Palpitations: menopause or the heart?

Summary

A heart that suddenly races, "skips" or pounds in the chest: between a quarter and half of women in the menopause transition report palpitations. Most of the time they are harmless and linked to hot flashes, anxiety, insomnia or caffeine. But palpitations can also be a sign of causes unrelated to menopause that do need treatment (thyroid problems, anemia, a rhythm disorder); so they should not be waved away as "just menopause" — they deserve assessment at least once.

What is happening?

Palpitations in the menopause transition reach you through several channels:

• Part of the hot flash: Heart rate rises briefly during a vasomotor episode; many women feel the palpitation just before the flash or along with it.

• The autonomic nervous system: Fluctuating estrogen affects the balance of the system that regulates heart rate; "unprovoked" racing can come from here.

• Anxiety and panic: Anxiety, which increases in this period, is one of the commonest causes of palpitations — and palpitations in turn increase anxiety.

• Insomnia, caffeine, alcohol, nicotine: Each triggers palpitations, and most of them increase in this period.

• Thyroid problems and anemia: Both are common in midlife women, both cause palpitations and a sensation of heat, and both are easily confused with menopausal symptoms.

• Rhythm disorders: Rhythm problems such as atrial fibrillation become more common with age, and their frequency in women rises after menopause. That is why irregular, persistent palpitations are taken seriously.

What do we know?

• Frequency and course: In the SWAN cohort, reported palpitations increased during perimenopause and partly decreased after menopause; they were strongly associated with hot flashes, disturbed sleep and depressive symptoms ¹. Because most studies of menopausal palpitations do not measure the symptom with a standard scale, the true prevalence range is wide ².

• Most are benign, but they must be distinguished: Palpitations that are brief, settle on their own and come with anxiety or a hot flash are usually not due to a rhythm disorder. Palpitations that are prolonged, irregular or accompanied by fainting or chest pain do require cardiological assessment ³.

• The assessment is straightforward: History, examination, an ECG, if needed a 24-48 hour rhythm recording, thyroid tests and a blood count. For many women these steps provide both reassurance and a chance to catch a real cause ³.

• A period of cardiac risk: The American Heart Association describes the menopause transition as a period when cardiovascular risk clearly rises; palpitations alone are not a marker of risk, but they are a reason to pay attention to heart health ⁴.

• Treatment follows the cause: Where palpitations come with hot flashes, treating the vasomotor symptom may reduce them too; where they are driven by anxiety, CBT and relaxation techniques are effective; a rhythm disorder needs cardiological treatment.

What does this give you?

• Record them, and count your pulse if you can: When the palpitation started, how long it lasted, whether it was regular or irregular, and whether it came with a hot flash, anxiety or caffeine — this is the most valuable information for your doctor. If you have smartwatch or phone recordings, take them with you.

• Reduce the triggers: Caffeine (especially in the afternoon), alcohol, nicotine and insomnia. These increase both palpitations and hot flashes.

• During an episode: Sit down and breathe out slowly and long; it should settle within a few minutes. The breathing tool in Lumia can be used for this. If it does not settle, or there are other symptoms with it, do not wait.

• The fear that "something is wrong with my heart": This fear makes palpitations worse. The best remedy is to be assessed properly once and know the result.

Sources

1. Carpenter JS, et al. Palpitations across the menopause transition in SWAN. Menopause. 2021;28(5):511-520.
2. Sheng Y, et al. Review of menopausal palpitations measures. Womens Midlife Health. 2021;7(1):5.
3. Van Gelder IC, et al. 2024 ESC Guidelines for the management of atrial fibrillation. Eur Heart J. 2024;45(36):3314-3414.
4. El Khoudary SR, et al. Menopause transition and cardiovascular disease risk: AHA scientific statement. Circulation. 2020;142(25):e506-e532.

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