Postmenopausal women with established or severe osteoporosis, at high risk for additional vertebral and nonvertebral fractures need to be treated with antiresorptive therapy in combination with recommended daily amounts of calcium and vitamin D. Initiation of an appropriate weight-bearing exercise program is highly recommended. In general the use of HT therapy for the prevention or treatment osteoporosis is not recommended. Any decision to use HT must take into consideration its impact on overall health outcomes, including not only its potential to reduce the risk of fractures, but also its potential to increase the risk of other health problems. Although HT is effective for the prevention of postmenopausal osteoporosis, it should only be considered for women at significant risk of osteoporosis who cannot take non-estrogen medications. Anabolic therapy with teriparatide is available in those patients at high risk for fracture who do not respond or cannot tolerate bisphosphonate therapy.