Hormones, Cortisol, and POTS: What We Know So Far
Postural Orthostatic Tachycardia Syndrome (POTS) is a complex condition that affects the autonomic nervous system, causing symptoms such as dizziness, fatigue, brain fog, rapid heart rate, and digestive issues. While POTS has many contributing factors, hormonal imbalances—particularly involving cortisol—play a critical role in symptom severity and management. In this article, we’ll explore what research and clinical observations tell us about hormones, cortisol, and POTS, including both low and high cortisol, what this means for daily life, and how coaching can help patients navigate these challenges.
Understanding POTS and the Role of the Autonomic Nervous System
POTS is a form of dysautonomia, meaning it is a disorder of the autonomic nervous system (ANS). The ANS controls bodily functions that are largely automatic, such as heart rate, blood pressure, digestion, and sweating. In POTS, the body’s ability to regulate heart rate and blood flow in response to standing is impaired.
Key characteristics include:
• Rapid heartbeat upon standing
• Lightheadedness or dizziness
• Fatigue and exercise intolerance
• Digestive issues and gut dysmotility
• Temperature regulation problems
While POTS is often thought of in terms of heart rate and blood pressure, hormones—especially cortisol—play an essential role in modulating how the body responds to stress, maintains blood pressure, and supports energy levels.
Hormones Commonly Involved in POTS
POTS is influenced by multiple hormones. Understanding their function helps explain why symptoms can fluctuate and why certain strategies help manage daily life.
1. Cortisol
Cortisol, often called the “stress hormone,” is produced by the adrenal glands. It regulates:
• Blood pressure
• Blood sugar levels
• Inflammatory responses
• Energy availability
In POTS, research and clinical observation indicate that cortisol levels may be abnormally low, dysregulated, or sometimes elevated, depending on the individual and subtype of POTS.
• Low cortisol or dysregulated rhythms: This can cause fatigue, dizziness, poor stress tolerance, and difficulty maintaining blood pressure.
• High cortisol (hypercortisolism): In some patients, particularly those with hyperadrenergic POTS, cortisol can be elevated due to chronic stress or sympathetic overactivity. High cortisol can contribute to:
• Anxiety and jitteriness
• Rapid heartbeat or palpitations
• Difficulty sleeping or insomnia
• Blood sugar fluctuations
• Weight changes and digestive issues
Cortisol imbalances—whether too low or too high—interact with other hormones and the nervous system, often exacerbating POTS symptoms.
2. Adrenaline and Norepinephrine
Adrenaline (epinephrine) and norepinephrine are key neurotransmitters and hormones involved in the “fight or flight” response.
• In POTS, especially the hyperadrenergic subtype, norepinephrine may be elevated when standing, leading to:
• Rapid heart rate
• Anxiety or panic-like symptoms
• Tremors and shakiness
High cortisol often coincides with hyperadrenergic activity, creating a cycle of heightened sympathetic nervous system activation and worsened symptoms.
3. Sex Hormones (Estrogen and Progesterone)
Many people with POTS are female, and symptoms often fluctuate with the menstrual cycle.
• Estrogen can affect vascular tone, meaning it influences how blood vessels expand and contract.
• Progesterone affects fluid balance and may influence heart rate.
Fluctuations in these hormones can worsen POTS symptoms at certain points in the menstrual cycle. Combined with cortisol imbalances, this can amplify fatigue, dizziness, and palpitations.
4. Thyroid Hormones
The thyroid regulates metabolism and energy.
• Hyperthyroidism or hypothyroidism can mimic or worsen POTS symptoms.
• Many POTS patients are screened for thyroid dysfunction because addressing thyroid imbalances can improve energy, heart rate regulation, and overall well-being.
Cortisol Dysregulation in POTS: Low, High, and Abnormal Patterns
Cortisol follows a natural circadian rhythm, peaking in the morning and gradually decreasing throughout the day. In people with POTS, this rhythm may be abnormal in multiple ways:
1. Low or Blunted Cortisol:
• Fatigue, dizziness, morning “crashes”
• Poor stress tolerance
• Difficulty maintaining blood pressure upon standing
2. High Cortisol:
• Anxiety, racing heart, insomnia
• Blood sugar swings
• Muscle tension or weight gain
• Increased symptom flares during stress or illness
3. Flattened Cortisol Curve:
• Low in the morning, high in the evening (or vice versa)
• Impaired sleep and energy regulation
Both high and low cortisol levels can worsen POTS symptoms, meaning each patient’s approach must be personalized.
Why Cortisol Matters for Blood Pressure, Energy, and Stress
Cortisol plays a critical role in:
• Maintaining Blood Pressure: Cortisol helps the body respond to standing by constricting blood vessels and regulating sodium and water retention. Both low and high cortisol can disrupt blood pressure stability.
• Regulating Energy Levels: Cortisol mobilizes glucose for energy. Low cortisol can cause fatigue, while high cortisol can create energy spikes followed by crashes.
• Stress Response: Cortisol modulates the nervous system. Dysregulation can make normal activities feel overwhelming, contribute to anxiety, and increase palpitations.
Understanding whether cortisol is too low, too high, or just out of rhythm helps guide lifestyle interventions, symptom tracking, and coaching strategies.
How Hormone Imbalances Affect Daily Life
Hormone imbalances in POTS affect day-to-day functioning, including:
• Morning fatigue or afternoon crashes
• Brain fog or trouble concentrating
• Heart palpitations and rapid heartbeat
• Anxiety or panic-like sensations
• Digestive issues, appetite changes, or weight fluctuations
Recognizing patterns—whether linked to low, high, or fluctuating cortisol—can help patients anticipate and manage symptoms.
Strategies for Supporting Cortisol and Hormone Balance in POTS
While medical management is essential, lifestyle and coaching strategies can help support hormone balance and symptom management.
1. Hydration and Electrolytes
Adequate fluids and electrolytes support blood pressure and adrenal function. Sodium intake, in particular, can help maintain blood volume, supporting both low and high cortisol scenarios.
2. Stress Management and Nervous System Regulation
Mind-body practices such as deep breathing, meditation, gentle yoga, or paced movement can reduce sympathetic overactivity and help normalize cortisol rhythms.
3. Sleep Optimization
Maintaining consistent sleep-wake cycles supports cortisol’s natural rhythm. Poor sleep can worsen both low and high cortisol patterns.
4. Balanced Nutrition
Frequent, balanced meals with complex carbohydrates, protein, and healthy fats help stabilize blood sugar, which interacts with cortisol and other hormones.
5. Exercise Modification
Gentle, structured movement—like recumbent cycling, swimming, or resistance training—supports circulation and hormone regulation without triggering symptom flares. Hyperactive cortisol patients may need more gradual pacing to avoid overactivation.
When to Consider Medical Evaluation
Hormonal dysregulation can mimic or worsen POTS symptoms, making medical evaluation crucial. Common tests include:
• Morning cortisol and diurnal cortisol patterns
• 24-hour urine cortisol
• ACTH stimulation test (adrenal function)
• Thyroid panel
• Sex hormone panel
Collaboration with a clinician familiar with dysautonomia or POTS ensures comprehensive care for both low and high cortisol situations.
How POTS Coaching Can Help
POTS coaching complements medical care by offering:
• Personalized symptom tracking: Identify patterns related to high, low, or fluctuating cortisol
• Lifestyle and stress management strategies: Support cortisol and nervous system balance
• Education and guidance: Translate medical advice into actionable daily strategies
• Practical daily planning: Adjust routines based on energy levels and hormonal fluctuations
For example, a coach might help a client with high cortisol implement calming morning routines to reduce sympathetic activation, or help a low-cortisol patient structure meals and rest periods to maintain energy throughout the day.
Hormones, especially cortisol, play a significant role in POTS symptom severity. Both low and high cortisol can impact blood pressure, energy, and overall functioning. Dysregulation of adrenaline, sex hormones, and thyroid hormones also interacts with POTS symptoms.
Understanding these connections empowers patients to:
• Advocate for targeted medical care
• Adjust daily routines strategically
• Implement coaching strategies that complement medical treatment
A combination of medical management, lifestyle adjustments, and coaching offers a holistic approach to navigating POTS and improving quality of life.
Key Points to Remember
1. POTS is influenced by multiple hormones: cortisol (high or low), adrenaline, sex hormones, and thyroid hormones.
2. Cortisol imbalances can contribute to fatigue, dizziness, palpitations, anxiety, and sleep disturbances.
3. Lifestyle interventions—hydration, sleep, stress management, nutrition, and gentle exercise—support hormone balance.
4. Coaching helps translate medical guidance into practical, daily strategies tailored to each patient.
5. Working with healthcare professionals ensures safe, effective care for both low and high cortisol patterns.
If you or a loved one are struggling with POTS, understanding the hormonal component—especially cortisol—is empowering. POTS coaching provides practical strategies, personalized guidance, and emotional support to navigate the ups and downs of this complex condition.