Saturday, January 22, 2011

Homeopathy in Hemorrhoids: ouch or aahh?

In the last post, I mentioned the conversation I had with my friend regarding homeopathic remedies. During this conversation was revealed the source of my friend's strange and firm beliefs in this quackery. He presented several anecdotes about members of his family as living proofs of the benefits of homeopathy.

Well, it turns out that the symptom - that homeopathy had apparently helped him and others to be rid of - was the occurrence and persistence of painful hemorrhoids (a.k.a 'piles'). The usual treatment in most cases, according to him, is surgical removal of the hemorrhoids (N.B. I discovered that this is not completely correct; see below), but they recur. Homeopathy 'cured' him and people he knew. He asked me to explain how this was possible, if there was nothing in the homeopathic remedies.

I decided to dig a little deeper into the problem and the claims. The source that I chose to research the issue is the Hemorrhoids information page at the National Digestive Diseases Information Clearinghouse (NDDIC), a service of the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK) of the NIH.

Hemorrhoids are swollen and inflamed veins around the anus or in the lower rectum... External hemorrhoids are located under the skin around the anus. Internal hemorrhoids develop in the lower rectum. Internal hemorrhoids may protrude, or prolapse, through the anus. Most prolapsed hemorrhoids shrink back inside the rectum on their own. Severely prolapsed hemorrhoids may protrude permanently and require treatment.

This was an 'A-ha!' moment, because, as you can see, right there it says, "Most prolapsed hemorrhoids shrink back inside the rectum on their own." Could this be responsible for the observation of homeopathy's miraculous effect? I read on and gathered the following points.

  • Internal hemorrhoids occur just inside the anus, at the rectal beginning; external hemorrhoids, on the other hand, occur at the anal opening and may hang outside the anus.
  • The most common symptom of internal hemorrhoids is bright red blood on stool, on toilet tissue, or in the toilet bowl after a bowel movement.
  • Internal hemorrhoids that are not prolapsed (protruding through the anus) are usually not painful; however, prolapsed hemorrhoids often cause pain, discomfort, and anal itching.
  • Thrombosed (veins with clotted blood) external hemorrhoids cause bleeding, painful swelling, or a hard lump around the anus; when the blood clot dissolves, extra skin is left behind that can become irritated or itch.
  • At the appearance of any such symptom, it is advisable to consult a physician, who has various means of visualizing and confirming the diagnosis of hemorrhoids.

Several factors may be responsible for the swelling in the anorectal veins leading to hemorrhoids, including:

  • chronic constipation or diarrhea.
  • excessive straining during bowel movements, which may be a behavioral consequence of chronic constipation.
  • similarly, sitting on the toilet for long periods of time.
  • fiber-poor diet.
  • weakening of anorectal connective tissue with age (45-65yrs).
  • pregnancy, which increases abdominal pressure, sometimes leading to an enlargement of veins in the lower rectum and anus; the hemorrhoids usually disappear postpartum.

But by far, the most significant information I found was one that pertained to the treatment:

  • Hemorrhoids are not dangerous or life threatening; symptoms usually go away within a few days, and some people with hemorrhoids never have symptoms.
  • Simple home remedies may suffice to treat hemorrhoids and prevent recurrence.
    1. Simple diet and lifestyle changes (more fibers, more fluids; exercise; less sitting and/or straining during bowel movement; sitting in a tub of warm water) often reduce the swelling of hemorrhoids and relieve hemorrhoid symptoms.
    2. Use of bulk stool softener or a fiber supplement such as psyllium (Metamucil) or methylcellulose (Citrucel) may help with the constipation.
    3. Over the counter corticosteroids or creams with topical analgesics (such as lidocaine) may reduce the itch.
  • Medical treatment options are considered only when these home remedies don't alleviate the symptoms. Even then, the physician may be able to shrink the hemorrhoid with relatively non-invasive techniques. Only in cases of large external or internal hemorrhoids, not amenable to other treatments, causing severe pain and bleeding, surgical removal ('hemorrhoidectomy') may be required.

So much for my friend's theory of 'almost always requiring surgery'! Here, then, we have a clinical situation that may be largely asymptomatic and/or self-correcting, or amenable to rather simple, easily do-able home remedies. Sounds familiar? It should, because these are the ideal situations in which homeopathic quackery flourishes and homeopaths cry themselves hoarse claiming success.

What are these homeopathic remedies, then? I plumbed the murky depths of the world of woo (IOW, various alt med websites) to find out.

One herbal remedy that is topically applied is Witch Hazel (Hamamelis spp.), a flowering plant containing a flavonoid astringent in its bark and leaves. Because of the presence of the active principle in the prepared distillates used as medicine, I don't consider this 'homeopathic'. There appears to be some evidence for efficacy of micronized flavonoids as treatment for hemorrhoids, and at least one Cochrane Review found flavonoids effective in conservative management of symptomatic and/or complicated haemorrhoids in pregnancy; another meta-analysis acknowledged the apparent beneficial effect while expressing concerns about limitations in methodological quality, heterogeneity and potential publication bias in the reviewed studies.

Truly 'homeopathic' remedies for hemorrhoids, on the other hand, use the absurd dilutions (30C, 200C) with the fancy names - Aesculus hippocastanum, Aloe socotrina, Collinsonia, Arsenic album, Nux Vomica, and - surprise! - Hamamelis. Of course, at those dilutions, nothing of the original substance (presumably herbal preparations, like Witch Hazel) remains. However, other suggested remedies are prima facie even more absurd and border on crazy - but are probably safe because they are diluted to homeopathic proportions (whew!); these include Muriatic acid (that's HCl for you!), Nitric acid, phosphorus and sulfur, as well as the so-called homeopathic/biochemic medicines, Kalium carbonicum (Potassium carbonate), Calcarea fluorica (Calcium fluoride), et cetera.

In the end, it boils down to the same old problem: extraordinary claims of efficacy from an implausible, pseudoscientific modality such as homeopathy should require extraordinary evidence in order to be considered valid. Such evidence is severely lacking. In the meantime, homeopaths focus on various self-correcting ailments or expressions of the nonspecific placebo effects to claim 'treatment success' with their quack remedies. Belief in homeopathy may be culturally driven, and often feeds off ignorance and desperation of hapless patients.

As a particularly egregious example that I came across while researching for this post, there is an Indian homeopath with a spiffy website; he offers online treatment for a price to patients from India, US and Canada. Apart from suggesting homeopathic remedies for hemorrhoids, this self-styled 'homeopathic specialist' also offers homeopathic treatment for autism, touting "miraculous cures"! I was too disgusted to read on and left the website, but not before realizing how this despicable man is capitalizing on the desperation of gullible parents of autistic children, in order to peddle his brand of quackery to them. The section of his website featuring 'cured cases' has, unsurprisingly, a few photos, a couple of testimonials, and a YouTube video - but no link to any proper empirically-derived evidentiary basis of his claims.

Sadly, homeopathy is popular in India and even has complete official sanction for operation; faith in homeopathy as 'popular medicine' is deeply entrenched in the Indian psyche, not to be displaced in foreseeable future - not even, apparently, if one studies science and chemistry and molecular biology, and makes out a career in biomedical research.

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