condition
POTS and Dysautonomia
POTS — postural orthostatic tachycardia syndrome — is a disorder of the autonomic nervous system, the part of you that runs heart rate, blood pressure, digestion, temperature and breathing without being asked. It is not a heart condition. The racing heart that gives POTS its name is the most visible sign of it, but it is not the problem. It is the body’s solution to a problem happening somewhere else. We treat the somewhere else. Our clinic is at 180 Lithia Way in Ashland, Oregon.
The racing heart is not the disease
When you stand up, gravity pulls somewhere between a pint and a quart of blood down into your legs. A healthy autonomic nervous system responds instantly: the blood vessels in the legs squeeze, the blood is pushed back toward the heart, and you notice nothing at all.
In POTS that squeeze is weak, or late, or missing. Blood pools in the legs, less of it returns to the heart, and the nervous system does the only thing still available to it — it drives the heart rate up to keep circulation going.
So the tachycardia is a compensation. It is the body coping. Treatment aimed only at slowing the heart takes away the compensation without touching what caused it, and people often feel worse rather than better. The clinical work is to find out what the heart rate is compensating for.
What POTS looks like
Fatigue that is worse on standing and worse after exertion — sometimes the next day, or two days later, or a week later
Lightheadedness, or the feeling that you are about to pass out when you stand
Palpitations or a pounding heart on standing
Brain fog — forgetfulness, losing words, cloudy thinking, not being able to hold a thought
Nausea and bloating
Blurred vision
Shakiness or tremor
Chest pain and breathlessness
Cold or numb hands and feet
Acrocyanosis — a dusky blue-purple mottling of the legs after standing
Look at that list as a whole. Gut, brain, circulation, temperature, breathing. That is not a heart problem. That is an autonomic nervous system that has lost the plot across every system it governs.
Why it mostly affects young women
Around eighty percent of people with POTS are female, most diagnosed between seventeen and thirty-five. The reason is not fragility. It is fine tuning.
When a man stands up, he holds his blood pressure largely by clamping down his blood vessels — strong vasoconstriction, and the blood volume to spare. A woman holds hers by raising her heart rate, on a smaller blood volume, in a more elastic vascular bed, recalibrated every month by hormones.
Less blood volume to begin with, so less margin for error
More compliant veins, which pool more readily
Iron metabolism — decades of monthly loss, which makes oxygen delivery and mitochondrial function harder to sustain
Cyclic hormones — estrogen is a vasodilator, progesterone shifts fluid and sodium
More elastic connective tissue, which means more elastic blood vessels
Autoimmunity, which is roughly eighty percent female
A man holds his blood pressure with reserve. A woman holds hers with regulation. Reserve is forgiving. Regulation is precise — and precision is what fails first when the terrain goes.
So POTS is not a broken system. It is a normal female orthostatic strategy that has run out of reserve. Margin is the thing we can give back.
How POTS is confirmed
POTS is confirmed with a chair, a blood pressure cuff and ten minutes. No exotic testing is required, and you do not need a tilt table. There are three criteria:
A heart rate rise of thirty beats per minute or more within ten minutes of standing — forty in adolescents.
No significant drop in blood pressure on standing. This is the hinge the whole diagnosis hangs on.
The symptoms are chronic, not acute — six months is the usual bar. Dehydration and a bad flu can both produce this pattern temporarily.
We use an active stand test: you lie down for a full ten minutes, we take a resting heart rate and blood pressure, then you stand and we take both again at one, three, five and ten minutes. When the stand test is equivocal but the history is loud, we use the NASA lean test, where you rest your shoulder blades against a wall for ten minutes so your leg muscles are not quietly compensating.
What POTS is not. The whole differential turns on one question: what is the blood pressure doing while the heart rate climbs. In POTS the heart races and the pressure holds. In orthostatic hypotension the pressure is what gives way. In vasovagal syncope the rate climbs, then crashes, the pressure collapses and you faint — an event rather than a state. Plenty of people have both POTS and vasovagal syncope, so it is not either/or.
There is more than one kind of POTS
POTS has recognized subtypes, and they do not respond to the same treatment.
Neuropathic — damage to the small nerve fibers that tell leg vessels to constrict. About half of cases, and the most common.
Hypovolemic — low circulating blood volume that the body fails to correct. Around seventy percent. This is why fluids and salt help almost everyone with POTS and cure almost nobody: you are topping up a leaky tank.
MCAS-associated — mast cell activation. Around forty-five percent. Histamine and related mediators cause vasodilation and leak plasma out of the vessels. This is the episodic version: flushing, good days and bad days tied to triggers you have not identified yet, often with itching or a runny nose after eating. It is the subtype most often labeled anxiety.
Post-viral — about thirty-five percent of new cases and rising steeply since 2020. It runs two mechanisms at once, nerve damage and autoantibodies, which is why it is more severe and why these patients only half-respond to treatment that works well in pure neuropathic POTS.
Autoimmune — around eighteen percent, and rising.
Hyperadrenergic — about ten percent, and the one that inverts everything. See the safety section below.
Those percentages add up to well over a hundred, and that is not an error. Almost nobody has one subtype. Most people have two or three running at once. That is the single most useful thing to understand about this condition — and it is why a POTS protocol applied to everybody works about half the time.
How we work out what is going on
Work three POTS patients up conventionally and you will very often get the same answer three times: bloods unremarkable, ECG fine, echo fine. That is not because nothing is wrong. It is because those tests measure analytes, and POTS is a disorder of regulation.
So alongside a long history and serum and functional laboratory testing, we measure regulation directly:
Heart rate variability for autonomic tone and balance — the single most useful measurement in POTS
Bioimpedance analysis for body composition, cellular hydration and phase angle
Live and dried blood analysis for the cellular terrain in real time, and for oxidative stress and older patterns
Bioenergetic testing with QUEX, OMNIS and the Kvantum Bioscan, for organ-level disturbance, stress reactivity, and to test whether a remedy is one your body will actually respond to before we ask you to take it
The point is not the instruments. It is that these subtypes look identical on a conventional workup and completely different the moment you look at regulation — and the subtype is what tells us how to treat you.
The order of treatment matters more than the treatments
Almost every treatment used for POTS appears on somebody’s protocol somewhere. What is usually got wrong is the order.
One — stabilize the basic terrain. Sun, earth, air, water. Daylight within fifteen minutes of waking to anchor circadian rhythm. Time outdoors and barefoot contact with the ground. Slow, low, nasal breathing. Hydration with minerals — water without electrolytes in someone running low on volume is close to useless. Sleep. This step costs nothing and it is where we start with almost everyone.
Two — stabilize the autonomic nervous system and the vagus nerve. Vagal toning, breathing work, heart rate variability biofeedback, gemmotherapy, flower essences, and referral for limbic retraining.
Three — stabilize the mast cells, where mast cell activation is part of the picture.
Four — and only now — detoxify and drain. Binders, drainage remedies, antimicrobials, immune modulation. Then, and only then, we rebuild according to subtype.
Skip a step and you plateau, or you crash.
This is close to the opposite of the order POTS is usually treated in. Most treatment starts at the subtype and never arrives at the terrain. Someone with POTS, Epstein-Barr reactivation and mold exposure who is taken straight at the infection will usually crash — not because the treatment was wrong, but because they had no capacity to spend and we spent it.
What we use
Gemmotherapy — remedies made from embryonic plant bud tissue, and one of our most-used tools in POTS because they work at the level of tissue and terrain rather than pushing on a receptor. Black currant bud is in nearly every plan we write. Fig bud where the gut and the nervous system are clearly tangled together. Silver linden where sympathetic overdrive is the dominant picture.
Drainage and spagyric remedies — lymphatic, liver and kidney drainage, adrenal and thyroid support, remedies for sleep and autonomic balance. If you mobilize something and the body cannot excrete it, you have not treated it — you have relocated it. Drainage is what makes everything that comes after it tolerable.
Homeopathy and isopathy — including biotherapeutic drainage to support detoxification and organ function. Homeopathy
Flower essences — used in essentially every case, for the limbic, autonomic and trauma-related layer of this syndrome.
Vagal toning and breathing — slow resonant breathing at four to six breaths a minute, nasal breathing, humming, gargling, cold water on the face. We use your heart rate variability to choose which, because a breathing practice that heals one person can push another further into dysregulation.
Volume and mechanical support — real electrolytes and minerals rather than water alone, compression garments, elevating the head of the bed, calf pumping before you stand.
Mitochondrial and nutrient support — an autonomic nervous system running on an energy deficit cannot regulate, whatever else it is given. We correct measured deficiencies rather than guessing.
Graded movement, recumbent first — rowing, recumbent cycling, swimming. No upright exercise to begin with. Lying or reclining takes gravity out of the equation so you can rebuild cardiac output and leg muscle without triggering a crash. We start at five minutes, not twenty, and the rule is absolute: if you are worse the next day at all, we went too fast.
Hyperbaric oxygen — for nerve repair and for the flattened energy that follows a long illness. Hyperbaric oxygen therapy
Intravenous therapy and ozone — for nutrient repletion and systemic support where they are indicated. IV therapy · Ozone therapy
Referral, deliberately. Limbic retraining programs, upper cervical chiropractic, craniosacral therapy and skilled physical therapy are part of how these patients get better, and we send out for all of them.
Safety — the things that make POTS worse
Salt and volume loading are not right for everyone. Hyperadrenergic POTS — about one in ten — is the exception to nearly everything above. In that subtype the sympathetic nervous system is the primary problem rather than the compensation, and blood pressure rises on standing instead of holding. Volume loading, licorice root and blood-pressure-raising medication can all make it worse. This is why we subtype before we treat, and why we are careful with over-the-counter advice to just add salt.
Post-exertional malaise sets people back months. Post-viral POTS is not deconditioning. Push graded exercise too hard too soon and you can lose months of progress. The pacing rule applies to everyday life as well as exercise — housework counts.
Some people are not ready to detoxify. When heart rate variability and phase angle are very low, that is a stop sign, not a starting gun. That person needs feeding, hydrating, mineralizing, grounding, daylight and rest until those numbers move. Detoxification and antimicrobial treatment come later.
Bring your medication timeline. One question earns its keep almost every week: what did you start taking in the eight weeks before your symptoms began? Not just the obvious ones — every medication. Sometimes the trigger is sitting in the medication list and nobody has looked at it as a timeline.
Being straight with you about this work
Most people who find this page have been told their tests are normal, and a good number have been told this is anxiety. It is not. It is a measurable disorder of a measurable system, and ten minutes with a blood pressure cuff will usually show it.
What we cannot promise is speed. Getting the sequence right means the early work looks unimpressive — daylight, minerals, breathing, sleep — and the interesting treatments come later, once your body can afford them. Done in that order, quite ordinary treatments start working. Done in the wrong order, brilliant treatments make people worse.
You have usually been dismissed. We will look underneath the hood.
Common questions
Is POTS a heart condition?
No. POTS is a disorder of the autonomic nervous system. The heart is responding normally to an abnormal signal — the racing heart rate is a compensation, not the underlying problem.
Is POTS just anxiety?
No. POTS is confirmed objectively with a heart rate and blood pressure measurement on standing. Anxiety does not care what position you are in; POTS symptoms are reliably triggered by standing and settle on lying down. Most of our POTS patients have been told at some point that this was anxiety.
Can I have POTS if all my tests came back normal?
Yes, and most people do. Bloodwork, ECG and echocardiogram are usually unremarkable in POTS. They are worth doing to exclude other things, but they are not what confirms it.
Do I need a tilt table test?
No. An active stand test in the office meets the diagnostic criteria. Where the stand test is equivocal we use the NASA lean test, which approximates a tilt table with nothing but a wall.
Can POTS come on after COVID or another virus?
Yes. Post-viral onset accounts for roughly a third of new cases and has risen sharply since 2020. Sudden onset after a viral illness in someone previously healthy and active is the classic picture.
Does POTS ever go away?
Yes, it can. POTS is a syndrome rather than a permanent diagnosis — a pattern with something driving it. When what is driving it is found and treated, the pattern can resolve. How completely and how quickly depends on what is underneath it and how long it has been going on, and we will give you a realistic picture rather than a generic one.
How long does treatment take?
Monthly visits to begin with, then every other month as we work on the deeper patterns underneath, then quarterly for maintenance. POTS differs from our other chronic cases in one respect: the pace is set by what your nervous system can tolerate rather than by the calendar. If the work is moving faster than you can absorb it, we slow down — pushing through is what sets these patients back.
Do you treat teenagers with POTS?
Yes. The diagnostic threshold is different in adolescents — a heart rate rise of forty beats per minute rather than thirty — and the average age at diagnosis is in the late teens, so this is a condition we see in young people regularly.
Is this covered by insurance?
We do not participate with any form of insurance, including Medicare. If you are accepted into the practice we can create superbills on request as a courtesy.
How do I start?
Begin with the New Patient Questionnaire. Schedule an appointment
Reviewed by Dr. Chris Chlebowski, ND.
