Adnexal masses in post-menopausal women pose a diagnostic and therapeutic challenge due to their significantly higher risk of malignancy compared to premenopausal women. A systematic approach is essential, beginning with detailed history, clinical examination, and imaging—most notably transvaginal ultrasound (TVUS), which remains the first-line modality. Serum CA-125 is the most widely used tumour marker, though its limited specificity necessitates adjunctive use with other biomarkers such as HE4 and multimodal scoring systems, including the Risk of Malignancy Index (RMI), ROMA, and IOTA rules, which aid in risk stratification. When malignancy is suspected, further imaging with MRI or CT is warranted to evaluate disease extent and operability. Management decisions are guided by risk assessment, symptoms, and patient factors, with surgical intervention being the cornerstone of treatment. In post-menopausal women, even benign-appearing lesions often warrant surgical removal due to the increased baseline risk of malignancy. Multidisciplinary evaluation, appropriate risk stratification, and individualized treatment strategies remain crucial for optimizing outcomes in this population.