Osteoporosis is a skeletal disorder characterized by compromised bone strength, which predisposes a person to increased risk of fracture. In the United States, 26% of women aged > or =65 years and >50% of women aged > or =85 years have osteoporosis. Over 1.5 million fractures per year are attributable to osteoporosis; these fractures result in 500,000 hospitalizations, 800,000 emergency room visits, 2.6 million physician visits, 180,000 nursing home placements, and 12 billion dollars to 18 billion dollars in direct healthcare costs each year. Fracture also results in loss of function and has a negative impact on psychological status. In recognition of the importance of bone health, the US Surgeon General has, for the first time, issued a comprehensive report on bone health and treatment. The report recommends a pyramidal approach to osteoporosis treatment that includes calcium and vitamin D supplementation, physical activity, and fall prevention as the first line in fracture prevention. The second level consists of treating secondary causes of osteoporosis; the third and top level consists of pharmacotherapy. Pharmacotherapeutic interventions (e.g., bisphosphonates, selective estrogen receptor modulators, calcitonin, and teriparatide) in women with postmenopausal osteoporosis provide substantial reduction in fracture risk over and above risk reduction with calcium and vitamin D supplementation alone. Despite the effectiveness of therapy, most patients who receive treatment do not remain on treatment for >1 year. An important approach to reducing the rate of fractures is first to target our treatments to patients at high risk for fracture and then to develop strategies to improve treatment continuation rates.