This review aims to draw a clearer clinical picture of postmenopausal endometriosis. Based on limited literature, postmenopausal endometriosis emerges as an infrequent entity but with a clinical picture significantly unlike that of premenopausal endometriosis. In contrast to the premenopausal disease, postmenopausal endometriosis occurs in a state of ovarian estrogen deficiency, appears to have a greater predisposition to malignant change, may have a greater tendency to spread to extragonadal organs and develop into constrictive and/or obstructive lesions, and is preferably treated surgically. The need to use hormone therapy for the management of menopausal symptoms that may concomitantly affect women with postmenopausal endometriosis is an unresolved therapeutic dilemma. This is mainly because the relationships of menopausal hormone therapy to recurrence of endometriosis and, more importantly, to increased risk of malignant degeneration, remain unclear.