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This article will review established and newer approaches to osteoporosis. With greater awareness of this major public health problem and highly sensitive, safe, and accurate measures of bone mass, it is now possible to identify women with osteoporosis well before they begin to suffer some of its devastating consequences. One of the most important approaches to therapy is prevention. Measures of importance relate to the establishment of peak bone mass in young adulthood. Along with issues of life style, adequate calcium intake looms as one of the important nutritional features of a program designed to establish peak bone mass. Calcium is also important later on in life to prevent bone loss and to help restore bone that might have been lost due to osteoporosis. Sufficient calcium intake is an essential component of any preventive regimen. New guidelines for optimal calcium intake are based upon the Consensus Development Conference that was held at the National Institutes of Health in June 1994. These guidelines recommended calcium intake somewhat higher than the official recommended dietary allowances (RDA) as published by the Food and Drug Administration. For women who are not yet menopausal as well as for those who are taking hormone replacement therapy (up to the age of 65) an intake of 1,000 mg daily is recommended. For women beyond the age of 65, as well as for women over 50 who choose not to take hormone replacement therapy, 1,500 mg of calcium a day are recommended. Along with sufficient calcium, it is important that vitamin D be sufficient in supply. Adequate vitamin D is essential for optimal dietary calcium absorption. In the United States, many factors are predisposing women to become less sufficient with respect to vitamin D stores. These factors include routine avoidance of sun, which is a major source of vitamin D; avoidance of milk, which is fortified with vitamin D; and physiological factors that make it more difficult for an older individual to activate vitamin D and to respond to it. Thus, along with adequate calcium, it is important that vitamin D stores are adequate. If vitamin D stores are inadequate or if they are marginal, a supplement regimen is usually advisable. Another helpful preventive measure is an exercise program. It is also important to minimize the likelihood of falling because hip fractures do not generally occur among those who do not fall. Attention to factors that may predispose an individual to fall, such as her balance, eyesight, stairs, and bathtubs that are difficult to get into and out of, are all items that need attention. The controversy surrounding hormone replacement therapy in postmenopausal women continues to be active. On the other hand, there is no question that estrogen replacement therapy in the menopausal years is a highly effective means to prevent bone loss. In its absence, women experience a 5- to 8-year period of accelerated bone loss-beyond what would be expected to occur as a function of age alone. Estrogen essentially prevents this bone loss, and it continues to be prevented for as long as estrogens are taken. Estrogen therapy has also been strongly associated with preventing deaths due to cardiovascular disease. In fact, recommendations for hormone replacement therapy are more compelling when cardiovascular risks are considered than those for osteoporosis alone. More women die of cardiovascular causes than any others, far exceeding the mortality associated with hip fracture. The controversy around estrogen replacement therapy specifically related to the increased risk of uterine cancer is essentially negated because a progestational agent is part of the regimen when the uterus is present. Breast cancer, however, continues to be a potential risk for those who take long-term estrogen therapy. (ABSTRACT TRUNCATED)