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Hormonal alterations Since stress has been described as a potential trigger for ME/CFS (422) and cause of symptom flare-ups (423, 424), it is likely that the HPA axis- the neurobiological stress system- may be implicated in ME/CFS (53, 425, 426), as well as abnormalities in growth hormone (GH) secretion and dysfunctional adrenergic metabolism (255)