Perimenopause vs POTS: How to Tell These Two Conditions Apart

When Your Heart Races and the Room Spins

Heart palpitations, lightheadedness when you stand up, persistent fatigue that does not respond to rest, heat intolerance, brain fog. If you are in your 40s or early 50s, these symptoms might reasonably be attributed to perimenopause. And they might be. But they are also characteristic features of POTS, postural orthostatic tachycardia syndrome, a form of dysautonomia that affects the autonomic nervous system's ability to regulate heart rate and blood flow.

Both conditions are far more common in women than men, and POTS most frequently develops or worsens in women during their reproductive years, with another wave of cases emerging or intensifying around the perimenopausal transition. The overlap is real and clinically significant, and many women with POTS go undiagnosed for years because their symptoms are attributed entirely to hormones.

What Perimenopause Does to the Cardiovascular System

Estrogen has significant effects on the cardiovascular system, including on blood vessel tone, heart rate regulation, and autonomic nervous system function. As estrogen levels fluctuate and decline during perimenopause, these effects become less stable.

Heart palpitations are one of the most commonly reported perimenopausal symptoms. They often feel like a pounding, fluttering, or skipping sensation, and may occur at rest, during hot flashes, or with minimal exertion. They are generally benign in women without underlying cardiac conditions, though they warrant evaluation if they are frequent, prolonged, or accompanied by chest pain or breathlessness.

Lightheadedness and a sense of unsteadiness can also occur during perimenopause, particularly during hot flashes when blood vessels dilate rapidly. Fatigue, heat intolerance, and brain fog complete a picture that can look very similar to POTS on the surface.

What POTS Is and How It Presents

POTS is a syndrome characterized by an abnormal increase in heart rate when moving from lying or sitting to standing. The diagnostic criterion is a heart rate increase of at least 30 beats per minute within 10 minutes of standing, in the absence of a drop in blood pressure that would explain it, and in the presence of associated symptoms.

Those symptoms typically include palpitations when upright, lightheadedness or near-fainting when standing, brain fog, fatigue, nausea, and exercise intolerance. Many people with POTS find that their symptoms worsen significantly in warm environments, after meals, with prolonged standing, and with physical exertion. Heat intolerance is a distinctive and often prominent feature.

POTS affects the autonomic nervous system, which regulates the involuntary functions of the body including heart rate, blood pressure, digestion, and sweating. In POTS, the normal cardiovascular compensation to standing (blood vessels in the lower body constricting and heart rate adjusting briefly) does not work properly, causing blood to pool in the lower body and reducing the amount reaching the brain.

The Key Differences to Look For

The most important distinguishing feature of POTS is the postural nature of the symptoms. Palpitations, dizziness, and fatigue in POTS are consistently worse when upright, particularly after standing from lying or sitting. Lying down tends to bring rapid relief. This positional pattern is characteristic of POTS and less typical of perimenopause, where symptoms like palpitations may occur at any time and are more likely tied to hot flashes or anxiety.

In perimenopause, hot flashes are a defining symptom that POTS does not produce. If heat surges involving sweating and flushing are part of your experience, that points toward perimenopause as at least one component of the picture.

POTS is also frequently associated with other features of dysautonomia, including significant exercise intolerance where even light exertion produces disproportionate symptoms, gastrointestinal symptoms, and in some cases a tendency toward fainting. These features, particularly if they began well before the perimenopausal years, suggest POTS deserves attention as a separate diagnosis.

POTS can begin or worsen during perimenopause due to estrogen's effects on autonomic regulation and blood volume. This means the two conditions can coexist and interact.

How Each Condition Is Diagnosed

Perimenopause is evaluated through symptom history, menstrual pattern, and sometimes hormone levels, though FSH and estradiol fluctuate and are not always definitive in the early transition.

POTS is evaluated through a tilt table test, where heart rate and blood pressure are monitored as you are moved from horizontal to vertical positions, or through a poor man's tilt table test, where heart rate is taken lying down and then repeated at intervals after standing. A consistent increase of 30 or more beats per minute on standing, accompanied by typical symptoms, meets diagnostic criteria.

POTS is frequently undiagnosed or diagnosed late, often after years of symptoms being attributed to anxiety, deconditioning, or in midlife women, perimenopause. If you have prominent positional palpitations and dizziness, or if exercise intolerance is a major feature, raising POTS specifically with your doctor is worth doing. Many GPs are not familiar with it, so you may need to request a referral to a cardiologist, neurologist, or autonomic specialist.

Can You Have Both at the Same Time?

Yes, and this is not uncommon. The hormonal changes of perimenopause affect autonomic nervous system function and blood volume regulation. For women who have subclinical autonomic instability, the perimenopausal transition can push them into symptomatic POTS territory.

Some women who are diagnosed with POTS during midlife may have had milder, unnoticed autonomic irregularities for years that became more symptomatic as estrogen declined. Others may have had clear POTS symptoms earlier in life that were never properly assessed.

When both conditions are present, addressing the hormonal component, including considering HRT where appropriate, may significantly reduce the POTS symptom burden. Estrogen supports blood volume and vascular tone, and restoring it can improve the autonomic stability that POTS disrupts. This is an emerging area of clinical interest, and individualized assessment is essential.

Tracking Symptoms to Clarify the Pattern

The pattern of your symptoms over time is one of the most useful pieces of information for distinguishing between these conditions. Key questions include: Do your palpitations and dizziness get reliably better when you lie down? Are they consistently worse when you first stand up? Do they worsen in heat or after meals? Is exercise particularly difficult even at low intensity?

PeriPlan lets you log symptoms and track patterns over time. Noting the timing, position, and context of your palpitations, dizziness, and fatigue can reveal whether they follow a postural pattern characteristic of POTS or a more varied and cycle-related pattern more typical of perimenopause.

This information is genuinely useful in a clinical context. Arriving at your appointment with several weeks of symptom logs that show when and how your symptoms occur gives your doctor more to work with than a general description.

What to Do If You Think POTS Might Be Involved

If your symptoms include prominent palpitations and dizziness that are clearly worse when standing, heat intolerance that is extreme, significant exercise intolerance, or if these features have been present since well before perimenopause, ask your doctor specifically about POTS evaluation.

Do not accept a response that attributes everything to perimenopause without considering other possibilities. Both conditions deserve assessment. Effective management exists for POTS, including increased salt and fluid intake, compression garments, graded exercise therapy, and in some cases medication.

You deserve an accurate diagnosis and a care plan that addresses what is actually going on.

This content is for informational purposes only and does not replace medical advice. Always consult a qualified healthcare provider about your specific situation.