Impact of POTS Disease (Postural Orthostatic Tachycardia Syndrome) on Adrenal Fatigue

By: Michael Lam, MD, MPH; Justin Lam, ABAAHP, FMNM; Dorine Lam, RDN, MS, MPH

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POTS Disease and Adrenal Fatigue Syndrome

POTS disease and Adrenal FatigueAdrenal Fatigue Syndrome (AFS) is a neuroendocrine condition induced by stress that can be physical or emotional. There are four stages, with symptoms ranging from mild to severe. Fatigue is the hallmark symptom, and can be incapacitating. Symptoms of advanced AFS include reactive hypoglycemia, heart palpitations, lightheadedness or dizziness on arising, insomnia, fatigue, salt craving, brain fog, and low blood pressure. The presence of Postural Orthostatic Tachycardia Syndrome or POTS disease can further complicate the individual’s health.

When the body perceives a threat to survival, it releases anti-stress hormones, including cortisol, norepinephrine, and epinephrine. If external stressors are not removed, continued release leads to a body chronically overloaded with norepinephrine in what is known as sympathetic overtone. In other words, the body is bathed in a sea of norepinephrine in order to keep the brain on high alert and the heart ready to run away or face danger. Sufferers of advanced AFS are therefore often in a constant alarm state as part of the body’s automatic response to stress.

While norepinephrine’s purpose is to ensure our survival, there are unintended negative consequences when produced in large quantities over time. The cardiovascular system is particularly at risk.

A quick comparison with the most cardiovascular related symptoms of POTS disease mentioned earlier shows many commonalities with advanced stages of AFS. Both tie to and are largely the result of excessive norepinephrine. Specifically, hyperadrenergic POTS disease is associated with elevated levels of norepinephrine, and so is advanced AFS; where chronic stress triggers excessive outpouring of norepinephrine as part of the hypothalamic-pituitary-adrenal (HPA) axis activation stress response.

Norepinephrine Overload

Excessive norepinephrine in the brain acts as a potent stimulatory neurotransmitter. It puts the brain in a state of high alert and keeps us mentally sharp on the look-out for danger. We feel wired, unable to relax. Sleep is a low priority in such a situation as far as the body is concerned. Falling asleep is a challenge unless physically exhausted. Many require sleep aids and even medications just to fall asleep. After a few hours of rest, the body automatically awakens, and is unable to fall asleep again. Sometimes this is also accompanied by heart palpitations. During the day, a sense of nervousness and anxiety may be present.

Norepinephrine also acts outside the brain as it travels as a hormone to the heart, increasing the heart rate as well as the force of the heartbeat. A pounding heart rate is largely the result of excessive norepinephrine.

Constant overload of norepinephrine, sympathetic overtone, can contribute or lead to hyperadrenergic POTS mentioned earlier, with symptoms mimicking it on a subclinical or clinical basis.

Epinephrine Overload

Epinephrine overload is a cause of POTS disease and Adrenal FatigueIn the case of advanced AFS, there is an additional aggravating factor of hormonal overload, and it has to do with epinephrine, norepinephrine’s chemical daughter. Epinephrine is the strongest of all emergency hormones. It is similar in action to norepinephrine, but much more potent. It is responsible for the flight-or-fight response and is the body’s hormone of last resort when dealing with stress. When the body’s norepinephrine level is high, part of it is automatically converted to epinephrine, leading to a higher epinephrine level. Epinephrine also acts on the cardiovascular system as norepinephrine, but stronger. The negative effects of epinephrine on the cardiovascular system are compounded.

Furthermore, in cases of severe stress, a branch of the autonomic nervous system called the adrenomedullary hormonal system is activated. Epinephrine is released directly from inside the adrenal glands in an area called the adrenal medulla when this system is activated.

Epinephrine is called the body’s hormone of last resort for good reason. It is the most powerful hormone in the body in terms of potency, and has no opposing hormones once released. Epinephrine released from the adrenal medulla travels to the heart and leads to a fast heart rate in order to deliver more blood to the brain. It works along-side norepinephrine, but is more powerful. Reactive sympathetic response is the term we use to describe a body bathed in a sea of epinephrine with its negative side effects.

It comes as no surprise that those in advanced stages of AFS often have symptoms mimicking POTS disease. Unfortunately, this is seldom recognized.

Typical Case History

Ellen is a 35-year-old adrenal fatigue sufferer in advanced stages. She has been struggling with fatigue and lethargy for about ten years, and has been under the care of seven doctors over this time. It started with a stressful workload and relationship problems. Her fatigue was mild at first, but gradually worsened. In the past few years, she began to experience lightheadedness on arising along with a fast heart rate, as well as salt cravings and low blood pressure at rest. She used to be a very active person but now spends much of her free time resting. She is barely able to hang on to her job, and feels that it is in jeopardy because of frequent absenteeism in recent years. When she is severely stressed, she feels palpitations and a fast heart rate, even at rest. These symptoms are accompanied by anxiety, headache, shortness of breath, and hypoglycemia. She goes on numerous visits to the emergency room as a result. Cardiac workup is invariably normal and she is sent home with anti-anxiety agents. She saw an endocrinologist who ordered a tilt table test but the result was inconclusive. All other laboratory tests are normal. Her fatigue continues to worsen with time, and energy crashes are more prominent and frequent. Her doctor also gave her an ACTH test that showed unremarkable levels. She was told her adrenal glands are normal.

POTS disease and feeling dizzyEllen’s quality of life is severely restricted. She does not have the energy for regular exercise or dance. She has to get up slowly in order not to feel dizzy. She is easily startled with loud sounds. She cannot tolerate long exposure to direct sunlight, and she gets dehydrated easily. During the day, she feels anxious, and at night, wired and tired. Falling asleep can take an hour or more. She is dependent on sleep medicine to fall asleep, however, she wakes up in the middle of the night unable to go back to sleep. She gets up in the morning feeling lethargic and unrefreshed.

Her doctor told her she is borderline POTS disease and wants to start her on medication. She wants to pursue a more natural solution to her problem.

Natural Recovery Principals of POTS Disease

Any astute clinician must consider AFS as a secondary cause of POTS disease if the history of the patient has an indication or history of physical or emotional stress. This includes a history of excessive exercise, infection, surgery, accident, overwork, relocation, divorce, or relationship problems. Frequent visits to the emergency room complaining of chest pain, palpitations and anxiety but accompanied by negative cardiac workup in a setting of stress is a classic alert.

Treatment for POTS disease by conventional medicine could help alleviate some of the symptoms. For long-term recovery, the focus should be on removing the underlying stressors and healing the adrenals. Once the adrenals are healed, symptoms of POTS disease automatically and spontaneously resolve. It can happen in a short time.

One should be careful not to begin heart rate suppression medication too early. Such a move could potentially force the heart to seek alternative electrical conduction pathways over time that can create a deeper set of problems while the underlying cause is being masked. One should also avoid anti-anxiety agents and antidepressants unless they are for temporary use, as these also tend to mask underlying problems.

Recovery Tips for Early Adrenal Fatigue and POTS Disease Symptoms

If your AFS is mild (stages 1 and 2) and you have symptoms of POTS disease that are not debilitating or prevent you from carrying out your active daily living, you can consider vitamin C, the B vitamin pantothenate, the amino acid l-tyrosine, licorice, maca, green tea, ginseng, ashwagandha, and adrenal gland extracts. They support healthy adrenal function, strengthen blood vessel constriction, and increase heart function. Because many of these are stimulatory in nature, always pay attention to the delivery system to ensure bioavailability and avoid over-dosage. Side effects include jitters, addiction, cramps, brain fog, and tremors. This is especially true if the dosage does not match the body’s need.

Recovery Tips for Advanced AFS and POTS Disease

Vitamin C can help both POTS disease and Adrenal FatigueThose with advanced AFS (stages 3 and beyond) and symptoms of POTS disease that are troublesome to the degree of interfering with normal living should not embark on any nutritional supplement program without careful consideration and a master recovery plan in place. One should proceed with extreme caution because a body with advanced AFS is thus far most likely in a state of hypersensitivity by the time POTS disease, either clinically or subclinically, is present. They are also at risk of paradoxical reactions and a low threshold for adrenal crashes. Their extracellular matrix is often congested, and the liver overburdened. Energy level is very low. Attempts to stimulate the adrenals and cardiovascular system using supplements that may have worked in earlier stages of AFS may backfire. Even a small amount of these vitamins, such as vitamin C or B, ashwagandha, rhodiola, maca, licorice, and glandulars can make POTS disease worse and trigger adrenal crashes.

Consider the following:

  • Gentle macro nutrition to match the body’s dietary needs and physical condition should be encouraged, with easy to digest soups and broths as part of the diet.
  • Avoid gluten, dairy, wheat and corn, as these are harder to digest and can lead to inflammatory reactions that trigger POTS disease.
  • Symptoms of irritable bowel should be addressed and stabilized with enzymes, probiotics etc. so that food assimilation from the gut is optimized.
  • A special form of breathing called Adrenal Breathing Exercise, as compared to regular breathing or deep breathing should be encouraged. Doing so enhances the parasympathetic tone to reduce the sympathetic tone, with acetylcholine replacing norepinephrine as neurotransmitter, and creates a sense of calmness. Heart rate normalizes and blood pressure stabilizes as a result.
  • Avoid antibiotics if possible as they can upset the internal flora and thus the pH of the body.
  • Avoid aggressive detoxification approaches such as chelation, liver flushes, cleanses, fasting, hyperthermia treatment, hot yoga, acupuncture and the like as they can aggravate extracellular matrix congestion and trigger POTS disease.
  • Mild and gentle liver support such as liposomal glutathione should be considered, along with fermented herbs such as milk thistle and others that have excellent bio delivery systems. Care must be taken to titrate the proper amount at the right time. Incorrect dosing and delivery systems are common mistakes and can make matters worse.
  • Take time to decongest the extracellular matrix first to stabilize the body’s internal biosphere.
  • Do use medication if there are no other choices and the body fails to respond.


POTS disease can be a very serious condition. Symptoms tend to occur in those in advanced stages of AFS when the body is flooded in a sea of norepinephrine and epinephrine. Frequent visits to the emergency room with complaints of heart palpitations amidst a negative cardiac workup are the norm.

AFS is perhaps the most commonly overlooked secondary cause of hyperadrenergic POTS disease. Quickly beginning a comprehensive adrenal fatigue recovery plan should be the priority. A recovery plan is required for long-term success to prevent POTS disease from recurring.

As the adrenals heal, one should notice that the frequency and intensity of POTS disease subsides. This can happen in a short time, especially for those who are young and have good rebound capabilities.

If you think that you are in, or have symptoms of POTS disease and suffer from Adrenal Fatigue Syndrome, recovery needs to be personalized. An improper approach to recovery can complicate, deter, or even exacerbate your current state.

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© Copyright 2015 Michael Lam, M.D. All Rights Reserved.

POTS disease
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Lately I have become aware that I have POTS. After standing for 10 minutes, my heart rate went from a resting rate of 70 to 150-160. Now that I have been doing your adrenal breathing exercises for two months, my heart rate only goes up 30-40 beats from resting, whether I am just standing or walking while shopping. This is a great improvement for me and I expect to reach my goal of being cured of the POTS symptoms.