women experience pregnancy determination on a spectrum from speculation to medical certainty, “pregnancy status may be a much more ambiguous state” than simply pregnant or not pregnant. In other words, because women don’t experience pregnancy as a binary, pregnancy status itself should not be considered a binary. Dr. Bell believes this ambiguity is beneficial for women because it “can foster more rigorous studies of fertility that better capture potential pregnancy and the range of post-coital fertility-inhibiting actions women take, both intentionally and not.”
Based on that assertion, Dr. Bell claimed that productive ambiguity provides advantages for women, saying that “[d]enial of pregnancy, both to others and perhaps to [the woman] herself, can function as a form of agency in situations in which pregnancy is not a desired outcome.”
One such form of agency included plausible deniability in the face of gossip and social criticism. Dr. Bell outlined the experience of a Tanzanian woman, which was initially reported as part of an ethnography survey of Tanzanian attitudes towards abortion. The woman had experienced what she called “stomach troubles,” and had received medical treatment in a hospital which remedied the situation. In Dr. Bell’s words, “[s]ince she had never defined herself as pregnant, she was able to continue to counter such gossip, despite comments about how she had formerly walked like an expectant mother, and was now suddenly thinner.”
For women dealing with unplanned pregnancies in America, the concept of productive ambiguity may seem appealing. In a survey of women seeking pregnancy test services, the women were asked about potential interest in MPPs. The researchers found that “psychological or emotional benefits, including management of abortion stigma” were among the top reasons for interest in the pills. In the words of Dr. Bell, “Respondents indicated the missed period pill option would be ‘easier on my emotional well-being to not know,’ cause ‘less moral conflict,’ and provide a ‘psychological cushion’ for those who are unsure of their feelings towards abortion.” More succinctly, in the words of one of the survey respondents, “I wouldn’t feel I am a bad person.”
The Period Pill Project website highlighted some of the participants’ responses in greater detail. One woman said, “It would be easier on my emotional well-being to not know I was actually pregnant but to alleviate the issue which is my missed period.” Another said she would consider MPPs “[b]ecause [she] feel[s] most young girls are not ready to be mothers like [herself]. But family and friends frown on the fact of abortion and therefore [girls] have to keep it most of the time.” These results indicate that, even where abortion is legal, the social stigma surrounding it has the capacity to leave a deep impression. MPPs may be attractive for women seeking to avoid that social pressure.
It is important to note that this survey was purely prospective, and did not record how women using MPPs actually felt following the experience. Whether or not MPPs actually have the proposed emotional outcome remains to be seen. Two clinical trials are currently examining women’s experience of MPPs after actual use, one at Gynuity Health Projects and the other at UCSF, but the results of these studies have not been published.
Possible Legal Protection from Prosecution for Seeking an Abortion
Dr. Bell also indicated legal protection as another advantage of productive ambiguity.
This sentiment was echoed in another 2021 article in the Berkley Journal of Gender, Law, and Justice, in which then law student Samantha Gogol Lint discussed the legal implications of the use of MPPs. She wrote, “[menstrual regulation, or] MR reveals the grey space in both the personal experience and legal framework of fertility control,” both because of the lack of pregnancy confirmation and because “[m]ethods of MR have uses besides ensuring non-pregnancy.” In a legal setting, establishing intent for MPP use would therefore be substantially complicated because “[if] the intent is to regulate menses, then a secondary outcome of pregnancy elimination would not constitute knowledge or purpose.” Lint concluded that criminalization for users of MPPs is unlikely, although policy makers may seek to restrict access due to the close connection to abortion.
In America’s current legal landscape, the promise of legal protection may offer a source of comfort to some women. While some pro-life groups such as Americans United for Life (the oldest pro life group in the US) vehemently oppose legislation prosecuting the mothers in cases of abortion, several states – including Alabama and South Carolina – have had such cases earlier this year.
With the legislative future of abortion and the standards for prosecution yet unknown, MPPs have the potential to shield women from legal action more than the current branding as the abortion pill does.
Medical and Philosophical Concerns Over MPPs
Other Medical Issues May Go Undiagnosed and Untreated
Another consideration around the use of MPPs has to do with their impact on medical diagnosis and treatment, as well as funding for common women’s health issues.
In Lint’s paper, she outlined potential medical benefits, including shorter time scales between suspected pregnancy and pregnancy termination. Lint explained, “Proceeding with MR before confirming pregnancy allows people who can become pregnant to take action after the window for emergency contraception has passed … but sooner than they might be able to obtain an abortion…” Thus, using MPPs “would reduce the time and expense of obtaining an abortion later and avoid more degrading requirements, such as forced ultrasounds, while allowing people to control their reproductive health outcomes.”
However, administering an intervention for a delayed period without medical diagnosis creates a possibility of missing medical issues that, like pregnancy, can cause a late period. Among these are reproductive illnesses like endometriosis and PCOS, as well as other hormone imbalances. Without a thorough screening for possible causes of a delayed period, physicians might overlook these issues, leaving women ignorant of their real health status and without the treatment they need to address any problems.
Avoiding pregnancy determination also leaves open the possibility of an undiagnosed ectopic pregnancy, a dangerous condition requiring prompt intervention. Ectopic pregnancy will not be resolved by mifepristone/misoprostol treatment. For this reason, in the case of a chemical abortion, the FDA currently requires physicians to be able to diagnose ectopic pregnancy prior to administering the drugs. Using these drugs as MPPs would circumvent this check and potentially leave some women vulnerable to a serious medical condition.
In addition to the potential for missing medical diagnoses, widespread use of MPPs could hinder progress in developing better treatments for reproductive illnesses.
The medical issues leading to irregular or late periods are frequently understudied and underfunded, leading to a dearth of treatment options (such as in the case of PCOS research). Because MPPs will temporarily treat the symptoms of a delayed period without taking a deeper look at the underlying cause, using these pills could be seen as another instance of ignoring women’s health concerns.
Indeed, while mifepristone has been explored as a treatment for endometriosis, no research has been done on the use of mifepristone or misoprostol in treating PCOS. Therefore, the use of MPPs without screening for non-pregnancy related causes for a late period could mask the prevalence of other medical issues in women. This could, in turn, further decrease the incentive for scientists to develop better treatments for these chronic illnesses.
Is the “Productive Ambiguity” Mindset Empowering or Paternalistic?
Returning to the claim that productive ambiguity provides emotional, moral, and psychological relief to women who take MPPs, some scholars argue that the “productive ambiguity” mindset is not empowering to women.
Lint said in her article that “earlier literature on the psychological benefits of [menstrual regulation] sometimes contains undertones of sexism around what information and decisions women are able to cope with, which both assumes the decision is emotional or difficult and reflects a paternalism that should remain in the pre-Roe era.” The thought process is that abortion is an emotionally and mentally heavy decision that women just can’t bear, and the availability of MPPs keeps them from crumbling under the weight of that burden.
Dr. Abigail Favale, a professor at the University of Notre Dame with experience in feminist thought both academically and in her own personal life, believes that the concern about paternalism is shared throughout much of modern secular feminism, even beyond the issue of MPPs. She noted that “[i]n recent years, there has been an increased focus on protecting women from ‘harm,’ and ‘harm’ has broadened to include various forms of emotional discomfort.” Favale called this mindset a “protectionist” posture, one that claims that “women need to be protected from the reality of what’s going on in their bodies and protected from the moral weight of their choices.” From this perspective, MPPs can act as another iteration of this protectionist narrative.
Dr. Favale also noted that, in addition to being emotionally paternalistic, MPPs also have the potential to hinder women’s moral agency.
An underlying principle of productive ambiguity is the belief that one’s perspective defines one’s reality; therefore, the morality of our choices is directly linked to our experience of them. This means that, because a woman doesn’t know whether she’s pregnant when taking MPPs, she can use that fact to determine the morality of her choice. NPR reporter Abby Wendle summarized this in the interview with Dr. Bell and others, saying, “For many people, because you'd take them without that confirmation, there would be no abortion.”
This seems appealing on the surface, as indicated by the survey responses mentioned earlier: Productive ambiguity promises women more agency by relieving them of external moral pressures. However, if there is no confirmed pregnancy that a woman has to make a decision about, and there is no real weight to her decision making, how much moral agency does she actually have?
For Dr. Favale, the answer is clear. She said, “The appeal of these pills seems to be that they hide a woman from the reality of her situation, the voice of her own conscience, and the gravity of the choice she’s making. This is infantilizing and actually undermines the moral agency of women. It seeks to protect women from reality.” In other words, using MPPs actually robs women of power because they are not given the opportunity to consider the true weight of their choices and face those choices head on.
Missed Period Pills Are Sure to Remain a Topic of Conversation
MPPs have the potential to impact women in real and personal ways. There is uncertainty about the social and emotional benefits. There are concerns and confusion around the ever-changing legal landscape and the possibilities of medical risk. There are farther reaching implications for women’s health research and women’s empowerment to consider, as well.
One thing is certain, though: MPP’s and the conversation surrounding them aren’t going away anytime soon.