Can a pregnant patient use Anusol (hydrocortisone) suppositories?

Use of Anusol (Hydrocortisone) Suppositories in Pregnancy

Yes, hydrocortisone suppositories can be used during pregnancy, particularly in the third trimester for symptomatic hemorrhoids, with evidence supporting their safety when used appropriately. 1

Evidence for Safety

The most direct evidence comes from a prospective study of 204 pregnant patients treated with hydrocortisone foam for hemorrhoids in the third trimester, which demonstrated no adverse events compared with placebo. 1 This provides reassurance for use of rectal hydrocortisone formulations during late pregnancy.

Trimester-Specific Considerations

Third Trimester (Preferred)

• Hydrocortisone suppositories are safe and effective for hemorrhoid management in the third trimester, when hemorrhoids are most common due to compression of the rectum by the gravid uterus. 1
• Approximately 80% of pregnant persons develop hemorrhoids, most commonly during this period. 1

First and Second Trimesters (Use with Caution)

• The FDA classifies topical corticosteroids as Pregnancy Category C, indicating that they should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. 2
• Avoid extensive use, large amounts, or prolonged periods of treatment, particularly in the first trimester. 2
• Systemic corticosteroid use in the first trimester has been associated with a small but significant increased risk of oral clefts, though this evidence primarily relates to oral/systemic steroids rather than topical rectal preparations. 1, 3

Treatment Algorithm for Hemorrhoids in Pregnancy

Step 1: Non-Pharmacological Management (All Trimesters)

• Increase dietary fiber to approximately 30 g/day through fruits, vegetables, whole grains, and legumes. 1, 4
• Ensure adequate fluid intake, particularly water, to soften stools. 1, 4
• Encourage avoidance of straining during bowel movements using relaxation techniques. 1

Step 2: Bulk-Forming Laxatives (If Constipation Present)

• Psyllium husk or methylcellulose are safe due to lack of systemic absorption. 1
• Polyethylene glycol 17g daily or lactulose can be used safely. 1, 4

Step 3: Topical Hydrocortisone (For Symptomatic Relief)

• Use hydrocortisone suppositories or foam for symptomatic hemorrhoids, particularly in the third trimester. 1, 4
• Consider glycerin suppository for immediate relief if severely uncomfortable. 4, 5

Important Caveats

• Avoid stimulant laxatives as safety data are conflicting during pregnancy. 1, 6
• The rectal route of hydrocortisone administration results in minimal systemic absorption compared to oral corticosteroids, reducing theoretical fetal risks. 2
• If first-trimester use is necessary, limit duration and amount of application, and ensure the benefit clearly outweighs potential risks. 2
• Hemorrhoids presenting with severe pain, bleeding, or signs of thrombosis may require additional evaluation beyond topical therapy. 1

Clinical Reasoning

The evidence strongly supports the safety of hydrocortisone suppositories in the third trimester based on prospective controlled data. 1 For earlier trimesters, the theoretical concerns about corticosteroid teratogenicity must be balanced against the minimal systemic absorption from rectal administration and the significant impact of untreated hemorrhoid symptoms on maternal quality of life. 2 The key is to use the lowest effective dose for the shortest duration necessary, particularly before the third trimester. 2