For many years, osteoporosis management guidelines have recommended anti-resorptive therapies as first line treatments, particularly with bisphosphonates. However, recent randomised trials in patients with severe osteoporosis have demonstrated that anabolic agents reduce fractures to a greater extent than antiresorptive medications. Consequently, international osteoporosis guidelines have proposed an individualised approach based on fracture risk stratification to include patients at ‘very high risk of fracture’, who should be managed with anabolic agents as first-line therapy. This talk will discuss stratification of fracture risk, examine the efficacy of antiresorptive and anabolic therapies and will also give practical guidance in the management of post-menopausal osteoporosis.