The approval of RU-486 would be a symbolic victory for abortion activists. But for women seeking early abortions, it would be just one option. And not the most popular one, many doctors in the field say.

Instead, the demand might largely be met with a new form of surgery.

Not long ago, a woman with a positive home pregnancy test and the desire for an immediate abortion was likely to get a shock when she called a clinic: She would have to wait until she was seven or eight weeks pregnant - two months after her last period.

The problem: Only when the sac containing the embryo got bigger than a pea could doctors count on seeing it in the material suctioned out of the uterus; smaller sacs were destroyed by the suction. And without today's sophisticated ultrasound machines, doctors could not look into the uterus to see if the abortion was complete.

Sending a woman home still pregnant - perhaps to experience bleeding, infection and other complications - was too much of a risk.

Then, in the 1980s, a French drugmaker introduced a pill that, taken three at a time and followed a few days later by another drug, could reliably induce an early abortion. RU-486 caught on quickly in France, Sweden, Britain and China. In the USA, it remained off the market, at first because of political forces and later because of business blunders by U.S. developers.

Meanwhile, abortion clinics were fielding calls from pregnant women who had heard of RU-486. And they soon found ways to respond. By 1995, doctors were offering early abortions with a cancer drug called methotrexate, long on the U.S. market. About a year later, a group of frustrated activists and doctors found a way to make limited supplies of RU-486 available. They set up a secret lab to make the stuff themselves and got FDA approval to use the drug in trials. Those trials continue at 15 sites, says Lawrence Lader of Abortion Rights Mobilization.

But the most important development may have happened at a Planned Parenthood clinic in Houston. There, a doctor named Jerry Edwards began offering a procedure called manual vacuum aspiration (MVA), using a hand-held vacuum syringe instead of the standard electric vacuum machine.

Most doctors thought of MVA as a low-tech, Third World procedure. But Edwards had an insight: Combined with early pregnancy tests and modern ultrasound, MVA was an ideal early surgery. Its main advantage was gentle suction: In most cases, tiny gestational sacs would come out intact and visible. When needed, ultrasound and blood tests could confirm abortions.

In 1997, Edwards published a study showing that MVA worked as early as eight days after conception - nearly a week before a woman would miss her period.

"The women love the fact that they can get this over with and move on," he says. "For the woman emotionally, it's a lot easier to know they are getting rid of something that, at most, is the size of a pea, rather than something formed with arms and legs and a beating heart."

Abortion availability

Today, even without commercially available RU-486, early abortion is widely available, especially in large cities.

The NAF, representing 350 abortion providers, says it can refer hot-line callers to 117 clinics that offer methotrexate and 101 that offer early surgical procedures. Those sites are in addition to the 15 involved in the RU-486 trials.

In clinics that offer both early surgery and drugs, women have a clear preference. "The vast majority choose surgical," says Rebecca Horne of Planned Parenthood League of Massachusetts, based in Boston and Worchester. At Planned Parenthood of San Diego and Riverside County, Calif., 300 women chose methotrexate, and 2,400 chose early surgery in the past year, medical director Katherine Sheehan says.

The reasons are clear: A methotrexate abortion requires at least two clinic visits and can involve weeks of bleeding and cramping. An MVA abortion takes five minutes.

Of course, RU-486 is not methotrexate.

"It's much cleaner, the bleeding is shorter, the procedure is done in a few days," Sheehan says. "It will be a much better option for women who want a medical abortion."

Eric Schaff, a Rochester, N.Y., physician, heads the current RU-486 trials. He's working to refine the method. For example, he has shown that a one-pill dose works as well as the three-pill dose. And though women in earlier trials had to return to clinics to take a second contraction-inducing drug and wait through several hours of cramping and bleeding, he has shown that they can safely and reliably take the second drug at home - increasing the odds that they will complete their abortion there, not in a clinic bathroom.

Experts agree there always will be women who hate the idea of any surgery and want to control the abortion themselves. RU-486 will fill that niche.

But it may be the most costly choice. "We think it's probably going to be incredibly expensive" because of the drug company's costs, says Maureen Paul, medical director of Massachusetts' Planned Parenthood.

Planned Parenthood's national medical director, Michael Burnhill, says he "wouldn't be surprised" if RU-486 abortions cost $75 to $100 more than surgery. Clinics already are struggling to offer methotrexate in the same $300-to-$400 range as surgical abortions, he says, because of the extra counseling and office visits involved.

Opening avenues

Whether early abortions are done surgically or with drugs, a question for the abortion movement is whether the new methods will spread to new providers, making abortion more accessible and more private.

In surveys, many doctors say they'd like to offer RU-486.

Echevarria says abortion foes will change their minds. "It's much more complicated and more involved than a lot of doctors think and a lot of women think," she says. But Schaff says his simplified approach will catch on - if it's not discouraged by what he fears will be overly cautious FDA labeling.

As for early surgery, Edwards, who now practices in Little Rock , says he has encountered "zero interest" from doctors who don't already perform abortions.

But Carole Joffe, a sociologist at the University of California, Davis, says the new methods will bring more doctors to abortion eventually. The moral discomfort that has kept some from providing abortions will diminish in the face of these very early methods, she says.

Planned Parenthood's Burnhill predicts that some gynecologists will quietly make the methods part of their regular office practices. "Maybe it won't be 75%, but even 10% or 15% would dramatically increase accessibility."

But, he says, it's foolish to make too many predictions.

"What exactly will happen out there? We don't know. But we'll find out soon enough."

Procedures by pill, injection, vacuum Mifepristone (RU-486) How it works: Taken by pill, it blocks the action of the hormone progesterone, causing the uterine lining to break down and dislodge the embryo. A second drug, taken a day or two later, causes contractions that expel the embryo. How long it takes: 90% of abortions are completed within four days of the first pill, but it can take two weeks. When used: Up to seven weeks after the last menstrual period; later use is under study. Effectiveness: In studies, 92% to 97% of abortions are completed without surgery. Methotrexate How it works: Given by injection, it stops embryo cell division. A second drug, used days later, causes contractions that expel the embryo. How long it takes: 65% of abortions are completed in a week , 85% in two weeks, but it can take a month. When used: Up to seven weeks after the last period. Effectiveness: In studies, 90% to 95% of abortions are completed without surgery. Manual vacuum aspiration How it works: Cervix is numbed; a hand-held syringe suctions out the embryo. How long it takes: About five minutes. When used: Usually three to seven weeks after the last period, though doctors differ. Effectiveness: In one U.S. study, more than 99% of abortions were completed in one procedure.