Panic Attacks

What It Is

Out of nowhere, terror crashes over you. Your heart pounds, racing out of control. You can't breathe. Your chest tightens—am I having a heart attack? Your hands tingle. You feel dizzy, unsteady, like you might faint or die. The room closes in. You're sweating, shaking, terrified. You feel utterly out of control, like you're going to lose your mind or your body is shutting down. It lasts 5, 10, 20 minutes—an eternity—and then slowly fades, leaving you shaken, exhausted, and terrified it will happen again. You've never had panic attacks before. But no one told you perimenopause could trigger them.

A panic attack is a sudden episode of intense fear or discomfort that reaches a peak within minutes and includes multiple physical and psychological symptoms. It's not "just anxiety"—it's a full-body neurological and physiological crisis. Panic attacks are surprisingly common in perimenopause, even in women who have never experienced anxiety before.

Diagnostic criteria (from DSM-5) include at least 4 of the following:

• Pounding heart, palpitations, or accelerated heart rate
• Sweating
• Trembling or shaking
• Shortness of breath or smothering sensation
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Dizziness, lightheadedness, or feeling faint
• Chills or heat sensations
• Numbness or tingling (paresthesias)
• Derealization (feelings of unreality) or depersonalization (feeling detached from oneself)
• Fear of losing control or "going crazy"
• Fear of dying

Women describe panic attacks as:

• "I thought I was dying. My heart was racing. I couldn't breathe. I was sure I was having a heart attack."
• "It came out of nowhere. I was fine, and then suddenly I was terrified and my body was going haywire."
• "I felt like I was losing my mind. I couldn't control my body or my thoughts."
• "After it passed, I was terrified it would happen again. I started avoiding places where I'd had attacks."

Why It Happens

Estrogen and GABA: GABA (gamma-aminobutyric acid) is the brain's primary calming neurotransmitter. It inhibits nerve transmission, reduces neuronal excitability, and promotes relaxation. Estrogen enhances GABA activity. When estrogen drops suddenly (estrogen withdrawal), GABA activity plummets. The brain becomes hyperexcitable, reactive, and prone to panic. The brake system fails.

Progesterone and allopregnanolone: Progesterone is metabolized into allopregnanolone, a powerful GABA agonist with calming, anti-anxiety, sedative effects. When progesterone declines (which happens early in perimenopause), allopregnanolone levels drop, and anxiety and panic increase. Women who are sensitive to hormonal fluctuations are particularly vulnerable.

Serotonin dysregulation: Estrogen enhances serotonin synthesis, receptor sensitivity, and reuptake inhibition. Serotonin regulates mood, anxiety, and the stress response. When estrogen fluctuates or declines, serotonin becomes dysregulated, and panic attacks can occur. SSRIs (which increase serotonin) often help perimenopausal panic attacks.

Autonomic nervous system dysregulation: Estrogen regulates the autonomic nervous system (which controls heart rate, blood pressure, breathing, digestion). When estrogen declines, the sympathetic nervous system (fight-or-flight) becomes overactive. The body stays in a state of heightened arousal, making it prone to panic attacks triggered by minor stressors or even spontaneously.

Norepinephrine and adrenaline surges: Estrogen withdrawal triggers surges of norepinephrine and adrenaline—stress hormones that increase heart rate, blood pressure, alertness, and arousal. These surges can occur spontaneously (especially at night or upon waking) and trigger panic attacks.

Hyperventilation and CO2 sensitivity: During panic attacks, hyperventilation (rapid, shallow breathing) lowers CO2 levels in the blood. This causes dizziness, tingling, chest tightness, and a sensation of suffocation—which worsens panic. Perimenopausal women often have increased CO2 sensitivity, making them more prone to hyperventilation-triggered panic.

Sleep deprivation and fragmentation: Poor sleep worsens anxiety and lowers the threshold for panic. Sleep-deprived brains are hyperreactive and less able to regulate emotions and stress responses.

Thyroid dysfunction: Hyperthyroidism (overactive thyroid) can cause panic attacks, rapid heart rate, tremors, sweating, and anxiety. Hypothyroidism can also contribute to anxiety and mood instability.

Caffeine and stimulants: Perimenopausal women often become more sensitive to caffeine due to autonomic dysregulation. Even small amounts can trigger panic attacks.

Fear of panic (panic about panic): After the first panic attack, many women develop anticipatory anxiety—fear of having another attack. This hypervigilance and fear can actually trigger more attacks, creating a vicious cycle.

Common Experiences

The first attack: "I'd never had a panic attack in my life. Then one day, out of nowhere, I thought I was dying. I went to the ER. They said it was anxiety. I couldn't believe it."

The nighttime attack: "I woke up at 3 a.m. with my heart pounding, sweating, terrified. I thought something was seriously wrong."

The grocery store attack: "I was in the grocery store and suddenly I couldn't breathe. My heart was racing. I felt like I was going to pass out. I abandoned my cart and fled."

The driving fear: "I had a panic attack while driving. Now I'm terrified to drive, especially on highways or bridges."

The spiral: "Once I had one attack, I became terrified of having another. I started avoiding places and situations. My world got smaller and smaller."

The disbelief: "I've always been calm, in control. I can't believe this is happening to me."

What Helps

Hormone therapy (HT): Stabilizing estrogen and progesterone levels with HT can significantly reduce or eliminate panic attacks. Estrogen supports GABA and serotonin. Progesterone (especially micronized progesterone) provides calming allopregnanolone. Many women report that panic attacks resolve completely with HT.

SSRIs and SNRIs: Selective serotonin reuptake inhibitors (SSRIs like sertraline, escitalopram, paroxetine) and serotonin-norepinephrine reuptake inhibitors (SNRIs like venlafaxine) are highly effective for panic disorder. They increase serotonin, reduce panic frequency and intensity, and treat anticipatory anxiety.

Benzodiazepines (short-term or as-needed): Benzodiazepines (lorazepam, clonazepam, alprazolam) enhance GABA activity and rapidly abort panic attacks. They're highly effective but carry risks (tolerance, dependence, cognitive impairment). Use cautiously, short-term, or as-needed for breakthrough panic.

Beta-blockers: Propranolol or other beta-blockers block the physical symptoms of panic (racing heart, tremors, sweating) by blocking adrenaline receptors. They don't treat the psychological component but can reduce the terror and prevent the panic spiral.

Cognitive-behavioral therapy (CBT): CBT for panic disorder is highly effective. It teaches:

• Cognitive restructuring: Challenging catastrophic thoughts ("I'm dying" → "This is uncomfortable but not dangerous")
• Exposure therapy: Gradually facing feared situations to reduce avoidance and fear
• Interoceptive exposure: Deliberately inducing panic-like sensations (rapid breathing, spinning) to reduce fear of the sensations themselves

Breathing retraining: Slow, diaphragmatic breathing prevents hyperventilation and activates the parasympathetic (calming) nervous system. Techniques:

• 4-7-8 breathing: Inhale for 4, hold for 7, exhale for 8
• Box breathing: Inhale for 4, hold for 4, exhale for 4, hold for 4
• Diaphragmatic breathing: Breathe deeply into the belly, not the chest

Grounding techniques: During a panic attack, grounding can help:

• 5-4-3-2-1 technique: Name 5 things you see, 4 you can touch, 3 you hear, 2 you smell, 1 you taste
• Cold water: Splash cold water on your face, hold ice cubes, or drink cold water to activate the dive reflex and calm the nervous system
• Movement: Walk, stretch, shake out your limbs

Magnesium: Magnesium (400-600 mg daily, glycinate form) supports GABA function, calms the nervous system, and can reduce panic.

Reduce caffeine and stimulants: Cut back or eliminate caffeine, nicotine, and other stimulants. Even small amounts can trigger panic in sensitive individuals.

Sleep restoration: Treat insomnia and sleep fragmentation. Better sleep reduces panic susceptibility.

Thyroid evaluation: Check thyroid function (TSH, free T4, free T3). Treat hyperthyroidism or hypothyroidism as appropriate.

Acceptance and education: Understanding that panic attacks are benign (though terrifying) can reduce fear. Panic attacks are not dangerous. You will not die, lose control, or go crazy. The symptoms are uncomfortable but temporary.

Avoid avoidance: Avoiding places or situations where you've had panic attacks reinforces fear and worsens the disorder. Gradual exposure (with support) is critical for recovery.

Duration and Recovery

Panic attacks often emerge or worsen during the Wild Tide and Henapause stages, when estrogen and progesterone fluctuate most wildly and GABA/serotonin dysregulation is most severe.

Post-menopause, as hormones stabilize, panic attacks often improve or resolve completely—especially with hormone therapy, SSRIs, CBT, and stress management.

For some women, panic disorder persists and requires ongoing treatment. However, with appropriate therapy and medication, most women achieve significant improvement or complete remission.

The Bottom Line

Panic attacks during perimenopause are not weakness, mental illness, or loss of control. They're neurochemical crises triggered by estrogen and progesterone withdrawal, GABA and serotonin dysregulation, and autonomic nervous system instability. With hormone therapy, SSRIs, CBT, breathing techniques, and education, panic attacks can be controlled and often eliminated. You're not losing your mind. Your brain chemistry is hormonally destabilized. And it can be rebalanced.