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For research design, this supports the need to systematically verify cycle phase with hormonal or ovulatory markers, explicitly report cycle characteristics, andwhere feasiblestratify or adjust for phase, rather than excluding women or treating the menstrual cycle as statistical noise. It also highlights the need for multi-system study designs that incorporate endocrine, immune, microbiome, and behavioral readouts, and for sex-specific analyses that recognize that female vs

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However, it should be noted that an Alvarado score of lower than 4 does not rule out AA