Perimenopause, Panic Attacks, and Palpitations: What Is Actually Happening
Panic attacks and heart palpitations are common in perimenopause but often alarming. Learn why they happen, how to tell them apart, and what treatment options work.
Why Perimenopause Triggers Panic Attacks
Panic attacks, sudden episodes of intense fear accompanied by physical symptoms like racing heart, breathlessness, dizziness, chest tightness, and a sense of unreality or impending doom, are significantly more common during perimenopause than at other life stages. The neurobiological reasons overlap with the broader anxiety vulnerability of perimenopause: falling estrogen reduces GABA activity, lowering the nervous system's threshold for triggering the alarm response. Hot flashes, which activate the same sympathetic nervous system pathways as panic, can blur into or directly trigger panic episodes. Sleep deprivation, extremely common during perimenopause, sensitises the nervous system and lowers the stress threshold further. For women with no prior history of panic disorder, their first panic attack in perimenopause can be genuinely bewildering and frightening.
Palpitations: Cardiac or Anxiety?
Heart palpitations, sensations of the heart beating rapidly, irregularly, or forcefully, are one of the more alarming and least discussed symptoms of perimenopause. They can be hormonal in origin, triggered directly by estrogen fluctuation acting on the cardiovascular system, or they can be a manifestation of anxiety and panic. Distinguishing between the two requires medical assessment because, while most perimenopausal palpitations are benign, some arrhythmias do require treatment. Palpitations that are accompanied by chest pain, significant shortness of breath, or that cause you to faint or feel faint require urgent assessment. Palpitations that occur in the context of heat, stress, or hormonal cycles and resolve quickly without other cardiac symptoms are more likely to be hormonal or anxiety-related.
How to Distinguish a Hot Flash from a Panic Attack
Hot flashes and panic attacks share several features: sudden onset, a surge of internal heat or adrenaline, a rapid heart rate, and a feeling of needing to escape. The differences are useful to notice. Hot flashes typically start with a wave of heat, particularly in the chest and face, and are followed by sweating and then chilling. Panic attacks typically start with a sense of threat or fear (even if the source is not identifiable), followed by the physical symptoms of the fight-or-flight response, and are accompanied by catastrophic thinking about the physical sensations. In practice, many women experience both simultaneously, as a hot flash triggers the nervous system enough to tip into panic. Knowing that you are experiencing a hot flash, not a cardiac event, can reduce the secondary fear that escalates a hot flash into a full panic attack.
Acute Management Strategies
During a panic attack, the goal is to activate the parasympathetic nervous system and interrupt the catastrophic appraisal cycle. Slow, extended exhalation breathing (inhale for 4 counts, hold for 1, exhale for 6 to 8 counts) is the most evidence-backed acute technique and can shorten a panic episode significantly. Grounding strategies, such as naming 5 things you can see, 4 you can touch, 3 you can hear, 2 you can smell, and 1 you can taste, interrupt the loop of internal focus that sustains panic. Reminding yourself that panic, however frightening, is not dangerous and will pass within minutes to half an hour is also helpful, though harder to apply in the heat of the moment. These techniques become more effective with practice.
Tracking Patterns
Panic attacks during perimenopause often follow identifiable patterns that only become visible over time. They may cluster in the week before your period (if cycles are still occurring), after several nights of poor sleep, during periods of high work or family stress, or in environments that are hot or over-stimulating. Using PeriPlan to log your symptoms daily, including panic episodes and palpitations alongside other physical and hormonal symptoms, helps you identify these patterns. This kind of data is also useful for your GP, who can see whether the presentations are cycle-linked and whether HRT or other interventions might be appropriate.
When to Seek Medical Assessment
See your GP if panic attacks are frequent (more than once a week), are significantly limiting your activities, or if you are uncertain whether what you are experiencing is panic or a cardiac event. Your GP can arrange an ECG to check your heart rhythm and rule out arrhythmias, check thyroid function (which can cause palpitations and anxiety if disrupted), and assess whether you have panic disorder requiring targeted treatment. If you have any palpitations accompanied by chest pain, fainting, or significant breathlessness, seek urgent assessment rather than a routine appointment. Do not assume it is anxiety until cardiac causes have been excluded.
Treatment Options
Treatment for perimenopausal panic attacks typically involves a combination of approaches. HRT can reduce panic frequency and severity in women whose panic is clearly hormonally driven, particularly when it is cycle-linked or accompanied by other perimenopausal symptoms. Cognitive behavioural therapy for panic disorder has one of the best evidence bases in all of mental health treatment and involves learning to interrupt the catastrophic appraisal cycle that sustains panic. SSRIs and SNRIs can reduce panic frequency with regular use and may be considered when panic is frequent and impairing. Beta-blockers can be used situationally for palpitations and are sometimes prescribed to manage acute episodes in specific high-anxiety situations.
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