Perimenopausal Menstrual Irregularities:An Evidence Based Narrative Review

Perimenopause is a dynamic transitional phase in a woman’s reproductive life characterized by progressive ovarian aging and fluctuating endocrine activity. Alterations in menstrual pattern are among the earliest and most frequent manifestations of this transition and constitute a major cause of gynecological consultation in midlife women. Clinical interpretation of perimenopausal bleeding is challenging becausee physiological cycle variability may coexist with structural uterine pathology or premalignant and malignant endometrial conditions. This narrative review synthesizes evidence on the epidemiology, biological mechanisms, clinical patterns, diagnostic approach, and management of perimenopausal menstrual irregularities. Emphasis is placed on individualized assessment using the FIGO PALM-COEIN framework and stepwise management strategies supported by international and national guidelines. A balanced approach is essential to provide symptom relief while ensuring timely detection of serious underlying pathology.