Standing Up to POTS: Investigating Causes, Symptoms, and Inequities
- Neko Dossett
- Apr 6
- 6 min read
Millions of women in the U.S. experience severe dizziness during their daily activities. These women are likely familiar with the term POTS; some may even have a diagnosis, but many more are left struggling and confused. This condition that leads to dizziness or fainting upon standing is called postural orthostatic tachycardia syndrome, or POTS.
When you stand up, your body has to counteract the force of gravity and pump blood toward your heart to ensure normal circulation continues. However, this process is severely impaired in patients with POTS. In other words, only a small volume of blood returns to the heart upon standing, at which point the body tries to resolve the issue by increasing heart rate. POTS is therefore characterized by an increase of 30 beats per minute (bpm) or exceeding 120 bpm within 10 minutes of standing without a drop in blood pressure (Cardiac & Vascular Institute, n.d.). For comparison, a normal cardiac response is an increase of 10-20 bpm that generally does not exceed 95 bpm (Kavi et al., 2012). While lightheadedness due to poor blood circulation after standing is the defining symptom, people with POTS may also experience the following (U.S. Department of Health and Human Services; Bourne et al, 2021):
Exhaustion
Headaches
Blurred vision
Chest pain
Fatigue
Sleep disturbances
Digestive issues
Brain fog
Headaches
Heart palpitations
Shortness of breath
Neurologic symptoms in the hands and feet
POTS in Women
POTS primarily impacts females aged 15-50, and more than 85% of those diagnosed are women. On top of this, women tend to have more symptoms, more challenges with diagnosis, and more frequently have a comorbid condition (Bourne et al, 2021). These problems are all interconnected. We already discussed the range of symptoms possible, and when a patient presents with more symptoms, receiving a POTS diagnosis becomes more difficult due to symptom overlap with other conditions. This often leads to unnecessary referrals, excessive testing, diagnostic delays, and misdiagnosis (Aboseif et al, 2023). The cumulative result is a lengthy diagnostic journey filled with challenges. A 2021 study found it takes men an average of 0.92 years to get diagnosed, while it takes women significantly longer, at an average of 1.50 years. Additionally, misdiagnosis is alarmingly common. The same study revealed that approximately 75% of POTS patients had been previously misdiagnosed. Even more troubling is that the majority of individuals were told their symptoms were “all in their head” or the result of a psychological disorder (Bourne et al, 2021). This tendency to dismiss POTS patients not only leads to unnecessary diagnostic challenges but also contributes to medical distrust and fatigue.
POTS is also commonly comorbid with conditions such as Ehlers-Danlos syndrome (EDS), mast cell activation syndrome (MCAS), and autoimmune disorders, all of which are also more prevalent in women (Bourne et al, 2021). These conditions have symptom overlap with POTS and may help explain why women commonly experience more symptoms. These patterns are critical to be aware of during diagnosis, as women should also be evaluated for comorbid conditions.
What Causes POTS?
The exact cause of POTS and the reason it predominantly impacts women is still not well understood, though there are some preliminary answers. Research is ongoing as the medical community searches for more definitive answers as to why POTS patients' blood does not return to the heart quickly when standing up. The science behind this condition is complex, but understanding the basics of the biological processes potentially involved in POTS is both fascinating and beneficial to those navigating symptoms.
The Neuropathic Explanation
To return blood to the heart, the muscle around your blood vessels must contract to push blood into the upper body. If there is poor nerve connection to these muscles in the lower body, nerve signals telling the muscle to contract may not be received. This results in the blood vessels not constricting like they’re supposed to (Cleveland Clinic, 2026; Fu et al, 2005).
The Hyperadenic Explanation
Another proposed explanation is that the sympathetic nervous system is overactive in POTS patients. This can lead to high levels of norepinephrine being released into the blood plasma when standing, resulting in an elevated heart rate (Cleveland Clinic, 2026; Fu et al, 2005).
The Hypovolemic Explanation
POTS could also be due to low blood volume. When the body doesn't have enough blood, it's harder for sufficient amounts of blood to reach the heart after standing (Cleveland Clinic, 2026). Low blood volume occurs when there are low levels of the hormones that regulate blood pressure and volume-- renin and aldosterone. This hormone deficiency causes the kidneys to filter out excessive amounts of water and sodium, resulting in a lower blood volume (Raj et al, 2007).
The Autoimmune Explanation
Finally, newer research suggests a potential immune mechanism. POTS can develop after a specific event, the most common one being an infection (Bourne et al, 2021). This, along with the shared symptoms between POTS and autoimmune conditions, suggests the immune system may be a contributing factor. Although the exact role the immune system plays remains unclear, research from the Cleveland Clinic found POTS patients had various autoantibodies that could be disrupting normal vascular function (Aboseif et al, 2023).
All of these explanations are plausible and may combine to create the symptoms we see with POTS. Regardless, this research provides preliminary insights into why women are more commonly affected. The key is that women are more susceptible to orthostatic intolerance. This means that, even if the same physiological processes occur in males and females, women have a harder time effectively counteracting the issues that occur upon standing. Women pump out less blood from the heart, have a lower blood volume, smaller hearts, and weaker blood vessel constriction compared to men (Fitzgibbon-Collins et al., 2025). All of these factors make the compensatory mechanisms for blood pooling in the lower body less effective, and lightheadedness more likely as your body works harder to return to normal blood flow.
Diagnosing and Managing POTS
POTS can be diagnosed by a neurologist or a cardiologist, with the most common diagnostic tool being a tilt test, which involves lying on a table that is tilted to an upright position while heart rate and blood pressure are monitored (U.S. Department of Health and Human Services). Other tests, such as blood work and ECGs, are common during the diagnostic process to rule out alternative conditions. It is important to note that seeking a diagnosis is not the right choice for everyone. Some individuals prefer to manage symptoms on their own, while others want medical assistance and an official diagnosis.
Individuals experiencing POTS symptoms can implement several lifestyle changes to help manage symptoms. First, drinking water and consuming salt are critical. These two things raise blood pressure and increase blood volume, helping to prevent the issue at its source. Wearing compression socks or other lower-body compression garments is also effective, as this helps prevent blood pooling and allows blood to return to the heart faster after standing. Finally, cardio exercise that slowly builds in intensity may improve the body's tolerance to postural changes (U.S. Department of Health and Human Services).
We hope that future research will provide more tools for managing the POTS symptoms that impact patients' daily lives. This research must continue to investigate the complex physiology underlying this condition to effectively enhance patient care and improve the quality of life for the millions of women affected by POTS. In the meantime, it is essential to educate both physicians and patients about POTS to help reduce delays in diagnosis, minimize misdiagnoses, and facilitate symptom management.
Citations
Aboseif, A., Bireley, J. D., Li, Y., Polston, D., & Abbatemarco, J. R. (2023, July 1). Autoimmunity
and postural orthostatic tachycardia syndrome: Implications in diagnosis and
management. Cleveland Clinic Journal of Medicine. https://www.ccjm.org/content/90/7/439
Bourne, K. M., Hall, J., Stiles, L. E., Sheldon, R. S., Shibao, C. A., Okamoto, L. E., Garland, E. M., Gamboa, A.
C., Peltier, A., Diedrich, A., Biaggioni, I., Robertson, D., & Raj, S. R. (2021, September 4). Symptom
presentation and access to medical care in patients with postural orthostatic tachycardia
syndrome: Role of sex. CJC open. https://pmc.ncbi.nlm.nih.gov/articles/PMC8712580/
Cardiac & Vascular Institute. (n.d.). Understanding postural orthostatic tachycardia syndrome (POTS). https://www.tcavi.com/conditions/peripheral-vascular/postural-orthostatic-hypotension-
Cleveland Clinic. (2026, January 29). Pots: Causes, symptoms, diagnosis & treatment.
Fitzgibbon-Collins, L. K., Pereira, T. J., & Edgell, H. (2025, June). Women, orthostatic tolerance, and pots: A
narrative review. ScienceDirect.
Fu, Q., Witkowski, S., Okazaki, K., & Levine, B. (2005, July). Effects of gender and hypovolemia on
sympathetic neural responses to orthostatic stress. American journal of physiology. Regulatory,
integrative and comparative physiology. https://pubmed.ncbi.nlm.nih.gov/15761188/
Kavi, L., Gammage, M. D., Grubb, B. P., & Karabin, B. L. (2012, June). Postural tachycardia syndrome:
Multiple symptoms, but easily missed. The British journal of general practice : the journal of the
Royal College of General Practitioners. https://pmc.ncbi.nlm.nih.gov/articles/PMC3361090/#
Raj, S. R., & Robertson, D. (2007, July). Blood volume perturbations in the postural tachycardia syndrome.
The American journal of the medical sciences. https://pubmed.ncbi.nlm.nih.gov/17630594/
U.S. Department of Health and Human Services. (n.d.). Postural tachycardia syndrome (POTS). National
Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/health- information/disorders/postural-tachycardia-syndrome-pots
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