Treatment is individualized and layered. Lifestyle foundations matter more in perimenopause than at any prior point in adult life. Sleep hygiene, regular resistance training, protein-focused nutrition, blood sugar stability, alcohol moderation, and stress management all become disproportionately impactful. None of these alone treat perimenopause, but each amplifies the benefit of medical treatment. Hormone therapy (HT) is the most effective treatment for moderate-to-severe perimenopausal symptoms. The terminology has evolved — what was historically called HRT (hormone replacement therapy) is now more commonly called MHT (menopausal hormone therapy) or simply HT. The goal in perimenopause is to stabilize the hormonal volatility, not to recreate reproductive-age levels. Transdermal estradiol with cyclic or daily progesterone (or a progestin) is the most common approach. The form, dose, and route are individualized. The timing of initiation matters. Post-WHI re-analyses have established a 'timing hypothesis': women who begin hormone therapy within ten years of their final menstrual period or before age sixty have a favorable risk-benefit profile, including cardiovascular benefit in many cases. Initiating treatment during perimenopause — well within this window — is exactly the scenario where the benefit-to-risk ratio is most favorable. Non-hormonal options have a role for women who cannot or prefer not to take hormones. Certain SSRIs and SNRIs treat hot flashes. Gabapentin can help vasomotor symptoms and sleep. Cognitive behavioral therapy for insomnia (CBT-I) is highly effective for perimenopausal sleep disruption. The new neurokinin antagonists represent a meaningful advance for hot flash treatment without hormones. Vaginal estrogen for genitourinary symptoms (vaginal dryness, urinary symptoms, painful intercourse) is highly effective, very low systemic absorption, and appropriate for almost all women including many with a history of breast cancer. It is one of the most underused interventions in women's health.