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Figure 1 The key to understanding PEM lies in elucidating why exercise, which is generally protective in healthy individuals, induces pathological exacerbation in patients with PEM ( Thus, our study aims to synthesize pathophysiological evidence of energy metabolism, immune inflammation, and neurovascular system abnormalities observed following physical or cognitive exertion

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Additionally, hyperinsulinemia stimulates the hypothalamus to increase GnRH secretion, leading to an imbalanced LH/FSH ratio that disrupts follicular development and ovulation, while simultaneously suppressing hepatic production of SHBG