In the United States, hemorrhoids are the fourth leading outpatient gastrointestinal diagnosis, accounting for 3.3 million outpatient care visits. The worldwide prevalence of hemorrhoids is estimated to be 4.4% in the general population. While generally considered a benign condition, hemorrhoids have significant implications for quality of life, related to the psychological and physical discomfort they can cause. Fortunately, with appropriate intervention, hemorrhoids are treatable. A functional medicine approach to hemorrhoids increases treatment success and prevents their recurrence. (13)

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What Are Hemorrhoids?

​​Hemorrhoids, also called piles, are swollen veins in the lower part of the rectum and anus. They can be internal (inside the rectum) or external (under the skin around the anus). Hemorrhoids are a common condition, affecting about half of all men and women by age 50. 

What Are the Signs & Symptoms of Hemorrhoids?

Symptoms of hemorrhoids will depend upon the type of hemorrhoid.

Because internal hemorrhoids lie inside the rectum, they are rarely visible and don't typically cause pain or other discomfort. The most common indicator that a person has an internal hemorrhoid is painless bleeding, presenting as bright red blood on toilet paper or in the toilet during bowel movements. Internal hemorrhoids may sometimes prolapse, protruding through the anal opening and causing pain. (17) 

Most symptoms associated with hemorrhoids are due to external hemorrhoids. External hemorrhoids appear as a lump or swelling around the anus. They commonly cause pain, discomfort, itching, and irritation around the anus. As with internal hemorrhoids, rectal bleeding is common during bowel movements. (17) 

What Are the Possible Causes of Hemorrhoids?

Hemorrhoids occur under increased pressure in the lower rectum, causing the veins around the anus to stretch, bulge, and swell. Hemorrhoids, both internal and external, are commonly attributed to chronic constipation or diarrhea, obesity, pregnancy, low-fiber diets, and regularly lifting heavy objects. (7) 

Hemorrhoids also become more common with age, with a peak prevalence in persons aged 45-65 years. This is because of a weakening of the connective and supporting tissues in the rectum and anus, predisposing the veins to stretch (17).

Studies have shown that patients with hemorrhoids have anatomical variations in the venous network compared to those without. The terminal branches of the superior rectal artery supplying the anus in patients with hemorrhoids have a significantly larger diameter, greater blood flow, and higher peak and acceleration velocity than healthy subjects. Additionally, patients with hemorrhoids tend to have a higher resting anal canal muscular tone even when not straining. 

Functional Medicine Labs to Test for Root Cause of Hemorrhoids

Patients suspecting they have hemorrhoids should seek medical help to successfully treat existing hemorrhoids and prevent the formation of future ones. Your doctor will diagnose hemorrhoids by conducting a comprehensive visit, starting by gathering information about symptoms. A physical examination will also be required to visualize the hemorrhoids. This may involve a digital rectal exam, anoscopy, or sigmoidoscopy.  

While hemorrhoids don't require diagnostic testing, many functional medicine doctors will opt to order comprehensive testing to investigate underlying factors known to cause and exacerbate the development of hemorrhoids. 

Comprehensive Stool Test

A comprehensive stool test offers the opportunity to map out the intestinal microbiome, thoroughly analyzing the composition and diversity of the various microorganisms that comprise the microbial community living in the large intestine. Dysbiosis, an imbalance in the beneficial and harmful organisms, is a common cause of constipation and diarrhea. Other intestinal markers included on these stool panels help to evaluate the overall health and integrity of digestive health and function, further providing insight into underlying causes of abnormal stool patterns.

Weight Management

Because obesity can contribute to hemorrhoid risk, weight loss and achieving an optimal weight may be recommended as part of an integrative treatment plan. For those struggling with weight loss, specialty lab tests, such as the DNA Diet and Weight Management Profile, evaluate genetic and hormonal factors acting as obstacles to achieving weight goals.

Anemia Panel

Patients with chronic, recurrent hemorrhoids are at risk for iron deficiency and anemia due to blood loss. Therefore, ordering a CBC and iron panel to screen for iron deficiency and iron deficiency anemia can be beneficial. 

Cardiovascular Health

Chronic venous insufficiency (CVI) is when veins have problems moving blood back to the heart and commonly presents with varicose veins. Varicose veins have a similar etiology to hemorrhoids, resulting from a stretching of the veins (most commonly in the legs) due to sustained increased pressure. The CHORUS study evaluated over 5,000 patients with hemorrhoids and found that over half of the participants had coexisting CVI; furthermore, the presence of CVI was strongly associated with advanced hemorrhoidal grade (severity). 

Understanding these results, it makes sense that hemorrhoids can be a sign of poorer cardiovascular health and function, and those with hemorrhoids may have an increased risk for cardiovascular events. Calculating and estimating cardiovascular risk can be done with tools like the ASCVD Risk Estimator, which estimates a person's 10-year risk for atherosclerotic cardiovascular disease by considering lifestyle factors (i.e., history of smoking), blood pressure, cholesterol levels, and HbA1c. 

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Conventional Treatment for Hemorrhoids

Many hemorrhoids can be treated and prevented by implementing lifestyle changes to reduce rectal and anal pressure. These may include strategies such as eating high-fiber foods, taking a stool softener or fiber supplement, drinking adequate amounts of water, not straining during bowel movements, and not sitting on the toilet for prolonged periods. Over-the-counter oral and topical medications can help relieve mild pain, swelling, and itching of hemorrhoids. (23) 

Office-based and surgical procedures can treat hemorrhoids that do not respond to first-line medical therapies. Office treatments include rubber band ligation, sclerotherapy, infrared photocoagulation, and electrocoagulation. These procedures cut the blood supply from the hemorrhoid, causing it to shrink and fall off. Hemorrhoidectomy, the surgical removal of hemorrhoids, may be recommended to remove large external hemorrhoids and prolapsing internal hemorrhoids. (23)

Functional Medicine Treatment for Hemorrhoids

A functional medicine approach to hemorrhoids integrates many of the first-line therapies documented in the conventional treatment guidelines; however, a stronger emphasis lies in treating and addressing the underlying cause of hemorrhoids and venous insufficiency. Therefore, treatment plans will be customized based on patient history and lab findings, focusing on short-term symptomatic treatment while addressing the identified factors contributing to increased venous pressure. 

Nutritional Recommendations 

All patients with hemorrhoids should make every effort to increase dietary fiber to at least 25-35 grams daily. Water intake should also be increased to prevent constipation that can occur with increased fiber intake. Examples of high-fiber foods include fruits, vegetables, whole grains, legumes, nuts, and seeds. Increasing fiber through diet and, when necessary, supplementation decreases hemorrhoidal bleeding by 50% and improves overall pain and itching. (1, 18) 

Supplements & Herbs

Astringent herbs are rich in chemicals called tannins, which bind proteins on exposed tissues to have a drying effect and reduce tissue irritation and inflammation. Witch hazel is one such example commonly used topically in the treatment of hemorrhoids, shown to be effective in reducing pain, itching, and inflammation.

Bioflavonoids, a group of natural compounds in certain plants, have shown promising benefits in treating hemorrhoids. These compounds, often found in citrus fruits, berries, and green tea, are known for their antioxidant and anti-inflammatory properties. Bioflavonoids help strengthen blood vessels and reduce inflammation. By stabilizing and strengthening the walls of blood vessels, bioflavonoids can lessen the discomfort, swelling, and bleeding associated with hemorrhoids. (2, 3) 

Complementary and Integrative Medicine

Warm water sitz baths are warm, shallow baths you sit in to soak the perineum. Sitting in sitz baths effectively reduces hemorrhoidal pain, itching, and swelling. The warm water relaxes the internal anal sphincter and reduces rectal pressure. Warm water sprays are as effective and more convenient as sitz baths for providing relief of hemorrhoid symptoms. (20, 21) 

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Summary

Functional medicine offers a promising approach to understanding and treating hemorrhoids. By delving into the underlying causes, lifestyle factors, and individual health histories, functional medicine practitioners provide tailored solutions that extend beyond mere symptom management. Through comprehensive analysis, patients can discover personalized strategies that integrate dietary changes, targeted supplements, and other holistic approaches that address the symptoms and root causes of their hemorrhoidal discomfort.