In the US, future access to mifepristone, the gold standard for medication abortion, is increasingly uncertain. Misoprostol alone, the primary alternative, is effective but has lower efficacy and more side effects than the standard mifepristone-misoprostol regimen. Emerging evidence suggests that ulipristal acetate (UPA) plus misoprostol may offer another alternative, but research is needed to evaluate its effectiveness, safety, acceptability, and feasibility of implementation into routine care. To address this evidence gap, we propose a double-blind, randomized trial comparing the two leading alternatives to mifepristone-based medication abortion: UPA plus misoprostol versus misoprostol alone. The requested funds would support the initial phase of this trial. We will enroll 200 individuals seeking a lower-cost misoprostol-alone regimen through carafem’s telehealth and clinic-based services. Eligible, consenting participants will be randomized to receive either UPA plus misoprostol or misoprostol alone. Follow-up will occur through carafem’s virtual abortion care companion, an online survey approximately five weeks after enrollment, and communication with carafem staff as needed. Participants who complete follow-up will receive $50 remuneration. The primary outcome will be complete abortion without additional clinical intervention. Secondary outcomes will include safety, side effects, acceptability, and feasibility of integrating UPA plus misoprostol into routine abortion care. Interviews with carafem staff and providers will identify implementation considerations relevant to adoption of a UPA plus misoprostol regimen. This study will provide the first randomized comparative evidence regarding UPA plus misoprostol versus misoprostol alone for early medication abortion. The findings will inform clinical practice, service delivery, and future research and implementation efforts.