ITALY – How much will it hurt? Factors associated with pain in 1st trimester medical abortion

by Alessandro Arena, Elisa Moro, Eugenia Degli Esposti, Margherita Zanello, Jacopo Lenzi, Paolo Casadio, Renato Seracchioli, Antonino Perrone, Marinella Lenzi

Contraception, March 2023;119 (Not open access)


Objectives: Few studies have investigated the features associated with pain levels during abortion. We aimed to investigate the risk factors for experiencing pain during medication abortion, focusing on women’s psychological distress and anxiety levels.

Study design: We carried out this observational study at two centers in Bologna, Italy. We included women aged 18 years or more with a viable intrauterine pregnancy of up to 63 days of amenorrhea, who chose medication abortion. Women received 600 mg of mifepristone orally and after 48 hours 400 mcg of buccal misoprostol, repeated after 3 hours according to local and regional medication abortion guidelines, as well as prophylactic analgesia. We evaluated the clinical characteristics which may represent risk factors for severe pain (Visual Analogue Scale ≥ 70) through a multivariate model.

Results: 242 patients were included in our analysis; 92 (38.0%) reported severe pain during medication abortion. Women with higher baseline anxiety levels (General Health Questionnaire 12 score ≥ 6 and General Anxiety Disorder 7 score ≥ 10) had a higher probability of experiencing pain with a Visual Analogue Scale ≥70 (OR = 3.33, 95% CI 1.43–7.76), as well as those who reported dysmenorrhea [painful periods] in the past year (OR = 6.30, 95% CI 2.66–14.91). Previous vaginal deliveries were inversely correlated with pain intensity (OR 0.26, 95% CI 0.14 – 0.50).

Conclusions: Increased baseline anxiety levels, dysmenorrhea and no previous vaginal deliveries are associated with severe pain in women undergoing medication abortion.

Implications: The identification of women at risk for severe pain based on clinical and historical factors as well as the definition of an adequate analgesic regimen may help to improve women’s care and pain management during medication abortion.

Information about pain management for medical abortion can be found in WHO Abortion Care Guideline. NCBI, 2022. Scroll down to:
CLINICAL SERVICES Recommendations 15 and 16. Pain management for medical abortion.