Perimenopause is increasingly recognized as a critical biological transition that extends beyond reproductive aging to influence multiple organ systems. Accelerated bone loss during the menopausal transition is supported by robust epidemiological, mechanistic and imaging evidence, whereas evidence for concurrent changes in muscle health and particularly neurocognitive function is more heterogeneous. Subjective cognitive complaints, including reduced concentration, forgetfulness and 'brain fog', are commonly reported, but objectively measured cognitive changes are generally modest and less consistent. Endocrine, inflammatory and mitochondrial pathways provide biological plausibility for interactions among bone, muscle and brain; however, direct evidence demonstrating an integrated relationship among these systems specifically during perimenopause remains limited. This narrative review critically synthesizes current evidence and proposes the bone-brain-muscle axis as an integrative conceptual framework. The model is presented as a biologically plausible clinical framework rather than a validated mechanistic pathway. Recognizing perimenopause as a potential neuro-musculoskeletal window may support earlier identification of multidimensional risk and individualized strategies to preserve physical function, cognitive health and healthy aging.