The study examined 30 perimenopausal women with hypertension and 30 healthy controls using 3T MRI, blood pressure monitoring, and serum hormone analysis. The main gradient of cortical morphometric similarity in hypertensive patients showed a “stretching” pattern with positive spatial correlation with healthy subjects, with increased values in the visual and somatomotor networks, the left parietal subregion of the frontoparietal network, and the right medial subregion of the ventral attention network. The thalamus showed atrophy in sensory and executive nuclei (eg VPL, LGN, MDm) and hypertrophy in intralaminar nuclei (eg CL, AV). Estradiol depletion and FSH elevation were associated with atrophy of specific thalamic regions, such as the right Pc. This thalamic atrophy predicted lower scores on the MMSE and ventral attention network impairments. Perimenopausal hypertension thus links neuroendocrine-vascular interaction with thalamocortical disorganization and cognitive decline.