Back pain is a common symptom in postmenopausal women. As in younger age groups, most cases of back pain in postmenopausal women do not represent serious disease and resolve spontaneously within four weeks. However, acute back pain in postmenopausal women may be caused by vertebral fracture, and "red flags" in the history and physical examination can help clinicians decide on the appropriate work-up. When findings suggest vertebral fracture, anteroposterior and lateral radiographs of the thoracolumbar spine should be obtained. The diagnosis of existing vertebral fractures is critical because the probability of sustaining new spine and hip fractures is increased in women with one vertebral fracture, and the presence of multiple fractures puts the patient at risk for chronic debilitation. Acute fractures should be treated supportively, and a further work-up should be performed to assess the degree of osteoporosis and to exclude secondary causes. Evaluation of bone mineral density is a helpful guide to further management. Treatment may include calcium and vitamin D, hormone replacement therapy, bisphosphonates and/or calcitonin.