Abortion provider Carafem’s phones were ringing nonstop over the weekend after a US federal appeals court reinstated a nationwide requirement that the drug mifepristone, one of two pills used for a medication abortion, must be obtained in person. The decision, handed down on Friday, left patients unsure if they could gain access to their treatment through telehealth. “People are afraid, and they’re angry,” says Carafem’s chief operations officer, Melissa Grant. “I had people contact us saying, This can’t be true. Do you still have the medication available? Can’t you just give it to me? They were bargaining.”

With the restriction in place, Carafem quickly pivoted to a backup approach. Instead of prescribing the two-drug protocol typical for a medication abortion—mifepristone, which blocks progesterone and prevents the pregnancy from progressing, and then misoprostol, which causes the uterus to contract—the organization began prescribing misoprostol on its own. While slightly less effective than the dual-pill option, it’s been widely used in the past. “We feel comfortable prescribing it,” says Grant.

Some Planned Parenthood clinics also pivoted to the misoprostol-only regimen this weekend. “Planned Parenthood providers are doing everything they can to make sure patients know that medication abortion is still safe, legal, and available,” says Danika Severino, vice president of care and access at Planned Parenthood Federation of America.

On Monday, the Supreme Court offered a temporary reprieve, pausing the appeals court ruling for a week. The measure allows patients to once again get mifepristone through virtual clinics at least until May 11, when SCOTUS will take another look at the case. Carafem and Planned Parenthood say they are prepared to shift back to misoprostol-only if necessary. Other providers, including the digital abortion clinic HeyJane, have confirmed that they will also take that approach if necessary.

Mifepristone was developed in the 1980s in France and has been extensively studied for safety and efficacy. It was approved by the Food and Drug Administration in 2000. Under President Joseph Biden, the FDA first allowed the drug to be obtained by mail instead of in person in April 2021, during the Covid-19 pandemic. The agency permanently lifted the in-person dispensing requirement in 2023.

After the Supreme Court overturned Roe v. Wade in 2022, ending the constitutional right to an abortion, medication abortion via telehealth became a more sought-after option, especially for patients in states that adopted abortion restrictions. Approximately one in three abortions that took place in the first half of 2025 used abortion pills obtained through telehealth, according to public health nonprofit Plan C.

Access to mifepristone has become the next major battleground in reproductive health, with anti-abortion politicians and lobbyists seeking to reinstate in-person dispensing requirements on the drug and, by doing so, make medication abortion harder to obtain.

After conflicting legal rulings in 2023 sparked confusion over whether mifepristone would be available from virtual clinics, some of them planned to temporarily shift to offering misoprostol-only medication abortions. Some virtual clinics have offered single-pill options even before that. Carafem offered misoprostol-only medication abortions beginning in 2020, in an effort to provide patients with options for virtual care during the early days of Covid.

Originally developed to treat gastric ulcers, misoprostol has been used for medication abortion since the late 1980s. It remains the primary method of medication abortion in many parts of the world where access to mifepristone is limited.

“Mifepristone and misoprostol are both very safe medications, and in general, having mifepristone increases the efficacy and decreases complication rates of medication abortion,” says Rachel Jensen, a fellow with the American College of Obstetricians and Gynecologists, which endorses the misoprostol-only protocol when mifepristone isn’t available. The single-drug regimen is also endorsed by the World Health Organization, the Society of Family Planning, and the National Abortion Federation.

“Before mifepristone became available, misoprostol was the only medication that was used for medication abortion. So we know that it's also safe and effective,” Jensen says. “It’s just a little bit less effective than the combined regimen.”

Most people only need one dose of misoprostol when using mifepristone, as opposed to three or more doses when using just misoprostol. The medication can cause nausea, vomiting, and uterine cramping, and using it alone can cause more intense or prolonged side effects since more doses are needed. Jensen recommends that patients have anti-nausea and pain medication on hand to manage side effects.

Abortion providers that decide to continue allowing patients to get mifepristone through virtual appointments may face civil repercussions if the Supreme Court sides with the appeals court. There is a chance that the FDA may decide to use enforcement discretion not to pursue health care professionals who continue to offer it.

“This FDA has become both incredibly politicized, but at the same time, we've also seen it stick aligned to the science,” says human rights lawyer Julie F. Kay. “So it's very hard to tell what the FDA will do.” The FDA did not respond to a request for comment.

Even if the courts allow remote mifepristone prescribing to resume, other challenges await. Anti-abortion activists are also trying to restrict mifepristone access through legislation. This year, Republican senator Josh Hawley introduced a bill banning the medication.

Despite the wave of challenges, reproductive health care activists are determined to keep providing care. “Abortion will proceed no matter what,” Plan C director Elisa Wells says. Even if domestic virtual clinics run into challenges, Wells says that alternative routes for the medicine have been built up over the years, including international clinics willing to ship pills into the United States, as well as underground peer-to-peer networks that import pills from India.

For now, though, domestic clinics are pushing forward. “Women will continue to get the care they need,” Kay says, “although with more confusion and stigmatization than is necessary.”