Why POTS and endometriosis respond to diaphragm work (when nothing else has)

If you've been navigating POTS or endometriosis, you've probably heard a version of the same advice from a dozen different people: "Just exercise more." "Try yoga." "Build up your fitness gradually."

And you've probably tried. And found that most of it makes you worse.

The standard exercise advice fails women with these conditions for a specific reason: it ignores the engine that drives both — the diaphragm, the fascial system it pumps, and the autonomic nervous system it speaks to constantly. Until you address that engine, no amount of cardio, strength work or stretching is going to give your body what it actually needs.

Here's how the picture looks once you understand it. And why Hypopressives and internal fascial work tend to land where everything else hasn't.

Two conditions, one shared problem

POTS (Postural Orthostatic Tachycardia Syndrome) and endometriosis are very different diagnoses. But they have an unsettling number of women in common — and they share a hidden mechanical theme.

In POTS, the autonomic nervous system can't regulate blood pressure properly when you change position. Stand up, and your heart races to compensate for blood that's pooling in your lower body. The result is dizziness, fatigue, brain fog, palpitations, and the kind of exercise intolerance that makes well-meaning fitness advice unbearable.

In endometriosis, tissue similar to the uterine lining grows outside the uterus, causing inflammation, adhesions and chronic pelvic pain. Over time, the inflammatory environment creates dense, dehydrated, sticky fascia throughout the pelvis — and often around the diaphragm too, if diaphragmatic endometriosis is part of the picture.

Both conditions sit in bodies where:

• The diaphragm has often become restricted (from shallow breathing, pain guarding, surgery, scarring)

• Internal fascia has become dehydrated and stuck

• The autonomic nervous system runs hot in a sympathetic, "fight or flight" mode

• Venous return from the lower body is compromised

• The pelvic floor and deep core are dysregulated

This isn't coincidence. It's mechanics.

The hypermobility connection

For a striking proportion of women with POTS, there's another piece in the picture: hypermobility. Studies consistently find that somewhere between 30% and 50% of people with POTS also have joint hypermobility, often meeting criteria for hypermobile Ehlers-Danlos Syndrome (hEDS) or Hypermobility Spectrum Disorder (HSD). If you've always been the "bendy" one — the gymnast, the dancer, the child who could put her leg behind her head — and you now have POTS, this isn't coincidence.

The reason is connective tissue. Hypermobility is, at its core, a difference in how your collagen behaves. Collagen is the protein that gives connective tissue — including blood vessel walls, fascia, ligaments and the pericardium — its structural integrity. In hypermobile bodies, that tissue is more compliant. More stretchy. More giving.

For your joints, that means more range of motion (often impressive, often painful). For your blood vessels, it means walls that don't constrict as efficiently when you stand up — so more blood pools in the lower body, and your heart has to race harder to compensate. This is one of the primary mechanical drivers of POTS in hypermobile women.

But the implications go much further than blood vessels. In a hypermobile body:

• Fascia is more compliant and less supportive. It can't passively hold structures in place the way it does in non-hypermobile bodies. Stability has to come from active control — breath, deep core, postural tone — rather than from structural restraint.

• The diaphragm itself can be lax. Diaphragmatic excursion is often poor in hypermobile women, and the rib cage can be hypermobile too — meaning the central pump that drives venous return, lymphatic flow and pelvic floor coordination is structurally less efficient before you even add the breath restriction that pain and dysautonomia create.

• Pelvic organs are more prone to prolapse and the pelvic floor more prone to dysfunction, because the ligaments and fascia holding everything in place are more compliant.

• Proprioception — your body's sense of where it is in space — is often impaired, because connective tissue is densely packed with proprioceptive receptors that fire less reliably in hypermobile bodies.

This is why so many hypermobile women with POTS find traditional strength training useless or actively harmful. Loading a structurally compliant body with heavy weights doesn't fix the problem — it asks already-overstretched tissue to absorb more force. What hypermobile bodies need is active stability: precise, slow, deeply controlled movement that builds reflexive tone in the deepest layers of muscle and fascia.

Classical Pilates and Hypopressives are unusually well-suited to this. Every spring setting on the Reformer can be calibrated to your individual instability. Hypopressives create reflexive lift exactly where compliant tissue isn't providing structural support. And fascia release rehydrates and tones the connective layer, restoring some of the responsiveness that compliant tissue lacks.

The diaphragm: the engine no one talks about

Your diaphragm isn't just a breathing muscle. It's the central pressure pump of your torso, and it's connected — fascially — to almost everything that matters in POTS, endometriosis and hypermobility.

A few of its less-talked-about jobs:

• Venous return. Every breath, the diaphragm acts like a piston, drawing blood up from the abdomen and pelvis into the heart. When it's restricted, this "thoracic pump" weakens, and more blood pools where it shouldn't — a major mechanical driver of POTS symptoms.

• Lymphatic drainage. The cisterna chyli, the body's main lymphatic reservoir, sits just below the diaphragm. Diaphragmatic movement is what drives lymphatic flow upward. Restricted diaphragm, stagnant lymph.

• Vagal tone. The vagus nerve — the main highway of the parasympathetic (rest, digest, repair) nervous system — passes directly through the diaphragm at the oesophageal hiatus. Slow, full lateral 360 breath stimulates vagal tone and shifts you out of sympathetic dominance.

• Pelvic floor coordination. The diaphragm and pelvic floor are paired pistons. They move together on every breath. A restricted diaphragm means a restricted pelvic floor — and vice versa.

• Pressure management. The intra-abdominal pressure that determines whether your organs sit happily or strain against weakened fascia is largely set by the diaphragm.

If the diaphragm isn't working, none of these systems are working. Which is exactly the picture POTS and endometriosis present.

Fascia, water and movement

Fascia — the continuous web of connective tissue that wraps every structure in your body — is around 70% water. Healthy fascia is hydrated, springy, slides cleanly over surrounding structures. Restricted fascia is dehydrated, dense, sticky.

The process that keeps fascia hydrated is movement and pressure change. Specifically: the rhythmic compression and decompression that the diaphragm creates with every breath. Twelve to fifteen times a minute, all day, your diaphragm is meant to be pumping fluid through every fascial layer in your torso.

When chronic pain (endometriosis) or autonomic dysfunction (POTS) shifts you into shallow chest breathing, that pump stops. The fascia begins to dry. The pelvic and diaphragmatic layers stiffen, the organs lose mobility, and the system as a whole becomes a tighter, drier, less responsive version of itself.

This is why so many women with these conditions describe a feeling of being "stuck inside their own body". It's not metaphorical. The internal fascia really is more dehydrated, less mobile and less responsive than it should be.

Why Hypopressives change the picture

Hypopressives are a breath-based, low-pressure exercise system that does something almost no other exercise does: they actively decompress the abdominal cavity.

The technique combines specific postures with a reflexive exhalation manoeuvre that creates a vacuum effect inside the torso. The diaphragm draws upward. The internal organs lift. The pelvic floor reflexively engages. And — critically — the internal fascia is pulled, decompressed and effectively "rinsed" by the pressure change. Movement plus pressure equals hydration. After years of stagnation, that's a profound shift.

For POTS, this means:

• The diaphragm is mobilised and retrained as a pump, improving venous return

• Vagal tone is stimulated through slow, controlled breath

• Postural tone improves, supporting the autonomic system in regulating blood pressure

• The sympathetic-dominant nervous system is given a path back to parasympathetic

For endometriosis, this means:

• Pelvic fascia is mobilised without bracing, impact or aggravation of inflammation

• The diaphragm–pelvic floor relationship is restored, so the upper compartment stops pulling on the lower

• Intra-abdominal tension reduces, which often reduces pain

• Internal fascial hydration improves, restoring the glide that adhesions and inflammation steal

For hypermobile bodies, this means:

• Reflexive deep core and pelvic floor tone is built without loading compliant joints

• The lax diaphragm is retrained as the central stabiliser of the trunk

• Postural tone improves, giving the autonomic system more to work with

This is gentle work. It's deliberately low pressure. There's no high impact, no straining, no "feel the burn". And yet for the right body, it does more in a few weeks than years of conventional exercise.

Why 360 breath, not belly breath

If you've spent time in yoga or general wellness, you've probably been told to "breathe into your belly". The cue is so common that it's become a kind of universal shorthand for "relax".

It's also wrong for almost every body we've talked about so far.

Belly breathing pushes the abdominal wall out on every inhale. In a healthy person with a strong pelvic floor and no diastasis, that's mostly fine — though it's never as efficient as it could be. In a body with prolapse, diastasis recti, stress incontinence, hypermobility, POTS or endometriosis, repeatedly pushing the abdominal wall outward on every breath is actively unhelpful. It increases pressure downward and forward, exactly where compliant tissue can't take it.

What we want instead is 360 breath: a breath that expands the rib cage in every direction — front, sides and back — while the deep abdominal wall and pelvic floor stay quietly engaged. The diaphragm still descends fully. The lungs still fill completely. But the pressure goes laterally, into a rib cage built to expand, rather than downward into structures that aren't built to take it.

A few things 360 breath does that belly breathing can't:

• Mobilises the rib cage. The intercostal muscles, costovertebral joints and thoracic spine — all of which stiffen with stress, shallow breathing and desk work — are forced to articulate again.

• Activates the deep core reflexively. The transverse abdominis and pelvic floor co-contract on the exhale automatically, without you having to "squeeze".

• Manages intra-abdominal pressure instead of dumping it downward. This is the variable that determines whether your organs sit happily or strain against weakened fascia.

• Supports the autonomic nervous system more effectively. The combination of lateral ribcage expansion and a slow, complete exhale is a stronger parasympathetic signal than belly breathing alone — particularly important in POTS, where the autonomic system is the whole problem.

Learning to breathe like this takes time. Most people need three or four sessions before it feels natural — but once it lands, every other piece of the work changes.

What sessions look like

We start with assessment: how you're breathing, how your ribs move (or don't), how your pelvic floor and diaphragm are coordinating, what tension patterns are sitting where. Most women are surprised by how much information their breath alone gives away.

From there, the work is layered slowly:

1. Restoring breath mechanics — full 360 breath, expanding the ribs at the front, sides and back rather than pushing the belly out. The deep core stays engaged throughout, which is what gives the pelvic floor and diaphragm something to work with.

2. Roll Model® fascia release for the diaphragm, ribs, psoas and pelvic floor attachments — gently rehydrating the internal layer.

3. The Hypopressive postures and apnea technique, introduced slowly and built up over weeks.

4. Integration with classical Pilates and daily home practice.

For most clients, meaningful change appears within four to six weeks of consistent practice. Not a cure — these are complex conditions — but a felt sense of more space, more ease, more capacity. A body that's working with you again.

Important cautions

This work isn't for everyone, and timing matters.

• Hypopressives are not suitable during pregnancy, during menstruation, or with uncontrolled high blood pressure or certain cardiac conditions. With POTS, we'll discuss medication, hydration and which positions are safe for you.

• If you have diaphragmatic endometriosis specifically, sessions need to be paced carefully and ideally coordinated with your gynaecologist or endometriosis specialist.

• If you're hypermobile or have a diagnosis of hEDS or HSD, we'll work especially carefully with positioning — your joints have more range than is structurally helpful, and the goal is precise control, not maximum stretch. Hypermobile bodies often need more time, not less, to learn the work safely.

• Postnatally, please wait for your six-week check (or ten to twelve weeks after a C-section) and ideally a women's health physio assessment before starting.

We talk through your full health picture at your first session and adapt accordingly. There's also an excellent physiotherapist on site at Botanica Health when a joint approach helps.

How to start

You can begin this work in two ways.

In studio, 1:1 with me at Botanica Health, Tunbridge Wells. This is the most effective way to learn — I can observe your breath, refine your apnea, palpate your diaphragm, and integrate everything with Pilates and fascia release.

Book a 1:1 Session →

Online with my mentor, Susannah White. If you're not local, or you want to explore the work at home first, Susannah's Movement for Pelvic Health platform is the best online resource I know for women with POTS, endometriosis, hypermobility and complex pelvic conditions. You'll get a free mini workshop and a free 7-day pelvic health investigation before paying anything.

Start Free with Susannah's Online Platform →

If you've spent years being told to "just push through" or "try harder", and your body keeps refusing — this might be the work it's been waiting for.

X Alyssia