Osteopenia—defined by a bone mineral density T-score between −1.0 and −2.5—is more common than osteoporosis and accounts for most fragility fractures in postmenopausal women. Approximately 50% of Korean women aged ≥ 50 years have osteopenia. Despite this high prevalence, optimal therapeutic strategies remain unclear. This review summarizes the clinical significance and management of osteopenia. Clinical practice often categorizes osteopenia into mild, moderate, and severe based on specific T-score ranges. Studies indicate that women transitioning from normal or moderate osteopenia to lower bone density experience more fractures. One study reported that approximately 10% of women with normal BMD or osteopenia progressed to osteoporosis, mostly from moderate to severe osteopenia groups. Fracture risks, particularly for hip and vertebral fractures, are elevated mainly in moderate to severe osteopenia.The National Osteoporosis Foundation and the American Association of Clinical Endocrinologists incorporate FRAX® scores alongside T-scores and clinical history to guide pharmacological intervention. Accordingly, South Korean guidelines classify fracture-risk groups as low, moderate, high, or very high, allowing treatment of patients with osteopenia in the high-risk categories. Evidence supporting medications for fracture prevention remains limited. However, growing interest in preventing fractures has directed the ongoing studies to evaluate various drugs. Food and Drug Administration-approved treatments include menopausal hormone therapy, bisphosphonates, and selective estrogen receptor modulators. To reduce fractures in postmenopausal women, treatment should not be restricted to osteoporosis alone. Women with moderate to severe osteopenia may also benefit from medications used for osteoporosis. Clinicians should assess individual fracture risks and select preventive treatments based on risk level, fracture site, menopausal symptoms, patient preference, and cost-effectiveness.

The treatment strategy for postmenopausal symptoms resulting from estrogen deficiency in breast cancer survivors receiving endocrine therapy should differ from that in normal women. Several nonhormonal pharmacological therapies can be used to treat vasomotor symptoms. Cognitive-behavioral therapy can help alleviate psychophysiological symptoms, including depression and sleep disorders.Topical vaginal estrogen and moisturizers may aid in treating genitourinary symptoms. Additionally, chronic conditions must be individually managed. Prevention of osteoporosis should always be included in the management, and physicians should be alert to possible cardiovascular risk and cognitive function changes.