I am getting palpitations on Rogaine: what do I do?

Palpitations with Rogaine: What should I do?

I’ve selected this question below for this week’s question of the week. It allows us to review the topic of minoxidil related heart palpitations in women.

QUESTION

I am a 55 year old female with female pattern hair loss. I am getting palpitations on Rogaine! I use a full cap instead of 1/2 cap as I wanted to really try do everything I can. I realize that I’ve been using too much! What should I do?

ANSWER

Thank you for your question.

Palpitations are common - even without Rogaine in the picture. One study suggested that up to 16 % of the population has palpitations.

2-4 % of Minoxidil Users Have Palpitations

Palpitations can certainly occur with Rogaine. In the original 2011 randomized controlled trial comparing 5 % minoxidil foam once daily to 2 % minoxidil solution twice daily, 1.8 % of women using the foam once daily had palpitations and 3.5 % using the minoxidil solution had palpitations.

I would recommend that anyone with palpitations speak to his or her doctor. This is really the best step to take. It’s easy enough to focus only on the Rogaine and what to do with the Rogaine - but that’s not really the ideal way to evaluation this for most patients.

ALL PATIENTS WITH HEART PALPITATIONS NEED A REVIEW!

Although the palpitations may be related to Rogaine (minoxidil) use, one needs a full history and good general examination to see if any other contributors may be relevant. Other medications, substance abuse, caffeine intake, psychological stresses and mental health issues, other heart rhythm issues (atrial fibrillation, PVCs, PACs), family history of heart issues all need to be reviewed carefully. Your doctor will want to find out when they occur (sleep or awake), how often they occur, and what provokes them and what they feel like. A review of your blood pressure, weight, general health (obesity, smoking, sleep apnea) all need to be taken into account. Your doctor needs to listen to the chest, evaluate your JVP, and look for evidence of ankle edema or other signs of heart failure. Blood tests for thyroid stimulating hormone, hemoglobin, ferritin, calcium, potassium, magnesium, creatinine, urinalysis, blood sugars, cholesterol are often appropriate. In some cases, cardiac troponins are ordered but this is generally only ordered in the case of more prolonged or frequent palpitations - and in more acute settings (like the emergency room). Women of child bearing age should have a pregnancy test in the standard evaluation of palpitations.

What are the most common causes of palpitations?

As your doctor goes about evaluating your specific situation, he or she will be thinking about all the causes of palpitations. Doctors typically divide these into two big groups - cardiac causes and non-cardiac causes. The cardiac causes include things like atrial fibrillation, premature ventricular and atrial contractions, heart failure, valvular disease, ventricular tachycardia, autonomic dysfunction, long QT syndrome, supraventricular tachycardia. Non cardiac causes include things like alcohol, anemias, stress, cocaine, smoking, pregnancy, thyroid problems, fever, medications (including withdrawal).

Your doctor will be trying to figure out where you fall in this list:

Common Causes of Palpitations and their Frequencies. From: Wexler  RK Palpitations: Evaluation in the Primary Care Setting. Am Fam Physician. 2017 Dec 15;96(12):784-789.

Reducing or Stopping Rogaine: Considerations

Reducing or stopping the Rogaine is an option. You and your doctor can review what is most appropriate in your case. If there are no major worries about the heart (such as non concerns for ischemic heart disease or cardiac issues), then reducing the dose may make sense. If there are concerns, then stopping it may be the best option.

There are situations where continuing Rogaine makes sense - even at the off label dose of 1 cap daily. For example, if palpitations occur once every 2 months, this is very different than if they occur once every 2 hours. A patient with extremely infrequent palpitations mightt continue Rogaine while the exact cause is being evaluated.

A person will possibly lose hair if Rogaine is stopped. However, the likelihood of this depends on many factors. For example, if you just started Rogaine last week, then there probably won’t be much hair loss that occurs. If you started Rogaine 8 months ago, there is likely to be hair loss. These are clearly important discussions that you and your doctors will need to have as nobody wants to lose hair.

In some cases, your family doctor or dermatologist may consider ordering an electrocardiogram (ECG or EKG) for you. This is a tracing of the heart electrical patterns and gives helpful information about whether any other issues might be present. If there are any concerns about your pattern of palpitations on your ECG tracing, then other tests like a 24 hour monitoring test (HOLTER TEST) or echocardiography may be considered before or at the same time as referral to a cardiologist. In some cases, a chest xray is also done. The more often the palpitations occur and the more accompanying signs and symptoms that are present (dizziness, chest pain, shortness of breath, leg swelling, syncope and passing out), the more likely a patient will be advised to seek urgent medical attention rather than wait for a standard cardiologist referral. Again you and your own medial team will want to carefully review your issues.

Conclusion

As far as what’s the right step for you to take, I do not know. I would need to have all the facts, review all your story. Be sure to speak to your doctor. Most of the time there are no undelrying worries. But one should not jump to that conclusion without a proper review. There may be situations where stopping the Rogaine is the right answer. There may be situations where reducing the dose is the right answer.

If Rogaine (minoxidil) is felt to be the only cause (no other issues), some patients find it helpful to divide Rogaine into two daily smaller applications rather than one without losing effect. This means using ½ the cap in the morning and ½ the cap in the evening. In the morning the frontal area can be targeted with the Rogaine. In the evening the more posterior areas of the scalp can be targeted. The results is that each area of the scalp still receives the same amount of Rogaine on a given day, it just receives it at different times. Many patients of my own report that palpitations disappeared with this strategy. Again, you’ll want to talk to your doctor if stopping, reducing or adjusting how you apply Rogaine is the best step for you.

Thank you again for your question.

REFERENCES

Blume-Peytavi U et al. A randomized, single-blind trial of 5% minoxidil foam once daily versus 2% minoxidil solution twice daily in the treatment of androgenetic alopecia in women. J Am Acad Dermatol. 2011 Dec;65(6):1126-1134.e2.

Govender I et al. Palpitations: Evaluation and management by primary care practitioners. S Afr Fam Pract (2004). 2022; 64(1): 5449.

Raviele A et al. Management of patients with palpitations: A position paper from the European Heart Rhythm Association. Europace 2011;13(7):920–34. doi: 10.1093/europace/eur13

Wexler  RK Palpitations: Evaluation in the Primary Care Setting. Am Fam Physician. 2017 Dec 15;96(12):784-789.