A Functional Medicine approach to Endometriosis
In this article one of our trusted professionals a fellow Nutrition & Functional Medicine Practitioner Katie takes a look at the traditional symptoms associated with endometriosis, how it can develop, risk factors and the conventional approach to treatment. Following on from that she then looks at nutrition and lifestyle considerations, potential use of supplementation and finish with a summary of your key considerations.
Introduction to Endometriosis
What is endometriosis?
Endometriosis is a condition in which endometrial tissue develops outside the womb, most commonly around the ovaries, fallopian tubes, lining of the abdomen and on the bowel or bladder. It is understood to affect approximately 1.5 million women in the UK and most commonly occurs between the ages of 24 – 40 years. (1)
Typical symptoms of Endometriosis
Just like the cells in the lining of the womb, endometrial tissue found in other areas of the body responds to the monthly hormonal fluctuations of the menstrual cycle by thickening, breaking down and bleeding. However, unlike the womb lining which can leave the body each month via menstrual blood, the blood produced from the breakdown of endometrial growths has nowhere to go. Instead it can become trapped, causing inflammation, swelling and pain. This can lead to chronic and debilitating symptoms such as:
- painful menstruation (dysmenorrhea)
- heavy or irregular periods
- spotting or bleeding between periods
- pain in the lower abdomen, pelvis or lower back
- chronic fatigue
- painful intercourse (dyspareunia)
- problems conceiving or infertility
Symptoms can also manifest in other areas too, depending on where the endometrial growths are located. Some women can experience discomfort with urination or bowel movements, joint pain, bleeding from the nose, blood in urine or stool and coughing up blood. However, others may be completely asymptomatic and only discover they have the condition when they experience problems getting pregnant.
How does endometriosis develop?
Heredity is the main risk factor, so you are more likely to develop endometriosis if your mother or sister has the condition. There is also a strong link between endometriosis and imbalance in the immune system: levels of immune cells in the peritoneal fluid of women with endometriosis are positively correlated with severity of symptoms, suggesting an autoimmune component. Diet and lifestyle have also been implicated, with lack of exercise, a diet high in processed foods and sugar and exposure to synthetic oestrogens and hormone disruptors (PCBs, plastics, detergents, aluminium) all playing a part. Compromised liver and detoxification pathways can also contribute to development due to improper clearance of excess oestrogen.
The conventional approach to treatment
Your GP may refer you to a gynaecologist for an internal examination and/or ultrasound to determine any swelling in the pelvic area or ovaries. A definitive diagnosis can usually only be given following an abdominal laparoscopy and/or a biopsy to pinpoint any potential pelvic endometrial implants. (2)
At present there is no absolute cure for endometriosis so conventional treatment is centred around easing symptoms through anti-inflammatory pain relief. Hormone treatments including the contraceptive pill and medicines called gonadotrophin-releasing hormone (GnRH) analogues are also used to regulate oestrogen levels and help to shrink or slow down endometrial tissue growth. A levonorgestrel-releasing IUD (commonly known as the Mirena coil) is sometimes used to help slow the growth of tissue in the womb lining and reduce pain and periods. Depending on the severity of symptoms, your doctor may recommend surgery to remove sections of endometrial tissue or affected organs (such as a hysterectomy). (3)
The Functional Medicine Approach
Endometriosis is characterised by high levels of inflammation and oestrogen activity, alongside potential imbalance in the immune system. Employing a functional medicine approach means we can start to address these issues at their root by using targeted diet and lifestyle interventions to reduce inflammation and support healthy oestrogen metabolism. This in turn can have a positive knock-on effect on symptom expression. You can learn more about how nutrition and lifestyle can help to support endometriosis below.
Nutrition and Endometriosis
Establishing the root cause
As we have discussed previously, endometriosis is often characterised by increased inflammation, an imbalanced immune response and high levels of oestrogenic activity – or a combination of all or some of these elements. While every woman’s endometriosis experience is unique depending on her health history, environment and lifestyle, there are some key nutritional considerations which can start to provide a much-needed baseline of support if you have this condition.
Increasing your intake of naturally anti-inflammatory foods is a fantastic place to start for anyone with endometriosis. Eating a rainbow of different colour vegetables on a daily basis will ensure that you are consuming a variety of phytochemicals, important plant nutrients which have powerful anti-inflammatory properties. In particular, the following phytonutrients have been shown to reduce the inflammatory response:
- Carotenoids and flavonoids in dark green vegetables such as kale, spinach, bok choy, watercress, broccoli and chard
- Beta-carotene, found predominately in orange and yellow vegetables and fruits such as carrots, peppers and mangoes (1)
- Bromelain, an anti-inflammatory enzyme found in pineapple (2)
- Carnasol, found in rosemary (3)
- Quercetin, an immunity-enhancing flavonoid found in apples, darkly-coloured berries, broccoli, cauliflower, cabbage, sprouts, olive oil, capers and onions (4)
- Pterostillbene, found in blueberries (5)
- Curcumin, the active anti-inflammatory compound in turmeric (6)
Alongside these plant foods, herbs and spices such as cinnamon, ginger, cloves and (somewhat paradoxically) capsaicin from chilli peppers have also been shown to promote an anti-inflammatory response in the body. (7)
High insulin levels can aggravate inflammation by increasing the activity of the enzyme responsible for converting omega-6 fatty acids into inflammatory by-products. Choosing foods with a lower glycaemic load (GL) is therefore important to help regulate insulin levels. Including healthy protein and fat sources with every meal also helps to better manage blood glucose and insulin. (8)
7 Features of the anti-inflammatory food plan include:
1. Emphasis on anti-inflammatory fats. 2. Optimising blood glucose regulation. 3. Removal of highly refined and processed foods. 4. Increased level of dietary antioxidants and phytonutrients. 5. Restriction of dietary arachadonic acid commonly found in meat and dairy based foods. 6. Increased plant-based diet or purely plant-based diet depending on the plan you choose. 7. Nutrient dense food choices.
Improving immune tolerance
Key to choosing healthy fats is ensuring a good balance of anti-inflammatory omega-3 fats. Oily fish, eggs and flaxseeds are all good dietary sources of omega-3 fats. These foods are also rich in vitamin D which can assist with improving immune tolerance, another central consideration when addressing the root cause of endometriosis. (9) It’s worth noting that organic and grass-fed meat and game tend to have higher concentrations of omega-3 fatty acids than meat from conventionally-farmed sources. Choosing organically raised produce also lowers your exposure to xenoestrogens, synthetic compounds which mimic the action of oestrogen and disrupt hormone balance.
Reducing pro-inflammatory foods
While eating an abundance of anti-inflammatory foods is a good idea, it’s also important to limit or eliminate foods which can provoke an inflammatory response in the body. Avoiding foods high in sugar and trans or omega-6 fats is a great place to start. These include processed foods, refined carbohydrates such as pasta, cakes, biscuits and conventionally produced meat. Caffeine and alcohol should also be kept to a minimum. Many people can struggle to digest dairy and gluten, so if you think these foods might be an issue for you it could be worth avoiding them for a few weeks and monitoring your symptoms.
Supporting a healthy hormone balance
High levels of circulating oestrogens can both trigger and exacerbate endometriosis. Optimising liver and gut function helps to ensure excess oestrogen can be eliminated effectively from the body. A diet rich in high fibre foods and those that support healthy detoxification such as cruciferous vegetables (broccoli, Brussel sprouts, cabbage, cauliflower), beetroot, watercress, artichokes and lemons is key. In particular, cruciferous veggies contain a compound called indole-3-carbinol, which helps to bind excess oestrogens, allowing for safe excretion and preventing recirculation in the body. The fibre from these foods and other vegetables can support a healthy transit time, further assisting with the elimination process.
Despite the name, phytoestrogens found in plants, seeds and pulses such as flaxseeds (linseeds), apples and chickpeas can actually have an anti-oestrogenic effect which may help to promote a healthy oestrogen balance. (10) It is best to avoid soy protein and soy isolates however, as these contain unnaturally high levels of plant oestrogens which can have a negative effect on hormone balance.
Endometriosis & Lifestyle
A functional medicine approach to endometriosis involves considering the individual as a whole and assessing all areas which may be contributing to ill health. Lifestyle factors such as sleep, movement and stress can all play a role alongside nutrition in supporting endometriosis.
Exercise can feel like the last thing you want to do when you are in pain. However, gentle, restorative forms of exercise such as yoga, Pilates, walking and tai chi can help to lower inflammation as well as promote the release of endorphins, your body’s natural pain-killing hormones. (1) Exercise also stimulates your lymph glands which help your body to clear excess oestrogen from the system.
On the days when you do feel more energetic, stick to short bursts of high intensity exercise rather than pounding away for hours on the treadmill. Excessive and prolonged exercise can increase inflammation & cortisol production, potentially leading to disruption in hormones as well.
Address your stress levels
Easier said than done perhaps, but reducing your stress levels is possibly one of the most important areas to consider when supporting endometriosis. Stress sets up a vicious cycle by increasing cortisol and adrenaline. Over time chronic stress can result in an inability to properly manage inflammation. This can aggravate symptoms, thereby leading to more pain and a continually heightened stress response, which continues the cycle.
Studies have shown regular mindful meditation practice can reduce the physiological effects of stress. This includes a reduction in blood pressure, heart rate and cortisol, thereby helping to minimise the inflammatory response. (2) Even ten minutes of deep breathing every day can help reset the stress response.
Stress reduction can also take the form of simple pleasures such as a catch-up with a good friend, a walk in the park, listening to a favourite album or half an hour curled up with a good book. Choose whatever feels good for you – the key is to take time every day to look after yourself and do something you enjoy, without feeling guilty!
Get some zzzzzz
Even small amounts of sleep deprivation (getting less than 7-8 hours a night on a regular basis) can increase stress and reduce pain thresholds, making coping with the symptoms of endometriosis even more challenging. Frustratingly, sufferers often find that the symptoms themselves can disrupt sleep and lead to poorer sleep quality. (3) Much like the stress response, this initiates a vicious cycle which can become chronic.
As much as you can, aim to prioritise sleep by keeping a regular bedtime and rising time. This helps to regulate your circadian rhythm and promote hormone balance. Have a digital detox before bed and reduce or avoid exposure to blue light from mobile phones, computers and other electronic devices which can suppress melatonin production and induce wakefulness. Some women find a mug of camomile or valerian root tea can be calming in the evening and help to promote sleep.
A warm bath with magnesium salts before bed can be deeply relaxing and help ease painful cramps in the abdomen and back, as well as encouraging a restful night’s sleep.
Reduce your exposure to xenoestrogens
Xenoestrogens are chemicals or synthetic substances which mimic the effect of our natural oestrogens by attaching to hormone receptors in the body and interfering with oestrogen signalling mechanisms. (4) This can disrupt hormone balance and encourage oestrogen dominance, a key issue for women with endometriosis. In order to reduce your exposure to xenoestrogens in the environment try taking the following steps:
- Avoid using plastic to store or heat food. Phthalates in plastic have been shown to play a role in the development of endometriosis. (5) Instead, store food in glass containers or jars and especially avoid heating food in plastic containers in the microwave or drinking hot liquids such as coffee from Styrofoam cups.
- Choose jars over canned goods. Cans are usually lined with a plastic coating that contains bisphenol-A (BPA), a xenoestrogen which can negatively impact female reproductive health. (6)
- Switch to natural skincare products, shampoos, soaps, toiletries, detergents and cleaning products. Xenoestrogens in these products including parabens and phenoxyethanol chemical compounds can be absorbed through the skin. These then go directly to tissues without passing through the liver for detoxification, making them much more potent than those consumed orally.
- Consider installing a water filter in your home and invest in a re-usable stainless steel or BPA-free water bottle which you can take out and about. Not only will this reduce your exposure to xenoestrogens but it will save you money on bottled water in the long run, as well as being better for the environment.
Choose organic foods where possible
This is especially important when it comes to meat and dairy such as beef, pork, chicken, milk, butter, cheese and ice cream. Unfortunately, the meat and dairy from commercially-raised animals tends to contain growth hormones which can significantly interfere with our hormone balance when eaten on a regular basis. Instead, choose grass-fed, organic and humanely-raised animal products whenever you can.
Insecticides and pesticides used in other farming can also disrupt hormone balance. In an ideal world we would all eat organic 100 per cent of the time, but in real life this is often not possible or practical. Instead, do the best you can within your budget and the options available to you. Check out this article on organic vs non organic showing the foods which are most commonly contaminated with pesticides and those which are less likely to be affected, so you can make the best choice for you.
Acupuncture for assistance with pelvic pain
A small Harvard Medical School study showed that acupuncture can be a safe and well-tolerated therapy for helping to relieve chronic pelvic pain associated with endometriosis. Participants in the acupuncture group displayed a 62 per cent reduction in pain over the course of a four-week treatment. (7)
Endometriosis and Supplementation
We previously discussed the importance of dietary and lifestyle approaches when it comes to looking after your body when you have endometriosis. Now I look at specific nutrients which may be helpful in providing additional support for this condition.
A tailored approach
It is important to remember that we are all individual, with a unique biochemistry that requires a personalised approach to nutrient levels. This is particularly true with endometriosis: while there are common symptoms, the reasons why and how those symptoms started and continue to manifest can vary widely between women depending on physiology, environment, genetics and health history.
This is often why the Functional Medicine approach, which seeks to ask these very questions – “why” and “how” a particular individual came to their current health state – can be so effective.
For the same reasons, there is no one-size-fits-all remedy when it comes to supplementation and specific nutrient levels. I strongly advise working with a nutrition professional to determine the nutrient requirements that are right for your body. As part of my work, I assess a client’s individual case history, medication use and often run tests to establish any additional requirements beyond those that can be attained through targeted diet and lifestyle support.
Additional nutrient requirements
Below are the key supplements to consider if you have endometriosis, along with the dietary sources of each nutrient so you can better understand what may be right for your body:
Vitamin C – enhances cellular immunity and supports mucosal barrier function, making it important for healthy tissue function both within the gut and pelvic region (1) Food sources include brightly coloured fresh vegetables and fruit and dark green leafy vegetables.
Vitamin E – women with endometriosis have been shown to have lower levels of this anti-oxidant, which can contribute to increased inflammation and excessive growth of endometrial tissue. (2) Nuts and seeds, especially sunflower seeds, pine nuts, almonds and hazelnuts, alongside avocadoes, spinach and olive oil are all good dietary sources.
Supplementation with anti-oxidants vitamin E and C has been shown to lower chronic pain and dysmenorrhea (painful periods), dyspareunia (pain with sex) and inflammation in women with endometriosis. (3)
Vitamin A – critical for the health of mucus membranes in the digestive tract, reproductive organs and pelvis, helping support effective oestrogen metabolism and clearance. Beta-carotene is the precursor to vitamin A and is found in abundance in orange and yellow vegetables and fruits and dark green leafy vegetables. However, up to 45 per cent of healthy women may be poor convertors of beta-carotene to the active form of vitamin A.(4) The only dietary sources of bioavailable vitamin A are from animal sources such as eggs and liver so if you are vegetarian or vegan supplementation may be beneficial. An upper tolerable limit of 10,000IU has been defined for supplementation. (5)
Vitamin A works synergistically with other fat-soluble vitamins D and K, so it’s important to ensure you have adequate levels of these vitamins if you chose to supplement with vitamin A. If you are pregnant take extra care to monitor your intake of vitamin A from all sources (diet and supplements) so as not to exceed the upper safe limit.
Magnesium – this mineral is a wonderful muscle relaxant and can be helpful to alleviate the pain and cramping which are often hallmarks of endometriosis. As magnesium is needed for over 600 enzyme reactions in the body and is used up more quickly during times of stress it is vital to ensure you are getting enough. Dark green leafy vegetables, almonds, cashews, pumpkin seeds and broccoli are good dietary sources. If supplementing, choose a chelated form such as magnesium malate or glycinate which tend to be better absorbed. Enjoying a bath with magnesium salts (also known as Epsom salts) is also a great way of getting magnesium into your system, as well as being a nice way to relax and de-stress.
Essential fatty acids – these are essential for healthy hormone function; however, it is important to get the right balance of omega-3 to omega-6. A greater ratio of omega-6 to omega-3 can increase inflammation and potentially worsen endometriosis symptoms. Additionally, the minerals zinc and vitamin B6 are needed for the metabolism and conversion of fatty acids into beneficial prostaglandins PGE1 and PGE3. These hormones have an anti-inflammatory effect in the body, unlike PGE2 which is pro-inflammatory and increases the risk of oestrogen dominance. (6) Oily fish such as sardines, salmon, mackerel, herring and trout are a good dietary source.
B vitamins – as well as supporting the conversion of essential fatty acids to their beneficial anti-inflammatory form, B vitamins are also crucial for effective oestrogen metabolism in the liver, helping to protect against oestrogen dominance. In particular, B6 has been shown to reduce the intensity and duration of period pain which may be helpful if you suffer with endometriosis.
Selenium – supports liver detoxification, helping to promote clearance of excess oestrogen. Selenium also supports immune function and helps to reduce inflammation. (7) Brazil nuts, eggs, sunflower seeds, liver, fish and chia seeds are good dietary sources.
Pine bark (pycnogenol) – in a study published in the Journal of Reproductive Medicine, women who took 60 mg French maritime pine bark extract daily for 48 weeks saw a slow but steady reduction in endometriosis symptoms. (8)
Although there is no cure for endometriosis, there is much you can do to prevent and support the condition by instilling positive diet and lifestyle habits into your daily routine. As we are all unique, every woman responds differently to treatment, so finding what works for your body is key. You know yourself best, so making supportive nutritional and lifestyle choices and listening to your body can reap dividends in the long run.
The first step is understanding and identifying symptoms so you can make a choice about the right type of treatment for you. Incorporating some or all of the supportive measures below can then help you balance your hormones and reduce your chances of more drastic treatment options.
Top tips for supporting endometriosis
- Eat an anti-inflammatory diet, rich in fresh vegetables, fruits, herbs and spices, omega-3 fats (oily fish, flaxseeds) and phytonutrients.
- Balance blood sugar levels by choosing low-GL foods and eating regular meals with a good balance of protein, healthy fats and carbohydrates from vegetables.
- Keep pro-inflammatory foods to a minimum. These include caffeine, refined sugar and carbohydrates, gluten, dairy, trans-fats, non-organic meat, concentrated soy and processed foods.
- Encourage healthy oestrogen metabolism and clearance by supporting your liver and gut. Increase your consumption of cruciferous vegetables (broccoli, cabbage, Brussel sprouts, cauliflower) to promote detoxification.
- Take regular low-impact and restorative exercise such as yoga, tai chi and walking to support your immune system and detoxification pathways and encourage the release of endorphins, your body’s natural painkiller.
- Aim to get at least eight hours sleep every night. If you struggle to sleep because of your symptoms, consider some of the suggestions outlined earlier in this article which may help.
- Take steps to reduce your stress levels. Stress increases cortisol production and raises inflammation, which can make symptoms worse. Consider adopting a regular stress reduction practice such as meditation, yoga or deep breathing.
- Reduce your exposure to xenoestrogens and toxins in your environment which can disrupt hormone balance and aggravate symptoms. Switch to natural skincare and domestic products, eat organically where possible (particularly for meat and dairy products), avoid heating or storing food in plastic containers and drink filtered water.
- Treat yourself to some acupuncture or massage to assist with pain-relief.
- Consider supplementation to balance nutritional deficiencies and provide additional support.
- Work with a Functional Medicine practitioner who specialises in hormone balance and women’s health to better understand your unique requirements for supporting and optimising your health with endometriosis.
Professional support for Endometriosis
Living with endometriosis can be incredibly painful and frustrating, so it’s important to have a good support network around you. This can include family and friends, as well as local support groups. If you feel you could benefit from additional nutritional and lifestyle support fill in the form below to book a one-to-one consultation.
Introduction to Endometriosis
- Endometriosis UK. https://www.endometriosis-uk.org/understanding-endometriosis 2 Collinet P et al. (2018) Management of endometriosis CNGOF/HAS clinical practice guidelines, J Gynecol Obstet Hum Reprod., S2468-7847(18)30244-7. doi: 10.1016/j.jogoh.2018.06.003. [Epub ahead of print]. 3 NHS UK. https://www.nhs.uk/conditions/endometriosis/treatment/
Nutrition and Endometriosis
- 1 Ash M (2010) ‘Dysregulation of the Immune System: A Gastro-Centric Perspective’ in Biochemical Imbalances in Disease, ed. Nicolle L & Woodriff Beirne A. London: Singing Dragon.
- 2 Bromelain. Monograph (2010) Alternative Medicine Review 4: 361-368.
- 3 Johnson JJ (2011) Carnasol: A promising anti-cancer and anti-inflammatory agent, Cancer Letters 305 1:1-7.
- 4 Kelly G (2011) Quercitin: A Monograph, Alternative Medicine Review 2:172-194.
- 5 Li YR, Li S, Lin CC (2018) Effect of resveratrol and pterostilbene on aging and longevity, Biofactors 44(1):69-82. doi: 10.1002/biof.1400. Epub 2017 Dec 6.
- 6 Arablou T, Kolahdouz-Mohammadi R (2018) Curcumin and endometriosis: Review on potential roles and molecular mechanisms, Biomed Pharmacother 97:91-97. doi: 10.1016/j.biopha.2017.10.119. Epub 2017 Nov 6.
- 7 Jeena K, Liju VB, Kuttan R (2013) Antioxidant, anti-inflammatory and antinociceptive activities of essential oil from ginger, Indian J Physiol Pharmacol 57(1):51-62.
- 8 Esfahani et al (2009) The glycaemic index: Physiological significance, Journal of the American College of Nutrition 28: 439-445.
- 9 Hewison M (2010) Vitamin D and the immune system: New perspectives on an old theme. Endocrinology and Metabolism Clinics of North America 2:365-379.
- 10 Chen Y, Chen C, et al (2001) Endometriotic implants regress in rat models treated with puerarin by decreasing estradiol level. Reprod. Sci. 18: 886–891
Endometriosis and Lifestyle
- 1 Falkenberg RI, Eising C, Peters ML (2018) Yoga and immune system functioning: a systematic review of randomized controlled trials. J Behav Med. doi: 10.1007/s10865-018-9914-y. [Epub ahead of print]
- 2 Pascoe MC, Thompson DR, Jenkins ZM, Ski CF (2017) Mindfulness mediates the physiological markers of stress: Systematic review and meta-analysis, J Psychiatr Res 95:156-178. doi: 10.1016/j.jpsychires.2017.08.004. Epub 2017 Aug 23.
- 3 Nunes FR, Ferreira JM, Bahamondes L (2015) Pain threshold and sleep quality in women with endometriosis. Eur J Pain 19(1):15-20. doi: 10.1002/ejp.514. Epub 2014 Apr 14.
- 4 Sharpe R, Irvine (2004) How strong is the evidence of the link between environmental chemicals and adverse effects on human reproductive health? British Medical Journal 328: 447-451.
- 5 Kim SH et al. (2015) Possible Role of Phthalate in the Pathogenesis of Endometriosis: In Vitro, Animal, and Human Data, J Clin Endocrinol Metab 100(12):E1502-11. doi: 10.1210/jc.2015-2478. Epub 2015 Oct 6.
- 6 Caserta D et al. (2014) Bisphenol A and the female reproductive tract: an overview of recent laboratory evidence and epidemiological studies, Reprod Biol Endocrinol 9;12:37. doi: 10.1186/1477-7827-12-37.
- 7 Wayne PM et al. (2008) Japanese-style acupuncture for endometriosis-related pelvic pain in adolescents and young women: results of a randomized sham-controlled trial. J Pediatr Adolesc Gynecol. 21(5):247-57. doi: 10.1016/j.jpag.2007.07.008.
Endometriosis and Supplementation
- 1 Maggini S, Wintergerst ES, Beveridge S, Hornig DH (2007) Selected vitamins and trace elements support immune function by strengthening epithelial barriers and cellular and humoral immune responses, Br J Nutr 1:S29-35.
- 2 Seeber BE, Czech T, Buchner H, Barnhart KT, Seger C, Daxenbichler G, Wildt L, Dieplinger H (2010) The vitamin E-binding protein afamin is altered significantly in the peritoneal fluid of women with endometriosis. Fertil Steril. 94(7):2923-6. doi: 10.1016/j.fertnstert.2010.05.008. Epub 2010 Jun 17.
- 3 Santanam N, Kavtaradze N, Murphy A, Dominguez C, Parthasarathy S (2013) Antioxidant supplementation reduces endometriosis-related pelvic pain in humans. Transl Res. 161(3):189-95. doi: 10.1016/j.trsl.2012.05.001. Epub 2012 May 31.
- 4 Leung WC, Hessel S, Meplan et al. (2009) Two common SNPs in the gene coding beta-carotene 15,15’-monooxygenase alter beta-carotene metabolism in female volunteers. Journal of the Federation of American Societies for Experimental Biology 23 4:1041-1053.
- 5 Food and Nutrition Board, Institute of Medicine (2002) Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press. Available at: www.nap.edu/books/0309072794/html/.
- 6 Neil K (2010) Sex Hormone Imbalances, Biochemical Imbalances in Disease. Ed. Nicolle L and Woodriff Beirne A. London: Singing Dragon.
- 7 Rayman MP (2012) Selenium and human health, Lancet 31;379(9822):1256-68. doi: 10.1016/S0140-6736(11)61452-9. Epub 2012 Feb 29.
- 8 Kohama T, Herai K, Inoue M (2007) Effect of French maritime pine bark extract on endometriosis as compared with leuprorelin acetate, J Reprod Med. 52(8):703-8.
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