Hemorrhoids

References & Evidence Notes

Each numbered entry below is either a source you can follow or a note setting out what the evidence does and does not support. Both are numbered together so the markers in the text line up.

Last reviewed October 20, 2026. Supplement entries are cross-checked against the NIH National Center for Complementary and Integrative Health and the Linus Pauling Institute Micronutrient Information Center.¹⁴ Never assume rectal bleeding is hemorrhoids. Hemorrhoids are extremely common, which is exactly why they get blamed for bleeding that is coming from something else. Bleeding that is dark or black, bleeding in someone over 40 and bleeding that comes with a change in bowel habit, weight loss or anemia need assessment regardless of whether you also have hemorrhoids⁷. Colorectal cancer screening starts at 45 in current US guidance¹⁵, and a self-diagnosis is not a reason to skip it. Beyond that, the good news is real: for most people with early-stage hemorrhoids, conservative care that starts with fiber, fluid and not straining is enough⁶.

1. On pregnancy: hemorrhoids are common in pregnancy and postpartum because of raised pelvic venous pressure, progesterone effects on venous tone and constipation. Most resolve after delivery. Fiber, fluid and a stool softener are first-line, and any product should be checked with the maternity team. A review in Canadian Family Physician found that in most women most symptoms resolve on their own soon after giving birth, and that treatment rests on more fiber, stool softeners, more fluid and better toilet habits, PubMed 18272631. ↩
2. On who gets hemorrhoids and why: they affect about 1 in 20 Americans and about half of adults over 50; causes include straining, long periods on the toilet, chronic constipation or diarrhea, a low-fiber diet, weakening of the supporting tissues with age, pregnancy and regular heavy lifting, NIDDK. ↩
3. On age: a US and UK epidemiologic study drawing on four national data sources found that about 10 million people in the United States reported hemorrhoids, a prevalence of 4.4%, with a peak between the ages of 45 and 65 in both sexes, a decrease after 65 and onset before 20 unusual, PubMed 2295392. ↩
4. On sitz baths and topical treatment: a 2018 American Family Physician review names stool softeners, over-the-counter topical preparations, more fiber and water, and sitz baths as the mainstays of initial treatment, says warm water baths decrease pain temporarily, and notes that most over-the-counter topical ingredients, corticosteroids among them, have not been studied for long-term effectiveness or safety, PubMed 29431977. NHS guidance on hydrocortisone for piles says not to use it for longer than 7 days, that using it for a long time can make the skin around the anus thinner, and that the local anesthetic in these products can make the skin sensitive, NHS, about hydrocortisone for piles, NHS, side effects. ↩
5. On conservative management: increasing dietary fiber and fluid intake reduces symptoms and bleeding from hemorrhoids: a systematic review found fiber roughly halved the risk of persisting symptoms and of bleeding, and trials that followed people up, usually at 6 weeks and 3 months, showed consistent results over time, PubMed 16405552. The American Gastroenterological Association's 2026 update names avoiding straining and long periods on the toilet, with more fiber, as reasonable first-line care, PubMed 42067175. ↩
6. On conservative care and procedures: a 2021 review of conservative treatment found it effective for the majority of people with early-stage hemorrhoidal disease, with diet and lifestyle changes the first step, PubMed 33087033, and a surgical review notes that in most instances hemorrhoids are treated conservatively, with a surgeon involved when conservative measures fail or complications occur, PubMed 14766336. When first-line care fails, a 2018 American Family Physician review names office rubber band ligation as the preferred next step for grade I to III internal hemorrhoids, with a lower failure rate than infrared photocoagulation, and says excisional hemorrhoidectomy succeeds more often but brings more pain and a longer recovery, so it is reserved for recurrent or higher-grade disease, PubMed 29431977. The American Gastroenterological Association advises that people be told of the small possibility of pelvic sepsis after hemorrhoid procedures, PubMed 42067175. ↩
7. On not self-diagnosing rectal bleeding. A 2018 American Family Physician review notes that symptomatic internal hemorrhoids often present with painless bright red bleeding, that hemorrhoidal bleeding rarely causes anemia, and that people older than 40 with rectal bleeding should have the whole colon examined unless they had a normal colon examination in the previous 10 years, as should younger people with warning signs such as weight loss, abdominal pain, fever or signs of anemia; it lists a family history of colorectal cancer as a risk factor, PubMed 29431977. NIDDK advises seeing a doctor for any bleeding from the rectum, because it can signal Crohn's disease, ulcerative colitis or cancer of the colon or rectum, NIDDK. NHS guidance says to see a doctor if blood in the stool or a change in stools lasts 3 weeks, or with unexplained tiredness or weight loss, to get urgent advice for black or dark red stool or bloody diarrhea, and names colorectal cancer and inflammatory bowel disease among the causes, NHS, rectal bleeding. ↩
8. On hemorrhoids in pregnancy and on procedures: the American Gastroenterological Association's 2026 clinical practice update states that hemorrhoids occur in up to two-thirds of women during pregnancy. It advises that banding or infrared coagulation, done in the office, be used before surgery for grade I to III hemorrhoids, with banding giving the longer-term benefit for prolapse and recurrent bleeding; that a surgeon be consulted for grade III hemorrhoids that fail banding; and that grade IV hemorrhoids require surgery, PubMed 42067175. ↩
9. On rubber band ligation over the long term: in one practice, 805 people had 2,114 bandings for internal hemorrhoids; of the 701 followed up, for a median of 1,204 days, 70.5% were helped by the first course and 80.2% once returning symptoms were banded again, with repeat courses helping 73.6% at a first recurrence but holding for less time each time. Bleeding after banding (2.8%) was more common in people taking aspirin, other NSAIDs or an anticoagulant, PubMed 15484351. ↩
10. On guideline findings: the 2024 colorectal surgery guideline notes that people with hemorrhoids are about twice as likely to have constipation (odds ratio 2.09 across 19 studies), that straining and long toilet sits are linked to more symptoms, that in a single-center study of 2,635 people treated with rubber band ligation 86.7% had no symptoms at 8 weeks and 15.5% had symptoms return by 2 years, and that rectal bleeding should not automatically be put down to hemorrhoids, PubMed 38294832. ↩
11. On toilet posture: in a crossover study of 52 healthy volunteers who recorded 1,119 bowel movements, a footstool that raised the knees was associated with less straining and a greater sense of complete emptying, and bowel movements took longer without it, PubMed 30346317. The volunteers did not have hemorrhoids, so this shows an effect on straining, not on hemorrhoid symptoms. ↩
12. On thrombosed external hemorrhoids: current colorectal surgery guidance makes a conditional recommendation, on low-quality evidence, that selected patients may benefit from early surgical excision, which may give faster relief and fewer recurrences; it notes that most patients treated without surgery eventually see their symptoms resolve, and that there is no evidence on the best time period for non-operative management, ASCRS guideline, 2024. ↩
13. On the first weeks of home care: the NIH's National Institute of Diabetes and Digestive and Kidney Diseases states that for many people the symptoms of external hemorrhoids go away within a few days, NIDDK, symptoms and causes. It lists fiber, water, not straining, not sitting on the toilet for long and warm sitz baths as home treatment, and says doctors most often recommend over-the-counter creams, ointments or suppositories for 1 week, with a follow-up if they do not relieve symptoms after 1 week, NIDDK, treatment. NHS guidance on hydrocortisone for piles says not to use it for more than 7 days and to see a doctor if symptoms have not improved after 7 days, NHS. ↩
14. National Center for Complementary and Integrative Health (NIH), nccih.nih.gov, and the Linus Pauling Institute Micronutrient Information Center, lpi.oregonstate.edu/mic. ↩
15. US Preventive Services Task Force; Davidson KW, Barry MJ, Mangione CM, et al. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(19):1965-⁠1977. PubMed 34003218. The current recommendation, released May 18, 2021, advises screening for colorectal cancer in all adults aged 50 to 75 (grade A) and in adults aged 45 to 49 (grade B), USPSTF. ↩