The Supreme Court’s decision to overturn Roe v. Wade and send the decision to ban or permit abortion back to the states will likely have health implications beyond banning abortion in many states. There have already been reports of clinicians and pharmacists denying women access to medications like methotrexate and misoprostol to manage their chronic conditions, such as autoimmune diseases and gastric ulcers because the drugs are also used for medication abortions and treatment of ectopic pregnancies. In these reports, pharmacists have denied or delayed filling prescriptions unless specific codes for non-pregnancy-related conditions are given. Some providers also request that patients take a pregnancy test to confirm a non-pregnant status before prescribing the medications. This analysis finds that most of those who use these drugs are women who are not pregnant but have diagnoses for other chronic conditions and rely on these medications to manage their health. Consequently, these actions will most impact women of reproductive age with chronic conditions.
Indications for the use of Methotrexate and Misoprostol
Methotrexate is indicated for treating rheumatoid arthritis and other autoimmune diseases that disproportionately affect women. The drug works by suppressing the immune system. Additionally, many chemotherapy regimens include methotrexate for treating adult and pediatric cancers, such as leukemia and breast cancer, where it works to slow or stop the growth of cancer cells. It also has some off-label uses for common conditions like Crohn’s disease, lupus, and eczema. The drug is also a common treatment for ectopic pregnancies, stopping cells from dividing by interfering with the folic acid in your body.
Beyond methotrexate, misoprostol is another drug that may be limited because of its use in pregnancy terminations. Misoprostol is a prostaglandin that causes cervical softening, dilation, and uterine contractions. It is frequently used in obstetrics and gynecology for procedures like the medical management of miscarriage, induction of labor, cervical ripening before surgical procedures, and the treatment of postpartum hemorrhage. It is also indicated for reducing the risk of a nonsteroidal anti-inflammatory drug (NSAIDs like aspirin and ibuprofen) induced gastric ulcers in patients at high risk of complications from gastric ulcers. In combination with mifepristone, misoprostol can be used to terminate an intrauterine pregnancy through 70 days gestation. Access to methotrexate and misoprostol is essential for patients with these cross-cutting conditions, especially women.
We examined the gender, age, and diagnosis of people with methotrexate and misoprostol prescriptions and injections in claims from the IBM MarketScan Encounter Database in 2019, a database of claims paid on behalf of enrollees of large employer private health plans. We looked at utilization for both men and women enrollees ages 0-64, with a focus on reproductive-aged women, ages 15-49, who did not have an indication of a pregnancy in the year. The claims used in this analysis only reflect use under the benefit plan. They do not include services for which the enrollee did not file a claim, such as a medication abortion that was paid for out-of-pocket without using insurance, which could result in an underestimate of individuals using these drugs.
We find that women make up the majority of people (71%) with a methotrexate prescription in the 2019 IBM MarketScan Encounter Database compared to 29% of methotrexate prescriptions going to men (Figure 1). Over a quarter (29%) of people with a methotrexate prescription are women of reproductive age, ages 18-49, while 39% are women ages 50-64.
Among reproductive-aged women with a methotrexate prescription claim, 92% had no indication of pregnancy in the measurement year (Figure 2). Among those who were not pregnant, over half (55%) of reproductive-aged women with a claim for a methotrexate prescription had a diagnosis code for rheumatoid arthritis at some point during the year. Nearly a third (33%) had a diagnosis of another autoimmune disease we looked at, and just over one in five (18%) had a cancer diagnosis at some point in the year (Table 2).
Among misoprostol prescriptions, 97% are prescribed to women compared to 3% for men. Most women using misoprostol are of reproductive age (80%) (Figure 3).
The Majority of People With a Misoprostol Prescription Are Women
Among reproductive-aged women with misoprostol prescription, 61% had no indication of pregnancy in the year (Figure 4). Over half (52%) of non-pregnant women of reproductive age had a diagnosis for conditions where misoprostol would be indicated for cervical ripening, such as for an IUD insertion. In comparison, another one in three (36%) had a diagnosis code for abnormal bleeding (Table 3).
As abortion bans are implemented in states in the South and Midwest, reproductive-aged women with autoimmune diseases or cancer could see delays or denials in receiving medications like methotrexate and misoprostol, used to manage their chronic conditions. The abortion bans also have implications for managing a broad range of conditions that impact women. This analysis finds that limitations and barriers to these treatments will disproportionately impact women beyond limiting the availability of abortions to terminate pregnancies.
Providers and pharmacists in states where abortion is banned could refrain from prescribing or dispensing these drugs out of fear of prosecution. In response to concerns about access to these medications, on July 13, 2022, the U.S. Department of Health and Human Services issued guidance reminding retail pharmacies that as recipients of federal financial assistance, including Medicare and Medicaid payments, they are prohibited from discriminating based on sex and other bases (i.e., race, color, national origin, age, and disability) under Section 1557 of the Affordable Care Act. The administration’s stance is that decisions to limit access to these medications could be discriminatory based on age, sex, and disability and could violate Section 1557 of the ACA. This is one of the many unanticipated consequences of the Supreme Court’s decision to overturn Roe v. Wade and states actions to ban abortion.