menopause and irregular heartbeat

You are lying in bed and your heart does something. A flip, a thud, a run of beats too fast, a pause where a beat should have been. It lasts a few seconds and then it is gone, and you lie there wide awake wondering whether you should be worried.

Palpitations are one of the most common and least discussed menopause symptoms. They are also the one where we are going to be most careful, because the heart is not the place for reassuring generalities.

Call for help now if any of these are happening

Get emergency help immediately if palpitations come with:

• chest pain, pressure, tightness or a squeezing feeling
• pain or discomfort in one or both arms, the jaw, neck, back or between the shoulder blades
• shortness of breath
• nausea, vomiting, or sudden cold sweat
• fainting, or nearly fainting
• sudden overwhelming fatigue or a sense that something is badly wrong

Women's heart attack symptoms are frequently not the ones in the films. Crushing central chest pain is the classic picture. Women more often present with jaw, neck, back or arm pain, breathlessness, nausea, indigestion-like discomfort and profound fatigue, sometimes with no chest pain at all. Those symptoms are easy to attribute to stress, to indigestion, or to menopause.

If something feels seriously wrong, get it checked. Being sent home reassured is a good outcome, not an embarrassment.

How common are palpitations in menopause?

Much more common than most women are led to expect. Research indicates up to nearly 47 percent of women experience an irregular heartbeat through menopause.

Nearly half. And yet almost nobody is warned about it, which is why the first one is so frightening. Researchers have found exactly that: women do not expect palpitations as a menopause symptom and are alarmed when they occur. The same work found that women who report distress about palpitations have worse insomnia, depression and perceived stress.

That connection runs both ways. Frightening symptoms disturb sleep, and poor sleep and stress make palpitations more frequent.

Why does menopause cause them?

The decline in estrogen through perimenopause and menopause is associated with a rise in resting heart rate and more frequent palpitations and benign arrhythmias, and these can increase as estrogen reaches its lowest levels.

Estrogen helps keep the inner layer of the artery wall flexible and has effects throughout the cardiovascular system, so a decline can contribute. The honest position is that the mechanism is not fully worked out.

Janet S. Carpenter, PhD, RN, associate dean of research at Indiana University School of Nursing, put it plainly in Everyday Health: "It's not clear why they happen, we don't know if they're associated with EKG changes, and we don't know if they increase women's risk for cardiovascular disease."

Carpenter also named the reason so little is known: "the fact that there's been a historic bias against women in cardiology. Women's symptoms often aren't believed or listened to in the same way that men's symptoms are."

That is worth carrying into any appointment you have about this. Not as cynicism, but so that you describe your symptoms concretely and ask for the test rather than accepting reassurance you did not ask for.

Are palpitations just part of a hot flash?

Sometimes, and not always, and it appears to be a symptom in its own right.

Some women get palpitations as part of a flash, in which case they arrive with the heat and pass with it. But not every woman who gets palpitations gets them during flashes, which suggests it is separate rather than a component. Menopause and heart palpitations covers this in more detail.

What else causes an irregular heartbeat?

Worth working through, because several are simple and correctable.

• Thyroid. An overactive thyroid is a classic cause, and so is too high a dose of medication for an underactive one. Straightforward blood test, and it should be near the top of any list.
• Caffeine, alcohol and nicotine. All three, and alcohol in particular, which is well known for producing palpitations in the hours after drinking.
• Anemia. Common in perimenopause with heavy bleeding. The heart works harder when blood carries less oxygen. This is why palpitations and irregular periods so often turn up together.
• Medications. Decongestants containing pseudoephedrine, asthma inhalers, some thyroid and cold medicines.
• Dehydration, low blood sugar or low blood pressure.
• Anxiety and panic. Real and common, and worth taking seriously rather than dismissing.
• Genuine arrhythmias such as supraventricular tachycardia or atrial fibrillation.

Learn to check your own pulse, and check whether it is regular

This takes a minute to learn and it is the most practically useful thing on this page.

Atrial fibrillation is a specific arrhythmia that becomes more common with age, it substantially raises the risk of stroke, and it is very treatable once identified. Many people have it without knowing, because episodes come and go.

The thing that distinguishes it is not speed. It is rhythm. A normal pulse is regular even when fast. An atrial fibrillation pulse is irregularly irregular, with no pattern to it at all.

So during an episode, put two fingers on the inside of your wrist below the thumb and feel for 30 seconds. Is it evenly spaced, or completely disorganized? Note what you find. Many smartwatches and phones now detect irregular rhythm too, and a recording from one is genuinely useful to a doctor.

If your pulse is irregularly irregular during episodes, say exactly that at your appointment.

What helps?

Work out your own triggers

Keep a short note for two weeks: when it happened, what you had eaten or drunk, how you had slept, where you were in your cycle, and what you were doing. Patterns show up quickly. Alcohol the night before and poor sleep are the two most commonly identified.

Test caffeine properly rather than guessing

Cut it for two weeks and reintroduce. Sensitivity varies enormously between people, and there is no reason to give up coffee permanently if it turns out not to be your trigger.

Look at alcohol honestly

The link between alcohol and palpitations, including atrial fibrillation episodes, is well recognized. If yours cluster the day after a drink, that is your answer.

Slow breathing when it starts

In through the nose for four, out slowly for six, for a couple of minutes. This raises vagal tone and can settle a benign palpitation, and it also breaks the fear loop, which is doing half the damage.

Sleep and stress

Both worsen palpitations directly, and both are harder in perimenopause. If flashes are wrecking your nights, treating those is treating this. Menopause sleep problems and ways to reduce stress.

Stay hydrated and eat regularly

Both dehydration and low blood sugar provoke palpitations, and both are easy to fall into on a busy day.

Look after your heart properly, because the risk changes now

This is the part that outlasts the palpitations. Cardiovascular risk rises for women after menopause, and heart disease is the leading cause of death in women. Regular aerobic exercise, strength work, plenty of vegetables, fish, nuts and whole grains, and knowing your blood pressure, cholesterol and blood sugar numbers. More on supporting heart health for life.

What should you ask for at the appointment?

Do not accept a reassurance that was given without a test. Reasonable things to ask for:

• an ECG, though note it only shows what your heart is doing at that moment
• a Holter monitor or event recorder if episodes are frequent, since these record over 24 hours or longer and are far more likely to catch one
• thyroid function tests
• a full blood count and ferritin, for anemia
• blood pressure, cholesterol and blood sugar

Bring your diary and any smartwatch recording. Say how often, how long, whether the rhythm is regular or chaotic, and what else comes with it.

The short version

Almost half of women experience palpitations through menopause, and almost none are warned, which is why the first one is so alarming. Falling estrogen is associated with a higher resting heart rate and more frequent benign arrhythmias, though the mechanism is not fully understood, partly because women's cardiac symptoms have historically been under-researched. Get thyroid, anemia and alcohol ruled out. Learn to feel whether your pulse is regular or chaotic during an episode, since irregularly irregular points at atrial fibrillation, which is treatable and raises stroke risk. And know that women's heart attack symptoms are often jaw, back or arm pain, breathlessness, nausea and exhaustion rather than chest pain, so get anything that feels seriously wrong checked immediately.

Related perimenopause and menopause symptoms

• Menopause and heart palpitations
• Menopause and shortness of breath
• Menopause and anxiety
• Menopause and blood pressure

Frequently Asked Questions

Are heart palpitations normal in menopause?

They are common. Research indicates up to nearly 47 percent of women experience an irregular heartbeat through menopause. Falling estrogen is associated with a higher resting heart rate and more frequent palpitations and benign arrhythmias. Common does not mean it should go unchecked, particularly the first time.

When are palpitations an emergency?

Get emergency help immediately if they come with chest pain or pressure, pain in the arms, jaw, neck or back, shortness of breath, nausea or cold sweat, fainting, or sudden overwhelming fatigue. Women's heart attack symptoms are frequently not the classic crushing chest pain and are easily mistaken for indigestion, stress or menopause.

How do I know if it is atrial fibrillation?

The distinguishing feature is rhythm, not speed. A normal pulse is evenly spaced even when fast, while atrial fibrillation is irregularly irregular with no pattern at all. During an episode, feel your pulse at the inside of your wrist for 30 seconds and note whether it is even or chaotic. Many smartwatches also detect irregular rhythm, and those recordings are useful to a doctor.

What causes palpitations besides menopause?

An overactive thyroid, or too high a dose of medication for an underactive one. Anemia, which is common with heavy perimenopausal bleeding. Caffeine, alcohol and nicotine. Decongestants containing pseudoephedrine and some asthma inhalers. Dehydration, low blood sugar and low blood pressure. Anxiety and panic. And genuine arrhythmias such as supraventricular tachycardia or atrial fibrillation.

Are palpitations part of a hot flash?

Sometimes but not always. Some women get palpitations as part of a flash, arriving with the heat and passing with it. Others get palpitations without flashes, which suggests it is a symptom in its own right rather than only a component of vasomotor symptoms.

What tests should I ask for?

An ECG, keeping in mind it only captures that moment. A Holter monitor or event recorder if episodes are frequent, since these record over 24 hours or longer and are far likelier to catch one. Thyroid function tests. A full blood count and ferritin for anemia. And blood pressure, cholesterol and blood sugar, since cardiovascular risk rises for women after menopause.