Numerous medications do their job by interfering with the metabolism inside cells that enables cells to grow and reproduce and also to participate in inflammation, the process in which the immune system responds to damage to particular tissues or to the presence of infectious agents, or other foreign entities. Inflammation can be damaging in the particular body tissues and organs where it occurs, and can be damaging throughout the body. At the same time, excessive, abnormal growth of body cells is not good; depending on its exact nature, it can take the form of benign tumor growth or uncontrolled growth of abnormal cells with the ability to spread, namely cancer. But by suppressing the needed metabolic chemical pathways, various medications can fight abnormal normal cell growth and blunt the inflammatory process. This is why the classic anti-metabolite drug, methotrexate began its clinical career in the middle of the last century as an anti-cancer drug and why today, is still used in various cancer settings, and is also key to the effective and safe treatment of various rheumatological disorders, such as systemic lupus erythematosus (SLE) and rheumatoid arthritis. Similarly, methotrexate also is given for inflammatory bowel disease.
But because of its antimetabolite action, methotrexate is also an abortifacient. It can cause an abortion. It also can do severe harm to an embryo or fetus if a woman is given methotrexate while pregnant. In terms of therapeutic abortion and elective abortion, methotrexate is not the main drug of choice. It plays more of a peripheral role. The main drugs for inducing and completing medication abortion, which can be performed up to the 77th day of gestation, are mifepristone and misoprostol. In contrast, doctors may administer methotrexate to a woman who has suffered a spontaneous abortion, especially if they think it is likely that it was an incomplete spontaneous abortion, meaning that some products of conception remain within her uterus, and need to be cleared out to make sure that she won’t suffer an infection or severe bleeding. Methotrexate also is near the top of the list for treating ectopic pregnancy, if the ectopic pregnancy is early enough to be ended without surgery. Doctors also may turn to methotrexate for very early elective abortions.
Now, many non-pregnant women and girls, and for that matter many men, are receiving drugs like methotrexate for cancer or especially for inflammatory conditions. Doctors change this treatment in cases when a woman decides to try to become pregnant. This has been going on for many years and the specialists managing such conditions have things under control, but the environment in the United States is different now than it was at the onset of 2022. Today, we’re in the post-Roe era. This past June, the Supreme Court of the United States (SCOTUS) ruled on the Dobbs versus Jackson Women’s Health Organization abortion case, involving Mississippi’s Gestational Age Act. In deciding the case, five of the nine SCOTUS justices signed onto a majority opinion that overturned the 1973 Roe v Wade decision. In the aftermath of the Dobbs decision, numerous pro-choice states, including New York, Connecticut, Illinois, Oregon, and Washington have continued providing abortion services and even helping abortion seekers from other states. Other states have intermediate situations in which the basic right to an abortion is staying afloat for now, but it’s in the balance. At the same time though, many US states are extremely hostile to abortion rights. States such as Mississippi and Tennessee have enacted complete bans on abortion, for example. Similarly, Arizona has outlawed abortion by implementing a law passed in the year 1901 that got its start in 1864. In such environments, there have been a growing number of cases of activists, anti-abortion pharmacists denying medications to people on account of those medications being potential abortifacients.
Just to be clear, we are talking about people who normally receive such medications, methotrexate being a very common one, for various chronic conditions. Recently, there was a case in Arizona, of a 14 year-old girl being denied methotrexate that her rheumatologist had prescribed for juvenile arthritis. Cases of patients being denied their normal methotrexate regimen for all of the various conditions that we mentioned above have been popping up across the United States. Along with teens and tweens, people denied such medications have included post- and perimenopausal women (women, often in their fifties, headed toward menopause) and even men. Since the Dobbs decision first came to fruition in late June, things have gotten shockingly foolish, really quickly, and it’s putting a lot of people in a lot of danger —pregnant women in particular, but Dobbs, or future SCOTUS decisions using Dobbs as a precedent, also are on track to disrupt other aspects of reproductive care. The latter may include contraception, including the morning after pill (Plan B), and access to fertility technologies. And, as we have seen today, it’s even, directly affecting the health of men and of others who are not on track to become pregnant.