Why hEDS, POTS, and MCAS Almost Always Come Together: The Mechanistic Triad and the Upstream Lesion Standard Medicine Doesn't Treat — What This Means in Practice

Several practical implications follow from the framework. First, the search for a single explanation for the triad is finally productive. The explanation is not at the level of any one of the three diagnoses. It is at the bioenergetic layer that all three subsystems share. Once that is recognized, the question shifts from "which of my three diagnoses is primary" to "what is the state of my bioenergetic capacity, and what is moving it up or down." Second, the parallel treatment approach (one specialist for hEDS, one for POTS, one for MCAS) is structurally limited. Each specialist addresses a downstream slice of an integrated picture, and the integration is left for the patient to do alone, usually without the analytic support to do it well. The integration is the work. It requires reading the case at a level the standard appointment does not support. Third, the timescale of meaningful capacity work is months to years, not weeks. The structural vulnerability is permanent. The capacity layer can be moved, but the movement requires sustained attention to the inputs that determine capacity: mitochondrial cofactor status, NAD pool dynamics, redox balance, gut barrier integrity, autonomic regulation, mast cell stabilization through the underlying compartment biology, and the connective tissue maintenance work. None of this is a six week protocol. The patient who expects a six week pro