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Clinical guidance for perimenopausal hormone replacement therapy (HRT) varies across regions, creating uncertainty when clinicians need to balance safety with testing burden and cost. We conducted an evidence-based narrative review to summarize the clinical value of key indicators used in perimenopausal HRT decision-making. To gather relevant evidence, we searched PubMed, Web of Science, and Scopus for studies published from January 2014 to December 2025 using keywords related to perimenopause, HRT, biomarkers, clinical decision-making, and risk stratification. We focused on indicators from hormonal, skeletal, and cardiometabolic domains, as well as selected imaging and symptom measures. Traditional hormones such as follicle-stimulating hormone (FSH) and estradiol are useful for staging, but single measurements are limited by cyclic fluctuations. For bone health, combining bone mineral density with bone turnover markers (e.g., β-CTX and PINP) may improve the assessment of fracture risk and treatment response. For cardiometabolic safety, lipid profiles and inflammatory markers (e.g., C-reactive protein) support risk evaluation. Based on the literature, we propose a tiered evaluation framework: utilizing standard, widely available tests for routine assessment, while reserving advanced biomarkers for high-risk or unclear cases. This approach aims to support practical clinical assessment without replacing individualized clinical judgment, offering a highly cost-effective strategy tailored for resource-limited settings.