Treatment approaches to the management of Abnormal Uterine Bleeding (AUB) in the perimenopausal woman should ideally follow standardized evidence based guidelines in order to achieve the best outcome. The PALM-COEIN classification system, approved by the International Federation of Gynecology and Obstetrics (FIGO), is ideally used as a basis for management. It recognizes structural causes of AUB, which can be assessed with imaging techniques or histopathology, and non-structural causes such as coagulopathies, ovulatory dysfunctions and iatrogenic interventions. Once the diagnosis has been established, structural causes will typically be managed surgically and non-structural through medical interventions. Possible management pathways have been described by The International Menopause Society, Cochrane and NICE UK in their recommendations, meta-analyses and guidelines. Although the presentation will cover most management options, it will focus on the most common cause of perimenopausal bleeding which is due to inadequate release of progesterone in the luteal phase, due to anovulatory cycles. Endometrial growth, differentiation and shedding rely on a coordinated series of events in response to either cyclical ovarian function, in the premenopausal woman, or in response to exogenous hormones in the postmenopausal woman. Progesterone counteracts the effect of estrogen by inducing differentiation of endometrial cells and down-regulates the estrogen receptors in the endometrium. However, if there is disruption of the homeostatic balance between apoptosis (programmed cell death) and proliferation this can lead to bleeding problems, hyperplasia and carcinogenesis. The aim of exogenously applied progestogen/progesterone is to restore this balance. There seems to be reluctance to prescribe MHT in women who are still menstruating, possibly due to this not being covered by the product license of many preparations. However, judiciously targeted hormone therapy can not only alleviate bleeding problems, but can also restore quality of life and wellbeing during the menopause transition, through alleviation of concomitant PMS and menopause symptoms.