Botanical Treatments for Hemorrhoids

Abstract

Hemorrhoids are a very common condition. Hospital-based proctoscopy studies show prevalence rates of hemorrhoids in up to 86 percent of patients studied with many in an asymptomatic state. Botanicals used internally and topically can treat early stages of hemorrhoids effectively and can be used as adjuncts in more advanced stages when surgical treatments may be necessary. The roles of butcher's broom (Ruscus aculeatus), horse chestnut (Aesculus hippocastanum), stone root (Collinsonia canadensis), witch hazel (Hammamelis virginiana), arnica (Arnica spp.), oak (Quercus spp.), chamomile (Matricaria recutita), gotu kola (Centella asiatica), calendula (Calendula officinalis), and psyllium (Plantago ovata) in hemorrhoid treatment are discussed.

Full text

Kathy Abascal, B.S., J.D., R.H. (A.H.G.)
and Eric Yarnell, N.D., R.H. (A.H.G.)
Abstract
Hemorrhoids are a very common condition. Hospital-
based proctoscopy studies show prevalence rates of
hemorrhoids in up to 86 percent of patients studied with
many in an asymptomatic state. Botanicals used internally and
topically can treat early stages of hemorrhoids effectively and can
be used as adjuncts in more advanced stages when surgical treat-
ments may be necessary.
The roles of butcher’s broom (Ruscus aculeatus), horse chestnut
(Aesculus hippocastanum), stone root (Collinsonia canadensis), witch
hazel (Hammamelis virginiana), arnica (Arnica spp.), oak (Quercus
spp.), chamomile (Matricaria recutita), gotu kola (Centella asiatica),
calendula (Calendula officinalis), and psyllium (Plantago ovata) in
hemorrhoid treatment are discussed.
Introduction
Hemorrhoids are understudied and most likely undertreated.
It is estimated that about one half of all Americans have some
discomfort from hemorrhoids by the time they are 50 but only a
much smaller percentage (approximately 4 percent) seek medical
treatment for the condition.1Hospital-based proctoscopy studies
show prevalence rates of up to 86 percent with many patients in
an asymptomatic state.2Clinical experience suggests that botani-
cal treatments and lifestyle changes can relieve hemorrhoid
symptoms in the early stages and can provide significant benefit
as adjunct treatment in the later stages of the ailment. Unfortu-
nately, science has barely begun investigating these fairly ancient
treatments.
Hemorrhoidal tissues, cushions of tissue within the anal canal
that contain blood vessels and supporting tissue made up of
muscle and elastic tissue, are present in all individuals.2There
are usually three major hemorrhoidal cushions oriented to the
right posterior, right anterior, and left lateral positions.
There is a rich network of arteries around the anal canal,
providing a ready supply of arterial blood to hemorrhoidal
blood vessels. It is only when these cushions enlarge causing
negative symptoms that “hemorrhoids” in the vernacular
sense are present. Negative symptoms typically include the
passage of bright red blood that can occasionally be severe
and result in anemia.
If the hemorrhoid originates at the top of the anal canal, it is
referred to as an internal hemorrhoid. If it originates at the
lower end of the canal, near the anus, it is referred to as an
external hemorrhoid. Internal hemorrhoids are usually pain-
less (because this area of the body lacks pain receptors) but
they may bleed when they are irritated and, if large enough,
may protrude from the rectum and cause discomfort. Untreat-
ed internal hemorrhoids can lead to prolapse, in which the
distended internal hemorrhoids are pushed outside of the
anus. If the sphincter spasms, the blood supply to the pro-
lapsed hemorrhoid can be cut off, leading to a strangulated
hemorrhoid.
External hemorrhoids occur outside the anal verge. They can
be painful, swollen, and irritated. Itching can result from external
hemorrhoids although, typically, itching is most commonly
caused by skin irritation.
The stages of internal hemorrhoids are shown in Table 1. Obvi-
ously, pain, bleeding, and problems with passing stool can be
caused by conditions other than hemorrhoids. This article pre-
supposes that such conditions have been ruled out before any
treatment for hemorrhoids is undertaken.
The actual cause of hemorrhoids is not known.2Genetic pre-
disposition, straining during bowel movements, obesity, a seden-
tary lifestyle, pressure on the rectal veins caused by poor posture
and/or muscle tone, and pregnancy are believed to be causes.
Hemorrhoids are common in patients with spinal-cord injuries.
Constipation, chronic diarrhea, poor bathroom habits (such as
overzealous cleaning and wiping), postponing bowel move-
ments, and a fiber-poor diet are also considered to be contribut-
ing causes.3Alcoholic cirrhosis or other causes of portal
obstruction can cause severe hemorrhoids.
Internal Botanical Treatments
Botanical treatments for hemorrhoids have been poorly
researched. Butcher’s broom and horse chestnut are two herbs
that have some scientific validation of benefit in hemorrhoids
but have both been better studied in chronic vascular insuffi-
ciency (CVI) where they have more substantial evidence of
benefit.
285
Botanical Treatments
for Hemorrhoids

Butcher’s Broom
Butcher’s broom is a prickly, small berry–producing shrub in the
Liliaceae family. Its Latin name (Ruscus) is believed to come from the
Anglo Saxon word for holly or box because the plant has a pointed
leaf shape similar to holly leaves. The herb’s common name derives
from its use by butchers to clean meat stalls and keep flies away.
The whole plant contains steroidal saponins and ruscinogens—
the compounds deemed to be most active—but only the dried
rhizomes are used medicinally. Butcher’s broom is typically
administered in capsule form, and is frequently paired with
trimethylhesperidin chalcone (a flavonoid complex) and ascorbic
acid.* However, the plant is also available as an alcoholic extract
and a tea. There are also numerous topical preparations often
combining butcher’s broom with sweet clover (Melilotus spp.).
Butcher’s broom has a long history of clinical use as a treat-
ment for hemorrhoids, and its use for treating this condition
has been approved by the German Commission E.4In one
open-label multicenter study of 124 patients, 69 percent of the
patients rated butcher’s broom as having good or excellent
efficacy.5Seventy-five (75) percent of the treating physicians
rated this herb’s efficacy similarly. In addition, 92 percent of
the physicians rated butcher’s broom as safe and well-tolerated.
For this study, patients took 6 capsules per day of a product
containing 150 mg of butcher’s broom for 3 days and then
reduced their dose to 4 capsules per day. Statistically significant
improvement in a variety of symptoms (such as pain, local signs,
overall severity, etc.) was seen after 7 days of treatment. While a
single study does not prove efficacy, the very favorable observa-
tions of treating physicians combined with a long history of clini-
cal use are reasons to recommend that patients consider using
butcher’s broom as an internal treatment for hemorrhoids.
Butcher’s broom has been studied for use in pregnancy-related
varicosities. Two studies on pregnancy-related venous insuffi-
ciency both showed improvement in maternal symptoms with-
out any negative effects on the fetus.6,7 Two additional European
studies, one a multicenter study of 124 patients, showed a similar
reduction of symptoms in pregnant women.8,9 These studies do
not establish the safety of ruscus in pregnancy conclusively but
both animal and human studies indicate that ruscus has a high
degree of safety. Based on these studies, we favor butcher’s
broom when an internal remedy is needed for treating hemor-
rhoids in pregnant women (when surgical treatments are often
contraindicated).
In most clinical studies using this herb, the researchers gave
the subjects 150 mg of butcher’ broom, 3 times per day with
meals; the typical alcoholic tincture dose is 30–60 drops (1.5–3.0
mL) 3 times per day.10
Horse Chestnut
Horse chestnut is a beautiful deciduous tree that produces
large chestnut-like seeds that are dried for medicinal use. The
seeds contain a complex mixture of triterpene saponins collec-
tively referred to as escins (or as aescins).11 It also contains
flavonoids and tannins.12 The German Commission E has
approved the use of a standardized horse chestnut extract (con-
taining 16–20 percent anhydrous escin) for treating chronic
venous insufficiency (CVI).
Horse chestnut is the most widely prescribed oral remedy for
venous edema in Germany. Although widely used in Europe, the
herb’s popularity as a remedy in the United State is fairly recent.
286 ALTERNATIVE & COMPLEMENTARY THERAPIES—DECEMBER 2005
*Many of the studies on butcher’s broom combine it with various
flavonoids. There are, however, studies showing that butcher’s broom has
an action independent of these additional compounds. Some studies hint
that butcher’s broom used alone may actually have a stronger effect while
other studies indicate that the combinations may have a positive synergis-
tic effect. Thus, clinical results might be improved by the addition of com-
pounds such as trichalcone, ascorbic acid, and other flavonoids.
It should not be surprising to practitioners that patients suffering from
venous congestion problems may benefit from an overall treatment plan
that includes a variety of flavonoids and other compounds to reduce cap-
illary fragility and enhance healing.
Witch hazel (Hammamelis virginiana) flowers. Drawing © by Kathy
Abascal J.D., R.H. (A.H.G.).
Ta b l e 1. Staging of Internal Hemorrhoids
Stage Symptoms
I Occasional discomfort and/or bleeding
but no obvious external abnormality
II Hemorrhoids protrude with defecation
but reduce spontaneously
III Hemorrhoids protrude and require digital
reduction
IV Hemorrhoids protrude and cannot be
reduced
Adapted from Anonymous. American Gastroenterological Association medical position
statement: Diagnosis and treatment of hemorrhoids. Gastroenterol 2004;126:1461–1462.

There are some 20 clinical trials on horse chestnut and CVI, all of
which demonstrated a positive effect.11 In these studies, the
herb’s adverse effects were mild and infrequent and it was found
to be as effective as rutoside, another common treatment for CVI
in Europe.
There are European publications from the late 1800s and early
1900s reporting that horse chestnut benefits patients who have
hemorrhoids but there are no recent studies on the use of the
whole botanical medicine for treating hemorrhoids. One double-
blinded placebo-controlled study on 80 patients suffering from
acute symptomatic hemorrhoids showed that 40 mg of aescin
administered three times per day, for up to 2 months, reduced
symptoms in 81 percent of the subjects (compared to 11 percent
in the placebo group) and a notable reduction in bleeding (95
percent versus 62 percent) and swelling (87 percent versus 38
percent) as shown via endoscopic examination.13
Symptom reduction typically was reported after 6 days of
treatment and improvement in the condition was shown via
endoscopy after 2 weeks. Herbalist Michael Moore, director of
the Southwest School of Botanical Medicine, considers horse
chestnut to be the preferred remedy for hemorrhoids in individu-
als who are highly active physically (Michael Moore, personal
communication).
High levels of physical activity move more blood to the skele-
tal muscles, reducing the flow of blood to the gastrointestinal
tract. Mr. Moore says that this can lead to malabsorption, consti-
pation, and hemorrhoids, and he has found horse chestnut com-
bined with increased dietary flavonoids to be particularly helpful
in these cases. A typical dose of horse chestnut is 250 mg (corre-
sponding to 100 mg of escin) 2 times per day with meals.
Stone Root
Many American herbalists favor stone root, a nonaromatic
mint family plant, as a treatment for symptomatic hemor-
rhoids. The Eclectic physicians found this herb particularly
useful in patients with signs of congestion (dark red or purple
tissue) and hemorrhoids.14 Overweight, physically inactive
individuals who eat a diet high in fats and sugars and low in
fruits, vegetables, and grains tend to develop this state of con-
gestion. In our experience, stone root will often rapidly resolve
hemorrhoid symptoms and we favor its use in these types of
individuals.
There is virtually no research on stone root, except for con-
stituent studies showing that it contains flavonoids and
saponins.15,16 Of course, isolated flavonoids have been shown to
be of benefit for patients with hemorrhoids,17 and both butcher’s
broom and horse chestnut also contain flavonoids and saponins.
These data lend some very vague support for the use of stone
root. The Eclectics used a fairly low dose of stone root (1–30
drops); presently a typical dose of stone root tincture is 2–4 mL, 3
times per day.10,14
Witch Hazel
Witch hazel also has a long history of use as a hemorrhoid
treatment. Witch hazel is a shrub or small tree indigenous to
North America. The plant’s yellow flowers appear in the Fall,
and the leaves and bark are harvested for medicinal use. Both
the leaves and the bark contain tannins, primarily hamamelitan-
nins, and also contain catechins. The leaves contain more
flavonoids than the roots, and both contain a small amount of
volatile oil.12
Today, many people think of witch hazel primarily as a topical
treatment (see below). However, both European and American
herbalists typically use witch hazel both as an internal and topi-
cal remedy for hemorrhoids. Thus, both the European Scientific
Cooperative on Phytotherapy and France have approved the
herb’s combined use for treating hemorrhoids.12
Witch hazel is frequently prescribed as a decoction or as an
alcohol-preserved decoction. This makes sense as tannins are
highly soluble in hot water. Witch hazel extract has produced
anti-inflammatory, astringent, and vasoconstrictive properties in
pharmacologic studies.12 Its astringency is of help for patients
with bleeding hemorrhoids, and the Eclectics favored it for such
hemorrhoids as well as for any type of passive bleeding.14 The
ALTERNATIVE & COMPLEMENTARY THERAPIES—DECEMBER 2005 287
Calendula (Calendula officinalis). Horse chestnut (Aesculus hippocastanum).
Chamomile (Matricaria recutita).

dose for an infusion is 2–3 g of leaf or bark steeped in 150 mL of
boiled water, taken 2–3 times per day between meals. The tinc-
ture dose is 2–4 mL, 3 times per day.
Topical Treatments
Topical treatments to assist locally in calming inflammation
and for stopping bleeding and swelling are highly useful in
hemorrhoid treatment. According to the late Rudolf Fritz
Weiss, M.D. (a German phytotherapist and medical doctor),
acute hemorrhoidal inflammation is best treated with wet com-
presses.18 In addition, ointments can be applied but he did not
consider them to be sufficient if used alone. He recommended
that the compresses be cool, below room temperature, but not
cold because cold compresses can induce rectal spasming. Dr.
Weiss recommended that the wet compresses be applied for at
least 1 hour, morning and night, or that a sitz bath be used.
A hemorrhoid ointment should then be applied after each
treatment and after every bowel movement. As a practical mat-
ter, only a client with severe symptoms is likely to dedicate that
amount of time to treatment. Milder cases may be dealt with
effectively by a shorter time for compress application and an
occasional sitz bath with regular applications of ointment. Sup-
positories also work well.
Dr. Weiss favored arnica (Arnica spp.)compresses, which he
considered to be one of the fastest remedies for acute hemorrhoid
inflammation. He recommended using 1–2 teaspoons of arnica
tincture per half-liter of water for compresses. Alternatively, he
recommended the use of an oak bark decoction or a chamomile
infusion. He typically followed the application of compresses
with a witch hazel ointment.18
Topical application of witch hazel alone will often suffice to
soothe minor symptoms of acute inflammation. No doubt its
effectiveness explains why witch hazel remains a common ingre-
dient in over-the-counter hemorrhoidal preparations. Prepara-
tion H®Hemorrhoidal Cooling Gel (Wyeth, Madison, New
Jersey) for instance, contains 50 percent witch hazel. It is witch
hazel’s tannins that provide many aspects of its healing power,
and the clear witch hazel distillate so readily available over the
counter is not the medicine of choice because it is almost com-
pletely devoid of tannins.12 Instead, a more colorful tea or tinc-
ture should be used.
We tend to prefer combining several herbs in the compresses,
sitz baths, or ointments to provide a broader range of actions.
Any of the herbs used internally (stone root, butcher’s broom,
horse chestnut, and witch hazel) can be combined effectively for
topical application. We also like to include herbs that are noted
for their wound-healing properties, such as gotu kola, chamomile,
or calendula. If needed, tinctures of these herbs can be worked
into a cream base for topical application.
The Broader View of Hemorrhoid Treatment
Addressing hemorrhoids should go beyond simply prescribing
the botanicals discussed above. Dietary issues, while beyond the
scope of this article, are of great importance. Surprisingly little
research has been done on the connection between diet and hem-
orrhoids given the prevalence of the disorder and the fact that
isolated flavonoids have shown substantial benefit in the treat-
ment of hemorrhoids.17 Studies on fiber and hemorrhoids have
focused on the effect of soluble fiber; adding soluble fiber has
shown benefit in hemorrhoid treatment, at least when constipa-
tion is an aggravating factor.19
As a general rule, we consistently recommend that our clients
increase their intake of fruits and vegetables, with an emphasis
on foods containing soluble fiber. When constipation is an issue,
we often recommend psyllium seed husks. Lifestyle changes that
include increasing water intake and exercise to increase muscle
tone also help effect a long-term reduction of hemorrhoid symp-
toms.
As mentioned above, using botanicals both internally and top-
ically will speed healing. Botanicals such as gotu kola or ginkgo
(Ginkgo biloba), used to increase peripheral circulation, can act
synergistically with herbs used specifically for treating hemor-
rhoids.20 For instance, gotu kola and its isolated triterpenic frac-
tion improve microcirculation, decrease capillary permeability,
and reduce symptoms of CVI.21,22 The herb also has been shown
to increase tensile strength, collagen content, and epithelializa-
tion in many types of wounds when used internally or
topically.23–25
Dr. Weiss commented that it is important to address adequate-
ly the constipation and pain that accompanies many hemor-
rhoids as well.18 He typically prescribed a tea that combined
laxative, anti-inflammatory, and antispasmodic herbs with a bit-
288 ALTERNATIVE & COMPLEMENTARY THERAPIES—DECEMBER 2005
Dr. Rudolf Fritz Weiss’ Hemorrhoid Tea
Instructions
Use 1–2 tsp in a cup of boiling water infused for 10 minutes; patient should drink 1 cup in the morning and 1 cup at night.
Common name Latin binomial Part used Percentage
Chamomile Matricaria recutita Flowers 20%
Calamus Acorus calamus Root 20%
Fennel Foeniculum officinalis Seed 20%
Senna Senna spp. Leaves 20%
Frangula Frangula alnus Bark 20%
Adapted from ref. 18.

ter herb to tone the plexus hemorrhoidalis and an astringent to
relieve bleeding. One of his tea formulas is in the box entitled Dr.
Rudolf Fritz Weiss’ Hemorrhoid Tea..
A comprehensive treatment plan will work effectively on hem-
orrhoids in the early stages. More complicated or advanced hem-
orrhoids are likely to require allopathic intervention.
Nonetheless, botanicals as an adjunct to ligation and surgery will
be helpful for healing and preventing recurrences. ■
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Kathy Abascal, B.S., J.D., R.H. (A.H.G.), is executive director of the
Botanical Medicine Academy, Vashon, Washington. Eric Yarnell, N.D.,
R.H. (A.H.G.), is president of the Botanical Medicine Academy, a special-
ty board for using medicinal herbs, and is an adjunct faculty member at
Bastyr University, Kenmore, Washington.
To order reprints of this article, write to or call: Karen Ballen, ALTERNA-
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