Written by Jessica Mitter Pardo, DO, M.Sc.

Anemia is a common condition among people seeking abortion care and can influence clinical decision-making, monitoring, and management strategies. While neither procedural nor medication abortion has an absolute contraindication based solely on anemia, understanding how hemoglobin levels intersect with bleeding risk and recovery is essential for high-quality care and appropriate patient education.

Medication abortion with mifepristone and misoprostol is widely used and very safe; studies have shown that mean drops in hemoglobin after first-trimester medication abortion are modest (approximately 0.1–0.7 g/dL). However, current evidence has not established a definitive minimum hemoglobin cutoff for medication abortion eligibility, as studies excluded individuals with significant baseline anemia (e.g., hemoglobin <9.5–10 g/dL).^1-3 For most patients with mild to moderate anemia (e.g., hemoglobin 9–11.9 g/dL), medication abortion is likely appropriate with adequate counseling and access to follow-up care, as rigid thresholds can create barriers to care, especially in communities affected by strict legal barriers.^1–3 

Procedural abortion, especially first-trimester aspiration, typically results in lower overall blood loss than medication abortion.³ This can make procedural approaches preferable for individuals with significant anemia or those with increased risk factors for hemorrhage, such as coagulopathy.³ Current practice includes assessing hemoglobin or hematocrit pre-procedure for individuals with a history of anemia, fibroids, or when concerns about bleeding exist.^2,4 Some clinicians encourage procedural abortion for patients with hemoglobin ≤ 9 g/dL, especially beyond early gestations, but no universally accepted cutoff exists.⁵

Management of anemia in the context of abortion care should include accurate screening, pre-procedure planning when possible, and appropriate post-abortion monitoring. In addition to eliciting information regarding recent history of anemia or bleeding episodes, screening can be performed with point-of-care capillary hemoglobin tests; however, they may overestimate anemia prevalence and confirmatory venous testing is often not possible or may cause a delay in care.⁴ When possible, providers should address reversible causes of anemia prior to the abortion if there are significant hemorrhage risks. Patients may be started on iron supplementation, though there should not be a delay in care to wait for effect. Providers should also counsel patients on signs of heavy bleeding and ensure timely access to care if bleeding is excessive or if symptoms of anemia, such as dizziness or fatigue, persist. More about bleeding management after medication abortion can be found in the June 2025 Insights article.

Counseling and eligibility protocols should avoid arbitrary cut-offs as they can lead to additional barriers and further restrict access to care that is already limited, particularly for marginalized communities. Instead, clinical judgment and shared decision-making should drive the choice of modality rather than hemoglobin level alone. Abortion providers should also advocate for the reassessment and removal of existing institutional barriers by presenting updated data and amending internal protocols.

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