Carpenter JS, Sheng Y, Elomba C et al. A systematic review of palpitations prevalence by menopausal status. Current Obstetrics and Gynecology Reports, 2021. https://link.springer.com/article/10.1007/s13669-020-00302-z
Key takeaways
- Research from the large SWAN study, which followed over 3,000 women through the menopause transition, found that palpitations were not associated with measurable cardiovascular disease in the arteries or blood vessels. For most women, menopause-related palpitations are uncomfortable and frightening, but not a sign something is wrong with the heart itself.
- The cause is hormonal: oestrogen acts as a natural stabiliser of the autonomic nervous system, and its fluctuation during perimenopause makes the heart more sensitive and reactive. This is a physiological mechanism, not anxiety, and not imagination.
- Most menopause-related palpitations improve as hormonal fluctuation settles in later postmenopause. In the meantime, there are effective approaches, including HRT, lifestyle changes, and CBT, that reduce how frequently and intensely they occur.
First: what the research actually shows
The experience of noticing your heart doing something unexpected is alarming. Before explaining what causes this or how to manage it, the most useful thing is the finding that most directly addresses the fear.
The SWAN study, published in Menopause (2023), followed 3,276 women through the menopause transition and identified their palpitation patterns over time. The most important finding: changes in palpitations over time were not linked to early signs of heart and blood vessel disease. Women who experienced frequent palpitations during perimenopause and early postmenopause did not show greater signs of underlying heart disease than women who did not.
This is not a reason to ignore symptoms that concern you. But it is a significant reassurance for the majority of women whose palpitations are menopause-related: feeling your heart flutter or race during the perimenopause transition is not evidence that something is structurally wrong with your heart.
How common are they?
Very. You are not unusual.
A systematic review published in Current Obstetrics and Gynecology Reports (2021) estimated that palpitations affect between 20 and 40% of perimenopausal women, and between 15 and 54% of postmenopausal women. A large study published in npj Women's Health (2025) identified heart palpitations as one of eight symptoms significantly associated with the perimenopause transition.
“Despite this prevalence, palpitations receive far less clinical attention than hot flushes and sleep disruption. Many women experience them for months without being told they are a recognised menopause symptom. If that has been your experience, the lack of information is not evidence that your symptoms were unusual or unimportant.”
Why menopause causes heart palpitations
The mechanism begins with oestrogen's role in the autonomic nervous system (ANS): the part of the nervous system that regulates involuntary functions including heart rate, blood pressure, and the balance between "fight or flight" (sympathetic) and "rest and digest" (parasympathetic) activity.
Oestrogen can help calm the body’s stress response by reducing activity in the sympathetic nervous system (the system responsible for the “fight or flight” response) and supporting the parasympathetic nervous system, which helps the body relax and recover . A 2025 review in Autonomic Neuroscience confirmed that when oestrogen levels fall, the stabilising effect of oestrogen on the cardiovascular and nervous systems is reduced. This can make them more sensitive and more easily activated. As a result, things that previously caused little or no noticeable reaction may sometimes trigger a stronger response, such as a racing or pounding heartbeat.
A 2024 review in the Journal of Physiology confirmed that declining oestrogen triggers autonomic nervous system dysfunction, shifting the balance toward sympathetic dominance increased "fight or flight.") This mechanism underpins not only palpitations but also the broader cardiovascular and cognitive changes associated with the menopause transition.
An important distinction: in perimenopause, it is not simply "low oestrogen" that drives palpitations most intensely. It is the erratic fluctuation of oestrogen, dramatic swings up and down over days and weeks, that is most destabilising to the ANS. This explains why palpitations often feel worst in the middle of perimenopause, before hormone levels have settled, and why the SWAN study found that palpitation frequency diminishes in later postmenopause as fluctuation reduces.
When to take palpitations seriously
Most menopause-related palpitations are not dangerous. But some symptoms always warrant prompt medical attention, regardless of menopausal status.
Seek same-day medical assessment if you experience:
- Palpitations accompanied by chest pain or chest tightness
- Palpitations with shortness of breath that comes on suddenly
- Fainting or near-fainting (feeling like you are about to lose consciousness)
- A sustained rapid or irregular heartbeat lasting more than a few minutes that does not settle
- Palpitations alongside dizziness or lightheadedness that does not pass quickly
- New palpitations in a woman with a known heart condition
A note on atrial fibrillation (AF)
Atrial fibrillation is a type of irregular heartbeat that is more common in older adults, including postmenopausal women. Unlike the brief flutters, skipped beats, or isolated racing sensations most women experience with menopause-related palpitations, AF typically produces a sustained, chaotic, rapid heartbeat, often accompanied by breathlessness or lightheadedness. If you think you may be experiencing this pattern rather than brief episodic palpitations, seek medical assessment promptly.
If you are in any doubt about your symptoms, contact your GP or call NHS 111. The reassurance in this article applies to typical menopause-related palpitations, not to symptoms that feel urgent or different from what is described here.
Common triggers: why some things make palpitations more likely
With the ANS already sensitised by oestrogen fluctuation, certain additional stimuli can lower the threshold for a palpitation episode. Understanding why each trigger matters during menopause makes them easier to address.
Hot flushes
Palpitations frequently co-occur with vasomotor symptoms. The hypothalamic activation that triggers a hot flush also activates the sympathetic nervous system, producing a brief surge in heart rate that can feel like a palpitation. A scoping review published in Women's Health (2022)identified hot flushes as a significant correlate of palpitations in peri- and postmenopausal women. Treating vasomotor symptoms often reduces palpitation frequency alongside.
Caffeine and alcohol
The stimulant effect of caffeine becomes more pronounced in a sensitised ANS. Many women find that the amount of caffeine that had no noticeable effect before perimenopause now reliably triggers palpitations. Alcohol disrupts sleep architecture and directly affects heart rhythm, making it a relevant trigger particularly for nighttime palpitations.
Poor sleep and night sweats
Sleep disruption activates the sympathetic nervous system. Waking repeatedly from night sweats produces a surge of autonomic activation that the heart reflects. This is covered in more detail in the nighttime section below.
Anxiety and stress
The relationship between anxiety and palpitations is circular. Palpitations trigger anxiety; anxiety lowers the threshold for palpitations. This does not mean the palpitations are caused by anxiety. The hormonal mechanism is real and physiological. But the anxiety-palpitation loop is real too, and addressing anxiety has a direct secondary effect on palpitation frequency.
Dehydration
Reduced blood volume from inadequate hydration makes the heart work harder to maintain circulation, increasing heart rate and the likelihood of noticeable beats. Severe dehydration can result in additional symptoms which require more immediate medical assessment: confusion or drowsiness, fainting, reduced urinary frequency for longer than 8 hours.
Thyroid changes
Thyroid dysfunction is common in perimenopausal women and produces palpitations independently of menopause. It is worth having thyroid function checked if palpitations are a significant symptom. Voy's Women's Midlife MOT Blood Test includes TSH and free thyroxine alongside hormonal markers, providing a comprehensive starting picture.
Palpitations at night: why they happen and what helps
Night time palpitations are one of the most searched sub-topics for this keyword and are absent from almost all consumer-facing coverage on this subject.
When night sweats occur, the body undergoes a cascade of autonomic activation: blood vessels dilate, the heart rate rises, and sympathetic nervous system activity surges. Waking repeatedly from this experience maintains a state of sympathetic arousal that makes returning to sleep difficult and that can sustain palpitation episodes well beyond the original hot flush.
Sleep disruption itself, independent of night sweats, increases sympathetic dominance. Fragmented sleep is a recognised autonomic stressor, and the Women's Health 2022 scoping review confirmed sleep disturbance as a significant correlate of palpitations in this population.
There is also a specific consideration worth naming: oestrogen loss increases susceptibility to sleep apnoea, and sleep apnoea is associated with nighttime heart rhythm disturbances. If nighttime palpitations are accompanied by snoring, gasping, or consistently feeling unrefreshed despite a full night's sleep, this is worth raising with a specialist. Sleep apnoea is treatable, and addressing it can meaningfully reduce nighttime cardiac symptoms.
71% of Voy members reported improved sleep after starting menopause treatment (presented at The Menopause Society 2025, forthcoming in Climacteric). Improving sleep quality reduces the autonomic arousal cycle that drives many nighttime palpitations.
Other causes worth ruling out
The following can produce palpitations independently of menopause and are worth considering, particularly if palpitations are frequent or not clearly connected to hormonal patterns:
- Thyroid dysfunction: overactive thyroid causes palpitations, anxiety, and heat intolerance that can overlap significantly with menopause symptoms
- Anaemia: reduced oxygen-carrying capacity increases heart rate
- Anxiety disorder: distinct from the anxiety-palpitation loop discussed above, a clinical anxiety disorder may need its own assessment and treatment
- Medication side effects: some antidepressants, decongestants, and stimulant-based medications can cause palpitations
- Excess caffeine or alcohol: worth reviewing before pursuing investigation
A specialist will consider these alongside the hormonal picture rather than treating them as separate questions.
What actually helps
The evidence base for treating palpitations specifically is honest about its limitations. A systematic review published in Climacteric (2022), which examined 37 studies, concluded that no treatment can be fully recommended for palpitations in clinical practice based on current evidence. Among hormonal options, estradiol-based HRT can be recommended "with caution," based on positive evidence for reducing palpitation prevalence or severity.
HRT
By stabilising the hormonal fluctuations that destabilise the ANS, HRT addresses the root mechanism driving menopause-related palpitations. The evidence for palpitations specifically is limited but directionally positive. 88% of Voy members felt more hormonally balanced at three months, compared to 62% receiving standard care (presented at The Menopause Society 2025, forthcoming in Climacteric). Hormonal stabilisation is exactly the mechanism by which palpitation frequency tends to reduce.
If you have questions about HRT safety, including its cardiovascular effects, our dedicated article on HRT risks and benefits covers the current evidence in full.
Lifestyle modifications
Reducing caffeine, particularly in the afternoon and evening, reducing alcohol, improving sleep hygiene, and managing stress have all been identified as relevant in the correlated evidence. None individually resolves the hormonal mechanism, but each reduces the load on an already sensitised autonomic system.
CBT and psychological support
CBT is NICE-recommended for menopause-related mood and sleep symptoms. Given the circular relationship between anxiety and palpitations, psychological support that reduces anxiety has a direct secondary benefit on palpitation frequency. Voy offers structured CBT as part of its comprehensive menopause care.
83% of Voy members reported improvement in mood and emotional symptoms after starting treatment (presented at The Menopause Society 2025, forthcoming in Climacteric).
Beta blockers
A specialist may consider beta blockers as a short-term option for troublesome palpitations while hormonal treatment is being established. They are not a menopause treatment and are not appropriate for self-prescribing. If you feel this might be relevant for you, raise it with your GP or specialist.
Getting the right support
Any new palpitations are worth a conversation with your GP: partly for reassurance, partly to rule out the conditions described above. If your palpitations are frequent, distressing, or accompanied by other menopause symptoms, a specialist consultation that considers the full hormonal and cardiac picture together is more useful than treating each symptom separately.
A 45-minute consultation with a BMS-trained (British Menopause Society) specialist can cover vasomotor symptoms, sleep, mood, and palpitations as the interconnected hormonal picture they are. 93% of Voy members reported improvement in overall quality of life after starting treatment (presented at The Menopause Society 2025, forthcoming in Climacteric).
What most women who experience menopause-related palpitations want to know is whether their heart is in danger. The research says, for the great majority, it is not. What is happening is hormonal, it is physiological, it is real, and it has effective approaches behind it.
