INTRODUCTION AND HYPOTHESIS: Our aim was to characterize pelvic floor symptoms in postmenopausal women who had undergone osteoporosis evaluation and examine their association with bone mineral density (BMD). METHODS: Pelvic floor symptom questionnaires were mailed to 4,026 women. Multivariate logistic regression models controlling for age, race, body mass index (BMI), and chronic obstructive pulmonary disease (COPD) were performed comparing symptoms in women with osteoporosis (T score ≤ -2.5) and osteopenia (T score > -2.5 to < -1) at any site to women with normal BMD (T score: ≥ -1, referent). RESULTS: There were 1,774/4,026 (44%) questionnaires returned; 1,655 were included in the analysis (362 osteoporosis, 870 osteopenia, 423 normal BMD). Overall prevalence of any urinary incontinence (UI) was 1,226/1,640 (75%), with UI ≥2-3 times/week in 699/1,197 (58%), fecal incontinence over the past month in 247/1,549 (16%), and prolapse in 162/1,582 (10%). Multivariate analyses revealed that women with osteopenia had increased risk of incontinence of solid stool [adjusted odds ratio (aOR) 1.7, 95% confidence interval (CI) 1.1-2.4). Risk of UI ≥2-3 times/week was not increased in women with osteoporosis (aOR 0.9, CI 0.6-1.3) and was lower in women with osteopenia (aOR 0.7, CI 0.5-0.9). In women with osteoporosis, the odds of moderate- to large-volume urine loss versus small/none was higher for those in the lower T-score quartile (lower BMD; aOR 1.43, CI 1.1-1.9). CONCLUSIONS: In women undergoing osteoporosis evaluation, those with osteopenia were at increased risk of fecal incontinence but not UI compared with normal women. Osteoporotic women with the lowest T scores had higher risk of moderate- to large-volume UI. It is unclear whether there is a pathophysiologic link between BMD loss and development of pelvic floor symptoms.