Hormone therapy (HT) remains the treatment of choice for climacteric symptoms and for prevention and treatment of bone loss at least within ten years postmenopause. The usually prescribed HT doses have decreased during the past few years, and use of low-dose HT is becoming more popular, possibly decreasing the occurrence of unwanted side effects seen with conventional doses. HT has a fracture-reducing potential even at doses lower than usually recommended, but the positive effect of HT on bone disappears relatively soon after stopping HT. The fear of long-term side effects of HT, such as breast cancer, coronary heart disease (CHD) and thromboembolic events, has increased the demand to evaluate the role of alternative osteoporosis and fracture prevention medication in ageing women. The rapid worldwide decrease of HT use may increase the incidence of fractures if there are no compensative measures. Women who discontinue HT should be advised about rapid bone loss after HT, and given other potential treatment options. Intensive research into alternative approaches to deliver estrogenic activity to bone with no adverse effects on other tissues by using low doses of estrogen, selective estrogen receptor modulators (SERMs), or combinations of the two are ongoing. However, development of an ideal SERM has proved to be difficult, and individualization of bone-protective therapy is a remarkable challenge for professionals treating postmenopausal women.