Let's Talk Menopause spoke with Dr. Chrisandra Shufelt about heart palpitations and menopause.
A heart palpitation is something one feels in their chest. Patients describe it in various ways including as a pounding heart, skipping beats, a fluttering in the chest, and even as a “flip-flopping” sensation. It can last from one second to many seconds, and experiencing one can be unsettling.
One thing to consider is what are the more common causes of heart palpitations? Certainly, the menopause transition is one reason why people experience heart palpitations, but we should resist putting on blinders and saying heart palpitations are always about hormonal changes. Lack of sleep, stress, dehydration, and even caffeine intake may cause heart palpitations as thyroid dysfunctions.
Most heart palpitations are benign, but not all. Please see a doctor if you experience: chest or back pain; shortness of breath or trouble breathing; feeling faint or having fainted; nausea or vomiting; or if your incidents of palpitations last a long period of time. If a woman is experiencing other disruptive menopause symptoms along with her heart palpitations, or if her heart palpitations are becoming more frequent, please seek a medical evaluation.
One way doctors can measure the heart’s electrical system is through an electrocardiogram (EKG). They can look at the results and see specifically where there may be an issue. An EKG, though, is a quick snapshot in time so if you’re not experiencing a palpitation in that moment, it may go unregistered. Sometimes a cardiologist may ask a patient to wear a heart holter monitor to track several days of activity. It’s worth noting that this technology is not what it was just five years ago. Today, wearing a monitor involves little more than having a small device taped to your chest. They are also water-resistant so you can even shower and sweat while wearing it. After the test, the patient puts the device into an envelope and mails it back for analysis and the report goes right to her doctor.
Heart palpitations are common during perimenopause and are linked to the changes in both estrogen and progesterone. Perimenopause is the stage I often refer to as a hormonal roller coaster because estrogen may fluctuate more erratically, its levels rise and fall, while progesterone levels do the same. This results in a hormonal flux that is unpredictable and disruptive, often leading to a range of menopausal symptoms including heart palpitations.
To understand what happens within the heart, one should envision the electrical conduction system as a two-railed train track that originates at the top of the heart and travels southward carrying the electrical signal in pulses. As it nears the bottom, each rail separates into opposite directions that then curve up and around the bottom of the heart (the bottom two chambers, called ventricles). This electrical system is what causes the heart muscle to contract (i.e. the ‘lub-dub’ of the heart) and is what enables oxygen rich blood to flow throughout the body.
Heart palpitations, however, are misfirings within this electrical system. For example, calcium entering the cell of the muscle tells the heart to contract or squeeze, yet this system is sensitive to changes, such as letting in too little or too much calcium might cause misfirings. It is also reactive to changes in estrogen and progesterone levels, and that’s how the menopause transition plays a role in heart palpitations.
The menopause transition is a critical time for cardiovascular risk factors to rise. We know that about one in nine women who are younger than 52 (the average age of reaching menopause) have heart disease while that ratio leaps to one in three after reaching menopause. One in three. It’s important for women to know the traditional risk factors for heart disease: high cholesterol, diabetes, high blood pressure, smoking, and family history of early cardiovascular disease.
But there’s more. At the time of menopause, women’s rate of heart disease rises disproportionately to men’s. It’s a time when women experience changes in their blood pressure, blood sugars, cholesterol levels, and weight. This is what makes reaching menopause a pivitol time for women to grab hold of their heart health. They need annual exams and blood work so they can track their heart health numbers. What you do in your fifties will influence your health for decades to come. I currently direct a Menopause and Hormone program that is within the Barbra Streisand Women’s Heart Center. The purpose of this program is to identify risk factors that we can capture, to identify if a woman is an appropriate candidate for menopausal hormone therapy or if we should look at other avenues to treat her hot flashes because no one should suffer, and really to capture that risk prevention.
In treating benign palpitations, I encourage patients to begin by collecting a diary of their palpitations. When in the day do they occur? What were you doing? What did you recently eat or drink? I may suggest mild diet changes such as a reduction in caffeine intake. The next step would be to collect a thyroid panel and bloodwork to make sure there’s not another existing condition causing the palpitations. I might prescribe low dose beta-blockers to help with the palpitations.
If symptoms continue or worsen, I may refer a patient to my colleagues in the electrophysiology department as they specialize in heart rhythms and have the ability to look at the heart structure itself. If the heart palpitations do not resolve, an ultrasound of the heart called an echocardiogram may be required.
Today's cardiologists and the Go Red for Women Campaign by the American Heart Association are bringing attention to improving women’s cardiovascular health outcomes much like the pink ribbon campaign did for breast cancer ten to fifteen years ago. This is the result of considerable boots on the ground advocacy and activism for reducing the inequalities in women’s heart health care.
Dr. Shufelt holds the Anita Dann Friedman Endowed Chair in Women’s Cardiovascular Medicine and Research and is the Associate Director of the Barbra Streisand Women's Heart Center in the Smidt Heart Institute at Cedars-Sinai Medical Center. She is also the Director of the Women's Hormone and Menopause Program and co-Director of the Preventive and Rehabilitative Cardiac Center. Dr. Shufelt is Professor of Medicine and Faculty at Cedars-Sinai Medical Center.