Menstrual extraction

Menstrual extraction is both a surgical abortion method and a menstrual hygiene technique, which involves removing an entire menstrual period, or a blastocyst or small embryo--with or without confirmation of pregnancy. It was developed by unlicensed practitioners specifically to circumvent laws prohibiting abortion, and is still used for that purpose.

Early development
In 1971, two members of a feminist women's reproductive health self-help group, Lorraine Rothman and Carol Downer, modified the equipment used for manual vacuum aspiration (MVA) at medical clinics. They assembled soft Karman cannulas, syringes, one-way valves, and collection jars and learned to operate them to perform menstrual extractions, in order to provide access to abortion for women before Roe v. Wade. The device developed by Rothman and Downer is called a "Del Em." It differs in technical construction from MVA because uterine contents pass through a canula into a tube, and then into a collection jar, instead of going directly into a syringe. This is believed to make the procedure more comfortable for women, who also control the suction with a Del Em. Licensed medical providers sometimes call MVA menstrual extraction, even when they are not using a Del Em.

To differentiate their practice from abortion, Downer and Rothman called it menstrual extraction, or "ME." According to the National Women's Health Network, "the early self helpers advocated that women join self-help groups and practice extracting each other's menses around the time of their expected periods. If a pregnancy happened to be present, it would be extracted along with the contents of the uterus." They toured the country introducing menstrual extraction to other women's groups, and the practice became quite popular; an estimated 20,000 procedures were performed.

Police raided Downer and Rothman's Self Help Clinic in 1971, but the only evidence of criminal activity found was a container of yogurt used for vaginal yeast infections. Downer was arrested for practicing medicine without a license for using the yogurt, and the yogurt was taken into evidence. In December 1972, she was acquitted by a jury. The raid, arrest, and trial were referred to in the women's self-help movement as "the Great Yogurt Conspiracy."

Use following legalisation of abortion
After the Roe v. Wade Supreme Court decision made abortion legal in 1973, menstrual extraction was practiced far less. Then in the late 1980s and early 1990s, the technique was widely discussed in the mainstream press again when the U.S. Supreme Court ruled on Webster v. Reproductive Health Services, which limited access to abortion for some women by state of residence and type of medical insurance. Self helpers even reprised the 1971 tour, travelling around the U.S. sharing self examination and menstrual extraction techniques with groups of women.

Sixteen years ago, Richard Lacayo's May 4, 1992 Time magazine cover story "Abortion: The Future Is Already Here" said: Pro-choice groups are preparing for the day when they will have to provide an abortion underground, with networks to help women get to states where abortion is available. Some are urging more radical solutions. Carol Downer, director of the Federation of Feminist Women's Health Centers, based in Los Angeles, travels widely to talk to women's groups about "menstrual extraction," a home-abortion procedure she co-developed in the early 1970s. A suction technique similar to the vacuum-aspiration process that is now the most common form of first-trimester abortion, it requires a 50-mL syringe attached to a flexible plastic tube, which withdraws the contents of the uterus and deposits them into a closed container.

The premise behind menstrual extraction is that a home abortion provided by concerned friends is better than one carried out in some surgical speakeasy. Downer insists that women without medical training can learn to perform menstrual extraction on other women safely. A cooperative doctor may still be needed to obtain the equipment, some of which can be purchased legally only by physicians or clinics. "It will take some thinking and determination and motivation to put ((the kit)) together," she says.

Many doctors and abortion-rights groups consider her message irresponsible and menstrual extraction far too risky to contemplate. They stress the danger of infection, infertility or even deadly sepsis in the event of a puncture in the uterus. If menstrual extraction is attempted more than six weeks after a woman's last period, it can also lead to severe complications, including cramps, bleeding and blood clots.

Downer's critics also fear that poor women and teenagers -- the ones most likely to have trouble getting to states where abortion is legal -- are the ones least likely to master the procedures for performing an abortion safely. It is small comfort that hospital emergency rooms would be obliged to treat any woman who developed complications. "Abortion is minor surgery," says, Barbara Radford, the head of the National Abortion Federation, an association of abortion providers. "But you need backup, you need proper equipment, you need proper medication."

So long as women can get to any state where abortion is legal, menstrual extraction is unlikely to become a real alternative to physician-provided abortions. But the very fact that it's under discussion once more is a sign of the ways in which America is bracing itself for a partial return to the past. In the two decades since Roe was handed down, a generation has grown up that knows nothing of the days of illicit abortions conducted on kitchen tables, or in doctor's offices at night with the blinds drawn.

Fifteen years ago, Le Anne Schreiber's book review in The New York Times of Rebecca Chalker and Carol Downer's 1992 book A Woman's Book of Choices: Abortion, Menstrual Extraction, RU-486 said: Whether viewed from an anti-abortion or abortion rights perspective, there is one incontrovertible fact of abortion in America: for more than a century, American women's access to safe abortions has been controlled by doctors and legislators. In defiance of that pattern, Rebecca Chalker, an abortion counselor and the author of a number of popular medical books, and Carol Downer, a lawyer and the executive director of the Federation of Feminist Women's Health Centers, have issued a declaration of independence. In part, "A Woman's Book of Choices" is a consumer's guide to conventional abortion options, a print hot line in a time of Government-ordered gag rules. But it is also an outline for a more radical agenda, a program to foster the knowledge and skills that would permit women without medical credentials to terminate early pregnancies safely.

The book includes a how-to, but not a do-it-yourself, manual for a technique called menstrual extraction that requires the assistance of at least two experienced people. In effect, it is a low-budget, low-tech version of the suction method practiced in medical clinics. The safety of the technique depends on the skill of the practitioner, the sterility of the equipment and the ready availability of medical backup should complications arise -- all of which are hard to guarantee in a nonlicensed situation. As yet, the legal status of menstrual extraction is untested. But if there's a legal challenge, the authors suggest, an argument could be made that the procedure is a "home health-care technique," and therefore does not require a license. Furthermore, since by most state laws people without medical credentials cannot make a medical diagnosis of pregnancy, practitioners can also claim the modern equivalent of the "quickening" defense. How can one prove a firm intent to abort without firm knowledge of pregnancy?

"A Woman's Book of Choices" is, above all, a sign of the times -- a warning sign. When so few doctors perform abortions, when so few medical schools teach the techniques, when so many states seek to impose so many restrictions, women reluctantly begin to take risks that other people call choices. Roe v. Wade may be alive, but it is not very well.

According to laureli's 2005 article "Suction Yer Own Cunt" in the Berkeley quarterly anarchist newspaper Slingshot!, in 2002 she chose to have an illegal menstrual extraction abortion: It’s not crazy to want to participate in the fate of your cunt. And—surprise!—choosing to have an abortion doesn’t have to mean paying a wealthy HMO to do it. For those of us unhappy with inviting chemicals or surgery into the abortion scene, menstrual extraction (ME) is an alternative option that can be safe, effective & cheap.

While herbal abortion may be the most visible abortion option in radical culture, menstrual extraction provides another clear alternative to participating in the “health care” industry. And, despite what the medical profession, the church, and the state want you to believe, reclaiming this low-tech reproductive technology is possible, and it can be safe.

The first time this anarcha-feminist got pregnant, she also got a little confused. I didn’t want to be pregnant. But I also didn’t want to call some receptionist at a Planned Parenthood clinic, schedule an appointment, meet a doctor, fall asleep, and wake up groggy & un-pregnant, problem solved! I wanted to participate in my abortion, and I didn’t want to be separated from the physical & emotional sensations of it. Amazingly, I was lucky enough to have access to an experienced menstrual extraction practitioner, and I had the privilege of turning what could’ve been one of the most traumatic experiences in my life into one of the most empowering.

In the ME procedure, the contents of the uterus (i.e. the fetus) are manually suctioned out using equipment you can gather in your own kitchen and a science supply store for under $100. It usually lasts 15-30 minutes, and the pain is like experiencing a regular cycle worth of menstrual cramps in a few minutes. Yeah, it hurts, but I could take it. There’s no anesthesia, no painful & traumatic dilation of the cervix, and no high powered vacuums involved.

Oh yeah, and it’s illegal. A menstrual extraction performed on a woman without a confirmed pregnancy is legal, and can be used to get rid of an inconvenient period. But as soon as a fertilized egg is present, whoever’s performing it can be charged with practicing medicine without a license & lots of other bullshit. Obviously, anything that provides women with easy access to reproductive control should be outlawed.

Underground, though, the body of knowledge surrounding menstrual extraction still exists, as do networks of experienced women who’ve been performing them for 30 years—but these practitioners are few and far between. It’s amazing how many anarchist ladies & reproductive rights activists have never heard of this technique, which has the potential to change the way women experience abortion. It’s amazing that in 2002—30 years after the legalization of abortion—I found myself making a secret phone call and using code words to obtain an abortion. Roe v. Wade may have granted women the legal right to obtain publicly acceptable forms of abortion, but it didn’t grant me access to the low-tech, empowering abortion I wanted.

Use outside the United States
In other countries, menstrual extraction is referred to as "menstrual regulation." According to the National Abortion Federation, "in the developing world, menstrual regulation is still a crucial strategy to circumvent anti-abortion laws." Although abortion is illegal in Bangladesh, the government has long supported a network of menstrual regulation clinics. It is estimated that 468,000 menstrual regulations are performed each year in Bangladesh. NAF also reports "some other countries allow menstrual regulation because it presumably takes place without a technical verification of pregnancy", said countries are claimed to include Korea, Singapore, Hong Kong, Thailand, and Vietnam. In Cuba, where abortion is legal, menstrual regulation is widely practiced--every woman whose period is two weeks late is offered menstrual extraction, without a pregnancy test.

Complications
In a study from June 1973 to June 1974 at three London teaching hospitals, a physician performed electric vacuum aspiration (EVA) "menstrual extraction" on 424 women who were possibly pregnant at 4 to 6 weeks gestation (50% of the women had a positive urine latex-agglutination hCG pregnancy test): No cervical dilation was required in 411 (97%) of the patients. The uterus was completely evacuated in 401 patients (95%). Of the 260 patients with histologically proven pregnancies, the intital aspiration was successful in 248. The remaining 12 had a positive pregnancy test at the follow-up visit and needed further evacuation. Of the 128 patients who were shown not to be histologically pregnant the procedure was successful in 126. Two patients had a positive pregnancy test at follow-up and required further evacuation. No analgesia or anesthesia were used for the first 136 patients, but thereafter intracervical block was used for 258 patients. The rest had local anesthesia given by different routes. Intracervical block proved valuable in non-parous and non-pregnant women, who are likely to have irritable uteri that go into spasm more readily than those of parous or pregnant women. Only 28 (6%) considered the pain unacceptable. Most found the procedure uncomfortable but bearable and at one week follow-up only 5% said they had so much pain they would never consider having it done again. The procedure differed little in technique or its acceptability to the patient from termination done later in the first trimester. The similar incidence of complications suggested that it is not an alternative to conventional contraception.

The relevance of this study from 34 years ago to manual vacuum aspiration (MVA) "menstrual extraction" performed by unlicensed practitioners (e.g. radical feminists, anarchists) then or today, or to early vacuum aspiration using a rigorous protocol (which includes magnification of aspirated material and indications for serum βhCG follow-up) by licensed practitioners today, is unclear.

The Royal College of Obstetricians and Gynaecologists (RCOG) September 2004 National Evidence-based Clinical Guideline The Care of Women Requesting Induced Abortion says:
 * Recommendation 28. Conventional suction termination should be avoided at gestations below 7 weeks.
 * Suction terminations performed at less than 7 weeks of gestation are three times more likely to fail to remove the gestational sac than those performed between 7 and 12 weeks (level IIb evidence). Thus, for women presenting at less than 7 weeks of gestation, an alternative recommended technique should be chosen. If conventional suction termination is the only method of abortion available within a service, then the procedure is better deferred until the pregnancy exceeds 7 weeks of gestation.
 * Recommendation 29. Early surgical abortion using a rigorous protocol (which includes magnification of aspirated material and indications for serum βhCG follow-up) may be used at gestations below 7 weeks, although data suggest that the failure rate is higher than for medical abortion.
 * Creinin and Edwards have described a personal series (level III evidence) of early surgical abortions undertaken to a rigorous protocol developed at Planned Parenthood of Houston and Southeast Texas, USA. Their protocol included pre-abortion urinary pregnancy testing and ultrasound assessment, inspection under magnification of aspirated products and follow-up by serum βhCG estimation in those women in whom no gestation sac is verified in the aspirate. Using this protocol, the authors reported a complete abortion rate of over 99% in 2399 procedures performed at less than six weeks of gestation.
 * Both major UK abortion charities (bpas and Marie Stopes International) have introduced early surgical abortion techniques within their UK clinics. bpas has introduced a protocol that conforms to that described above, using local anaesthesia. Marie Stopes International has introduced manual vacuum aspiration (MVA) without anaesthesia. Low failure rates and high patient acceptability are reported.
 * Recommendation 30. Conventional suction termination is an appropriate method at gestations of 7–15 weeks, although, in some settings, the skills and experience of practitioners may make medical abortion more appropriate at gestations above 12 weeks.
 * In current UK practice, suction termination of pregnancy is the standard method at gestations of 9–12 weeks. This was the only method the Guideline Development Group was able to recommend for this gestation band. However, a pilot study had indicated that medical abortion was also effective at these gestations. Subsequent studies, discussed below in Section 7.2, have confirmed that both surgical and medical methods are safe, effective and acceptable in this gestation band.
 * The method of choice at gestations of 12–15 weeks varies according to the skills and experience of local clinicians. The Guideline Development and Update Groups were of the view that surgical abortion by conventional suction termination, without the need for specialised instruments, can be undertaken up to 15 completed weeks of gestation if local clinicians have gained experience with this method. Alternatively, medical abortion using mifepristone and prostaglandin is appropriate at all gestations.
 * Recommendation 34. For first-trimester suction termination, either electric or manual aspiration devices may be used, as both are effective and acceptable to women and clinicians. Operating times are shorter with electric aspiration.
 * Recommendation 39. Medical abortion using mifepristone plus prostaglandin is the most effective method of abortion at gestations of less than 7 weeks.
 * Recommendation 39 is based on a systematic review of cohort studies of combined mifepristone plus prostaglandin regimens for early medical abortion, which concluded that the complete abortion rate falls as gestation advances. Thus, unlike the situation with conventional suction termination, medical abortion is at its most effective at the earliest stages of pregnancy (level IIb evidence).
 * Recommendation 40. Medical abortion using mifepristone plus prostaglandin continues to be an appropriate method for women in the 7–9 week gestation band.