Perimenopause Heart Palpitations: Causes, When to Worry, and Management Strategies
Why heart palpitations are common in perimenopause, how to distinguish benign from serious causes, known triggers, and management strategies including HRT.
Why Palpitations Are So Common in Perimenopause
Heart palpitations, a sensation of the heart beating rapidly, irregularly, or more forcefully than usual, are reported by a significant proportion of perimenopausal women. They are often alarming but are usually benign. The primary driver is estrogen's regulatory role in the autonomic nervous system, which controls heart rate and vascular tone. Estrogen has a stabilising effect on the cardiac autonomic nervous system, and as estrogen becomes erratic during perimenopause, the heart's rhythm regulation becomes less consistent. Hot flashes and night sweats also directly trigger palpitations, because the same vasomotor mechanism that causes flushing also causes a surge in heart rate. Many women notice palpitations occurring at the same time as, or immediately after, a hot flash.
Benign Palpitations vs Concerning Symptoms
Most perimenopausal palpitations are benign and represent ectopic beats (extra heartbeats that feel like a flutter, thud, or skipped beat) or brief episodes of sinus tachycardia (a rapid heart rate that returns to normal quickly). These are uncomfortable but not dangerous. Symptoms that warrant prompt medical assessment include palpitations accompanied by chest pain, significant breathlessness, dizziness, fainting, or pre-syncope (a feeling that you are about to faint). Palpitations that are sustained for more than a few minutes, that begin very suddenly and feel like a very rapid regular beating (more than 150 beats per minute), or that occur at rest without an obvious trigger should be investigated. A prior history of heart disease or thyroid problems also lowers the threshold for seeking assessment.
When to Get an ECG
An electrocardiogram (ECG) is the standard initial investigation for palpitations. It records the electrical activity of the heart and can identify arrhythmias including atrial fibrillation, supraventricular tachycardia, and ectopic beats. A standard 12-lead ECG captures a snapshot in time, which is useful but can miss intermittent arrhythmias if they are not occurring during the recording. For palpitations that happen frequently, a Holter monitor, a wearable ECG device worn for 24 to 48 hours or longer, significantly increases the chance of capturing the arrhythmia. Wearable smartwatch ECG features (available on some Apple Watch and Fitbit models) can also capture irregular heart rhythm data between appointments, which is worth sharing with a GP. Any women with new, frequent, or unusual palpitations should have a baseline ECG.
Known Triggers and How to Reduce Them
Several lifestyle factors lower the threshold for palpitations in perimenopausal women. Caffeine is a stimulant that increases heart rate and ectopic beat frequency. Alcohol, despite its sedating effect, is a common trigger for palpitations, particularly in the hours after drinking as blood alcohol levels fall. Many women notice that even small amounts of wine trigger palpitations during perimenopause when this was not previously the case. Stress activates the sympathetic nervous system, directly increasing heart rate and ectopic activity. Hot flashes, particularly nocturnal ones, routinely trigger palpitations. Dehydration, missed meals (leading to low blood sugar), and thyroid dysfunction can all cause or worsen palpitations. Identifying your personal triggers through observation and reducing them where possible can meaningfully reduce frequency.
Management Strategies Beyond Trigger Avoidance
For women whose palpitations are clearly benign on investigation, management focuses on reducing their frequency and distress. Vagal manoeuvres (techniques that stimulate the vagus nerve to slow heart rate) can abort some episodes. These include the Valsalva manoeuvre (bearing down as if passing a stool), splashing cold water on the face, or applying a cold pack briefly to the face. Slow, diaphragmatic breathing activates the parasympathetic nervous system and can reduce both the frequency and distress of palpitations. Regular aerobic exercise improves autonomic regulation over time, though very intense exercise can trigger palpitations in susceptible individuals and should be approached gradually. Magnesium deficiency is associated with increased ectopic beats; ensuring dietary adequacy through green vegetables, nuts, and seeds is worthwhile.
HRT's Effect on Palpitations
HRT can reduce perimenopausal palpitations through two mechanisms. First, by stabilising estrogen levels, it reduces the vasomotor instability that triggers hot-flash-associated palpitations. Second, systemic estrogen has a direct calming effect on the cardiac autonomic nervous system. Many women report a significant reduction in palpitation frequency and severity after starting HRT, particularly if their palpitations were clearly associated with hot flashes. HRT is not a treatment for arrhythmias, but for vasomotor-driven palpitations in otherwise healthy women, it addresses the root cause. Women who have a diagnosed arrhythmia should discuss HRT with both their menopause specialist and cardiologist to ensure it is appropriate for their specific situation.
Tracking Palpitations and Seeking Help Confidently
Palpitations are one of the symptoms that women most commonly downplay or feel embarrassed to mention to a GP. Bringing concrete information about frequency, duration, associated symptoms, and potential triggers makes the consultation more productive. Logging palpitation episodes alongside hot flashes, sleep quality, caffeine intake, and stress levels in an app like PeriPlan helps you see patterns and communicate them clearly. If you are dismissed when you raise palpitations and feel that your concerns are not being taken seriously, you are entitled to ask for an ECG and to seek a second opinion. Most perimenopausal palpitations are benign, but establishing that they are benign through investigation is entirely reasonable.
Related reading
Get your personalized daily plan
Track symptoms, match workouts to your day type, and build a routine that adapts with you through every phase of perimenopause.