Perimenopause vs POTS: Why Dizziness, Palpitations, and Fatigue Get Confused
Perimenopause and POTS both cause heart palpitations, dizziness, and fatigue. Learn the key differences and when to ask for a tilt table test or hormone check.
What Is POTS and Why Does It Get Confused with Perimenopause?
Postural orthostatic tachycardia syndrome, known as POTS, is a condition affecting the autonomic nervous system in which standing up from a lying or seated position causes a rapid increase in heart rate, often accompanied by dizziness, lightheadedness, palpitations, and sometimes fainting. POTS affects women more often than men and can emerge or worsen in the fourth and fifth decades of life, which is exactly when perimenopause begins for many women. Because both conditions produce heart palpitations, fatigue, brain fog, and difficulty tolerating heat, they are frequently confused. The two are distinct in cause and mechanism, but the symptom overlap is substantial enough that misattribution is common.
Symptoms More Specific to Perimenopause
The hallmarks of perimenopause are tied to reproductive hormonal change. Irregular menstrual cycles, hot flushes, night sweats, vaginal dryness, and changes in libido are not features of POTS. Breast tenderness, particularly in the days before a period, and mood changes that track alongside the menstrual cycle point toward hormonal fluctuation rather than autonomic dysfunction. Weight changes, particularly around the abdomen, and the specific pattern of disturbed sleep associated with night sweats are also characteristic of perimenopause. Tracking how symptoms relate to the menstrual cycle over several months provides meaningful evidence that hormonal change is driving the experience.
Symptoms More Specific to POTS
The defining feature of POTS is a rapid rise in heart rate, typically more than 30 beats per minute, when moving from lying to standing, measured over a sustained period. This is accompanied by symptoms that reliably worsen on standing and improve on lying down. Lightheadedness or near-fainting on standing, a significant worsening of all symptoms when upright, and temporary relief when the person lies flat are characteristic of POTS. Some people with POTS also experience visible venous pooling in the legs when standing, cold and discoloured hands and feet, and gut symptoms including nausea and bloating. These positional patterns are not typical of perimenopause.
How Diagnosis Differs Between the Two
Perimenopause is assessed through symptom history and menstrual pattern, with blood tests sometimes used to check hormone levels, although these can fluctuate significantly from day to day during this phase. POTS is diagnosed through a tilt table test or an active stand test, in which heart rate and blood pressure are measured lying down and then at intervals after standing. A sustained heart rate increase of 30 beats per minute or more without a corresponding drop in blood pressure, over the first ten minutes of standing, meets the diagnostic criteria in adults. If a woman's symptoms consistently worsen on standing and improve lying down, requesting a tilt table test or referral to a cardiologist or neurologist is appropriate.
Can Perimenopause Trigger or Worsen POTS?
Some evidence and clinical observation suggest that hormonal fluctuations, including those occurring during perimenopause, can trigger or worsen autonomic instability in women who have underlying susceptibility to POTS. Estrogen affects blood vessel tone and blood volume regulation, and falling or erratic estrogen levels may reduce the efficiency of these mechanisms. Some women who were previously managing mild autonomic symptoms find that perimenopause causes a significant worsening. For these women, treating the hormonal component through HRT or lifestyle measures may provide some indirect benefit to their autonomic symptoms alongside any POTS-specific management.
Practical Steps When You Are Unsure
If you are experiencing palpitations, dizziness, or significant fatigue and are uncertain whether perimenopause, POTS, or another condition is responsible, start by logging symptoms in as much detail as possible. Note whether symptoms are consistently worse when you stand up, whether lying down brings rapid relief, and how symptoms relate to your menstrual cycle. Tracking over time in an app like PeriPlan gives you a concrete record to bring to a GP appointment. Ask your GP specifically about both perimenopause and autonomic function, and request appropriate testing for each. You do not need to choose between investigations. Both a hormone assessment and a simple standing heart rate measurement can be done in a primary care setting before any specialist referral.
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