Heart Palpitations in Perimenopause: When It's Hormones and When to Get Checked

She is sitting on the couch in the evening when her heart suddenly flips, skips, or starts to race for no reason. It lasts a few seconds or a few minutes, and then it is gone. It is frightening, and it is easy to wonder whether something is seriously wrong.

Palpitations are among the most common surprises of perimenopause, and also among the symptoms most likely to be brushed off, so it is worth being clear about both sides.

How common it is

A scoping review of palpitations in the menopause transition found that up to 42% of perimenopausal women and up to 54% of postmenopausal women report them. The same review noted that although many women aged 40 to 59 believed their palpitations needed treatment, a systematic review found no top-tier evidence for how to manage them.

Menopause palpitations are also associated with worse insomnia, worse depressive symptoms, and poorer quality of life, so they are not a trivial symptom even when the heart is structurally normal.

Why it happens

The likely driver is the drop and fluctuation of estrogen. Estrogen influences the autonomic nervous system, which controls heart rate and rhythm, but the exact mechanism in women is not settled. Several things commonly make it worse:

• Hot flashes and night sweats, which often come with a racing heart.
• Poor sleep.
• Caffeine and alcohol, which many women find they tolerate less well in perimenopause.
• Blood sugar dips, especially after skipped meals or high-sugar meals (the Sugar Sherry pattern).
• Anxiety and a stuck-on stress response, covered in Anxious Annie and Wired Wendy.

Get it checked, even if you think it's hormonal

Menopause palpitations are a diagnosis of exclusion. The scoping review also points out that there is a documented history of women's cardiac symptoms being trivialized, which leads to missed or delayed diagnoses. Perimenopause is also when cholesterol and blood pressure start to shift and atrial fibrillation becomes more likely with age. So I would want these checked:

• An ECG at minimum.
• A rhythm monitor if the palpitations are intermittent. A one- or two-week patch monitor is more likely to catch an episode than a single ECG or a 24-hour monitor.
• Thyroid tests. An overactive thyroid causes palpitations, and thyroid problems become more common in these years.
• Blood count and ferritin. Anemia and low iron both cause a racing heart.
• Electrolytes including potassium and magnesium, and blood sugar.
• Blood pressure and a lipid panel. You are there anyway, and this is the decade these start to move.

If everything comes back normal and the monitor shows only harmless extra beats, you can attribute it to hormones with much more confidence.

When to go now

Seek urgent care for palpitations with any of these:

• Chest pain or pressure
• Fainting or near-fainting
• Shortness of breath
• Palpitations that start during exertion
• A fast heartbeat that does not settle after several minutes
• A family history of sudden cardiac death or cardiomyopathy

What helps

• Track your triggers. Note the time of day, what you had to eat and drink, how you slept, and whether a hot flash came with it. Alcohol and caffeine are the most common avoidable triggers.
• Keep blood sugar steady. Eat regular meals with protein if episodes cluster after long gaps or sugary meals.
• Use slow breathing. A long, slow exhale can settle the rhythm and calm the stress response, and there is more on this in the nervous system article.
• Correct deficiencies. If ferritin or magnesium is low, replace it. Professional-grade options are in my Fullscript dispensary. If your levels are normal, extra magnesium is not proven to help.
• Know what the evidence says about treatment. A systematic review of treatments for menopausal palpitations concluded that no therapy can be fully recommended. Estradiol had some positive evidence and can be considered with caution, and the review did not find enough support to recommend other drugs or supplements. Treat it as a reason to be careful, not to give up.

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Most perimenopausal palpitations are not dangerous. But "most" is not the same as "yours," and a short workup is what lets you stop worrying about it.

References

1. “Correlates of palpitations during menopause: A scoping review.” Menopause / PMC. View source
2. Sheng Y, Carpenter JS, Elomba CD, Alwine JS, Yue M, Chen CX, Tisdale JE. “Effect of menopausal symptom treatment options on palpitations: a systematic review.” Climacteric, 2022;25(2):128-140. View source
3. Cleveland Clinic. “29 Perimenopause Symptoms You May Not Know About.” July 2025. View source