POTS syndrome, or Postural Orthostatic Tachycardia Syndrome(POTS), is a condition where someone experiences a large elevation in heart rate when they stand up. Typically, their heart rate jumps more than 30 bpm, or above 120bpm. Symptoms of the condition include:

• Brain fog
• Feeling dizzy or faint when standing
• Nausea
• Abdominal pain
• Excessive sweating
• Migraines/headaches
• Blurry vision
• Chronic pain
• Sleep problems

POTS syndrome is a form of orthostatic intolerance. Normally our blood flows at a constant rate, even when we change positions. But when people with orthostatic intolerance go from sitting to standing, one of the mechanisms that regulates this fails.

Our blood flow rate is dependent on many systems for proper control. First of all, it’s not under conscious control so the autonomic nervous system plays a role. The autonomic nervous system functions as sort of an operating system for us. It fine tunes things like heart rate, blood pressure, and blood volume based on our environment.

Furthermore there is the cardiovascular system. Three factors dictate our blood flow rate: how hard our heart pumps, how many times it pumps, and our blood pressure. Blood pressure, of course, is determined by how constricted our blood vessels are and our blood volume.

Our water intake and kidney function regulate blood volume. Though it seems as though that covers everything, it doesn’t. Due to the interdependence between systems of the body, anything that affects any of these systems is also in play.

Unfortunately, so little is known about POTS that people typically just manage symptoms. This involves simple lifestyle modifications.

Other systems in POTS syndrome

There are additional systems that affect POTS or vice versa. For example, any form of chronic inflammation impairs any of the regulatory systems mentioned above. Therefore, the immune system may be involved.

The digestive system is also important. The gut keeps bacteria and other inflammatory molecules out of our blood. If it doesn’t, chronic inflammation ensues which impairs the autonomic nervous system and kidney/blood vessel function.

Finally, the reproductive system plays a role, at least in women. Estrogen blocks the inflammatory and cardiovascular effects of “leaky gut”. These effects include hypotension and tachycardia. Decreasing estrogen unmasks “leaky gut” and lets these symptoms appear. Thus, menopausal women and those in the follicular phase of their menstrual cycle experience symptoms.

Causes of POTS syndrome

Defining the causes of POTS is not easy. Many conditions associate with POTS, but those conditions aren’t necessarily causes. Conditions that associate with POTS include:

• Autonomic dysfunction
• Ehler’s-Danlos syndrome
• ME/CFS
• Anemia
• Chagas disease
• Epstein-Barr
• Lymes disease
• Mast Cell Activation Syndrome
• Lupus, Sjogren’s and other autoimmune disorders
• Thyroid disease
• IBD
• Type 1 and 2 diabetes
• Guillain-Barre Syndrome
• Gastrointestinal problems (See below)
• And more

All of these conditions are considered causes of POTS Syndrome. Therefore, all of them affect one or more of these drivers to address:

• Circadian disruption
• Adrenal dysfunction
• Blood glucose dysregulation
• Chronic inflammation
• Mitochondrial dysfunction
• Anemia

These drivers feed in to one another. In fact, you could go up and down that list and make a case that each causes the other in either direction you go. So the important question becomes which group do you address?

People focus on addressing the conditions associated with POTS Syndrome while ignoring the drivers. For example, Lymes disease flares cause massive levels of inflammation. But so do circadian disruption, mitochondrial dysfunction, blood glucose dysregulation, and adrenal dysfunction.

Circadian rhythms and POTS syndrome

There’s a robust amount of data showing circadian disruption is a major issue in POTS. People with POTS typically have a delayed circadian phase which means they are “night owls”. This is made worse by poor sleep hygiene. Both light therapy and melatonin are used to treat this aspect of POTS, but this is probably not enough.

Furthermore, people with circadian rhythm sleep disorder(CRSD) have a high rate of POTS. More than 57% of people with CRSD have POTS and that number grows to 70% in those under 20 years of age. The reason the rate is higher in younger people is that they are typically night owls. But it can even be problematic in older people, as was the case in Mark who reversed chronic insomnia and dysautonomia.

Night owled-ness leads to poor behaviors that further disrupt circadian rhythms. It’s biologically normal for younger people to be night owls. In fact, age accounts for most of the variation between early-birds and night owls.

However, it’s not biologically normal for them to be exposed to light at improper times, be inactive, or eat at improper times. These behaviors make circadian disruption worse, and are likely why younger people experience POTS more than older people.

There is also a circadian variability to heart rate that holds true for people with POTS and healthy controls. Both groups had a 9 point bump in their standing heart rate in the morning compared to evening. More people met the diagnosis criteria for POTS in the morning than the evening. There is a strong circadian component to POTS, and every condition associated with POTS is made worse under circadian disruption.

If you have chronic Lymes disease that’s completely out of your control. Addressing these drivers is not, and makes much more practical sense.

POTS Syndrome and gut problems

Gut problems are very common in people with POTS. The relationship is likely bi-directional, as all of the drivers cause gut problems while gut problems cause the drivers. Most noteworthy, I’d put leaky gut as a primary “driver of the drivers” along with circadian disruption.

Consequently, most things that increase leaky gut will increase the risk for POTS. That’s why the woman who was the subject of my last blog had such tremendous results. Check that out here.

A study in 2015 identified some of the most common gut problems that people with POTS have. The gut problems and prevalence in people with POTS are:

• Nausea (86%)
• Heartburn (71.4%)
• Irregular bowel habits (71%)
• Abdominal pain (67%)
• Constipation (67%)
• Abdominal cramping (62%)
• Bloating (57%)

Furthermore, 81% said they experienced symptoms more than once per week and 71% said they lasted more than 3 hours.

The relationship between POTS syndrome and gut problems is pretty straightforward. All of the drivers mentioned above damage nerves, small blood vessels and impair the autonomic nervous system.

These nerves are how the autonomic nervous system regulate the cardiovascular system, kidneys, and gut. Also, the tiny blood vessels that serve the kidney, heart, and gut are damaged by these drivers.

As a result, the function of all 3 tissues is impaired. This leads to an inability to regulate blood flow and digestion. Hence, POTS and gut problems pair together because they share many of the same drivers.

Conclusion

People often get trapped in chronic disease because they treat things that associate with disease as the primary factors to address. Or worse, they find a workaround that allows them to manage symptoms. Consequently, they ignore factors that are actually driving the problem.

When we say “cause” or “causes”, we’re referring to the direction of a relationship, not how big of a factor it is. For example, Lymes disease leads to POTS syndrome, POTS doesn’t lead to Lymes disease. But that’s not the question most people with POTS are concerned with. Rather, they want to know what they can do to get rid of POTS.

Instead of focusing on the things that associate with POTS syndrome, it makes more sense to focus on the specific drivers that these conditions promote. These primary drivers include circadian disruption, leaky gut, adrenal dysfunction, blood glucose dysregulation, chronic inflammation, mitochondrial dysfunction, and anemia.