Postural Orthostatic Tachycardia Syndrome, Menopause and Hormone Replacement Therapy: Clinical Decisions in Times of Uncertainty

Postural orthostatic tachycardia syndrome (POTS), characterized by a rise in heart rate of at least 30 beats per minute from supine to standing position without accompanying orthostatic hypotension, is one of the most common autonomic disorders with disabling cardiovascular and neurologic manifestations. Hormonal influence has been long recognized by the disorder predominantly affecting women of reproductive age, with frequent onset around menarche, exacerbation of symptoms before or during menses, and pregnancy being one of POTS triggers. Hormone replacement therapy (HRT) and menopause in women with POTS have not been studied, but issues surrounding HRT are highly relevant as women with POTS transition from reproductive age to menopause. Given a rising prevalence of POTS due to post-COVID onset and the US Food and Drug Administration recently removing the black box warning on estrogen-containing HRT formulations, informed decisions and risk assessments regarding HRT use in women with POTS are warranted. In this narrative review, existing studies on hormones and POTS and its common comorbidities are reviewed, and key points in decision-making on the use of HRT in women with POTS are discussed. In summary, for women with significant menopausal symptoms and/or exacerbation of POTS during the peri- or postmenopausal period, using some forms of HRT for treatment of menopausal symptoms may be considered, accounting for comorbidities, cardiovascular risk and other factors. Vaginal estrogen appears to be safe for most women while transdermal estrogen and micronized progesterone can be utilized for significant menopausal symptoms, although outcomes of their long-term use are unknown.