Heart palpitations in perimenopause

A sudden pounding, fluttering or skipped-beat feeling, often at rest or lying in bed, is a common and unsettling perimenopause symptom. In most women the heart itself is healthy, and the sensation travels with the same changes that drive hot flashes and broken sleep. A few patterns do need a proper cardiac check, and those are easy to recognize.

What palpitations are

Palpitations are an awareness of your own heartbeat. The NHLBI describes them as feeling that your heart is skipping a beat, fluttering, pounding, or beating too hard or too fast. They can last seconds or minutes. Many women in perimenopause notice them at night, during or just before a hot flash, or in a stressful moment.

They are common and often distressing. In the MsFLASH trials, which enrolled 759 peri- and postmenopausal women aged 42 to 62, a quarter reported being bothered by heart racing or pounding in the previous two weeks. The authors note that up to 46.8% of menopausal women report palpitations in the wider research literature, yet the symptom has been studied far less than hot flashes.

Why palpitations happen in perimenopause

How hormones are involved

The exact mechanism is not settled. Estrogen influences the autonomic nervous system, the automatic circuitry that sets heart rate and blood vessel tone, and the swings in estrogen during perimenopause are thought to make the heart more reactive to adrenaline. The same system is involved in hot flashes, which is one reason palpitations so often ride alongside a flash: the body’s heat-release response includes a brief rise in heart rate that you can feel.

What the long-term data show

The best US data come from SWAN, which tracked palpitations in 3,276 women over the transition. Three patterns emerged:

• about 16% had a high probability of palpitations through perimenopause and early postmenopause, diminishing in late postmenopause
• about 34% had a moderate probability on the same timeline
• about 50% had a consistently low probability

So for roughly half of women, palpitations are a transition-phase symptom that tends to fade.

Who gets them more

Women in SWAN’s high-palpitation group were more likely to be in early perimenopause and to have hot flashes, poorer overall health, more depressive symptoms, higher perceived stress, more sleep problems and higher blood pressure at the start. A 2022 scoping review of 84 studies found a similar picture: worse hot flashes, worse sleep, lower physical activity and lower quality of life were the most consistent correlates. In MsFLASH, worse insomnia, depressive symptoms and stress each raised the odds of being distressed by palpitations.

Importantly, SWAN found that palpitation patterns were not associated with subclinical cardiovascular disease, measured as carotid artery plaque or arterial stiffness.

What else can cause palpitations

Perimenopause does not rule out other causes, and midlife is when several of them appear:

• Overactive thyroid. The NIDDK lists rapid or irregular heartbeat, nervousness, irritability, trouble sleeping, sweating or heat intolerance, shaky hands and weight loss despite a good appetite. Hyperthyroidism is more common in women and overlaps heavily with perimenopause, so a thyroid blood test is standard.
• Anemia. Heavier perimenopausal periods can drain iron, and a low red cell count makes the heart work harder.
• Stimulants. Caffeine, nicotine, decongestants, some asthma inhalers, ADHD medications, and “energy” or weight loss supplements.
• Alcohol, especially in the evening.
• Low blood sugar, dehydration and fever.
• Anxiety and panic, which can feel identical and also become more common during the transition.
• Sleep apnea, which strains the heart overnight and becomes more common around menopause.
• True arrhythmias. Extra beats are very common and usually harmless in a healthy heart. Less often, a fast rhythm such as supraventricular tachycardia or atrial fibrillation first appears in midlife, and these need diagnosis and treatment.

What helps, ranked by evidence

There are no trials of treatments aimed specifically at perimenopausal palpitations. What exists is evidence for treating the things that drive them, so the order below reflects that.

First: a basic work-up

A visit usually includes a pulse and blood pressure check, a resting ECG, and blood tests for thyroid function and anemia. If the ECG is normal but episodes continue, a wearable monitor worn for several days to a few weeks can record what your heart is doing during an episode. For many women, seeing a normal rhythm captured during a “bad” episode is what finally settles the worry.

Treat hot flashes and sleep (strong evidence for those symptoms)

Because palpitations track closely with hot flashes and poor sleep, treating those is the most practical lever. Hormone therapy is the most effective treatment for hot flashes and night sweats. Among nonhormonal options, SSRIs/SNRIs, gabapentin and fezolinetant carry Level I evidence in The Menopause Society’s 2023 position statement, as do cognitive behavioral therapy and clinical hypnosis. If palpitations wake you in the early hours, why perimenopause wakes you at 3 AM explains what is going on and what helps.

Beta blockers (clinical practice, not perimenopause-specific evidence)

For frequent, distressing palpitations after a normal work-up, some clinicians prescribe a low-dose beta blocker, which blunts the heart’s response to adrenaline. This is common practice for benign extra beats but has not been studied in perimenopause specifically.

Lifestyle (low risk, worth trying)

• Cut caffeine and alcohol for two weeks and note whether episodes drop.
• Protect sleep.
• Stay physically active. Lower physical activity was one of the consistent correlates of palpitations in the research.
• Keep a simple log of when episodes happen, how long they last and what you were doing. It makes a clinic visit far more useful.

Supplements (weak evidence)

Magnesium is often suggested for palpitations. Correcting a documented low level makes sense, but evidence that extra magnesium reduces palpitations in people with normal levels is weak, and it is not a substitute for a work-up. See the magnesium glycinate guide for what it can and cannot do.

When to see a clinician

Seek emergency care (call 911) if palpitations come with chest pain or pressure, or difficulty breathing.

Get same-day care if palpitations come with fainting, near-fainting, dizziness or confusion.

Book a visit soon if:

• palpitations are new and happen most days
• episodes last more than a few minutes, or your pulse feels clearly irregular
• you also have weight loss, tremor, heat intolerance or very heavy periods
• you have a personal or family history of heart disease, or of sudden death at a young age
• they worry you enough to change how you live

An ob-gyn trained in menopause can order the first-line tests and refer to cardiology if anything looks off. If you are not being taken seriously, here is how to find a menopause specialist, or search the directory. The symptom check can help you organize what you are noticing before the visit.