A racing, fluttering, or pounding heart is one of the less-discussed symptoms of perimenopause, yet it causes significant alarm. Many women in their 40s and early 50s experience episodes that feel like their heart is skipping beats, running too fast, or beating unusually hard. Combined with chest tightening during a hot flash, these episodes can be frightening.

The research is both reassuring and instructive. Palpitations during perimenopause are common, they peak during the transition, and the evidence does not link them to underlying structural heart disease.

What the SWAN Data Show

The Study of Women's Health Across the Nation (SWAN) is the largest longitudinal study of the menopausal transition in the US, tracking thousands of women across more than a decade. One analysis examined palpitation patterns across the transition specifically, tracking trajectories, characteristics, and associations with subclinical cardiovascular disease.[1]

The key finding: palpitations were not associated with subclinical CVD. When researchers looked for links between palpitations and measurable markers of cardiovascular risk, including carotid atherosclerosis and vascular stiffness, they found no significant relationship.[1]

What did predict palpitations? After adjusting for confounders, two factors independently predicted moderate to severe palpitations: vasomotor symptoms (hot flashes and night sweats) and anxiety scores.[1] This pattern matters clinically. It suggests that palpitations during perimenopause are more closely tied to the vasomotor and autonomic stress response than to direct cardiac pathology.

A 2025 pilot study examining heart racing in midlife women added further detail, finding that palpitation symptoms were prevalent and linked to the menopausal transition rather than structural cardiac causes.[2]

Why They Happen

Several mechanisms contribute to the palpitation experience during perimenopause, and they interact with each other.

The vasomotor connection. A hot flash involves a sudden surge of vasodilation, increased heart rate, and adrenaline release as the body attempts to shed heat. The rapid heart rate during a hot flash is not incidental; it is part of the thermoregulatory cascade. Women often experience palpitations as part of a hot flash rather than as a separate event, and many report they cannot tell where the hot flash ends and the palpitation begins.

Estrogen's direct cardiac effects. Estrogen has receptors in cardiac tissue and influences calcium handling in heart cells. SERCA2a function (a protein involved in regulating calcium in heart muscle) is diminished during perimenopause.[3] Disrupted calcium handling affects the regularity and strength of heartbeats and may contribute to the ectopic beats (skipped or early beats) many women describe.

Autonomic nervous system instability. The ANS, which controls heart rate among other things, is partly regulated by estrogen. As estrogen fluctuates unpredictably during perimenopause, the ANS becomes less stable. This can manifest as increased heart rate variability, greater sensitivity to triggers (caffeine, stress, temperature), and a general sense that the heart is behaving erratically.[4]

Anxiety amplification. The SWAN finding about anxiety is clinically significant. The physical sensations of a palpitation (racing heart, chest awareness) are identical to anxiety's somatic symptoms. Once a woman has experienced several alarming episodes, anticipatory anxiety about the next one lowers the threshold for perceiving subsequent episodes. The anxiety and the palpitation reinforce each other.

When This Is Not Benign

The SWAN data and other population research are reassuring about the general pattern, but palpitations warrant clinical attention in specific circumstances.

See your doctor promptly if palpitations are accompanied by: - Chest pain or pressure - Shortness of breath at rest or with minimal activity - Dizziness, lightheadedness, or fainting (syncope) - A sustained racing heart lasting more than a few minutes without resolving - Palpitations that begin after starting a new medication

If you have a personal history of heart rhythm problems, structural heart disease, or thyroid disease, palpitations need evaluation in that context rather than being attributed to hormonal change without investigation.

For women with none of these features, the standard clinical approach is a baseline ECG to rule out a primary rhythm disorder and blood tests to check thyroid function, as thyroid abnormalities are common in this age group and can cause or worsen palpitations independently of menopause.

Managing Palpitations

Because vasomotor symptoms and anxiety are the two strongest predictors of palpitations in perimenopause, interventions that reduce those underlying drivers also reduce palpitation frequency.

Managing hot flashes, whether through lifestyle measures (keeping rooms cool, avoiding triggers like alcohol and spicy food), behavioural approaches (slow breathing during a flush), HRT, or non-hormonal options, reduces the vasomotor events that trigger palpitations.

Reducing background anxiety with CBT, exercise, and adequate sleep dampens the sensitisation that makes palpitations feel worse.

Limiting caffeine and alcohol, both of which irritate cardiac rhythm, reduces ectopic beats and the general sense of cardiac irregularity.

References

[1] El Khoudary, S. R., Janssen, I., Matthews, K. A., et al. (2023). Palpitations across the menopause transition in SWAN: trajectories, characteristics, and associations with subclinical cardiovascular disease. Menopause, 30(2), 127-135. https://pmc.ncbi.nlm.nih.gov/articles/PMC9797427/

[2] Mintzer, M., et al. (2025). Palpitations in midlife women: the Menopause Racing Heart Pilot Study. Menopause. https://pubmed.ncbi.nlm.nih.gov/40554632/

[3] Velarde, M. C., et al. (2024). Perimenopause decreases SERCA2a activity in the hearts of a mouse model of ovarian failure. PLOS ONE. https://pmc.ncbi.nlm.nih.gov/articles/PMC11201532/

[4] Thurston, R. C., Chang, Y., Barinas-Mitchell, E., et al. (2022). Vasomotor symptoms of menopause, autonomic dysfunction, and cardiovascular disease. Climacteric, 25(1). https://pmc.ncbi.nlm.nih.gov/articles/PMC9744645/