Symptoms, from the outside

Anxiety, panic and palpitations

Original guidance written for MenoHealth by its editorial team. · 9 min read · Oct 2026

Medically reviewed by Karla F. Loken, DO, FACOOG on October 13, 2026

New anxiety, waking in panic and a heart that suddenly races are common in the transition and frightening from both sides. Which signs mean calling 911, what is happening, and how to help in the moment.

In brief

What this helps with. New anxiety, panic and palpitations, and which signs are emergencies.
One thing to do. Agree in a calm moment what she wants from you in a panic surge.
One thing to ask. "What helps when it happens?"

Get help now if she has chest pain or pressure, fainting, severe breathlessness, or a racing heart that does not settle, which means 911 before anything else.

It is four in the morning and she is sitting on the edge of the bed with a hand flat on her chest, certain something is wrong with her heart. Neither of you knows whether this is panic or her heart. So the emergency signs come first, and the calming comes after.

Palpitations, and the signs that mean 911

A racing, pounding or fluttering heart is one of the symptoms that frightens women most, because it feels like the heart rather than the mind. Before any reassurance, know the line. Chest pain or pressure, fainting, severe breathlessness, or a racing heart that does not settle means calling 911 now, before anything else. Do not drive her yourself, and do not try a breathing exercise first. If an episode like that has already passed, she still needs same-day assessment, because "it was probably menopause" is a conclusion for a clinician to reach after checking, not before.

Short of that line, palpitations are common in the transition. In the Study of Women's Health Across the Nation they tended to travel with hot flashes, poor sleep and mood symptoms rather than standing alone. A heart that pounds during a flash or a surge of anxiety and settles within minutes is the familiar version, and it still deserves a mention to her clinician.

Anxiety that arrives from nowhere

Some women carry anxiety all their lives. What surprises supporters is the woman who never did and now does. In the Study of Women's Health Across the Nation, women who had low anxiety before the transition were more likely to report high anxiety during and after it, while women who were already anxious tended to stay that way. New anxiety in a woman in her late forties is one of the recognized symptoms of this stage, and it has a place on the same questionnaire clinicians use to measure hot flashes.

The reasons are the same ones that drive the other mood changes of the transition. Estrogen swings act on the brain systems that regulate mood, sleep is broken, and hot flashes keep jolting the nervous system awake.

What it feels like

She may describe a dread that has no object, a sense that something terrible is about to happen with nothing to attach it to. Her heart races. Her chest feels tight. Small problems can become catastrophes in her head before she can stop them. She may wake at three or four in the morning in a state of panic that takes a long time to fade, and things she once did without thinking may now need to be talked through in advance. From the outside this looks like worry. From the inside it can feel like an emergency.

From where you stand it can also look like irritability, withdrawal or control. She is not being difficult. She may be managing a threat you cannot see.

A flash and a panic surge can feel the same

Heat, sweat, a pounding heart and a wave of dread arrive together in both. Once the emergency signs are ruled out, it does not matter which one she is having. Your response is the same.

In the moment

Check the emergency signs first. If any of the signs above are present, call 911 rather than starting a calming technique.
Stay. Do not leave the room to fetch something unless she asks. Your presence is the intervention. If you are not with her, staying on the phone does the same job.
Slow your voice. Speak lower and slower than feels natural. Many women find that steadying.
Do not say calm down. It tells her that what she is feeling is a choice, and it is not.
Do not argue with the fear. "There's nothing wrong with your heart" is a debate. "I'm here, I've got you" is not.
Water and a hand. A cold glass of water and something to hold. Ask before you hold her, because touch can help or crowd.
Breathe with her if she wants. Some women find it helps to breathe slowly alongside someone. Some find it irritating. Ask once.

Afterwards, do not debrief unless she wants to. A panic surge is exhausting, and the kindest thing is often tea and no questions. An episode that came with any of the emergency signs needs same-day assessment even once it has passed.

What helps over time

Anxiety in the transition is treatable. Cognitive behavioral therapy has good evidence for anxiety and low mood at this stage and is recommended in national guidance. SSRIs and SNRIs are front-line medicines for perimenopausal depression, which often travels with anxiety, and a clinician can judge whether one fits her. Treating the things that feed anxiety matters too, because broken sleep and frequent hot flashes keep the nervous system on alert. Hormone therapy is not a treatment for anxiety on its own, although the guideline on perimenopausal depression notes some evidence for estrogen on mood symptoms in perimenopause. Every one of these needs a clinician's evaluation, and contraindications exist.

A written timeline of when the panic comes and what her sleep and hot flashes were doing that week gives a clinician something concrete. If she logs her symptoms in the app, those logs can help her build it, and it is hers to write and hers to share.

When to encourage care

Occasional worry that tracks bad nights is part of the stage. Anxiety that is there most days for weeks, panic attacks that keep coming, avoiding things she used to do, or anxiety together with low mood is a reason to see a clinician who knows menopause, or a mental health professional. Raise it once, gently, and leave the decision with her. "I read that anxiety that starts now is common and treatable, and I'd come with you if you wanted" is enough.

A crisis is different from routine care. If she talks about not wanting to go on, or about harming herself, stay with her and help her reach professional support the same day. In the United States, call or text 988 (the Suicide and Crisis Lifeline) or call 911 if life is in danger.

Where to start this week

Learn the four emergency signs and agree that you will call 911, not debate. Do not be embarrassed to call 911 a lot of women blow off chest pain or pressure and that is why they often have worse outcomes than men when it is a cardiac event so they really do want you to get checked out. Many things can cause chest pain but ignoring it is not ok.
Agree in a calm moment what she wants from you during a panic surge, and do that.
Take the phrase calm down out of your vocabulary.
Help her get sleep, because a tired nervous system panics faster.
If anxiety is there most days, say once that it is treatable and offer to help with the booking.