As I begin writing this post on a nearly 90 degrees spring day in Upstate New York, I am reminded again how much the heat and humidity are POTS triggers that worsen my symptoms. My blood feels thick. I’m lethargic. I can see the discoloration in my feet from the blood pooling, and I know that when I get up, I will partially blackout, courtesy of pre-syncope. This is all to say that it’s super important to be aware of POTS triggers, along with others that are unique to your case. Here’s a list of my top POTS triggers that personally exacerbate symptoms.
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Trigger #1: Heat & Humidity
I know that everyone struggles to some degree in the heat, but for people with POTS, that struggle is amplified. It is hands-down one of the most difficult POTS triggers I deal with because it never fails to make my symptoms worse, and unless I sit in an air-conditioned building all day, it’s difficult–although, not impossible–to manage.
Any kind of hot environment is going to encourage vasodilation, or widening of blood vessels. Vasodilation promotes blood pooling, so our circulation becomes inefficient. This means that not enough blood is getting back up to our hearts and our brains where it’s needed, which can intensify symptoms.
Don’t worry, I have a few tricks to combat the heat!
I use an Elasto-Gel Cold Therapy Wrap on my legs and my abdomen after coming in from outside to help constrict my blood vessels. Filling a bucket with water and ice cubes for a foot soak also feels amazing after being outside, especially if I’ve been on my feet too long.
Finally, wearing light-colored and loose clothing can also help you stay cool. However, if blood pooling is a problem for you in the heat–like it is for me–put on a pair of compression socks. VIM & VIGR makes super stylish compression socks that you can wear with summer dresses and skirts that you’ll actually want to wear!
Although, if a heatwave is forecasted for your area, or the air is so humid outside that it better resembles soup, your best bet may be to stay indoors. Or, go outside in short shifts, ensuring that you stay hydrated and take frequent breaks inside where it’s cooler to recover.
Trigger #2: Caffeine
This is a painful trigger to admit to. I love my coffee, and I can’t go a morning without it. You might be thinking, now wait a minute, if caffeine is a trigger, then why are you drinking it?! Let me explain.
Too much caffeine triggers POTS symptoms for me. Obviously, I’ve experimented with this to figure out the right balance of what I can handle. Personally, I am fine if I drink my one morning cup of coffee, as long as it isn’t too strong. I tend to drink lighter to medium roast coffee because of this.
If I drink a second cup of coffee later in the day when I have my 3-4PM slump, more times than not it’s too much for my body to handle. Incoming of tachycardia! Hello insomnia and dehydration! I see you, shaking hands! It’s a fine line between just enough caffeine and too much, so I try not to offset that delicate balance.
Interestingly, drinking small amounts of caffeine actually helps my symptoms because I find that it raises my blood pressure slightly. Since my blood pressure tends to be lower in the morning, this is helpful. Again, it’s all about finding the right balance for YOU. Some POTS patients cannot handle any caffeine whatsoever.
Trigger #3: Alcohol
Another big POTS trigger? Alcohol. Drinking alcoholic beverages can cause hypotension and dehydration, which are both sources of worsening symptoms. Alcohol also interacts with many medications, so you may not even be able to drink alcohol depending on what prescriptions you take.
However, with the guidance and approval from my doctor, I am able to drink alcohol in moderation as long as I stay hydrated while doing so. I want to emphasize that this is completely unique to my case and where I’m at in managing my symptoms. If I’m in a flare-up, I don’t drink at all; it can be a huge trigger that worsens my symptoms for days afterward. Not just hours, days. As with caffeine, some POTS patients cannot tolerate alcohol at all and should avoid it completely.
*Talk to your doctor before consuming alcohol to determine if it’s safe for you!
Trigger #4: Diuretic Medications
Diuretic medications essentially flush water and salt out of the body, and they are commonly prescribed to treat high blood pressure. However, other medications can have diuretic effects as well. Anything that expels water and salt from the body is going to trigger POTS symptoms, so it’s crucial that you ask a pharmacist about potential diuretic effects before starting a new medication. While I actively avoid diuretic medications now, I’m still listing it here because it’s something that I learned along the way–the hard way.
This article explains why certain medications with diuretic effects can worsen tachycardia (scroll to “Pharmacological Treatment of POTS”). Read closely: This is very important! I was put on Spironolactone to help with acne and a hormonal imbalance, and I had to stop it immediately because I thought I was having heart problems (pre-POTS diagnosis). This medication acts as a strong diuretic and is primarily used to lower blood pressure–no wonder I felt like I needed to go to the ER! A similar compound called drospirenone is used as a progestin in Yaz and Yasmin birth controls, so be aware to avoid these if you have POTS and need to go on an oral contraceptive. Don’t make the same mistake and suffer like I did!
If you have POTS, consult your doctor about switching to other medication options that don’t have diuretic effects. Always ask a pharmacist before starting a prescription if you’re unsure.
Trigger #5: High Stress
Stress management is even more important for the chronically ill, especially those with POTS. Stress, despite its bad rap, is actually beneficial in small amounts. In fact, there’s even a good type of stress called eustress. Stress becomes a problem when there is either too much of it, or it persists, unabated, over long periods (chronic stress).
In case you didn’t know, POTS is a dysfunction of the autonomic nervous system (ANS), the part of the nervous system that regulates things we cannot control; they happen automatically without us needing to do anything. Think of heart rate and blood pressure as relevant examples here. POTS patients tend to experience an increase in the activity of the sympathetic nervous system, which is a branch of the ANS responsible for the fight or flight mechanism. Due to this extra activity, we experience an increase in circulating norepinephrine.
What’s norepinephrine, you may ask? It’s a hormone produced in the body when a stressful event has been perceived. It raises heart rate and increases blood flow to the muscles (preparing you to fight the perceived threat or flee the scene). So, because POTS patients have more of this hormone circulating normally–and contributing to tachycardia and other symptoms–one can arguably say we are in a constant level of stress to some degree. Then, when we encounter an actual stressor, our adrenal glands pump out more norepinephrine and epinephrine (adrenaline), which quickens the heart rate even further, among other effects. See how too much stress can be detrimental to healing with POTS?
Unfortunately, you can’t always wish away the stressors in your life. Instead, you have to acknowledge that your stress is there and then find ways to temporarily relieve yourself of it, whether that’s through a hobby, hanging out with friends or family, venting to a support system, meditation, exercise, or deep breathing. Practicing a change in perspective can also be beneficial to alter your mindset toward stressors that can better help you cope with them.
Trigger #6: Hot Environments
How are these POTS triggers different from heat and humidity? Well, in this section I’m specifically talking about environments that cause the body to potentially overheat and sweat out electrolytes. This includes saunas, hot tubs, swimming in heated pools, hot yoga, and buildings without AC in the summer. The same rationality from the heat and humidity section applies here: Heat promotes vasodilation and too much of that compromises circulation.
Trigger #7: Over-exercising/Over-exertion
Exercise is fantastic for treating and even healing POTS. However, one of the most prominent symptoms of the syndrome is exercise intolerance. Too much exercise that we aren’t conditioned to handle yet actually triggers POTS symptoms. It can leave us completely wiped out and afflicted by “rebound symptoms” for up to 24-48 hours after exercise sessions.
Following the Levine Protocol is the best way to slowly condition your body to better tolerate exercise and to avoid over-exerting yourself. I used this step-by-step guide when I was first diagnosed with POTS because I struggled to exercise without being exhausted the following day. I still use it as a guide today, and my exercise intolerance has improved so much that I’m back to running again! If you haven’t yet tried it, I’d recommend talking to your doctor about the program; it can reduce the intensity and frequency of this POTS trigger!
Along similar lines, it doesn’t even have to be too much exercise either; too much activity, in general, can worsen symptoms. That’s why you shouldn’t plan to do housework, gardening, grocery shopping, exercising, and cooking all in one day. I know how it goes: You feel great on a low symptom day and want to keep doing more because it’s wonderful to feel so great and full of energy, but then you immediately regret it the next day when you feel like you’ve been hit by a truck. Use your spoons wisely!
Trigger #8: Menstrual Periods
From what I’ve heard from other female POTS patients, I’m not alone in that time of the month triggering symptoms. I have definitely noticed that my symptoms get worse right before, during, and immediately after my periods. This article explains why POTS symptoms worsen during periods and suggests that people with POTS may feel their worst at this time of the month.
A 2012 study investigating POTS, lightheadedness, and gynecological disorders found that POTS patients reported more lightheadedness during all phases of the menstrual cycle in comparison to healthy controls. However, lightheadedness increased for both groups during menses, which may be related to shifts in estrogen levels. What’s also interesting is that this study found that POTS patients have a higher occurrence of gynecologic disorders influenced by estrogen compared to healthy participants.
So, what’s going on here? Are POTS patients more sensitive to estrogen, or is there something else causing these results? Hmm… I may be digging through some more research to investigate this trigger further!
While we can’t really avoid our periods, we can pamper ourselves a little extra when that time of the month rolls around. I’ll be eating anything and everything with chocolate and taking long baths. How about you?
Trigger #9: Standing For Long Durations
Prolonged standing–especially standing still–almost never fails to trigger my symptoms. Being upright compromises circulation in POTS patients, so that’s why we feel so much worse when we’re standing. Prolonged standing is an actual nightmare for me, although it has gotten better with time. (I think this has to do with better exercise conditioning and taking pyridostigmine.)
To counteract this trigger, I’ll wear compression socks, such as those made by VIM & VIGR, when I know I’ll be on my feet for a long time. I also minimize my time standing completely still. You’ll often catch me shifting my weight, nonchalantly performing calf raises in a crowd, or bending my legs in an effort to promote circulation. It’s not a cure, but it definitely helps!
Trigger #10: Eating Large Meals
You know that impending food coma feeling we get right after finishing Thanksgiving dinner each year? That sleepiness isn’t just from the turkey; it’s also because of the quantity of food we’ve just eaten. The technical term for a food coma is postprandial somnolence, or post-meal sleepiness (but “food coma” is much more fun to say, am I right?).
While a healthy individual may only feel sleepy after large meals, especially those high in fat or carbohydrates, a POTS patient can experience a full fledge of symptoms. According to one 2011 review, many POTS patients report feeling worse after eating large meals, particularly ones high in carbohydrates. The authors of this medical review suggest eating smaller, more frequent meals instead, and balancing macronutrients each time you sit down to a meal (carbohydrate, protein, fat).
In light of that, I try to split my meals into four-to-five smaller meals throughout the day. I am a classic grazer! For example, I eat breakfast, a mid-morning snack, lunch, an afternoon snack, and dinner. Sometimes, I’ll have another small snack after dinner if I eat earlier in the evening.
Remember, these aren’t huge portion sizes here. If you’re eating more frequently, then you don’t need to consume large quantities at a time.
Pinpointing and avoiding POTS triggers are both highly individual and imperative in managing your health with this chronic condition. Once you have a better idea of triggers that worsen your symptoms, you can take active steps to minimize them and be on your way to feeling stronger, happier, and healthier! Let me know in the comments below what POTS triggers are the worst for you!
Looking for more information? Check out this page from Dysautonomia International on how certain lifestyle adaptations can help mitigate flare-ups and worsening symptoms.
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- Dysautonomia International: Lifestyle Adaptations for POTS. Accessed May 31, 2020. http://www.dysautonomiainternational.org/page.php?ID=44.
- Mathias, Christopher J., David A. Low, Valeria Iodice, Andrew P. Owens, Mojca Kirbis, and Rodney Grahame. “Postural Tachycardia Syndrome—Current Experience and Concepts.” Nature Reviews Neurology 8, no. 1 (June 2011): 22–34. https://doi.org/10.1038/nrneurol.2011.187.
- O’Brien, Kelley. “My Chronic Illness Gets Worse When I Have My Period.” HelloFlo, May 25, 2018. https://helloflo.com/my-chronic-illness-gets-worse-when-i-have-my-period/.
- Peggs KJ, Nguyen H, Enayat D, Keller NR, Al-Hendy A, Raj SR. Gynecologic disorders and menstrual cycle lightheadedness in postural tachycardia syndrome. Int J Gynaecol Obstet. 2012;118(3):242‐246. doi:10.1016/j.ijgo.2012.04.014
- Raj, Satish R. “Postural Tachycardia Syndrome (POTS).” Circulation 127, no. 23 (November 2013): 2336–42. https://doi.org/10.1161/circulationaha.112.144501.
- “What You Need to Know about Water Pills (Diuretics).” Mayo Clinic. Mayo Foundation for Medical Education and Research, October 19, 2019. https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/diuretics/art-20048129.