Purpose of review: Osteoporosis is a growing problem worldwide, with the greatest burden resulting from fractures. Currently available are several treatment options that are effective in reducing fracture risk. Patient adherence to these medications is required for benefit to be seen. Yet, similar to other chronic asymptomatic diseases, adherence to osteoporosis therapies is poor. The reasons for suboptimal adherence are multiple but include fear of possible side effects, dosing requirements, and an unwillingness to take a medication for a 'silent' disease. Poor adherence leads to reduced effectiveness, increased morbidity, and increased medical costs. Recent findings: Efforts to improve adherence to osteoporosis treatments are ongoing. The first obstacle in improving adherence to osteoporosis treatments is determining causes of poor adherence. Despite several identifiable causes, improving adherence is difficult. Passive patient education with printed information alone does not appear very effective. Physician-patient interaction, including discussion of bone mineral density results, discussion of osteoporosis medication benefits, and feedback of treatment effects, may be more effective. Summary: Improved patient education, better tolerated and less frequently dosed medications, and more healthcare provider-patient interaction may improve adherence and lead to greater fracture reduction. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.